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Luo L, Cai Q, Liu X, Yun Z, Li X, Yan R, Li C. Characteristics and prognosis of elderly-onset antiphospholipid syndrome: An observational cohort study. Lupus 2024:9612033241266875. [PMID: 39033374 DOI: 10.1177/09612033241266875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is an autoimmune disease mainly affecting young individuals. Testing for antiphospholipid antibodies is recommended for young patients who are suspected to have APS. Yet, it is hard to differentiate APS from other acquired thrombophilia disorders in elderly-onset APS patients. This study aim to investigate the characteristics and prognosis of elderly-onset APS. METHODS This is an observational cohort study. Thrombotic APS patients who underwent follow-ups between 2009 and 2022 were included. Elderly-onset APS patients (onset age ≥60 years) were compared to non-elderly-onset APS patients (onset age <60 years) and matched cases of elderly non-APS patients (age ≥60 years with thrombosis). RESULTS A total of 161 APS patients were included in this study, 45 (28.0%) were elderly-onset APS. Stroke (35.6% vs. 18.1%, p = .018) was more common at disease onset in elderly-onset APS patients. Compared to non-elderly-onset patients, elderly-onset APS patients were associated with a higher number of cardiovascular risk factors. Elderly-onset APS patients showed significantly lower positive rate (51.1% vs. 71.6%, p = .014) and ratios [1.24 (1.01-1.38) vs. 1.37 (1.16-1.77), p = .004] of lupus anticoagulant. Elderly-onset APS patients had a significantly higher 10-years cumulative all-cause mortality (p < .001) and APS-related mortality than non-elderly-onset patients (p = .002) and elderly non-APS patients (p = .040). CONCLUSIONS Elderly-onset APS patients have unique disease characteristics with higher 10-years cumulative all-cause mortality and APS-related mortality. Early recognition and control of comorbidities may reduce the recurrence of thrombosis and mortality in elderly-onset APS patients.
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Affiliation(s)
- Liang Luo
- Department of Chinese Medicine, The People's Hospital of Yubei District of Chongqing City, Chongqing, China
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Qingmeng Cai
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xiangjun Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Zelin Yun
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Xuerong Li
- Department of Rheumatology and Immunology, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Rui Yan
- Department of Rheumatology and Immunology, Beijing Shunyi Hospital, Beijing, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
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Reis-Neto ETD, Seguro LPC, Sato EI, Borba EF, Klumb EM, Costallat LTL, Medeiros MMDC, Bonfá E, Araújo NC, Appenzeller S, Montandon ACDOES, Yuki EFN, Teixeira RCDA, Telles RW, Egypto DCSD, Ribeiro FM, Gasparin AA, Junior ASDA, Neiva CLS, Calderaro DC, Monticielo OA. II Brazilian Society of Rheumatology consensus for lupus nephritis diagnosis and treatment. Adv Rheumatol 2024; 64:48. [PMID: 38890752 DOI: 10.1186/s42358-024-00386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To develop the second evidence-based Brazilian Society of Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN). METHODS Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of Rheumatology participate in the development of this guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion. RESULTS All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy. CONCLUSION This consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil.
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Affiliation(s)
- Edgard Torres Dos Reis-Neto
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil.
| | - Luciana Parente Costa Seguro
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Emília Inoue Sato
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | - Eduardo Ferreira Borba
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Evandro Mendes Klumb
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lilian Tereza Lavras Costallat
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Eloisa Bonfá
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Nafice Costa Araújo
- Division of Rheumatology, Hospital do Servidor Público Estadual de São Paulo - Instituto de Assistência Médica ao Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Simone Appenzeller
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Emily Figueiredo Neves Yuki
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Rosa Weiss Telles
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - Francinne Machado Ribeiro
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrese Aline Gasparin
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Antonio Silaide de Araujo Junior
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | | | - Debora Cerqueira Calderaro
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Odirlei Andre Monticielo
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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Muñoz Muñoz C, Farinha F, McDonnell T, J'bari H, Nguyen H, Isenberg D, Rahman A, Williams D, Alijotas-Reig J, Giles I. Comparing pregnancy outcomes in patients with Systemic Lupus Erythematosus (SLE) and Undifferentiated Connective Tissue Disease (UCTD): a descriptive cohort study. Rev Clin Esp 2024; 224:357-365. [PMID: 38670225 DOI: 10.1016/j.rceng.2024.04.013] [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: 03/26/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Females diagnosed with systemic lupus erythematosus (SLE) face an elevated risk of adverse pregnancy outcomes (APOs). However, the evidence regarding whether a similar association exists in patients with undifferentiated connective tissue disease (UCTD) is inconclusive. METHODS We conducted a retrospective review (2006-2019) of pregnancy outcomes among patients with SLE (n = 51) and UCTD (n = 20) within our institution. We examined the occurrence of various APOs, encompassing miscarriage, stillbirth, termination, preterm birth, pre-eclampsia, eclampsia, HELLP syndrome, intrauterine growth restriction, abruption placentae, congenital heart block, or other cardiac abnormalities. RESULTS The mean age at pregnancy was 35 ± 7.0 years for patients with SLE and 35 ± 6.8 years for those with UCTD (p = 0.349). The proportion of Caucasian women was 47% in SLE and 80% in UCTD. Pregnancies in both groups were planned (81% in SLE and 77% in UCTD), and patients presented with inactive disease at conception (96% in SLE and 89% in UCTD). Hydroxychloroquine at conception was utilized by 86% of women with SLE, in contrast to 36% in the UCTD group. Both, SLE and UCTD cohorts exhibited low rates of disease flares during pregnancy and/or puerperium (14% vs. 10%). The incidence of APOs was 15.6% in SLE patients compared to 5% in those with UCTD (Risk difference 19.5%; 95% confidence interval: -3.9 to 43.1; p = 0.4237). CONCLUSION Our study underscores the importance of strategic pregnancy planning and the maintenance of appropriate treatment throughout pregnancy to ensure optimal disease management and minimize adverse outcomes in both SLE and UCTD pregnancies.
