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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Lila AM, Nasonov EL. Global Antiphospholipid Syndrome Score (GAPSS) in Patients with Systemic Lupus Erythematosus. DOKL BIOCHEM BIOPHYS 2023; 511:227-234. [PMID: 37833610 PMCID: PMC10739503 DOI: 10.1134/s160767292370028x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 10/15/2023]
Abstract
The Global Antiphospholipid Syndrome Score (GAPSS) is a tool proposed to quantify the risk of clinical manifestations associated with antiphospholipid antibodies (aPL) and certain cardiovascular risk factors. To validate GAPSS in a cohort of patients with systemic lupus erythematosus in Russia. 115 patients with SLE were included in the study, including 51 (44%) patients with systemic lupus erythematosus (SLE) with antiphospholipid syndrome (APS), 14 (12%) SLE patients with aPL, and 50 (44%) patients with SLE. There was a history of thrombosis in 58 (50%) out of 115 patients; of them, 14 (24%) had arterial thrombosis, 29 (50%) had venous thrombosis, and 15 (26%) had combined thrombosis. Pregnancy against the background of the disease occurred in 43 women included in the study. Of them, 29 (67%) had obstetric pathology. Patients with thrombosis and obstetric pathology had a GAPSS score of 7.17 ± 5.64 versus 4.48 ± 4.55 without these manifestations (p = 0.0003). There was a significant association between GAPSS levels and thrombosis: patients with thrombosis had a GAPSS of 7.31 ± 5.70, those without thrombosis-4.00 ± 4.81 (p = 0.001). GAPPS values were higher in arterial thrombosis compared to venous thrombosis (10.40 ± 25.30 versus 5.82 ± 5.28, p = 0.01). GAPSS levels ≥ 6 and ≥10 were analyzed to select GAPSS values at which a high risk of recurrent thrombosis and/or obstetric pathology could be indicated. All GAPSS levels had a significant association with clinical manifestations of APS. The quality of GAPSS by ROC analysis showed an area under the curve (AUC) for GAPSS of 0.697. GAPSS can be used to assess the risk of recurrence or development of thrombosis and/or obstetric pathology in patients with SLE in the Russian Federation. The GAPSS ≥6 values should be used to stratify patients with SLE into high risk group for recurrence of vascular complications. Further prospective follow-up is needed to confirm the value of GAPSS.
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Affiliation(s)
- F A Cheldieva
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia.
| | - T M Reshetnyak
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - A A Shumilova
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - K S Nurbaeva
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - M V Cherkasova
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - A M Lila
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
- Department of Rheumatology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - E L Nasonov
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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El Hasbani G, Saliba AN, Uthman I, Taher AT. Hematological manifestations of antiphospholipid syndrome: Going beyond thrombosis. Blood Rev 2023; 58:101015. [PMID: 36175215 DOI: 10.1016/j.blre.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Thrombotic complications are a hallmark of antiphospholipid syndrome (APS). These vascular - arterial, venous, and/or small vessel - complications are well described and known to hematologists and healthcare providers caring for patients with this disease. In this review, we shed light on other hematological manifestations of the disease, including bleeding, thrombocytopenia, autoimmune hemolytic anemia, and thrombotic microangiopathy syndromes. While these manifestations are not bona fide clinical criteria for the diagnosis of APS, they frequently interact and contribute to the complexity of clinical management of APS.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, CT 06606, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon..
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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Samarkina EY, Lila AM. Global Antiphospholipid Syndrome Score (GAPSS) in patients with primary antiphospholipid syndrome. MODERN RHEUMATOLOGY JOURNAL 2023. [DOI: 10.14412/1996-7012-2023-1-31-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Stratification of patients into groups of high and low risk of adverse outcome is necessary for timely and early prevention of the disease, as well as the selection of adequate therapy.Objective: to validate the global risk scale for the development of clinical manifestations of antiphospholipid syndrome (GAPSS) in a cohort of patients with primary antiphospholipid syndrome (PAPS).Material and methods. The study included 64 patients with PAPS. Data on clinical manifestations, traditional cardiovascular risk factors, and antiphospholipid antibody profile were collected. GAPSS values were calculated for each patient by summing the scores corresponding to risk factors as follows: 3 points – for hyperlipidemia; 1 point – for arterial hypertension; 5 points – for antibodies to cardiolipin (aCL) IgG/IgM; 4 points – for antibodies to â2-glycoprotein 1 (anti-â2GP1) IgG/IgM and 3 points – for antibodies to the phosphatidylserine-prothrombin complex (aPS/PT) IgG/IgM.Results and discussion. GAPSS indicators were comparable in women and men with PAPS – 12.0 [9.0; 13.0] points. GAPSS values did not differ in patients with thrombosis and obstetric pathology: in thrombosis they were 10.0±4.46 (range 0.0–14.0) points, in obstetric pathology – 9.26±5.08 (range 0.0–14.0) points.The localization of thrombosis did not affect the GAPSS values, which reached 9.23±5.21 points in arterial thrombosis, 10.44±4.01 points in venous thrombosis, and 10.33±4.18 points in combined ones. Patients with recurrent thrombosis had higher GAPSS scores compared to patients without relapse: 8.19±5.25 points versus 11.00±3.65 points (p=0.01). There were no significant differences in GAPSS scores in obstetric pathology at different gestational ages.GAPSS values ≥6 showed a higher risk of thrombosis recurrence: odds ratio 5.23 (95% CI 1.34–20.37). GAPSS scores ≥6 demonstrated the highest accuracy, with sensitivity and specificity of 72% and 66%, respectively. According to ROC analysis, the AUC value for GAPSS was 0.675 (95% CI 0.542–0.808; p=0.01).Conclusion. The use of GAPSS makes it possible to identify patients at increased risk of recurrent thrombosis. GAPSS scores ≥6 have high sensitivity (72%) and specificity (66%), which can be used to stratify patients with PAPS into high and low risk groups for recurrent thrombosis.
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Affiliation(s)
- F. A. Cheldieva
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | - T. M. Reshetnyak
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | | | - K. S. Nurbaeva
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | | | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
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Bello N, Meyers KJ, Workman J, Marcano Belisario J, Cervera R. Systematic Literature Review and Meta-analysis of Venous Thromboembolism Events in Systemic Lupus Erythematosus. Rheumatol Ther 2023; 10:7-34. [PMID: 36471199 PMCID: PMC9931974 DOI: 10.1007/s40744-022-00513-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
The objective of this work was to conduct a systematic literature review (SLR) and meta-analysis (MA) to evaluate the relative risk (RR) of venous thromboembolism (VTE) events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), in patients with systemic lupus erythematosus (SLE) compared with patients without SLE, as well as the absolute risk (AR) (measured by incidence proportion) and incidence rate (IR) of VTE events in patients with SLE. The SLR was conducted using Embase, MEDLINE, and MEDLINE In-Process to identify observational studies evaluating the risk of VTE, DVT, and PE events in adult patients with SLE compared with the general population, published January 2000 to September 2020. Random-effects models were used as the primary approach in the MA. Heterogeneity was assessed on the basis of the I2 value. Sensitivity analyses were performed to assess the robustness of results to various conditions, and subgroup analysis was performed for the AR of VTE by antiphospholipid status (aPLs) and antiphospholipid syndrome (APS). Of the 50 publications included for data extraction, 44 contained data for consideration in the MA of any one of the measures of interest (RR, AR, or IR) for VTE, DVT, or PE. The pooled RR indicates statistically significantly higher risk of VTE (RR 4.38, 95% confidence interval 2.63-7.29) in patients with SLE compared with the general population. Considerable heterogeneity was present in nearly all MA (I2 = 75-100%). Moreover, a higher pooled AR of VTE was estimated in patients with SLE with aPLs (n/N = 0.13) and APS (n/N = 0.63) compared with patients with SLE without aPLs/APS (n/N = 0.07). Overall, there was evidence of an increased risk of VTE, DVT, and PE in patients with SLE compared with the general population.
