Kidney Week

Abstract: FR-PO0431

First-Line Use of Ravulizumab in Suspected Complement-Mediated Thrombotic Microangiopathy (TMA)

Session Information

• AKI: Case Reports - TMA, Vasculitis, Immune-Mediated Injury, and Systemic Disease
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Acute Kidney Injury

• 102 AKI: Clinical, Outcomes, and Trials

Authors

• Provot, Francois, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Francois Provot, MD

• Frimat, Marie, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Marie Frimat, MD, PhD

• Lebas, Celine, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Celine Lebas, MD

• Maanaoui, Mehdi, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Mehdi Maanaoui, MD, PhD

• Lenain, Remi, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Remi Lenain, MD, PhD

• Glowacki, Francois, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Francois Glowacki, MD, PhD

• Lionet, Arnaud, Centre Hospitalier Universitaire de Lille, Lille, Hauts-de-France, France

Arnaud Lionet, MD

Introduction

A recent classification of TMA by Nester et al., is based on pathophysiological mechanisms. Although TTP can be reliably excluded with ADAMTS13 activity above 10%, establishing TMA etiology within 48 hours remains challenging. However, renal prognosis in complement-mediated TMA is highly dependent on the timely initiation of anti-C5 therapy. We report our single-center experience using ravulizumab as first-line therapy in TMA with acute kidney injury (AKI) after TTP exclusion.

Case Description

From August 2024 to July 2025, 13 patients (7 men, 6 women; mean age 50 years) received first line Ravulizumab. Five had severe hypertension at admission. Mean baseline values: serum creatinine 7.2 mg/dL, proteinuria 1.5 g/g, platelet count 79 G/L, haptoglobin <0.10 g/L, LDH 1,040 IU/L, soluble C5b-9 (sC5b-9) 409 ng/mL, and Bb 2.3 µg/mL. AKI was KDIGO stage 3 in 10 patients and stage 2 in the remaining. 8 patients required hemodialysis. All received ravulizumab within 24 hours of admission. Platelet normalization (>150 G/L) was achieved in a median of 5 days. Prior to the second infusion, the etiological classification of TMA was established as follows: complement-mediated TMA (n=3), drug-induced TMA (n=3), vasculitis-associated TMA (n=3), malignant hypertension-associated TMA (n=1), pregnancy-associated TMA (n=1), infection-associated TMA (n=1), and transplant-associated TMA (n=1). All patients except two demonstrated improvement in estimated glomerular filtration rate (eGFR). Notably, 6 of the 8 dialysis-dependent patients were weaned off hemodialysis within the first week.

Discussion

Intravascular hemolysis is known to activate the alternative complement pathway, providing a rationale for early complement blockade in TMA adult patients. In this context, we elected to treat all TMA-AKI patients with ravulizumab as first-line therapy to optimize renal outcomes. Our results demonstrated the efficacy and safety of this strategy .
Conclusion: First-line ravulizumab appears to be a safe and effective therapeutic strategy in TMA with AKI after TTP has been ruled out. At day 15, the decision to continue or discontinue anti-C5 therapy should be reassessed based on the established etiological diagnosis and clinical response.