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Affiliation(s)
- Candido Muñoz Muñoz
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Filipa Farinha
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Rheumatology, Hospital Distrital de Santarém, Santarém, Portugal
| | - Thomas McDonnell
- Department of Biochemical Engineering, University College London, London, UK
| | - Hajar J'bari
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Hanh Nguyen
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - David Williams
- Women's Health, University College London Hospital NHS Foundation Trust, London, UK
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Medicine, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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de Assis V, Giugni CS, Ros ST. Evaluation of Recurrent Pregnancy Loss. Obstet Gynecol 2024; 143:645-659. [PMID: 38176012 DOI: 10.1097/aog.0000000000005498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/02/2023] [Indexed: 01/06/2024]
Abstract
Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.
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Affiliation(s)
- Viviana de Assis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
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Yelnik CM, Xie X, Guerra MM, Costedoat-Chalumeau N, Khosroshahi A, Kamen DL, Schwartz N, Katz P, Minett M, Amoss RT, Fu A, Guettrot-Imbert G, Lazaro E, Le Guern V, Oates J, Dall'Era M, Yazdany J, Molto A, Kim MY, Salmon JE. Prevalence of clinically meaningful antiphospholipid antibodies in patients with systemic lupus erythematosus varies by race and ethnicity. Ann Rheum Dis 2024; 83:404-406. [PMID: 37875285 PMCID: PMC10922457 DOI: 10.1136/ard-2023-224952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Cécile M Yelnik
- Département de Médecine Interne et d'Immunologie Clinique, Universite de Lille, Lille, France
| | - Xianhong Xie
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marta M Guerra
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Cochin Hospital, Paris, France
- ECAMO Team (INSERM U-1153), CRESS - Université Paris Cité, Paris, France
| | - Arezou Khosroshahi
- Lowance Center for Human Immunology, Emory University, Atlanta, Georgia, USA
| | - Diane L Kamen
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Noa Schwartz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patricia Katz
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Margaret Minett
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - R Toby Amoss
- Lowance Center for Human Immunology, Emory University, Atlanta, Georgia, USA
| | - April Fu
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Estibaliz Lazaro
- Department of Internal Medicine, Haut Lévêque Hospital, Bordeaux, France
- ImmunoconcEpT Lab, Bordeaux University, Bordeaux, France
| | | | - Jim Oates
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maria Dall'Era
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Jinoos Yazdany
- Department of Medicine/Rheumatology, University of California San Francisco, San Francisco, California, USA
| | - Anna Molto
- ECAMO Team (INSERM U-1153), CRESS - Université Paris Cité, Paris, France
- Department of Rheumatology, Cochin Hospital, Paris, France
| | - Mimi Y Kim
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jane E Salmon
- Department of Medicine/Rheumatology, Hospital for Special Surgery, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Rohm F, Kling E, Hoffmann R, Meisinger C, Linseisen J. Prevalence of a large panel of systemic autoantibodies in the Bavarian adult population. Front Immunol 2024; 15:1355905. [PMID: 38390318 PMCID: PMC10881743 DOI: 10.3389/fimmu.2024.1355905] [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: 12/14/2023] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Objective Autoimmune diseases commonly feature the presence of specific humoral autoantibodies. However, the prevalence of a large panel of systemic autoantibodies has never been assessed in the general population. We, therefore, described the prevalence of about 50 humoral systemic autoantibodies in a sample of the general Bavarian adult population. Methods Non-fasting venous serum samples from 331 participants were analyzed for 7 autoantibody screening tests (nuclear, cytoplasmic, and mitotic ANA, ANCA, cANCA and pANCA, anti-ENA autoantibodies) and 44 different monospecific humoral non-organ specific/systemic autoantibodies using indirect immunofluorescence tests, ELISAs, and line blots. In order to assess associations between sex, age, BMI, education level, smoking status and the presence of systemic autoantibodies, logistic regression analyses were conducted. Results At least one screening test was positive in 29.9% of the participants, and 42.3% of the participants were seropositive for at least one monospecific autoantibody. The most frequently found monospecific autoantibodies were rheumatoid factor (35.6%), ß2-glycoprotein 1 IgM (4.8%), and cardiolipin IgG (1.8%). Only few associations between sex, age, BMI, education, smoking status and autoantibody frequencies were observed. Conclusion Systemic autoantibodies are common in the general Bavarian population, and largely independent of sex, age, BMI, education, or smoking status. The study results may give orientation to clinicians about the occurrence of autoantibodies in the population, not (yet) associated with clinical symptoms.