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Affiliation(s)
| | | | | | | | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Lila AM, Nasonov EL. Global antiphospholipid syndrome score (GAPSS) in patients with systemic lupus erythematosus. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-546-553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. The Global Antiphospholipid Syndrome Score (GAPSS) is a tool proposed to quantify the risk of clinical manifestations associated with antiphospholipid antibodies (aPL) and certain cardiovascular risk factors.Objective. To validate GAPSS in a cohort of patients with systemic lupus erythematosus in Russia.Material and methods. 115 patients with SLE were included in the study, including 51 (44%) patients with systemic lupus erythematosus (SLE) with antiphospholipid syndrome (APS), 14 (12%) – SLE with aPL, and 50 (44%) – SLE.Results. There was a history of thrombosis in 58 (50%) patients with 115, of them 14 (24%) had arterial thrombosis, 29 (50%) – venous, 15 (26%) – combined. Pregnancy against the background of the disease occurred in 43 women included in the study. Of them, 29 (67%) had obstetric pathology. Patients with thrombosis and obstetric pathology had a GAPSS score of 7.17±5.64, versus 4.48±4.55 without these manifestations (p=0.0003). There was a significant association between GAPSS levels and thrombosis – patients with thrombosis had a GAPSS of 7.31±5.70, those without thrombosis – 4.00±4.81 (p=0.001). GAPPS values were higher in arterial thrombosis compared to venous thrombosis (10.40±25.30 versus 5.82±5.28; p=0.01). GAPSS levels ≥6 and ≥10 were analyzed to select GAPSS values at which a high risk of recurrent thrombosis and/or obstetric pathology could be indicated. All GAPSS levels had a significant association with clinical manifestations of APS. The quality of GAPSS by ROC analysis showed an area under the curve (AUC) for GAPSS of 0.697.Conclusion. GAPSS can be used to assess the risk of recurrence or development of thrombosis and/or obstetric pathology in patients with SLE in the Russian Federation. The GAPSS ≥6 values should be used to stratify patients with SLE into high risk group for recurrence of vascular complications. Further prospective follow-up is needed to confirm the value of GAPSS.
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Affiliation(s)
| | | | | | | | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuous Professional Education
of the Ministry of Healthcare of the Russian Federation
| | - E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; 3
I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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Barilaro G, Esteves A, Della Rocca C, Perez-Isidro A, Araujo O, Pires da Rosa G, Ruiz-Ortiz E, Penella DT, Viñas O, Reverter JC, Cervera R, Espinosa G. Predictive value of the Adjusted Global Anti-Phospholipid Syndrome Score on clinical recurrence in APS patients: A longitudinal study. Rheumatology (Oxford) 2022; 62:1576-1585. [PMID: 35997555 DOI: 10.1093/rheumatology/keac485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/31/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the effect of the average adjusted global APS score (aGAPSS) over time on recurrence of clinical manifestations in APS patients through a retrospective longitudinal study. METHODS The study included 200 patients with APS. The aGAPSS was calculated for each patient at baseline and on a yearly basis for either up to 6 years (minimum 3 years) or just before the clinical event in patients who experienced clinical recurrence. The mean score per patient was computed. In patients under vitamin K antagonists (VKA) the percentage of time spent within the therapeutic range (TTR) was calculated. Cox-regression analysis was performed to determine the cut-off value of the aGAPSS with the strongest association with clinical recurrence. RESULTS Higher average aGAPSS values were found in patients who experienced clinical recurrence in comparison to patients who did not [8.81 (95% C.I. 7.53-10.08) vs 6.38 (95% C.I. 5.64-7.12), p = 0.001], patients with thrombotic recurrence compared to patients with obstetric recurrence [9.48 (95% C.I. 8.14-10.82) vs 4.25 (95% C.I. 0.85-7.65), p = 0.006], and patients with arterial thrombosis compared to patients with venous thrombosis [10.66 (S.D. 5.48) vs 6.63 (S.D. 4.42), p = 0.01]. aGAPSS values > 13 points were associated with the highest risk of recurrence in multivariate analysis [HR = 3.25 (95% C.I. 1.93-5.45, p < 0.0001]. TTR was not statistically different between patients who had thrombosis recurrence and patients who had not. CONCLUSIONS Our data support the role of periodic (annual) monitoring of the aGAPSS score in predicting clinical recurrence in patients with APS.
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Affiliation(s)
- Giuseppe Barilaro
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Alexandra Esteves
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy 04100
| | - Albert Perez-Isidro
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Olga Araujo
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Gilberto Pires da Rosa
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Estibaliz Ruiz-Ortiz
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Dolors Tàssies Penella
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Hemotherapy and Hemostasis Department, ICMHO (Institut Clinic de Malalties Hematologiques i Oncologiques),Hospital Clinic, Barcelona, Catalonia, Spain
| | - Odette Viñas
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Joan Carles Reverter
- Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS).,Hemotherapy and Hemostasis Department, ICMHO (Institut Clinic de Malalties Hematologiques i Oncologiques),Hospital Clinic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques Pi I Sunyer (IDIBAPS)
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:jcm11030675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
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Chanloung W, Kasitanon N, Wichainun R, Louthrenoo W. Thrombotic risk assessment in patients with systemic lupus erythematosus: Validation of the adjusted-Global Antiphospholipid Syndrome Score (aGAPSS) in Thai patients. Int J Rheum Dis 2021; 24:1510-1519. [PMID: 34716670 DOI: 10.1111/1756-185x.14230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The adjusted-Global Antiphospholipid Syndrome Score (aGAPSS) has been validated and used to predict antiphospholipid antibodies (aPL) related to vascular thrombosis (VT). OBJECTIVE To validate aGAPSS for predicted aPL-related VT and pregnancy complications (PC) in Thai systemic lupus erythematosus (SLE) patients. METHODS A cross-sectional study was performed among Thai SLE patients with clinical manifestations; history of VT and PC, cardiovascular risk factors, and aPL profiles were collected. The aGAPSS was calculated from the sum of the risk factors (hyperlipidemia = 3.0, arterial hypertension = 1.0, anti-cardiolipin antibody = 5.0, anti-b2 glycoprotein I antibody = 4.0, and lupus anticoagulant = 4.0). RESULTS Of 132 SLE patients, 12 (9.1%) had VT and 5 (4.1%) had PC. When comparing the aGAPSS (median; interquartile range [IQR]) of patients with events (VT and/or PC) (6.5; IQR 3.3-9.0), VT (8.0; IQR 4.0-9.0), arterial thrombosis (3.5; IQR 1.0-5.8), and PC (9.0; IQR 8.0-11.5), and the aGAPSS of patients without an event (3.0; IQR 0-4.0), aGAPSS of patients with events was significantly higher, except in patients with arterial thrombosis. An aGAPSS of 4.5 or more was associated with risk of aPL-related VT (sensitivity 71.4%, specificity 76.7%), and an aGAPSS of 6.0 or more was associated with risk of aPL-PC (sensitivity 100%, specificity 84.0%). CONCLUSION The aGAPSS could predict the risk of aPL-PC and aPL-related VT in Thai SLE patients.
