Increased amounts of C4-containing immune complexes and inefficient activation of C3 and the terminal complement pathway in a patient with homozygous C2 deficiency and systemic lupus erythematosus

Plasma and serum samples from a patient with homozygous C2 deficiency and severe systemic lupus erythematosus who responded with full clinical remission after plasma infusions were examined for immune complexes (IC), C3 activation products, and the terminal complement complex (TCC). Plasma contained large amounts of C4-containing IC but no C3-containing IC or complement activation products. Classical pathway activation in vitro did not lead to C3 activation or TCC formation as seen in normal serum, but a very efficient binding of C1q and C4 was found. No disturbances in alternative pathway activation were observed. The results indicate an impaired formation of C3-containing IC and an inefficient clearance of C4-containing IC, supporting the idea of a causal relationship between the dysfunctional classical pathway, pathophysiology, and clinical manifestations in this patient.

The IgG subclass pattern of complement activation depends on epitope density and antibody and complement concentration

Using a matched series of human-mouse chimaeric IgG anti-5-iodo-4-hydroxy-3-nitrophenacetyl (anti-NIP) antibodies and NIP-bovine serum albumin (NIP-BSA) we examined how different variables influence the activation pattern of complement. When BSA was used with different hapten densities and the input of NIP-BSA was altered, we observed a change in the subclass reaction pattern. IgG3 fixed more Clq than IgG1 and IgG2 in all situations. IgG1 was slightly better than IgG3 and IgG2 at high antigen concentrations at activating C4 and C3 and inducing formation of the terminal complement complex (TCC). When the epitope density and/or the NIP-BSA concentration was reduced, IgG3 became best, followed by IgG1 and IgG2. IgG1 now revealed a marked prozone. Furthermore, IgG4 was found to activate C3 and mediate TCC formation at high epitope and complement concentrations.

Different activation patterns in the plasma kallikrein-kinin and complement systems during coronary bypass surgery

Components of the plasma kallikrein-kinin and complement systems were determined in patients undergoing open heart surgery with cardiopulmonary bypass. Spontaneous kallikrein activity (KK), plasma prekallikrein (PKK), functional kallikrein inhibition capacity (KKI), C3 activation products (C3-act), and the terminal complement complex (TCC) were measured. A marked, transitory increase in KK and a decrease in PKK were found prior to cardiopulmonary bypass just after heparin injection. An additional decline in PKK and KKI during bypass with a return to near control levels in the postoperative period was observed. C3-act increased in all patients during bypass, reaching a peak value at wound closure. The TCC concentration also increased significantly during cardiopulmonary bypass, returned to control levels in the early postoperative period, and then increased again in the late postoperative period. It is concluded that activation of the kallikrein-kinin system started after injection of heparin, prior to cardiopulmonary bypass. Activation of both the initial and the terminal complement cascade, however, started only after onset of cardiopulmonary bypass.

Biocompatibility of urinary catheters. Effect on complement activation

The ability of 2 brands of urinary catheters to activate the complement system in vitro as a marker of biocompatibility was investigated. Pieces of a silicone/latex catheter and an all-silicone catheter were incubated in human serum. Complement activation was tested in 2 enzyme immunoassays, one evaluating C3 activation and the other the terminal complement complex (TCC) formation. The silicone/latex catheter caused considerably more complement activation in both assays than did the all-silicone one. The findings are in agreement with previous results of tissue toxicity tests. The methods presented may prove valuable for the practical purpose of testing the biocompatibility of urinary catheters.

High doses of corticosteroids in total hip replacement. Effects on components of coagulation, fibrinolytic, plasma kallikrein-kinin and complement systems

Changes in components of the plasma proteolytic enzyme systems following a standardized musculoskeletal trauma were studied, and the effects of high-dose corticosteroids on these changes were evaluated. Twelve patients who had received an uncemented total hip prosthesis were divided into a steroid and a nonsteroid group. In the early postoperative phase there was reduction of plasma kallikrein, prekallikrein, functional kallikrein inhibition, plasmin, antiplasmin, plasminogen, prothrombin and antithrombin. These reductions closely followed the concentrations of albumin and IgG, and were mostly due to hemodilution, although weak protease activation was assumed to occur. In the high-dose corticosteroid group the values of antithrombin and functional kallikrein inhibition was significantly higher than in the non-steroid group. There was no systemic activation of the complement system following total hip replacement.