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Affiliation(s)
- Florian Rohm
- Epidemiology, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Elisabeth Kling
- Institute for Laboratory Medicine and Microbiology, University Hospital Augsburg, Augsburg, Germany
| | - Reinhard Hoffmann
- Institute for Laboratory Medicine and Microbiology, University Hospital Augsburg, Augsburg, Germany
| | | | - Jakob Linseisen
- Epidemiology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Ludwig-Maximilians-Universität München, München, Germany
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Efthymiou M, Bertolaccini ML, Cohen H. Viewpoint: Lupus anticoagulant detection and interpretation in antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI54-SI63. [PMID: 38320587 DOI: 10.1093/rheumatology/kead623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024] Open
Abstract
Lupus anticoagulant (LA) is a well-established risk factor for the clinical manifestations of antiphospholipid syndrome (APS). Accurate LA detection is an essential prerequisite for optimal diagnosis and management of patients with APS or aPL carriers. Variability remains a challenge in LA testing, with reliable detection influenced by multiple factors, including pre-analytical conditions, anticoagulation treatment, choice of tests and procedures performed, as well as interpretation of results, that can lead to false-positives or negatives. A standardised approach to LA testing, following current guidance, based on published data and international consensus, and with attention to detail, is required to underpin accurate detection of LA. Future work should focus on better characterisation of the nature of LA, which may ultimately lead to improved diagnosis and management of patients with APS and aPL carriers. This article reviews current practice and challenges, providing an overview on detection of LA.
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Affiliation(s)
- Maria Efthymiou
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Barbhaiya M, Taghavi M, Zuily S, Domingues V, Chock EY, Tektonidou MG, Erkan D, Seshan SV. Efforts to Better Characterize "Antiphospholipid Antibody Nephropathy" for the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria: Renal Pathology Subcommittee Report. J Rheumatol 2024; 51:150-159. [PMID: 37399462 DOI: 10.3899/jrheum.2022-1200] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE Antiphospholipid antibody (aPL) nephropathy (-N) can be challenging to recognize due to a lack of established classification or diagnostic criteria. As part of efforts to develop new antiphospholipid syndrome (APS) classification criteria (CC), the APS CC Renal Pathology Subcommittee aimed to better characterize the entity of aPL-N. METHODS We used a 4-pronged approach that included (1) administering Delphi surveys to worldwide APS physicians to generate aPL-N terminology; (2) conducting a literature review to demonstrate the association of nephropathy with aPL and identify published aPL-N histopathological terminology and descriptions; (3) evaluating aPL-N terminology used in renal biopsy reports from an international patient registry; and (4) evaluating proposed kidney pathologic features for aPL-N by assessment of international Renal Pathology Society (RPS) members. RESULTS After completing our metaanalysis demonstrating an association between nephropathy and aPL, we used Delphi surveys, a literature review, and international renal biopsy reports to develop a preliminary definition of aPL-N. The preliminary definition included include specific terms associated with acute (ie, thrombotic microangiopathy in glomeruli or arterioles/arteries) and chronic (ie, organized arterial or arteriolar microthrombi with or without recanalization, organized glomerular thrombi, fibrous and fibrocellular [arterial or arteriolar] occlusions, focal cortical atrophy with or without thyroidization, and fibrous intimal hyperplasia) lesions. Most RPS survey respondents agreed with this terminology and the importance of knowing aPL results for histopathological diagnosis. CONCLUSION Our results support the inclusion of aPL-N in the 2023 American College of Rheumatology/European Alliance of Associations for Rheumatology APS CC, and provide the most widely accepted terminology to date for both acute and chronic pathologic lesions of aPL-N.
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Affiliation(s)
- Medha Barbhaiya
- M. Barbhaiya, MD, MPH, D. Erkan, MD, MPH, Hospital for Special Surgery, and Weill Cornell Medicine, New York, New York, USA;
| | - Maxime Taghavi
- M. Taghavi, MD, Department of Nephrology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Belgium
| | - Stephane Zuily
- S. Zuily, MD, PhD, Université de Lorraine, Inserm, Défaillance Cardiovasculaire Aiguë et Chronique, and Centre Hospitalier Régional Universitaire de Nancy, Vascular Medicine Division, and French National Referral Center for Rare Autoimmune Diseases, Nancy, France
| | | | - Eugenia Y Chock
- E.Y. Chock, MD, MPH, Section of Rheumatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maria G Tektonidou
- M.G. Tektonidou, First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Doruk Erkan
- M. Barbhaiya, MD, MPH, D. Erkan, MD, MPH, Hospital for Special Surgery, and Weill Cornell Medicine, New York, New York, USA
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9
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Dicks AB, Moussallem E, Stanbro M, Walls J, Gandhi S, Gray BH. A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism. J Clin Med 2024; 13:362. [PMID: 38256496 PMCID: PMC10816375 DOI: 10.3390/jcm13020362] [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: 12/15/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient's risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation.
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Affiliation(s)
- Andrew B. Dicks
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Elie Moussallem
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Marcus Stanbro
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Jay Walls
- Department of Hematology, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA;
| | - Sagar Gandhi
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
| | - Bruce H. Gray
- Department of Vascular Surgery, Prisma Health, University of South Carolina School of Medicine—Greenville, Greenville, SC 29601, USA; (E.M.); (M.S.); (S.G.); (B.H.G.)