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Affiliation(s)
- Wanitcha Chanloung
- Faculty of Medicine, Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nuntana Kasitanon
- Faculty of Medicine, Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ramjai Wichainun
- Faculty of Medicine, Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Worawit Louthrenoo
- Faculty of Medicine, Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
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Upendran B, Kumar VR, Thomas P. Primary Anti-phospholipid Antibody Syndrome Presenting as Acute Nephritic Syndrome. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:860-864. [PMID: 32801249 DOI: 10.4103/1319-2442.292322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary anti-phospholipid antibody (APLA) syndrome in males most commonly presents with clinical manifestations of venous thrombosis, thrombocytopenia, and pulmonary embolism. Although most present with acute symptoms following arterial thrombosis, diagnosis following evaluation for elevated renal function tests and hypertension is less common. We report here a case of a 22-year-old man who presented with acute nephritic syndrome following an acute febrile illness. He was detected to have altered renal function tests with serum creatinine of 1.6 mg/dL (141.4 μmol/L), microscopic hematuria, and proteinuria along with hypertension. His 24-h urine protein was 1700 g/day. He was planned for a kidney biopsy. Subsequent evaluations revealed an isolated elevation of activated partial thromboplastin time. Further evaluation revealed positive APLA syndrome. He underwent kidney biopsy later which showed mesangial hypercellularity with no involvement of the renal parenchymal vasculature. The reported case is an unusual presentation of primary APLA syndrome with acute nephritic syndrome.
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Affiliation(s)
- Binu Upendran
- Department of Nephrology, Lourdes Hospital, Kochi, Kerala, India
| | | | - Punnoose Thomas
- Department of Nephrology, Lourdes Hospital, Kochi, Kerala, India
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Sciascia S, Radin M, Cecchi I, Levy RA, Erkan D. 16th International congress on antiphospholipid antibodies task force report on clinical manifestations of antiphospholipid syndrome. Lupus 2021; 30:1314-1326. [PMID: 34039107 DOI: 10.1177/09612033211020361] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The objectives of the 16th International Congress on Antiphospholipid Antibodies (aPL) Task Force on Clinical Manifestations of Antiphospholipid Syndrome (APS) were to critically analyze: a) the definition of "APS"; b) the current knowledge on non-traditional manifestations associated with aPL; and c) the risk stratification strategies in aPL-positive patients. The quality of evidence was assessed by the GRADE system. The task force concluded that: a) APS does not have a uniform definition given the heterogeneity of the clinical presentations and different aPL profiles; b) current literature supports the role for aPL testing in cases of thrombocytopenia and recurrent cardiac events but are limited by vast heterogeneity, providing an overall low-to-very low level of evidence; and c) risk stratification strategies in aPL-positive patients, such as aPL-Score and Global APS Score, can be useful in clinical practice. International multicenter studies are still highly needed to improve the quality of available evidence and consequently the strength of future recommendations.
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Affiliation(s)
- Savino Sciascia
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Radin
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,GlaxoSmithKline, Upper Providence, PA, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
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Validation of the adjusted global antiphospholipid syndrome score in a single centre cohort of APS patients from Turkey. J Thromb Thrombolysis 2020; 51:466-474. [PMID: 32588289 DOI: 10.1007/s11239-020-02195-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The adjusted global antiphospholipid syndrome score (aGAPSS) is a recently developed thrombotic risk assessment score that considers the antiphospholipid antibody (aPL) profile and conventional cardiovascular risk factors. In this retrospective study, we aimed to evaluate the validity of the aGAPSS in predicting clinical manifestations (criteria and extra-criteria) of antiphospholipid syndrome (APS) in a single centre cohort of patients. Ninety-eight patients with APS ± systemic lupus erythematosus (SLE) were classified according to clinical manifestations as vascular thrombosis (VT), pregnancy morbidity (PM) or both (VT + PM). The aGAPSS was calculated for each patient as previously defined. Mean aGAPSS of the cohort was calculated as 10.2 ± 3.8. Significantly higher aGAPSS values were seen in VT (n = 58) and VT + PM (n = 29) groups when compared to PM (n = 11) group (10.6 ± 3.7 vs 7.4 ± 2.9, P = 0.005; 10.7 ± 4 vs 7.4 ± 2.9, P = 0.008, respectively), mainly due to lower frequencies of cardiovascular risk factors in PM. Higher aGAPPS values were also associated with recurrent thrombosis (11.6 ± 3.7 vs 9.9 ± 3.6, P = 0.04). Regarding extra-criteria manifestations, patients with livedo reticularis (n = 11) and APS nephropathy (n = 9) had significantly higher aGAPSS values (12.9 ± 3.4 vs 9.9 ± 3.7, P = 0.02; 12.4 ± 2.9 vs 10 ± 3.8, P = 0.04, respectively). The computed AUC demonstrated that aGAPSS values ≥10 had the best diagnostic accuracy for thrombosis. Our results suggest that patients with higher aGAPSS values are at higher risk for developing vascular thrombosis (either first event or recurrence) and extra-criteria manifestations, especially livedo reticularis and APS nephropathy.
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Nascimento IS, Radin M, Gândara APR, Sciascia S, de Andrade DCO. Global antiphospholipid syndrome score and anti-ß2-glycoprotein I domain I for thrombotic risk stratification in antiphospholipid syndrome: A four-year prospective study. Lupus 2020; 29:676-685. [DOI: 10.1177/0961203320916527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This study aimed to assess prospectively the role of anti-ß2-glycoprotein I domain I antibody (aß2GPI-DI) and the Global Antiphospholipid Syndrome Score (GAPSS) in identifying antiphospholipid syndrome (APS) patients at higher risk of a new event. Methods Thrombotic APS patients were followed from May 2013 to July 2017. At baseline, we measured lupus anticoagulant, IgG/IgM anticardiolipin, anti-ß2-glycoprotein I, antiphosphatidylserine-prothrombin (aPS/PT) and IgG aß2GPI-DI, and calculated GAPSS for each patient. Results A total of 44 patients (age 43 ± 10 years, 89% female, 73% primary APS) were followed for 39 months (range 9–46 months). Four new thromboses occurred, two of them after vitamin K antagonist interruption. Recurrent patients presented higher GAPSS (median 20) and were triple and aß2GPI-DI positive; non-recurrent patients had lower GAPSS (median 10.5, range 0–20) and lower ratio of triple (33%) and aß2GPI-DI positivities (38%). aß2GPI-DI was associated with higher GAPSS (median 19 vs. 7, p < 0.001; Pearson correlation 0.82, p < 0.001) and had a greater proportion of triple (83% vs. 4%, p < 0.001) and aPS/PT positivity (94% vs. 50%, p = 0.002). Conclusion Our data show a significant correlation between a validated risk score such as GAPSS and the novel antiphospholipid antibody aß2GPI-DI. Future studies are needed. However, one could speculate a role of aß2GPI-DI as a risk-stratifying tool for thrombotic events in APS.
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Affiliation(s)
- Iana Sousa Nascimento
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases – Coordinating Centre of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Ana Paula Rossi Gândara
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases – Coordinating Centre of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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Salle V. [Seronegative antiphospholipid syndrome: Myth or reality?]. Rev Med Interne 2020; 41:265-274. [PMID: 32115196 DOI: 10.1016/j.revmed.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/23/2019] [Accepted: 02/02/2020] [Indexed: 10/24/2022]
Abstract
The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombosis and/or obstetrical manifestations and the persistent presence, at least 12 weeks apart, of antiphospholipid antibodies (aPL) such as lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACL) and/or anti-β2 glycoprotein I antibodies (aβ2GPI). The finding of patients with clinical profile highly suggestive of APS but who are negative for conventional biological criteria has led to the concept of seronegative APS. In the last few years, new antigen targets and methodological approaches have been employed to more clearly identify this syndrome in patients with thrombosis or obstetrical complications without conventional aPL. Although seronegative APS is still controversial, there is increasing recognition of the existence of this subgroup. However, clinical relevance of non conventional aPL need to be confirmed by efforts toward standardizing new biological tools and longitudinal studies involving large cohort of patients.
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Affiliation(s)
- V Salle
- Service de médecine interne, CHU Amiens-Picardie, 1, place Victor-Pauchet, 80054 Amiens cedex 1, France; Laboratoire de biochimie recherche, CHU Amiens-Picardie, Amiens, France.