Enzyme immunoassay detection of circulating immune complexes by monoclonal antibodies to C3 neoepitopes with special reference to IgG concentration and to interfering anti-immunoglobulin antibodies

A sensitive solid-phase anti-C3 enzyme immunoassay for detection of circulating immune complexes (CIC) is described. A mixture of the monoclonal antibodies (MoAbs) bH6 and Clone 9 specific for neoepitopes on C3 activation products was used as capture reagent. MoAb bH6 recognized C3b, iC3b and C3c, and Clone 9 recognized iC3b and C3dg. Detection antibody was a polyclonal peroxidase-conjugated rabbit anti-human Ig antiserum. A quantitative assay was constructed using serum incubated with heat aggregated IgG (HAG) as standard. The lower detection limit was 5 micrograms/ml of HAG. Interassay and intra-assay coefficient of variation was 15% and 5%, respectively. Anti-animal immunoglobulin antibodies were detected both in normal and pathological sera. This activity was efficiently absorbed by nonimmune immunoglobulins added to the samples. The present assay was compared with a polyethylene glycol precipitation assay for CIC determination. The latter assay was strongly influenced by the IgG concentration (rs = 0.78; P = 0.006), whereas no such correlation was seen for the anti-C3 immune complex assay (rs = -0.30; P = 0.20).

Activation-dependent antigenic changes of human C3

The C3 molecule is crucial in the function of the complement system. It is the only substrate for both the classical and the alternative pathways. Native C3 exhibits no biological activity. Upon activation, biologically active C3 fragments are formed, on which new antigenic determinants appear. Activated C3 express distinct binding sites for other complement proteins and cell surface receptors. Recently, it has been possible to study these neoepitopes with monoclonal antibodies. These antibodies are also found valuable in the detection and quantitation of C3 activation products and C3-containing circulating immune complexes.

Alterations in the terminal complement pathway in leukopenic children with malignant diseases during episodes with evidence of infection

A prospective study comprising 23 children under treatment with cytostatic drugs for malignant diseases was undertaken to search for complement abnormalities during episodes with evidence of infection. Eleven patients developed 17 episodes with fever (temperature greater than or equal to 38 degrees C) (n = 13) and/or increased concentration greater than or equal to 10 mg/l) of C-reactive protein (CRP) (n = 16). Complement factor C9 increased significantly (greater than or equal to 150%) in 12/13 of the events with fever, in 16/16 with increased CRP, and in 1 additional event with normal temperature and CRP concentration. The terminal complement complex (TCC) increased excessively (37.2 units/ml) parallel to a fall in C9 and S-protein in a single patient with a lethal septic shock, and was slightly increased (2.9 units/ml) in a 2nd case who was efficiently treated. These were also the only 2 cases with verified bacterial infections. We conclude that C9 is a valuable supplement to CRP for detection of events with probable infection and that TCC is increased only in severe infection and may be of prognostic importance.

Studies on the dose dependence of endotoxin-induced in vitro activation of the complement system

The dose and time dependence of in vitro endotoxin-induced activation of complement was studied in citrated pool plasma at 37 degrees C. C3 activation fragments (C3act) and the fluid-phase terminal complement complex (TCC) were used as indicators of initial and terminal activation, respectively. At 1 h marked elevation of C3act and TCC were found in plasma tested with the highest doses of endotoxin (2.10(9) and 2.10(8) ng/l). In test plasmas with 2.10(7) and 2.10(6) ng/l of endotoxin, no sign of activation was seen during the first 4 h, whereas both C3act and TCC values were increased at 12 h. In thest plasma with 2.10(5) ng/l of endotoxin and in control plasma no elevation of TCC values were seen during the observation period (24 h), whereas C3act values increased slightly and to the same extent in both at 24 h. Parallel to the increases in C3act and TCC concentrations, the functional C1 inhibitor (C1INH) values decreased. Changes in C1INH values, however, occurred with a time lag of approximately 6 h compared to the increases in C3act and TCC. Our in vitro study showed a dose-dependent endotoxin-induced activation of both the initial and the terminal part of the complement cascade evaluated by C3act and TCC.