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Di L, Zha C, Liu Y. Platelet-derived microparticles stimulated by anti-β 2GPI/β 2GPI complexes induce pyroptosis of endothelial cells in antiphospholipid syndrome. Platelets 2023; 34:2156492. [PMID: 36550078 DOI: 10.1080/09537104.2022.2156492] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Platelet microparticles (PMPs) are vesicles that are released by platelets into the extracellular space and play a role in antiphospholipid antibody syndromes. PMPs have recently been recognized as a new and viable cell. There is growing evidence that the anti-β2 glycoprotein (GPI)/β2GPI complex is associated with aberrant activation of PMPs. Although studies suggest that aberrant activation of PMPs may lead to inflammatory necrosis of endothelial cells, the underlying mechanisms remain unclear. We found that although the difference in the number of PMPs was not statistically significant, NLR family pyrin domain containing 3 (NLRP3) within PMPs was increased during stimulation of anti-β2GPI/β2GPI complexes. Furthermore, we demonstrated that anti-β2GPI/β2GPI complex-induced PMPs effectively stimulated endothelial cell pyroptosis via the NLRP3/nuclear factor (NF)-κB/gasdermin D (GSDMD) signaling pathway as well as the NLRP3/Caspase-1 signaling pathway. Additionally, inhibition of NLRP3 expression in PMPs effectively reduced the inflammatory response and pyroptosis in endothelial cells. Our data suggest that PMPs aberrantly activated by anti-β2GPI/β2GPI complexes play a vital role in endothelial cell pyroptosis, and these studies provide major insights into the mechanisms of thrombosis during the treatment of antiphospholipid antibody syndrome.
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Affiliation(s)
- Longjiang Di
- Department of Clinical Laboratory, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Caijun Zha
- Department of Clinical Laboratory, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yanhong Liu
- Department of Clinical Laboratory, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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11
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Oba S, Hosoya T, Kaneshige R, Kawata D, Yamaguchi T, Mitsumura T, Shimada S, Shibata S, Tateishi T, Koike R, Tohda S, Hirakawa A, Yoko N, Otomo Y, Nojima J, Miyazaki Y, Yasuda S. Thrombosis and antiphospholipid antibodies in Japanese COVID-19: based on propensity score matching. Front Immunol 2023; 14:1227547. [PMID: 37908357 PMCID: PMC10614020 DOI: 10.3389/fimmu.2023.1227547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/18/2023] [Indexed: 11/02/2023] Open
Abstract
Background Thrombosis is a unique complication of coronavirus disease 2019 (COVID-19). Although antiphospholipid antibodies (aPL) are detected in COVID-19 patients, their clinical significance remains elusive. We evaluated the prevalence of aPL and serum concentrations of beta-2 glycoprotein I (β2GPI), a major self-antigen for aPL, in Japanese COVID-19 patients with and without thrombosis. Methods This retrospective single-center nested case-control study included 594 hospitalized patients with COVID-19 between January 2020 and August 2021. Thrombotic complications were collected from medical records. Propensity score-matching method (PSM) (1:2 matching including age, sex, severity on admission, and prior history of thrombosis) was performed to compare the prevalence and titer of aPL (anti-cardiolipin (aCL) IgG/IgM, anti-β2GPI IgG/IgM/IgA, and anti-phosphatidylserine/prothrombin antibody (aPS/PT) IgG/IgM) and serum β2GPI concentration. In addition, PSM (1:1 matching including age and sex) was performed to compare the serum β2GPI concentration between COVID-19 patients and healthy donors. Results Among the patients, 31 patients with thrombosis and 62 patients without were compared. The prevalence of any aPLs was indifferent regardless of the thrombosis (41.9% in those with thrombosis vs. 38.7% in those without, p =0.82). The positive rates of individual aPL were as follows: anti-CL IgG (9.7% vs. 1.6%, p =0.11)/IgM (0% vs. 3.2%, p =0.55), anti-β2GP1 IgG (22.6% vs. 9.7%, p =0.12)/IgA (9.7% vs. 9.7%, p =1.0)/IgM (0% vs. 0%, p =1.0), and anti-PS/PT IgG (0% vs. 1.6%, p =1.0)/IgM (12.9% vs. 21.0%, p =0.41), respectively. The aPL titers were also similar regardless of thrombosis. The levels of β2GPI in COVID-19 patients were lower than those in the healthy donors. Conclusion Although aPLs were frequently detected in Japanese COVID-19 patients, their prevalence and titer were irrelevant to thrombotic complications. While COVID-19 patients have lower levels of serum β2GPI than healthy blood donors, β2GPI levels were indifferent regardless of thrombosis. Although most of the titers were below cut-offs, positive correlations were observed among aPLs, suggesting that the immune reactions against aPL antigens were induced by COVID-19. We should focus on the long-term thromboembolic risk and the development of APS in the aPL-positive patients with high titer or multiple aPLs.