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Radin M, Cecchi I, Schreiber K, Rubini E, Roccatello D, Cuadrado MJ, Sciascia S. Pregnancy success rate and response to heparins and/or aspirin differ in women with antiphospholipid antibodies according to their Global AntiphosPholipid Syndrome Score. Semin Arthritis Rheum 2020; 50:553-556. [PMID: 32089355 DOI: 10.1016/j.semarthrit.2020.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/14/2020] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The current treatment to prevent pregnancy morbidity (PM) associated with antiphospholipid antibodies (aPL) is based on the use of low dose aspirin and low molecular weight heparin (henceforth defined as standard of care (SoC) treatment). Despite the SoC, up to 30% of women with aPL continue to have pregnancy complications. The global antiphospholipid syndrome (APS) score (GAPSS) is a tool to quantify the risk for the aPL-related clinical manifestations. In this study, we investigated the individual clinical response to SoC in women with aPL after stratifying them according to their GAPSS. METHODS One-hundred-fourty-three women (352 pregnancies) with aPL ever pregnant treated with SoC therapy were included. The patients GAPSS was then grouped according to the patients' GAPSS into low risk (< 6), medium risk (6-11), and high risk (≥12). RESULTS The live birth rate was 70.5% (248 out of the 352 pregnancies), 45 patients (31%) experienced at least one event of PM, defined as early or late. Patients were stratified according to GAPSS values, in order to identify a low risk group (GAPSS <6, n = 72), a medium risk group (GAPSS 6-11, n = 66) and a high risk group (GAPSS ≥12, n = 5). When considering patients who ever experienced any PM while treated with SoC, all patients in the high risk group experienced PM, while patients in the medium group had a significant higher rate of PM when compared to the low risk group [29 (43.9%) patients V.s. 11 (15.3%), respectively; p < 0.001]. When analysing the number of pregnancies in the three groups, patients in the high risk group had significantly lower live birth rates, when compared to the other groups [11 (40.7%) live births vs. 100 (62.1%) and 137 (82.5%), respectively; p < 0.05]. Furthermore, patients with medium risk group also had significantly lower live birth rates, when compared to the lower risk group (p < 0.001). CONCLUSIONS GAPSS might be a valuable tool for to identify patients with a higher likelihood of response to SoC.
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Affiliation(s)
- M Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - I Cecchi
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - K Schreiber
- Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospital, London, United Kingdom; Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen University, Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - E Rubini
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy; School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - D Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - M J Cuadrado
- Rheumatology Department, Clinica Universidad de Navarra, Madrid, Spain
| | - S Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy.
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Petri M. Improvements in diagnosis and risk assessment of primary and secondary antiphospholipid syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:415-420. [PMID: 31808834 PMCID: PMC6913440 DOI: 10.1182/hematology.2019000046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Classification criteria for antiphospholipid syndrome have not been updated since the revised Sapporo classification criteria were published in 2006. These criteria have limitations in that they omit nonclassical manifestations (hematologic and neurologic), include anticardiolipin and anti-β2-glycoprotein I immunoglobulin (Ig)M isotypes, and do not separately consider primary (no autoimmune disease) or secondary (usually systemic lupus erythematosus) disease. Recent findings in antiphospholipid antibody include fluctuation of antiphospholipid antibodies, recognition that IgA isotypes do confer risk, identification of the role of complementopathy in catastrophic antiphospholipid syndrome, and elucidation of the role of thrombosis risk equations.
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Affiliation(s)
- Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
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Management of Antiphospholipid Syndrome in Patients with Systemic Lupus Erythematosus. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00126-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tonello M, Mattia E, Favaro M, Del Ross T, Calligaro A, Salvan E, Hoxha A, Fedrigo M, Ruffatti A. IgG phosphatidylserine/prothrombin antibodies as a risk factor of thrombosis in antiphospholipid antibody carriers. Thromb Res 2019; 177:157-160. [DOI: 10.1016/j.thromres.2019.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
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Nakamura H, Oku K, Amengual O, Ohmura K, Fujieda Y, Kato M, Bohgaki T, Yasuda S, Atsumi T. First-Line, Non-Criterial Antiphospholipid Antibody Testing for the Diagnosis of Antiphospholipid Syndrome in Clinical Practice: A Combination of Anti-β 2 -Glycoprotein I Domain I and Anti-Phosphatidylserine/Prothrombin Complex Antibodies Tests. Arthritis Care Res (Hoboken) 2019; 70:627-634. [PMID: 28686816 DOI: 10.1002/acr.23310] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/20/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the value of a combination of anti-β2 -glycoprotein I (anti-β2 GPI) domain I antibody and anti-phosphatidylserine/prothrombin complex (anti-PS/PT) antibody tests for the diagnosis of antiphospholipid syndrome (APS). METHODS This cross-sectional study involved a cohort of the patients who visited our clinic from April 2005 to March 2013. Tests for anti-β2 GPI domain I antibodies, IgG anti-PS/PT antibodies, and IgM anti-PS/PT antibodies, together with tests for criteria-defined antiphospholipid antibodies (aPL), were performed in all patients. The total antiphospholipid score (aPL-S) was calculated for each patient according to titers of and positivity for aPL. RESULTS The study enrolled 157 patients (51 patients with APS and 106 with non-APS autoimmune diseases). All 21 patients positive for both anti-β2 GPI domain I antibodies and IgG and/or IgM (IgG/IgM) anti-PS/PT antibodies had APS with a high total aPL-S (median 46, range 26-76), as did all of the 10 patients who were positive for anti-β2 GPI domain I antibodies but negative for IgG/IgM anti-PS/PT antibodies (median 22, range 4-39). Of the 14 patients who were positive for IgG/IgM anti-PS/PT antibodies but negative for anti-β2 GPI domain I antibodies, 11 (79%) had APS; these individuals also had high total aPL-S values (median 23, range 11-60). In contrast, only 9 of the 112 patients (8%) with none of these antibodies had APS. CONCLUSION The combination of the IgG anti-β2 GPI domain I antibody and IgG/IgM anti-PS/PT antibody tests shows a high positive predictive value for the diagnosis of APS and a strong correlation with the aPL-S. This combination as the first-line test for aPL may contribute to the simple and definite identification of APS with a high risk of thrombosis in clinical practice.
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Affiliation(s)
| | - Kenji Oku
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Olga Amengual
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazumasa Ohmura
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuichiro Fujieda
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Kato
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Shinsuke Yasuda
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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de Jesús GR, Sciascia S, Andrade D, Barbhaiya M, Tektonidou M, Banzato A, Pengo V, Ji L, Meroni PL, Ugarte A, Cohen H, Branch DW, Andreoli L, Belmont HM, Fortin PR, Petri M, Rodriguez E, Cervera R, Knight JS, Atsumi T, Willis R, Nascimento IS, Rosa R, Erkan D, Levy RA. Factors associated with first thrombosis in patients presenting with obstetric antiphospholipid syndrome (APS) in the APS Alliance for Clinical Trials and International Networking Clinical Database and Repository: a retrospective study. BJOG 2018; 126:656-661. [PMID: 30222236 DOI: 10.1111/1471-0528.15469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients. DESIGN Retrospective study. SETTING The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository. POPULATION Women with Ob-APS. METHODS Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM). MAIN OUTCOME MEASURES Risk factors for thrombosis and aGAPSS. RESULTS Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089]. CONCLUSION Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women. TWEETABLE ABSTRACT More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity.
