Hemolytic Uremic Syndrome in an Infant with Primary Hyperoxaluria Type II: An Unreported Clinical Association

Nephron. 2019;142(3):264-270. doi: 10.1159/000497823. Epub 2019 Mar 19.


A 6-month-old boy presented with acute renal failure, thrombocytopenia, and severe non-immune hemolytic anemia. Infection by Shiga-like toxin-producing Escherichia coli and other causes of microangiopathic hemolysis were ruled out, leading to a diagnosis of atypical hemolytic uremic syndrome (aHUS). Neither pathogenic variants in HUS-associated genes nor anti-factor H antibodies were identified. Copy number variation analysis uncovered 4 copies of complement factor H related genes, CFHR1-CFHR4, conceivably leading to higher than normal levels of the corresponding proteins. However, this abnormality was also found in the healthy relatives, neither explaining the disease nor the excessive complement deposition on endothelial cells detected by an ex-vivo test. Whole-exome sequencing revealed a pathogenic homozygous variant in GRHPR encoding the glyoxylate and hydroxypyruvate reductase. Recessive GRHPR mutations cause primary hyperoxaluria type 2 (PH2). The presence of renal calculi in the patient and elevated oxalate levels in the urine were consistent with the genetic diagnosis of PH2. We hypothesize that, in this patient, hyperoxaluria caused by the GRHPR genetic defect triggered endothelial perturbation and complement activation, which was amplified by impaired factor H regulatory activity due to the increased -CFHR1-CFHR4 copy numbers, resulting in aHUS.

Keywords: Atypical hemolytic uremic syndrome; Complement; Complement factor H related genes; Glyoxylate and hydroxypyruvate reductase gene; Primary hyperoxaluria type 2; Whole-exome sequencing.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Alcohol Oxidoreductases / genetics
  • Apolipoproteins / genetics
  • Atypical Hemolytic Uremic Syndrome / etiology*
  • Complement Activation
  • Complement C3b Inactivator Proteins / genetics
  • Exome Sequencing
  • Humans
  • Hyperoxaluria, Primary / complications*
  • Hyperoxaluria, Primary / genetics
  • Infant
  • Male


  • Apolipoproteins
  • CFHR1 protein, human
  • CFHR4 protein, human
  • Complement C3b Inactivator Proteins
  • Alcohol Oxidoreductases
  • glyoxylate reductase

Supplementary concepts

  • Primary hyperoxaluria type 2