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Affiliation(s)
- Seiya Oba
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tadashi Hosoya
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Risa Kaneshige
- Department of Laboratory Science, Faculty of Health Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Daisuke Kawata
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Taiki Yamaguchi
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takahiro Mitsumura
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
| | - Sho Shimada
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Sho Shibata
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tomoya Tateishi
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Ryuji Koike
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Shuji Tohda
- Clinical Laboratory, Tokyo Medical and Dental University (TMDU) Hospital, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Nukui Yoko
- Department of Infectious Diseases, Division of Comprehensive Patient Care, Medical and Dental Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
- Department of Infection Control and Laboratory Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Junzo Nojima
- Department of Laboratory Science, Faculty of Health Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Shinsuke Yasuda
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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12
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Cohen H, Werring DJ, Chandratheva A, Mittal P, Devreese KMJ, Isenberg DA. Survey on antiphospholipid syndrome diagnosis and antithrombotic treatment in patients with ischemic stroke, other brain ischemic injury, or arterial thromboembolism in other sites: communication from ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2023; 21:2963-2976. [PMID: 37391096 DOI: 10.1016/j.jtha.2023.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/05/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND The optimal strategy for diagnosis and antithrombotic treatment of patients with antiphospholipid syndrome (APS)-associated acute ischemic stroke (AIS), transient ischemic attack (TIA), or other brain ischemic injury is poorly defined. OBJECTIVES The survey goal was to capture variations in diagnosis and antithrombotic treatment of APS-associated ischemic stroke and related disorders to inform guidance and clinical trials to define optimal management. METHODS Professional colleagues, including key opinion leaders, were invited to complete a REDCap survey questionnaire initiated by the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. The survey data were tallied using simple descriptive statistics. RESULTS There was generally good agreement on several aspects, including which patients to test for antiphospholipid antibodies (aPL), use of a lifelong vitamin K antagonist for AIS or recurrent TIA, and formal cognitive assessment for suspected cognitive impairment. There was less agreement on other aspects, including aPL testing for brain ischemic injury other than AIS/TIA or if an alternative cause for AIS or TIA exists; choice of aPL tests, their timing, and age cutoff; the aPL phenotype to trigger antithrombotic treatment; management for patent foramen ovale; antithrombotic treatment for first TIA or white matter hyperintensities; head magnetic resonance imaging specifications; and low-molecular-weight heparin dosing/anti-Xa monitoring in pregnancy. The survey highlighted that approximately 25% practice at dedicated APS clinics and <50% have a multidisciplinary team structure for patients with APS. CONCLUSION Much of the variation in practice reflects the lack of evidence-based recommendations. The survey results should inform the development of a more uniform multidisciplinary consensus approach to diagnosis and antithrombotic treatment.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Prabal Mittal
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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13
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Donohue S, Gomez S, Singh T, Garg S. Triphasic: Preeclampsia, Systemic Lupus Erythematosus, and Severe Neutropenia With Use of Granulocyte Colony Stimulating Factor in the Partum and Postpartum Period. Arthritis Care Res (Hoboken) 2023; 75:2036-2043. [PMID: 37093032 DOI: 10.1002/acr.25138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/25/2023]
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14
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Mwansa H, Zghouzi M, Barnes GD. Unprovoked Venous Thromboembolism: The Search for the Cause. Med Clin North Am 2023; 107:861-882. [PMID: 37541713 DOI: 10.1016/j.mcna.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding risk. Risk prediction models can help identify patients at low VTE recurrence risk who may discontinue anticoagulation upon the completion of the primary treatment phase.
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Affiliation(s)
- Hunter Mwansa
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Mohamed Zghouzi
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.
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15
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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16
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Böhme R, Daniel C, Ferrazzi F, Angeloni M, Ekici AB, Winkler TH, Hilgers KF, Wellmann U, Voll RE, Amann K. Cardiovascular changes in the NZB/W F1 mouse model of lupus nephritis. Front Cardiovasc Med 2023; 10:1182193. [PMID: 37554366 PMCID: PMC10405627 DOI: 10.3389/fcvm.2023.1182193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Patients with systemic lupus erythematosus (SLE), an autoimmune disease, have a higher risk of cardiovascular (CV) disease and death. In addition, up to 40%-50% of SLE patients develop lupus nephritis (LN) and chronic kidney disease, which is an additional CV risk factor. Thus, the individual contributions of LN and other SLE-specific factors to CV events are unclear. METHODS In this study, we investigated the effect of LN on the development of CV changes using the female NZBxNZW F1 (NZB/W) mouse model of lupus-like disease, with female NZW mice as controls. Standard serologic, morphologic, immunohistologic, and molecular analyses were performed. In a separate group of NZB/W mice, systolic blood pressure (BP) was measured during the course of the disease using tail plethysmography. RESULTS Our data show marked CV changes in NZB/W mice, i.e., increased heart weight, hypertrophy of the left ventricle (LV) and septum, and increased wall thickness of the intramyocardial arteries and the aorta, which correlated with the progression of renal damage, but not with the age of the mice. In addition, systolic BP was increased in NZB/W mice only when kidney damage progressed and proteinuria was present. Pathway analysis based on gene expression data revealed a significant upregulation of the response to interferon beta in NZB/W mice with moderate kidney injury compared with NZB mice. Furthermore, IFI202b and IL-6 mRNA expression is correlated with CV changes. Multiple linear regression analysis demonstrated serum urea as a surrogate marker of kidney function and IFI202b expression as an independent predictor for LV wall thickness. In addition, deposition of complement factors CFD and C3c in hearts from NZB/W mice was seen, which correlated with the severity of kidney disease. CONCLUSIONS Thus, we postulate that the pathogenesis of CV disease in SLE is affected by renal impairment, i.e., LN, but it can also be partly influenced by lupus-specific cardiac expression of pro-inflammatory factors and complement deposition.