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Affiliation(s)
- G R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - S Sciascia
- Department of Clinical and Biological Sciences, Centre of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - D Andrade
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - M Barbhaiya
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - M Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - A Banzato
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - V Pengo
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - L Ji
- Rheumatology and Immunology Department, Peking University, First Hospital, Beijing, China
| | - P L Meroni
- Department of Rheumatology, University of Milan, Milan, Italy
| | - A Ugarte
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital Universitario Cruces, Barakaldo, Spain
| | - H Cohen
- Department of Haematology, University College London, London, UK
| | - D W Branch
- Department of Obstetrics and Gynecology, University of Utah Health Sciences and Intermountain Healthcare, Salt Lake City, UT, USA
| | - L Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - H M Belmont
- Division of Rheumatology, NYU School of Medicine, New York, NY, USA
| | - P R Fortin
- Division of Rheumatology, Centre Hospitalier de l'Université Laval, Québec, QC, Canada
| | - M Petri
- Division of Rheumatology, John Hopkins University, Baltimore, MD, USA
| | - E Rodriguez
- Rheumatology Department, Hospital 12 de Octubre, Madrid, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - J S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - T Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - R Willis
- Antiphospholipid Standardization Laboratory, Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - I S Nascimento
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - R Rosa
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - D Erkan
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - R A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,GlaxoSmithKline Immunology and Inflammation, Upper Providence, PA, USA
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Di Minno MND, Scalera A, Tufano A, Ambrosino P, Bettiol A, Silvestri E, Emmi G, Prisco D. The association of adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) with cardiovascular disease in subjects with antiphospholipid antibodies. Atherosclerosis 2018; 278:60-65. [PMID: 30253290 DOI: 10.1016/j.atherosclerosis.2018.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 09/05/2018] [Accepted: 09/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Cardiovascular disease (CVD), including coronary artery disease and stroke/peripheral artery disease, is less commonly reported than venous thromboembolism in subjects with antiphospholipid antibodies (aPLs) and little is known about the association of CVD with adjusted Global AntiphosPholipid Syndrome Score (aGAPSS). METHODS Consecutive aPLs subjects were enrolled to assess the association of CVD with aGAPSS. Moreover, additional risk factors of CVD were identified by means of multivariate analysis to design an aGAPSS specific for CVD (aGAPSSCVD). RESULTS A total of 192 aPLs subjects (34 males, 158 females, mean age 49.84 ± 12.0 years) were enrolled. CVD was reported in 52 subjects (27.1%), 26 episodes of coronary artery disease and 26 stroke/peripheral artery disease. The prevalence of CVD increased for increasing aGAPSS ranging from 20.5% in the lowest aGAPSS category, up to 37.9% in the highest category (p = 0.027). ROC analysis showed that aGAPSS detected 63.0% of CVD and was associated with OR for CVD of 2.52 (95%CI: 1.24-5.10, p = 0.010). When including obesity, diabetes and smoking habit in the score, we found that aGAPSSCVD detected 71.4% of CVD (72.4% for early-CVD and 69.0% for CVD after 50 years) with an OR for CVD of 4.68 (95%CI: 2.31-9.51, p < 0.001). CONCLUSIONS The aGAPSSCVD, obtained after adding obesity, smoking habit and diabetes to the standard aGAPSS, showed a higher detection rate of CVD in aPLs subjects, particularly of early-CVD. These results need to be validated in ad hoc designed prospective studies.
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Affiliation(s)
| | - Antonella Scalera
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Alessandra Bettiol
- Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Sciascia S, Radin M, Sanna G, Cecchi I, Roccatello D, Bertolaccini ML. Clinical utility of the global anti-phospholipid syndrome score for risk stratification: a pooled analysis. Rheumatology (Oxford) 2018; 57:661-665. [PMID: 29342292 DOI: 10.1093/rheumatology/kex466] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Indexed: 11/13/2022] Open
Abstract
Objective Recently, our group conceived a risk score for clinical manifestations of APS (the global APS score, or GAPSS) that takes into account the combination of independent cardiovascular risk factors and the aPL positivity profile. These include hyperlipidaemia, arterial hypertension, aCL, anti-β2 glycoprotein-I, aPS-PT and the LA. A complementary version, the adjusted GAPSS (aGAPSS), which excludes aPS-PT, was also designed. The aim of our study was to systematically review the literature to assess the clinical utility of the GAPSS and aGAPSS for risk stratification of any APS clinical manifestation. Methods We pooled data from available cohort studies, including a total of 10 studies, comprising 2273 patients, in which the GAPSS has been applied. A search strategy was developed a priori to identify an available cohort that reported findings which investigated the clinical utility of GAPSS or aGAPSS. Results Seven studies used the GAPSS in their cohort, whereas three studies used the aGAPSS. In brief, we found a statistically significant difference in the cumulative GAPSS and aGAPSS between patients that experienced an arterial and/or venous thrombotic event [cumulative mean GAPSS (s.d.) 10.6 (4.74) and aGAPSS 7.6 (3.95)], patients without any thrombotic manifestation [cumulative GAPSS 7.01 (5.46) and aGAPSS 4.9 (4.33)] and patients with pregnancy morbidity [cumulative GAPSS 8.79 (2.59) and aGAPSS 6.7 (2.8)]. The highest levels of GAPSS were found in patients that experienced arterial thrombosis [mean GAPSS 12.2 (5.2)] and patients that experienced any recurrences of clinical manifestations of APS [mean GAPSS 13.7 (3.1)]. Conclusion GAPSS may represent a useful tool to assess the thrombosis or pregnancy loss risk in aPL-positive patients, switching from the concept of aPL as a sole diagnostic antibody to aPL as risk factors for clinical events.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital Turin, Italy.,Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital Turin, Italy
| | - Giovanni Sanna
- Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital Turin, Italy.,Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, Cardiovascular Division, King's College London, London, UK
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Affiliation(s)
- David Garcia
- From the University of Washington School of Medicine, Seattle (D.G.); and the Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York (D.E.)
| | - Doruk Erkan
- From the University of Washington School of Medicine, Seattle (D.G.); and the Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York (D.E.)
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24
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An unusual case of heart attack. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2018. [DOI: 10.2478/hkbrd-2018-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
We reported a patient with antiphospholipid syndrome (APS) secondary to systemic lupus erythematosus (SLE) who suffered from myocardial infarction and graft occlusion after coronary artery bypass surgery. Our patient illustrates the impact of accelerated atherosclerosis in patients with SLE and APS and the importance of early institution of antithrombotic therapies. In this article, the treatment of APS is summarized. Although the main stay of treatment is anticoagulation, there is emerging evidence to support rituximab as an option for “refractory” cases of APS.
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Oku K, Amengual O, Yasuda S, Atsumi T. How to Identify High-Risk APS Patients: Clinical Utility and Predictive Values of Validated Scores. Curr Rheumatol Rep 2018; 19:51. [PMID: 28741233 DOI: 10.1007/s11926-017-0674-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is a clinical disorder characterised by thrombosis and/or pregnancy morbidity in the persistence of antiphospholipid (aPL) antibodies that are pathogenic and have pro-coagulant activities. Thrombosis in APS tends to recur and require prophylaxis; however, the stereotypical treatment for APS patients is inadequate and stratification of the thrombotic risks is important as aPL are prevalently observed in various diseases or elderly population. RECENT FINDINGS It is previously known that the multiple positive aPL or high titre aPL correlate to thrombotic events. To progress the stratification of thrombotic risks in APS patients and to quantitatively analyse those risks, antiphospholipid score (aPL-S) and the Global Anti-phospholipid Syndrome Score (GAPSS) were defined. These scores were raised from the large patient cohort data and either aPL profile classified in detail (aPL-S) or simplified aPL profile with classical thrombotic risk factors (GAPSS) was put into a scoring system. Both the aPL-S and GAPSS have shown a degree of accuracy in identifying high-risk APS patients, especially those at a high risk of thrombosis. However, there are several areas requiring improvement, or at least that clinicians should be aware of, before these instruments are applied in clinical practice. One such issue is standardisation of the aPL tests, including general testing of phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT). Additionally, clinicians may need to be aware of the patient's medical history, particularly with respect to the incidence of SLE, which influences the cutoff value for identifying high-risk patients.