Synthesis of soluble C3 and C9 neoepitopes by human alveolar macrophages in vitro

The aim of this study was to examine whether soluble neoepitopes of activated C3 (C3b, iC3b, C3c) and C9 are produced by human alveolar macrophages cultured in serum-free medium. There was a significant and inhibitable production of C3 and C9 neoepitopes and C9 by the macrophages from all donors, as detected by enzyme-linked immunosorbent assays based on monoclonal (bH6, aE11) and polyclonal (anti-C9) antibodies. A strong donor-dependent variation in the levels of the C3 neoepitope and C9 (five- to sevenfold) and the C9 neoepitope (twofold) was found. After 1 day (24 h) of incubation, the complement levels were largely unaltered. The presence of an exogenous alternative pathway activator (agarose beads) reduced the amount of soluble complement because of binding to the agarose. However, the relative fraction of C9 neoepitope versus C9 increased (two- to threefold), due to agarose-mediated activation of C9. The results demonstrate activation of the complement system in serum-free alveolar macrophage cultures, irrespective of the presence of a known complement activator.

Effect of time, temperature and anticoagulants on in vitro complement activation: consequences for collection and preservation of samples to be examined for complement activation

The effects of time, temperature, ethylene-diamine-tetra-acetic acid (EDTA), citrate and heparin on in vitro complement activation were examined in enzyme immuno assays (EIA) for detection of C3 activation products and the terminal complement complex (TCC). In vitro complement activation occurred during coagulation since baseline concentrations of activation products were considerably higher in serum than in plasma. EDTA was more efficient than citrate and heparin in inhibiting in vitro activation. Minimal activation was observed in all preparations when samples were kept at 4 degrees C for up to ten days, whereas a very rapid increase in activation products occurred even in EDTA plasma when the temperature was elevated. Based on the data obtained, guidelines for the collection and preservation of samples to be examined for complement activation are given.

Plasma exchange in myasthenia gravis: changes in serum complement and immunoglobulins

Serum concentrations of C4, IgG, IgA, and IgM were followed in 8 selected patients with myasthenia gravis (MG) during a 5-day course of plasma exchange (PE), using donor plasma as a replacement solution. C3 activation products (C3b, iC3b and C3c) and the terminal SC5b-9 complement complex were measured in 4 of the patients. All patients improved during the treatment, including 2 patients without detectable antibodies to AChR in serum. The main findings of the study were marked complement activation and an approximately 50% fall in the serum concentrations of IgM and C4 during PE, independent of the concentrations in the donor plasma. The concentrations of IgG and IgA did not change significantly. The fall in C4 during PE is presumably caused by C4 consumption. We postulate that the fall in IgM is an effect of a complement-induced vasodilatation and that PE-induced complement consumption may influence the effect of PE in patients with MG.

Characterization of a monoclonal antibody MoAb bH6 reacting with a neoepitope of human C3 expressed on C3b, iC3b, and C3c

Activation products of the complement cascade contain neoepitopes that are not present in the individual native components. Monoclonal antibodies detecting neoepitopes have been used for direct quantification of activation at different steps in the cascade. These methods are suggested to be more sensitive and reliable than conventional complement activation tests, which are hampered by precipitation or fractionation procedures. The present study describes production screening and characterization of a monoclonal antibody (MoAb) bH6. MoAb bH6 exhibited a significantly higher binding capacity to ELISA plates coated with zymosan-activated human serum than to plates coated with EDTA plasma. When fixed to the enzyme-linked immunosorbent assay (ELISA) plates, MoAb bH6 retained material from zymosan-activated serum that only reacted with anti-C3 antibodies. Crossed immunoelectrophoresis performed on zymosan-activated serum demonstrated that MoAb bH6 co-precipitated with anti-C3c antibodies. In experiments using highly purified cell-bound fragments MoAb bH6 showed reactivity with C3b and iC3b, but not with C3d. MoAb bH6 reacted in ELISA with purified C3c, but not with C3dg, both as capture antibody and in tests with the fragments absorbed to the solid phase. Thus, MoAb bH6 is highly specific for a neoepitope of human C3 expressed on the cleavage fragments of C3b, iC3b, and C3c.

