25,83,91 Most fI and MCP mutations functionally impair

their ability to inactivate C3b, but surprisingly the majority of fH mutations are not in the functional N-terminus; instead they cluster in the C-terminal domains (SCR 19-20) that mediate fH binding to the cell Proteasome inhibitor review surface.35,83 An additional population of aHUS patients (5%) are characterized by the development of autoantibodies to fH that inhibit fH binding to host cells.96 Recent studies have demonstrated that many of these autoantibody-positive patients have deletion or alternative splicing of CFHR1 and CFHR3,97,98 two fH-related genes that encode plasma proteins with 5 SCRs that have homologous C-termini with fH. These findings suggest that lack of CFHR may play a role in fH autoantibody production and aHUS pathogenesis. Corresponding biochemical and animal studies have selleck chemicals bolstered the clinical data and reaffirmed the causal link between increased AP activity and the development of aHUS symptoms. A number of in vitro studies with human fH have demonstrated that loss of fH binding to cells (with intact fluid-phase complement-regulating activity) can cause complement deposition, cell lysis and platelet activation, all characteristics of aHUS.31,99–101 For example, a recombinant protein composed of the two C-terminal SCR domains of

human fH and lacking complement regulator function has been shown to compete with native fH for cell binding and, when added to normal human serum, caused AP-dependent erythrocyte lysis.31 The concept that impaired binding to host cells but normal plasma AP complement-regulating activity of fH correlates with aHUS pathogenesis is also supported by a murine model of aHUS.102 While, as discussed above, complete fH deficiency led to depletion of plasma AP complement and the development of MPGN,64 transgenic expression in fH knockout mice of a truncated murine fH protein containing SCR1-16, which

lacks the ability to interact with host cells, partially restored plasma AP complement activity.102 Instead of developing MPGN, by 8 weeks of age most of the transgenic mice had spontaneously developed aHUS symptoms – significant haematuria and anasarca, Astemizole low platelet blood counts and significant kidney tissue remodelling with thrombi throughout the glomeruli.102 The development of this in vivo model of aHUS not only confirmed complement’s contribution to aHUS pathology and shed light on the mechanism of action of fH, but also created a valuable tool with which complement-focused therapies can be tested. The kidney diseases discussed above can be life-threatening and most have limited, often unsuccessful, treatment options. Many patients with MPGN and aHUS experience recurrent episodes that eventually lead to end-stage renal failure.40,57,84 Even when kidney transplants are successful, diseases that are caused by systemic factors such as mutated fH, C3 and fB can present again and the outcome is often fatal.