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Affiliation(s)
- Kenji Oku
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Olga Amengual
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo, 060-8638, Japan
| | - Shinsuke Yasuda
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tatsuya Atsumi
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo, 060-8638, Japan
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26
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Goodman SM, Bass AR. Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review. BMC Rheumatol 2018; 2:2. [PMID: 30886953 PMCID: PMC6390575 DOI: 10.1186/s41927-018-0008-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022] Open
Abstract
Total hip (THA) and total knee arthroplasty (TKA) are widely used, successful procedures for symptomatic end stage arthritis of the hips or knees, but patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and spondyloarthritis (SPA) including ankylosing spondylitis (AS) and psoriatic arthritis (PSA) are at higher risk for adverse events after surgery. Utilization rates of THA and TKA remain high for patients with RA, and rates of arthroplasty have increased for patients with SLE and SPA. However, complications such as infection are increased for patients with SLE, RA, and SPA, most of whom are receiving potent immunosuppressant medications and glucocorticoids at the time of surgery. Patients with SLE and AS are also at increased risk for perioperative cardiac and venous thromboembolism (VTE), while RA patients do not have an increase in perioperative cardiac or VTE risk, despite an overall increase in VTE and cardiac disease. This narrative review will discuss the areas of heightened risk for patients with RA, SLE, and SPA, and the perioperative management strategies currently used to minimize the risks.
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Affiliation(s)
- Susan M Goodman
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
| | - Anne R Bass
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
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27
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Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein 1 antibodies. APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature as well as obstetrical complications. The pathophysiological hallmark is thrombosis, but other factors such as complement activation might be important. Prevention of thrombotic manifestations associated with APS includes lifestyle changes and, in individuals at high risk, low-dose aspirin. Prevention and treatment of thrombotic events are dependent mainly on the use of vitamin K antagonists. Immunosuppression and anticomplement therapy have been used anecdotally but have not been adequately tested. Pregnancy morbidity includes unexplained recurrent early miscarriage, fetal death and late obstetrical manifestation such as pre-eclampsia, premature birth or fetal growth restriction associated with placental insufficiency. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low-molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.
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Radin M, Ugolini-Lopes MR, Sciascia S, Andrade D. Extra-criteria manifestations of antiphospholipid syndrome: Risk assessment and management. Semin Arthritis Rheum 2018; 48:117-120. [PMID: 29395258 DOI: 10.1016/j.semarthrit.2017.12.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/12/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Extra-criteria manifestations of antiphospholipid syndrome (APS) might impact on prognosis and morbidity of the disease. In this study, we aimed to evaluate a population of patients with primary APS (PAPS) whether the extra-criteria manifestations were more frequently found in subjects with higher adjusted Global APS Score (aGAPSS) values when compared to patients with thrombotic and/or obstetric APS ("criteria" manifestations) only. METHODS Clinical records were analyzed to retrieve extra-criteria manifestation of APS, cardiovascular risk factors and antiphospholipid antibodies profile. The aGAPSS was calculated by adding the points, as follows: 3 for hyperlipidaemia, 1 for arterial hypertension, 5 for anticardiolipin antibodies IgG/IgM, 4 for anti-β2 glycoprotein I IgG/IgM, and 4 for lupus anticoagulant. RESULTS This retrospective multicenter study included 89 consecutive PAPS [mean age 43.1 (S.D. ± 12.9), female 67%, 52% arterial and 65% venous]. Twenty-seven patients (30.3%) had a history of livedo, 19 (21.3%) had a history of confirmed thrombocytopenia, 3 (3.4%) had biopsy-proven antiphospholipid antibodies (aPL)-related nephropathy and 3 (3.4%) had a history of valvulopathy. Patients with extra-criteria manifestations presented a mean aGAPSS significantly higher [mean 10.30 (S.D. ± 3.57, range: 4-17) vs mean 8.16 (S.D. ± 3.52;range: 4-16, p = 0.005). When comparing patients with and without extra-criteria manifestations, the first group had significantly higher incidence of anti-β2GPI antibodies positivity (59% and 33%, respectively, p = 0.015), double aPL positivities (53% and 31%, respectively, p = 0.034), cerebrovascular events history (52% and 24%, respectively, p = 0.007) and arterial hypertension (52% and 24%, respectively, p = 0.007). CONCLUSIONS Our results suggest that patients with higher aGAPSS, might be at higher risk for developing extra-criteria manifestations of APS and should therefore undergo a thorough laboratory and instrumental evaluation.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy.
| | | | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
| | - Danieli Andrade
- Hospital dasClinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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29
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Radin M, Schreiber K, Cecchi I, Roccatello D, Cuadrado MJ, Sciascia S. The risk of ischaemic stroke in primary antiphospholipid syndrome patients: a prospective study. Eur J Neurol 2017; 25:320-325. [PMID: 29082583 DOI: 10.1111/ene.13499] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE The most common neurological manifestation of antiphospholipid syndrome (APS) is ischaemic stroke. Identifying patients with APS at high risk for developing any thrombotic event remains a major challenge. In this study, the aim was to identify predictive factors of ischaemic stroke in a cohort of primary APS (PAPS) patients who presented with new onset symptoms suggestive of acute stroke. METHODS This prospective multicentre study included 36 consecutive PAPS patients who presented with new onset symptoms suggestive of an acute stroke. Patients were prospectively followed up for 12 months. RESULTS In 10 (28%) out of 36 PAPS patients [mean age 41 years (SD 13.4), 70% female], the suspicion of an acute stroke was confirmed by brain magnetic resonance imaging. Sixty per cent of these patients were <50 years old. Eight of the 10 patients had a history of previous venous thrombosis and were receiving vitamin K antagonist (VKA), with international normalized ratio target 2-3; one patient had a history of a previous arterial event receiving treatment with VKA target international normalized ratio 2-3 plus low dose aspirin; and one patient had a history of previous pregnancy morbidity receiving only low dose aspirin. Time in the therapeutic range for patients receiving VKA was 77.7% (SD 6.6%). Hypercholesterolaemia was significantly higher in patients with confirmed stroke compared to those without (P < 0.05). Similarly, a significantly higher rate of anti-β2 glycoprotein-I (β2GPI) antibodies (immunoglobulin G/immunoglobulin M; P < 0.05) and higher adjusted global APS score (aGAPSS) values were found in patients with a confirmed stroke [mean aGAPSS 8.9 (SD 4.7) vs. mean aGAPSS 6.4 (SD 2.5); P < 0.05]. CONCLUSIONS Patients with PAPS, including young patients, have a high risk of recurrent thrombosis despite anticoagulation treatment. A careful risk assessment is mandatory to identify patients at risk for recurrence.
