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Avacopan (TAVNEOS® capsules) is an orally available selective C5a receptor (C5aR) antagonist. It has been approved in Japan since 2021 for the treatment of microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA), the two major subtypes of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The current standard therapy combining glucocorticoids (GC) and immunosuppressants has greatly improved the prognosis of AAV, however, issues such as side effects associated with GC use remain to be resolved. Avacopan suppresses priming of neutrophils induced by the complement component C5a, a process deeply involved in the pathogenesis of AAV. In pre-clinical studies, avacopan inhibited chemotaxis and priming of neutrophils induced by C5a-C5aR signaling. It also significantly suppressed nephritis and renal damage in an ANCA-induced glomerulonephritis mouse model. In the global phase 3 study "ADVOCATE", avacopan achieved both primary endpoints being 1) non-inferior to prednisone in inducing remission at week 26 and 2) superior in sustained remission at week 52 for MPA and GPA patients. Additionally, with avacopan, GC toxicity score was significantly lower and fewer adverse events possibly related to GC were observed. Furthermore, avacopan increased estimated glomerular filtration rate (eGFR) more than prednisone indicating improved renal function. Thus, the novel mechanism of avacopan targeting the complement system is a promising new therapeutic option for AAV with fewer GC-related side effects and better improvement of renal function. [ABSTRACT FROM AUTHOR]

The complement and coagulation systems are ancestrally related mechanisms of serine protease-induced protein activation. Recent studies have shown that the complement system enhances platelet aggregation by activating platelets and vascular endothelial cells. This system is also involved in the expression of tissue factor, which induces the coagulation reaction. Activated platelets and coagulation factors are also known to activate the complement system. In diseases involving the complement system, such as paroxysmal nocturnal hemoglobinuria, autoimmune hemolytic anemia, and atypical hemolytic uremic syndrome, excessive activation of this system contributes to complement-mediated thrombosis. The anti-C5 antibody eculizumab has shown a remarkable thromboprophylactic effect in these complement diseases. The recent surge in development of new anti-complement agents has raised expectations for the advancement of treatments and preventive measures for thrombosis associated with complement disorders. This review outlines the crosstalk between these two systems, and describes the mechanisms of several diseases featuring both thrombosis and complement activation.

PEGylated liposomes (approximately 100 nm in diameter) lose their long-circulating characteristic upon repeated injection at certain intervals in the same animal (referred to as the "accelerated blood clearance (ABC) phenomenon"), as described by our group and by researchers in the Netherlands. Recently, it was demonstrated by our group that anti-PEG IgM, induced by the first dose of PEGylated liposomes, is responsible for the ABC phenomenon. The IgM produced in this manner then selectively bound to the surface of subsequently injected PEGylated liposomes, leading to substantial complement activation. It is generally believed that nanocarriers coated with a polymer, such as PEG, have no immunogenicity. However, unexpected immune responses occurred even in response to polymer-coated liposomes. This immunogenicity to PEGylated liposomes presents a serious concern in the development and clinical use of liposomal formulations. In this review, we demonstrate our recent observations regarding with the ABC phenomenon against liposomes.

The terminal complement complex (TCC) has been reported to play an important role in the pathogenesis of proteinuria not only in experimental nephritis but also in human glomerulonephritis. In order to clarify the clinical significance of TCC, the author investigated a total of 129 pediatric patients with the following glomerular diseases: idiopathic nephrotic syndrome (INS; 40 cases), IgA nephropathy (IgAN; 48 cases), mesangio-capillary glomerulonephritis (MPGN; 16 cases), lupus nephritis (LN; 16 cases), purpura nephritis (5 cases) and membranous nephritis (4 cases). Results were analyzed in relation to the responsiveness to steroid treatment in INS and the degree of proteinuria and histopathologic severity in glonerulonephritis groups. In 40 patients who underwent renal biopsy, the localizations of vitronectin and clusterin, both of which are regulatory proteins for TCC, were examined by immunofluorescence microscopy in conjunction with that of TCC for the study of the mechanism of local defense in glomerulonephritis. The urinary TCC levels were elevated in 9 (90%) of 10 patients with steroid-resistant INS, while they were elevated only in 2 of 30 steroid-responsive patients. In glomerulonephritis groups, urinary TCC levels were elevated in 13 of 48 patients with IgAN, 6 of 16 with MPGN, 8 of 16 with LN, 2 of 5 purpural nephritis and 1 of 4 with membranous nephritis. Urinary TCC levels correlated with histological severity in IgAN and showed a reciprocal relation to C3 levels in MPGN and LN. Immunofluorescence findings showed that localization of TCC was quite similar to that of C3 in glomerulonephritis groups. Vitronectin and clusterin were also demonstrated to deposit in similar pattern to TCC. These results suggest that in INS urinary TCC levels could predict the responsiveness to steroid therapy and might be useful as a non-invasive diagnostic method in differential diagnosis of INS. In IgAN, urinary TCC could be a useful marker of histologic severity. The deposition of vitronectin and clusterin together with TCC in glomerulus suggests the possibility that vitronectin and clusterin play a role in reducing the formation of TCC in glomerular tissues.

The direct effect of four different radiographic contrast media (RCM) on the release of C3a and C5a and the production of IL-1 alpha and TNF-alpha from vascular endothelial cells was examined in vitro. The test RCM were as follows: diatrizoate (ionic monomer), iopamidol (nonionic monomer), ioxaglate (ionic dimer), and iotrolan (nonionic dimer). These were added to serum-free medium and adjusted to a final concentration of 1% (2.8 mg Iodine/ml). Human microvascular endothelial cells were stimulated by serum-free medium containing the test RCM for eight hours. After incubation, the media were aspirated and assayed for the concentrations of C3a, C5a, IL-1 alpha and TNF-alpha. Finally, the cells were harvested by trypsin, and their viability was determined by the dye-exclusion method. Diatrizoate and iotrolan had higher C3a release than the control (p < 0.05). No increase in C5a, IL-1 alpha or TNF-alpha levels was observed with any of the tested RCM, and there was no significant difference in cell viability with any of the tested RCM. The results of this study suggest that diatrizoate and iotrolan activated the complement system through the alternative pathway by directly stimulating vascular endothelial cells. These observations suggest that a direct effect of RCM on vascular endothelium might play a role in the pathogenesis of local drug eruptions due to RCM.