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Letter to the Editor
Interferon therapy: Mechanism of renal thrombotic microangiopathy in multiple sclerosis
Terapia con interferón: mecanismo de microangiopatía trombótica renal en la esclerosis multiple
Mohammad Bahadorama, Bijan Keikhaeia, Mohammad-Reza Mahmoudian-Sania,
Corresponding author
mohamadsani495@gmail.com

Corresponding author.
, Kosar Alikhanib, Ammar Helalinasabc
a Thalassemia and Hemoglobinopathy Research Center, Research Institute of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
b Medicinal Plant Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
c Chronic Renal Failure Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple sclerosis &#40;MS&#41; is a common and chronic autoimmune disorder in the central nervous system &#40;CNS&#41;&#46; It is an inflammatory and neurodegenerative disease&#44; in which the myelin sheath on the neurons is targeted and destroyed&#46; There are various treatment strategies for MS&#44; including immune-suppressants&#44; immune-modulators&#44; and monoclonal antibodies&#46; Immune-modulators such as Beta-interferons and glatiramer are among the primary therapies for the treatment and prevention of recurrence&#46; Interferon beta-1 &#40;IFN-&#946;1&#41; is a cytokine of the interferon family that is divided into two groups&#59; 1a and 1b&#44; depending on the culture medium used in the production of these drugs&#44; which do not differ significantly in function&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The exact mechanism of these immune-modulators is unknown&#44; but the current evidence suggests that they may affect the immune cells and cytokines that are involved in the pathogenesis of MS&#46; Beta interferons can modulate the immune system by acting on cytokines released from T-helper lymphocytes and by affecting the migration of leukocytes from the brain blood barrier&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Common side effects of these cytokines include reaction at the injection site&#44; flu-like symptoms such as fever&#44; fatigue and muscle weakness&#44; headache&#44; and gastrointestinal disorders such as diarrhea and nausea&#46; Common laboratory findings caused by the use of these cytokines include lymphopenia&#44; neutropenia&#44; and increased hepatic transaminases&#46; One of the rare side effects of long-term use of interferons is the occurrence of Thrombotic Microangiopathy &#40;TMA&#41;&#44; which is rare&#44; but due to the importance and possibility of irreversible damage&#44; we will study it here in more details&#46; It is hypothesized that interferons inhibit the proliferation and migration of epithelial cells and thus prevent angiogenesis&#44; and so triggering thrombotic microangiopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> TMA is an obstructive and thrombotic disorder in small blood vessels characterized by systemic or local plaque aggregation&#44; thrombocytopenia&#44; and mechanical damage to erythrocytes and hemolytic anemia&#46; The organ dysfunction that occurs in this complication is caused by blockage of small arteries with platelet and fibrin clots&#46; Also&#44; red blood cells collapse in contact with this fibrin net&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> TMA generally includes hemolytic uremic syndrome &#40;HUS&#41; and Thrombotic thrombocytopenic Purpura &#40;TTP&#41;&#46; Complications in TTP are more likely to cause brain damage&#44; and more kidney damage is expected in HUS&#46; Etiologically&#44; the manifestations of TMA are classified as follows&#58; TTP&#44; which occurs due to congenital or acquired deficiency of the enzyme ADAMTS 13&#44; HUS caused by contamination with Shiga toxin released from <span class="elsevierStyleItalic">Escherichia coli</span> and atypical HUS&#46; Atypical HUS&#44; commonly known as secondary microangiopathy&#44; depends on a variety of factors&#44; including the complement system&#44; coagulation cascade&#44; medications&#44; transplantation&#44; pregnancy&#44; etc&#46;&#44; which can be treated by controlling the underlying factors if possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a> As mentioned&#44; TMA has various underlying causes&#44; but the side effects of drugs&#44; including beta-interferons&#44; have been suggested for several years as a possible cause of thrombotic microangiopathy&#46; The microangiopathy induced by drugs&#44; can caused by an acute disorder of immune system mediators or as a result of gradual and dose-dependent of the drug poisoning&#46; During MS treatment the neurologic microangiopathy is more common and its complications include headache&#44; seizures&#44; and visual impairment&#44; but microangiopathy has been reported rarely in the renal and gastrointestinal systems&#46; Renal TMA induced by beta-interferon can be severe and very serious and even can lead to the kidney transplant&#46; Complications of renal TMA include acute renal failure due to acute tubular necrosis&#44; acute interstitial nephritis&#44; uremic hemolytic syndrome&#44; focal-segmental glomerulonephritis&#44; and minimal change disease &#40;MCD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The patient&#39;s first clinical manifestation before hospitalization due to TMA caused by beta-interferon may include severe or malignant hypertension&#46; Pathological changes due to kidney damage in malignant blood pressure are sometimes similar to renal lesions caused by HUS and TTP&#44; as would make the differentiation of the causes of the thrombotic microangiopathy difficult&#46; Some hypotheses have been suggested about the mechanism that leads to renal thrombotic microangiopathy in the patients taking interferon beta&#46; The pathogenesis of thrombotic microangiopathy may be due to inhibition of vascular endothelial cell growth factor activity &#40;VEGF&#41; in renal podocytes&#46; The vascular endothelial growth factor stimulates signal transmission and transcription in the process of activating its second subtype receptor&#44; which is essential for the angiogenesis process&#44; while this process is stopped by alpha and beta interferon cytokines&#46; So treatment with interferons due to its anti-angiogenesis effect has always been a significant cause of thrombotic microangiopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The vascular endothelial growth factor is also a major factor in regulating the production of nitric oxide in epithelial cells&#44; which plays a key role in dilating blood vessels and preventing thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> It should be noted that the duration of interferon treatment plays a role in vascular endothelial toxicity&#46; According to a study of MS patients&#44; microangiopathy caused by treatment with beta interferons may occur on average after 7 years&#46; Although the role of vascular endothelial growth factor in renal physiology has not been fully explained&#44; its role in the pathophysiology of several renal diseases has been reported&#44; so the cumulative effect of interferon may be effective in the development of renal lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> A hypothesis of the role of antiphospholipid antibodies in the induction of uremic hemolytic syndrome by alpha-interferon has been suggested&#46; Also in a study&#44; anti-phospholipid antibodies were detected in patients with multiple sclerosis since they were treated with beta-interferon revealed that the beta-interferon therapy could also induce antiphospholipid antibodies and occurrence of microangiopathic presentations&#46; In patients treated with interferon beta&#44; anti-ADAMTS13 IgG synthesis has been reported rarely&#44; and due to the role of this enzyme deficiency in thrombocytopenic purpura&#44; it may be another mechanism for the occurrence of renal microangiopathic presentations in patients with MS&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;9</span></a> TMA can occur in MS patients treated with beta-interferon even after years of appropriate response to the drug&#44; so symptoms such as headaches and high blood pressure should be taken seriously and the patient should be monitored for renal problems&#46; Any suspicious symptoms in these patients should be discontinued interferon treatment and other immunomodulators should be replaced to control the disease&#46;</p></span>"
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Article information
ISSN: 01218123
Original language: English
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