Quantification in enzyme-linked immunosorbent assay of a C3 neoepitope expressed on activated human complement factor C3

A sensitive double antibody enzyme-linked immunosorbent assay (ELISA) for quantification of C3 activation products in human plasma, synovial fluid, and cerebrospinal fluid is described. The monoclonal antibody MoAb bH6, which is specific for a C3 neoepitope expressed on C3b, iC3b, and C3c, was used as capture antibody. Detection antibody was a polyclonal rabbit anti-human C3c followed by development with a peroxidase-conjugated anti-rabbit Ig antiserum. The activity in normal human EDTA plasma was 1.5% of that in zymosan-activated serum (ZAS). The interassay and intra-assay coefficients of variation were 15% and 3%, respectively. The lower detection limit was 0.0005% of the ZAS standard. Reference range (1.1-2.1% of ZAS) was obtained by measuring EDTA plasma from 40 healthy blood donors. A positive correlation rs = +0.92; P less than 0.0002) was found between the present assay and an already established C3'g' activation ELISA, when samples from 16 patients were examined in both assays simultaneously. The present assay and an assay detecting the terminal complement complex showed virtually identical activation patterns in consecutively drawn samples from a patient undergoing extracorporal circulation.

Complement activation by extracorporeal circulation: effects of precoating a membrane oxygenator circuit with human whole blood

In an in vitro study of extracorporeal circulation (ECC), uncoated oxygenators (UC), oxygenators precoated with whole human blood (CN) and oxygenators precoated with blood and then rinsed with Ringer's acetate (CR) all significantly (p less than 0.001) activated the initial and terminal parts of the complement cascade. After 60 min C3 activation had increased by 692% (UC), 750% (CN) and 393% (CR), and terminal complement complex (TCC) concentrations by 194% (UC), 215% (CN) and 273% (CR). C3 activation was significantly (p less than 0.05) less in the CR than in the other groups. There was no statistical intergroup difference in increase of TCC concentration. Complement activation was accompanied by a significant drop in neutrophil counts, which was uninfluenced by coating or rinsing. The observed dissociation of the complement cascade shows that assessment of activation products from both parts is necessary for evaluation of total complement activation. The study suggests that protein precoating may improve biocompatibility of ECC.

Buspirone pharmacokinetics in patients with cirrhosis

The pharmacokinetics of a single oral dose of buspirone (20 mg) were determined in 12 patients with cirrhosis and 12 normal subjects. The mean AUC of buspirone was 55 +/- 38 s.d. ng ml-1 h in cirrhotics and 3.5 +/- 2.4 s.d. ng ml-1 h in normals. The time until maximum concentration (tmax) attained was similar in the two groups (0.6 vs 0.7 h), but mean maximum concentration Cmax was higher in patients (18.8 +/- 16.3 s.d. ng ml-1) than in normals (1.2 +/- 0.8 s.d. ng ml-1). Mean elimination half-life of buspirone was greater in cirrhotics, but this difference was marginally significant statistically (cirrhotics, 6.1 +/- 3.5 s.d. h, normals 3.2 +/- 1.5 s.d. h, P = 0.05). Eight of 12 patients and seven of 12 normal subjects had a second peak in the plasma concentrations of buspirone. In patients this occurred at 10.8 +/- 7.4 s.d. h after the dose, and its mean concentration was 3.1 +/- 6.6 ng ml-1. In normal subjects the second peak occurred at 4.3 +/- 2.1 h after the dose and its mean concentration was 0.5 +/- 0.3 ng ml-1. On the kinetic evidence buspirone should be used with caution in liver disease.