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Affiliation(s)
- Romy Böhme
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Fulvia Ferrazzi
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
- Institute of Pathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Miriam Angeloni
- Institute of Pathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Arif Bülent Ekici
- Institute of Human Genetics, University Hospital Erlangen, Friedrich–Alexander–Universität Erlangen–Nürnberg, Erlangen, Germany
| | - Thomas H. Winkler
- Divison of Genetics, Department of Biology, Nikolaus–Fiebiger–Center of Molecular Medicine, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Karl-Friedrich Hilgers
- Department of Nephrology and Hypertension, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Ute Wellmann
- Divison of Genetics, Department of Biology, Nikolaus–Fiebiger–Center of Molecular Medicine, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Reinhard E. Voll
- Department of Rheumatology and Clinical Immunology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kerstin Amann
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
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17
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Liu M, Li G, Song X, Fan Y, Li C. Prevalence, risk factors, and prognosis of central nervous system manifestations in antiphospholipid syndrome. Sci Rep 2023; 13:8915. [PMID: 37264095 DOI: 10.1038/s41598-023-35955-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
The central nervous system (CNS) is considered as one of the most frequently affected organs in antiphospholipid syndrome (APS). This study investigated the prevalence of CNS manifestations in APS and associated risk factors and evaluated stroke recurrence. We carried out this retrospective study from 2009 to 2021 at Peking University People's Hospital, which enrolled 342 APS patients, and 174 neurologic events were suffered by 119 patients (34.8%). Patients with and without CNS involvement were compared regarding demographics and laboratory parameters. The analysis showed that older age, livedo reticularis, and dyslipidaemia were significant related factors for CNS manifestations (P = 0.047, 0.038, and 0.030 respectively). The use of anticoagulants (P = 0.004), and/or hydroxychloroquine (P = 0.016) appeared to associated with a lower incidence of CNS manifestations. During a median follow-up of 4.1 years, 10 individuals developed new episodes of stroke in APS patients with previous ischemic strokes. Livedo reticularis, smoking and male gender may predict the risk of recurrent stroke (P = 0.020, 0.006, and 0.026 respectively). Collectively, our results indicated the protective and risk factors for CNS manifestations, as well as demonstrated that APS patients appeared at high risk of stroke recurrence despite current therapy.
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Affiliation(s)
- Meige Liu
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Gongming Li
- Department of Rheumatology and Immunology, Linyi Traditional Chinese Medicine Hospital, Shandong, China
| | - Xiaodong Song
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yangyi Fan
- Department of Neurology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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18
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Liu Q, Yang S, Tan Y, Cui L. High-throughput sequencing technology facilitates the discovery of novel biomarkers for antiphospholipid syndrome. Front Immunol 2023; 14:1128245. [PMID: 37275905 PMCID: PMC10235516 DOI: 10.3389/fimmu.2023.1128245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/09/2023] [Indexed: 06/07/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis and/or morbid pregnancy, accompanied by persistent antiphospholipid antibody (aPL) positivity. However, due to the complex pathogenesis of APS and the large individual differences in the expression of aPL profiles of patients, the problem of APS diagnosis, prognosis judgment, and risk assessment may not be solved only from the antibody level. It is necessary to use new technologies and multiple dimensions to explore novel APS biomarkers. The application of next-generation sequencing (NGS) technology in diseases with a high incidence of somatic mutations, such as genetic diseases and tumors, has been very mature. Thus, we try to know the research and application progress of APS by NGS technology from genome, transcriptome, epigenome and other aspects. This review will describe the related research of NGS technology in APS and provide more reference for the deep understanding of APS-related screening markers and disease pathogenesis.
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Affiliation(s)
- Qi Liu
- Department of Clinical Laboratory, Peking University Third Hospital, Beijing, China
- Core Unit of National Clinical Research Center for Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Shuo Yang
- Department of Clinical Laboratory, Peking University Third Hospital, Beijing, China
- Core Unit of National Clinical Research Center for Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Yuan Tan
- Department of Clinical Laboratory, Peking University Third Hospital, Beijing, China
- Core Unit of National Clinical Research Center for Laboratory Medicine, Peking University Third Hospital, Beijing, China
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Liyan Cui
- Department of Clinical Laboratory, Peking University Third Hospital, Beijing, China
- Core Unit of National Clinical Research Center for Laboratory Medicine, Peking University Third Hospital, Beijing, China
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19
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Ambati A, Knight JS, Zuo Y. Antiphospholipid syndrome management: a 2023 update and practical algorithm-based approach. Curr Opin Rheumatol 2023; 35:149-160. [PMID: 36866678 PMCID: PMC10364614 DOI: 10.1097/bor.0000000000000932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is an acquired thrombo-inflammatory disease that has morbid and sometimes devastating effects on patients and their families. This review will discuss the most recent international societal treatment guidelines and propose practical management algorithms for various APS sub-types. RECENT FINDINGS APS represents a disease spectrum. Although thrombosis and pregnancy morbidities are traditional hallmarks of APS, a variety of extra-criteria clinical phenotypes can often be seen, which makes clinical management more challenging. Primary APS thrombosis prophylaxis should take a risk-stratified approach. Although vitamin K antagonists (VKAs) or heparin/low molecular weight heparin (LMWH) remain the preferred treatment for secondary APS thrombosis prophylaxis, some international society guidelines support the use of direct oral anticoagulants (DOACs) in certain circumstances. Careful monitoring and individualized obstetric care with the use of aspirin and heparin/LMWH will improve pregnancy outcomes among pregnant individuals with APS. Treatment of microvascular and catastrophic APS remains challenging. While the addition of various immunosuppressive agents is often utilized, further systemic evaluations of their use are warranted before definitive recommendations can be made. Several new therapeutic strategies are on the horizon that might enable more personalized and targeted APS management in the near future. SUMMARY Although the knowledge of APS pathogenesis has grown in recent years, the management principles and strategies are largely unchanged. There is an unmet need for evaluating pharmacological agents, beyond anticoagulants, that target diverse thromboinflammatory pathways.