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Affiliation(s)
- M Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
| | - K Schreiber
- Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospital, London, UK.,Department of Rheumatology, Copenhagen University Hospital, Copenhagen, Denmark
| | - I Cecchi
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
| | - D Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
| | - M J Cuadrado
- Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
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30
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Zohoury N, Bertolaccini ML, Rodriguez-Garcia JL, Shums Z, Ateka-Barrutia O, Sorice M, Norman GL, Khamashta M. Closing the Serological Gap in the Antiphospholipid Syndrome: The Value of "Non-criteria" Antiphospholipid Antibodies. J Rheumatol 2017; 44:1597-1602. [PMID: 28864642 DOI: 10.3899/jrheum.170044] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Most clinicians use the 2006 Sydney classification criteria to evaluate patients suspected of having antiphospholipid syndrome (APS). Although sensitive and specific for APS, many patients fulfilling clinical criteria for the syndrome are persistently negative for the specific serological tests ("laboratory criteria"). These "seronegative APS" (SN-APS) patients can go undiagnosed and untreated until they experience serious clinical events. This study's objective was to describe antibody profiles of SN-APS patients using non-criteria markers, assess the clinical utility of these markers separately and in combination, and suggest incorporation into guidelines for patients suspected of APS. METHODS We categorized 175 consecutive patients suspected of APS into 2 subgroups: 107 fulfilling Sydney APS classification for seropositive APS (SP-APS) and 68 with clinical manifestations suggestive of APS but having negative serology, on 2 occasions, for criteria markers (SN-APS). On study inclusion, samples were retested for criteria and 11 non-criteria markers, including antiphosphatidylserine/prothrombin antibodies. RESULTS Using 4 of 11 non-criteria tests, a cumulative 30.9% of SN-APS patients were detected. Combining results of all 11 non-criteria tests, 25 SN-APS (36.8%) and 89 SP-APS (83.2%) were positive for 1 or more non-criteria antibodies. CONCLUSION Failure to diagnose APS can result in severe clinical consequences. Patients displaying clinical features of APS, but negative for conventional criteria markers, should undergo additional testing for non-criteria biomarkers. In our cohort, around one-third of SN-APS patients showed reactivity to 1 or more non-criteria markers. An update to the current classification criteria incorporating new serological markers should be considered to identify and stratify patients with APS for more effective treatment and management.
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Affiliation(s)
- Navid Zohoury
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy. .,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics. .,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital.
| | - Maria Laura Bertolaccini
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Jose Luis Rodriguez-Garcia
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Zakera Shums
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Oier Ateka-Barrutia
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Maurizio Sorice
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Gary L Norman
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
| | - Munther Khamashta
- From Inova Diagnostics Inc., San Diego, California, USA; Academic Department of Vascular Surgery, King's College London; Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital, London, UK; Department of Internal Medicine, University of Castilla-La Mancha, Albacete, Spain; Department of Experimental Medicine, La Sapienza University, Rome, Italy.,Navid Zohoury, Zakera Shums, and Gary L. Norman are employees of Inova Diagnostics.,N. Zohoury, BS, Inova Diagnostics Inc.; M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London; J.L. Rodriguez-Garcia, PhD, Department of Internal Medicine, University of Castilla-La Mancha; Z. Shums, MSc, Inova Diagnostics Inc.; O. Ateka-Barrutia, MD, Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital; M. Sorice, MD, Department of Experimental Medicine, La Sapienza University; G.L. Norman, PhD (AGAF, FAASLD), Inova Diagnostics Inc.; M. Khamashta, MD, PhD (FRCP), Graham Hughes Lupus Research Laboratory, Lupus Research Unit, The Rayne Institute, Division of Women's Health, King's College London, St. Thomas' Hospital
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Sciascia S, Amigo MC, Roccatello D, Khamashta M. Diagnosing antiphospholipid syndrome: 'extra-criteria' manifestations and technical advances. Nat Rev Rheumatol 2017; 13:548-560. [PMID: 28769114 DOI: 10.1038/nrrheum.2017.124] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
First described in the early 1980s, antiphospholipid syndrome (APS) is a unique form of acquired autoimmune thrombophilia in which patients present with clinical features of recurrent thrombosis and pregnancy morbidity and persistently test positive for the presence of antiphospholipid antibodies (aPL). At least one clinical (vascular thrombosis or pregnancy morbidity) and one lab-based (positive test result for lupus anticoagulant, anticardiolipin antibodies and/or anti-β2-glycoprotein 1 antibodies) criterion have to be met for a patient to be classified as having APS. However, the clinical spectrum of APS encompasses additional manifestations that can affect many organs and cannot be explained exclusively by patients being in a prothrombotic state; clinical manifestations not listed in the classification criteria (known as extra-criteria manifestations) include neurologic manifestations (chorea, myelitis and migraine), haematologic manifestations (thrombocytopenia and haemolytic anaemia), livedo reticularis, nephropathy and valvular heart disease. Increasingly, research interest has focused on the development of novel assays that might be more specific for APS than the current aPL tests. This Review focuses on the current classification criteria for APS, presenting the role of extra-criteria manifestations and lab-based tests. Diagnostic approaches to difficult cases, including so-called seronegative APS, are also discussed.
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Affiliation(s)
- Savino Sciascia
- Centre of Research of Immunopathology and Rare Diseases (CMID), Coordinating Centre of Piedmont and Aosta Valley Network for Rare Diseases, Department of Clinical and Biological Sciences, St Giovanni Bosco Hospital and the University of Turin, Piazza del Donatore di Sangue 3, 10154 Turin, Italy.,SCDU Nephrology and Dialysis, Department of Clinical and Biological Sciences, St Giovanni Bosco Hospital and the University of Turin, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Mary-Carmen Amigo
- Service of Rheumatology, ABC Medical Center, Sur 136 No. 116, Colonia Las Américas, Mexico City 01220, Mexico
| | - Dario Roccatello
- Centre of Research of Immunopathology and Rare Diseases (CMID), Coordinating Centre of Piedmont and Aosta Valley Network for Rare Diseases, Department of Clinical and Biological Sciences, St Giovanni Bosco Hospital and the University of Turin, Piazza del Donatore di Sangue 3, 10154 Turin, Italy.,SCDU Nephrology and Dialysis, Department of Clinical and Biological Sciences, St Giovanni Bosco Hospital and the University of Turin, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Munther Khamashta
- Department of Rheumatology, Dubai Hospital, PO box 7272, Dubai, UAE.,Graham Hughes Lupus Research Laboratory, Division of Women's Health, King's College London, The Rayne Institute, 4th Floor Lambeth Wing, St Thomas' Hospital, London SE1 7EH, UK
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Antiphospholipid Syndrome: Role of Vascular Endothelial Cells and Implications for Risk Stratification and Targeted Therapeutics. J Am Coll Cardiol 2017; 69:2317-2330. [PMID: 28473138 DOI: 10.1016/j.jacc.2017.02.058] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/21/2017] [Accepted: 02/28/2017] [Indexed: 12/28/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by venous thromboembolism, arterial thrombosis, and obstetric morbidities in the setting of persistently positive levels of antiphospholipid antibodies measured on 2 different occasions 12 weeks apart. Patients with APS are at increased risk for accelerated atherosclerosis, myocardial infarction, stroke, and valvular heart disease. Vascular endothelial cell dysfunction mediated by antiphospholipid antibodies and subsequent complement system activation play a cardinal role in APS pathogenesis. Improved understanding of their pathogenic function could help in the risk stratification of patients with APS and provide new molecular therapeutic targets.