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Affiliation(s)
- Amala Ambati
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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20
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Al-Attar N, Gaer J, Giordano V, Harris E, Kirk A, Loubani M, Meybohm P, Sayeed R, Stock U, Travers J, Whiteman B. Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19. J Cardiothorac Surg 2023; 18:96. [PMID: 37005650 PMCID: PMC10066978 DOI: 10.1186/s13019-023-02195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 03/29/2023] [Indexed: 04/04/2023] Open
Abstract
The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.
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Affiliation(s)
- Nawwar Al-Attar
- Golden Jubilee National Hospital, University of Glasgow, Agamemnon Street, Clydebank, Glasgow, G81 4DY, Scotland, UK.
| | - Jullien Gaer
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Emma Harris
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Alan Kirk
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | - Rana Sayeed
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ulrich Stock
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jennifer Travers
- West of Scotland Cancer Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Becky Whiteman
- Cluster Medical Manager Advanced Surgery - UKI and Nordics Worldwide Medical, Baxter Healthcare Limited, Berkshire, UK
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21
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Suzuki J, Furuta S, Sugiyama T, Iwamoto T, Ikeda K, Suzuki K, Nakajima H. Antiphospholipid antibody positivity and the thrombotic risk in Japanese patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. Mod Rheumatol 2023; 33:346-351. [PMID: 35411394 DOI: 10.1093/mr/roac031] [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: 11/26/2021] [Revised: 01/19/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES It has been reported that 21.0-51.7% of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) patients were antiphospholipid antibody (aPL)-positive. However, the clinical significance of aPL positivity in AAV is not fully understood. METHODS We retrospectively assessed patients with AAV diagnosed from 2013 to 2020 at our hospital. Positivity of aPL was defined as positivity of anti-cardiolipin antibody, anti-cardiolipin β2 glycoprotein 1 complex antibody, and/or lupus anticoagulant at least one time during the follow-up periods. The thrombotic risk of aPL positivity was examined by multivariate analyses with the Cox regression model. RESULTS A total of 93 patients with a median age of 71.9 years were included in the study. The median follow-up period was 35.4 months. Thirty-one patients (33.3%) were aPL-positive. Twenty-two thrombotic events occurred in 17 patients (18.3%). Thrombotic events occurred more frequently in aPL-positive patients than in aPL-negative patients (P = 0.011). Multivariate analyses with two different models identified aPL positivity as a thrombotic risk factor (hazard ratios 4.302 and 5.956, 95% confidence intervals 1.546-11.968 and 1.940-18.281, respectively). CONCLUSIONS The proportion of aPL-positive patients was 33.3%, and aPL positivity increased the thrombotic risk in Japanese patients with AAV.
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Affiliation(s)
- Junya Suzuki
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Takahiro Sugiyama
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Taro Iwamoto
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Kotaro Suzuki
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University, Chiba, Japan
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22
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Nevras V, Milaras N, Katsioulis C, Sotiriou Z, Tsalamandris S, Gkounti G, Skevos S. Acute Coronary Syndromes in Antiphospholipid Syndrome-above Suspicion: A Systematic Review. Curr Probl Cardiol 2023; 48:101503. [PMID: 36402221 DOI: 10.1016/j.cpcardiol.2022.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Antiphospholipid syndrome(APS) is an autoimmune disorder characterized clinically by vascular thrombosis and/or pregnancy morbidity, associated with persistently elevated titers of antiphospholipid antibodies on at least two measurements over 12 weeks apart. In this study, we conducted a systematic review of the literature utilizing the Pubmed platform, in order to acquire clinical information about acute coronary syndromes in patients with APS. The obtained articles were reviewed in order to register the clinical characteristics, the rate of occurrence, the prognosis and the therapeutic approach of these patients. APS should be considered in young patients with acute myocardial infarction, even in patients with normal coronary arteries. The pharmaceutical approach is mainly based on the vitamin K antagonists, and in certain occasions aspirin, without any definite guidelines on the subject. Further randomized clinical trials are imperative for a better understanding of the particular characteristics of this group of patients, so that a more complete therapeutic approach to be obtained.
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Affiliation(s)
- Vasileios Nevras
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Nikias Milaras
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece.
| | - Christos Katsioulis
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Zoi Sotiriou
- Pediatrics Department, General Hospital of Karditsa, Karditsa, Karditsa, Greece
| | - Sotirios Tsalamandris
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
| | - Georgia Gkounti
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Sideris Skevos
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
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23
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Capozzi A, Manganelli V, Riitano G, Caissutti D, Longo A, Garofalo T, Sorice M, Misasi R. Advances in the Pathophysiology of Thrombosis in Antiphospholipid Syndrome: Molecular Mechanisms and Signaling through Lipid Rafts. J Clin Med 2023; 12:jcm12030891. [PMID: 36769539 PMCID: PMC9917860 DOI: 10.3390/jcm12030891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
The pathological features of antiphospholipid syndrome (APS) are related to the activity of circulating antiphospholipid antibodies (aPLs) associated with vascular thrombosis and obstetric complications. Indeed, aPLs are not only disease markers, but also play a determining pathogenetic role in APS and exert their effects through the activation of cells and coagulation factors and inflammatory mediators for the materialization of the thromboinflammatory pathogenetic mechanism. Cellular activation in APS necessarily involves the interaction of aPLs with target receptors on the cell membrane, capable of triggering the signal transduction pathway(s). This interaction occurs at specific microdomains of the cell plasma membrane called lipid rafts. In this review, we focus on the key role of lipid rafts as signaling platforms in the pathogenesis of APS, and propose this pathogenetic step as a strategic target of new therapies in order to improve classical anti-thrombotic approaches with "new" immunomodulatory drugs.