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Shusterman M, Golub E, Mowrey WB, Broder A. The association between ABO blood types and venous thromboembolism in individuals with a positive antiphospholipid profile is varied by sex. Lupus 2017; 27:319-326. [DOI: 10.1177/0961203317721352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- M Shusterman
- Department of Medicine, Montefiore Medical Center, New York, USA
| | - E Golub
- Department of Medicine, Montefiore Medical Center, New York, USA
| | - W B Mowrey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, USA
| | - A Broder
- Division of Rheumatology, Montefiore Medical Center, New York, USA
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Posch F, Gebhart J, Rand JH, Koder S, Quehenberger P, Pengo V, Ay C, Pabinger I. Cardiovascular risk factors are major determinants of thrombotic risk in patients with the lupus anticoagulant. BMC Med 2017; 15:54. [PMID: 28279213 PMCID: PMC5345189 DOI: 10.1186/s12916-017-0807-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/06/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with the lupus anticoagulant (LA) are at an increased risk of thrombotic events, which in turn increase the risk of death. Understanding the determinants of thrombotic risk in patients with LA may pave the way towards targeted thromboprophylaxis. In the Vienna Lupus Anticoagulant and Thrombosis Study (LATS), we systematically evaluate risk factors for thrombotic events in patients with LA. METHODS We followed 150 patients (mean age: 41.3 years, female gender: n = 122 (81.3%), history of thrombosis or pregnancy complications: n = 111 (74.0%)), who tested repeatedly positive for LA until development of thrombosis, death, or censoring. The primary endpoint was a composite of arterial or venous thrombotic events (TEs). RESULTS During a median follow-up of 9.5 years (range: 12 days-13.6 years) and 1076 person-years, 32 TEs occurred (arterial: n = 16, venous: n = 16; cumulative 10-year TE incidence: 24.3%). A prolonged lupus-sensitive activated partial thromboplastin time (aPTT-LA) (adjusted subdistribution hazard ratio (SHR) = 2.31, 95% CI: 1.07--5.02), diabetes (adjusted SHR = 4.39, 95% CI: 1.42-13.57), and active smoking (adjusted SHR = 2.31, 95% CI: 1.14-5.02) emerged as independent risk factors of both arterial and venous thrombotic risk. A risk model that includes a prolonged lupus-sensitive aPTT, smoking, and diabetes enabled stratification of LA patients into subgroups with a low, intermediate, and high risk of thrombosis (5-year TE risk of 9.7% (n = 77), 30.9% (n = 51), and 56.8% (n = 22). CONCLUSIONS Long-term thrombotic risk in patients with LA is clustered within subjects harboring typical cardiovascular risk factors in addition to a prolonged lupus-sensitive aPTT, whereas patients with none of these risk factors represent a large subgroup with a low risk of thrombosis.
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Affiliation(s)
- Florian Posch
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria.,Division of Oncology, Department of Internal Medicine, Medical University of Graz, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Jacob H Rand
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Silvia Koder
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Vittorio Pengo
- Division of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria.
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Ahluwalia J, Sreedharanunni S. The Laboratory Diagnosis of the Antiphospholipid Syndrome. Indian J Hematol Blood Transfus 2016; 33:8-14. [PMID: 28194050 DOI: 10.1007/s12288-016-0739-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/13/2016] [Indexed: 01/04/2023] Open
Abstract
The Antiphospholipid Syndrome (APS) is classified based on the presence of both clinical and laboratory criteria. Both sets of criteria are subject to much review and intense research as it is becoming increasingly clear that no single test is specific for defining this autoimmune disorder. A number of leading international bodies have released guidelines in an attempt to improve the laboratory testing and reporting. The current review is an appraisal of some of the literature pertaining to the laboratory testing.
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Affiliation(s)
- Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Thrombotic risk assessment in antiphospholipid syndrome: the role of new antibody specificities and thrombin generation assay. Clin Mol Allergy 2016; 14:6. [PMID: 27429595 PMCID: PMC4947367 DOI: 10.1186/s12948-016-0043-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/07/2016] [Indexed: 11/28/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune condition characterized by the presence of antiphospholipid antibodies (aPL) in subjects presenting with thrombosis and/or pregnancy loss. The currently used classification criteria were updated in the international consensus held in Sidney in 2005. Vascular events seem to result of local procoagulative alterations upon triggers influence (the so called “second-hit theory”), while placental thrombosis and complement activation seem to lead to pregnancy morbidity. The laboratory tests suggested by the current classification criteria include lupus anticoagulant, a functional coagulation assay, and anticardiolipin and anti-β2-glycoprotein-I antibodies, generally detected by solid phase enzyme-linked immunosorbent assay. The real challenge for treating physicians is understanding what is the actual weight of aPL in provoking clinical manifestations in each case. As thrombosis has a multi-factorial cause, each patient needs a risk-stratified approach. In this review we discuss the role of thrombotic risk assessment in primary and secondary prevention of venous and arterial thromboembolic disease in patients with APS, focusing on new antibody specificities, available risk scoring models and new coagulation assays.
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Khamashta M, Taraborelli M, Sciascia S, Tincani A. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2016; 30:133-48. [DOI: 10.1016/j.berh.2016.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Elevated partial antiphospholipid score is a strong risk factor for thrombosis in patients with systemic lupus erythematosus: a validation study. Clin Rheumatol 2016; 35:333-40. [PMID: 26753544 DOI: 10.1007/s10067-015-3159-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/18/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
This study aims to identify risk factors for thrombosis in patients with systemic lupus erythematosus (SLE) and to validate the efficacy of the partial antiphospholipid (aPL) score for thrombosis prediction and diagnosis of antiphospholipid syndrome (APS). This study included 325 SLE patients, 188 of whom completed a follow-up of 31.01 months (range 23-48 months). Partial aPL score was calculated by adding up the individual scores for activated partial thromboplastin time (APTT), lupus anticoagulant, IgG/IgM anticardiolipin antibodies (aCL), and IgG/IgM anti-β2-glycoprotein I (anti-β2GPI). A simplified aPL score was developed using only APTT, IgG/IgM aCL, and IgG/IgM anti-β2GPI. Partial aPL scores were significantly higher in SLE patients with thrombosis (p < 0.0001). A history of thrombosis (p < 0.0001), a partial aPL score >10 (p < 0.0001), and immunosuppressant use (p = 0.012) were independent risk factors for thrombosis. For patients with a history of thrombosis, partial aPL score was the strongest risk factor for recurrent thrombosis (p < 0.0001, odds ratio = 30.34 (95 % CI 7.70-118.81)). For APS diagnosis, the area under the receiver-operating characteristic curve (AUC) was 0.809 (95 % CI 0.73-0.89) using the partial aPL score. Similarly, the simplified aPL score was significantly associated with thrombosis (p < 0.0001) and was acceptable for APS diagnosis (AUC 0.797, 95 % CI 0.72-0.88). An elevated partial aPL score is a strong risk factor for thrombosis in SLE patients and is a useful tool to predict recurrent thrombosis. Partial aPL score and simplified aPL score, although comprising fewer items than the original aPL score, also represent valuable quantitative indices for APS diagnosis.
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Forastiero R, Martinuzzo M. The emerging role of multiple antiphospholipid antibodies positivity in patients with antiphospholipid syndrome. Expert Rev Clin Immunol 2015; 11:1255-63. [DOI: 10.1586/1744666x.2015.1080121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Merashli M, Noureldine MHA, Uthman I, Khamashta M. Antiphospholipid syndrome: an update. Eur J Clin Invest 2015; 45:653-62. [PMID: 25851448 DOI: 10.1111/eci.12449] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/04/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) or 'Hughes syndrome' is a prothrombotic disease characterized by thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). More than three decades have passed, and experts are still uncovering new pieces of this disease complex pathogenesis and management. MATERIALS AND METHODS We searched in literature using MEDLINE and PubMed databases focusing on the latest development on disease pathogenesis, risk assessment of thrombosis and treatment of APS. RESULTS The phosphatidylinositol 3-kinase (PI3K)-AKT-mTORC pathway was most recently identified to have a crucial role in activating inflammation among endothelial vessel wall causing vascular lesions in APS. Additionally, new variables are being implemented to assess the risk of thrombosis in patients with APS. Global APS Score (GAPSS) utilizes cardiovascular risk factors and new autoimmune antibodies as part of the score assessment and is the most valid so far. It can be a promising tool in the future for prediction of thrombosis. Anticoagulation remains the cornerstone in APS; however, many new potential therapeutic agents are developing and are currently under investigation. CONCLUSIONS The most recent advances in pathogenesis, risk stratification and treatment provide a platform for high yield studies with the ultimate goal of providing the optimal management to patients with APS.
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Affiliation(s)
- Mira Merashli
- Division of Rheumatology, Faculty of Medicine, The Royal London Hospital, London, UK
| | | | - Imad Uthman
- Division of Rheumatology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Munther Khamashta
- Graham Hughes Lupus Research Laboratory, Division of Women's Health King's College London, The Rayne Institute, St Thomas' Hospital, London, UK
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