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24
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Cabling MG, Sandhu VK, Downey CD, Torralba KD. Cardiovascular disease and bone health in aging female rheumatic disease populations: A review. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231155286. [PMID: 36825447 PMCID: PMC9969471 DOI: 10.1177/17455057231155286] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Rheumatic diseases cover a wide spectrum of conditions, including primary and secondary degenerative joint diseases and autoimmune inflammatory rheumatic diseases. The risks of cardiovascular disease and osteoporosis and resultant fractures in aging female rheumatic disease populations, especially those with autoimmune rheumatic diseases, are increased. Changes in the immune system in aging populations need to be considered especially among patients with autoimmune rheumatic diseases. Immunosenescence is closely aligned to reduced adaptive immunity and increased non-specific innate immunity leading to chronic inflammation of inflammaging. The effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis. Rheumatic diseases, which largely manifest as arthritis, predispose patients to premature joint degeneration and poor bone health and therefore have a higher risk of developing end-stage arthritis requiring joint arthroplasties sooner or more often than other patients without rheumatic disease.
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Affiliation(s)
- Marven G Cabling
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Vaneet K Sandhu
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Christina D Downey
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Karina D Torralba
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
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25
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Capecchi M, Abbattista M, Ciavarella A, Uhr M, Novembrino C, Martinelli I. Anticoagulant Therapy in Patients with Antiphospholipid Syndrome. J Clin Med 2022; 11:jcm11236984. [PMID: 36498557 PMCID: PMC9741036 DOI: 10.3390/jcm11236984] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the persistent positivity of antiphospholipid antibodies (aPLA) together with thrombosis or obstetrical complications. Despite their recognized predominant role, aPLA are not sufficient to induce the development of thrombosis and a second hit has been proposed to be necessary. The mainstay of treatment of APS is anticoagulant therapy. However, its optimal intensity in different presentations of the disease remains undefined. Moreover, decision on which patients with aPLA would benefit from an antithrombotic prophylaxis and its optimal intensity are challenging because of the lack of stratification tools for the risk of thrombosis. Finally, decision on the optimal type of anticoagulant drug is also complex because the central pathway responsible for the development of thrombosis is so far unknown and should be carried out on an individual basis after a careful evaluation of the clinical and laboratory features of the patient. This review addresses the epidemiology, physiopathology, diagnosis and management of thrombosis and obstetrical complications in APS, with a special focus on the role of direct oral anticoagulants.
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Affiliation(s)
- Marco Capecchi
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Maria Abbattista
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mario Uhr
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Department of Hematology, Synlab-Suisse, 6900 Lugano, Switzerland
| | - Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Ida Martinelli
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Correspondence: ; Tel.: +41-91-960-80-81
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26
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Subramaniam S, Kothari H, Bosmann M. Tissue factor in COVID-19-associated coagulopathy. Thromb Res 2022; 220:35-47. [PMID: 36265412 PMCID: PMC9525243 DOI: 10.1016/j.thromres.2022.09.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022]
Abstract
Evidence of micro- and macro-thrombi in the arteries and veins of critically ill COVID-19 patients and in autopsies highlight the occurrence of COVID-19-associated coagulopathy (CAC). Clinical findings of critically ill COVID-19 patients point to various mechanisms for CAC; however, the definitive underlying cause is unclear. Multiple factors may contribute to the prothrombotic state in patients with COVID-19. Aberrant expression of tissue factor (TF), an initiator of the extrinsic coagulation pathway, leads to thrombotic complications during injury, inflammation, and infections. Clinical evidence suggests that TF-dependent coagulation activation likely plays a role in CAC. Multiple factors could trigger abnormal TF expression and coagulation activation in patients with severe COVID-19 infection. Proinflammatory cytokines that are highly elevated in COVID-19 (IL-1β, IL-6 and TNF-α) are known induce TF expression on leukocytes (e.g. monocytes, macrophages) and non-immune cells (e.g. endothelium, epithelium) in other conditions. Antiphospholipid antibodies, TF-positive extracellular vesicles, pattern recognition receptor (PRR) pathways and complement activation are all candidate factors that could trigger TF-dependent procoagulant activity. In addition, coagulation factors, such as thrombin, may further potentiate the induction of TF via protease-activated receptors on cells. In this systematic review, with other viral infections, we discuss potential mechanisms and cell-type-specific expressions of TF during SARS-CoV-2 infection and its role in the development of CAC.
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27
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Su L, Qi Z, Guan S, Wei L, Zhao Y. Exploring the risk factors for ischemic cerebrovascular disease in systemic lupus erythematosus: A single-center case-control study. Front Immunol 2022; 13:978910. [PMID: 36238309 PMCID: PMC9552613 DOI: 10.3389/fimmu.2022.978910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesIschemic cerebrovascular disease (ICVD) is one of the most common and severe complications in systemic lupus erythematosus (SLE). We aim to explore the risk factors for ICVD in SLE and to assess their associated clinical characteristics.MethodsIn this study, 44 lupus patients with ICVD (ICVD-SLE) and 80 age- and sex-matched lupus patients without ICVD (non-ICVD-SLE) who were hospitalized in our center between 2014 and 2021 were enrolled. A comprehensive set of clinical and socio-demographic data was recorded. In the ICVD-SLE group, the modified Rankin score (mRS) at 90 days after the occurrence of ICVD, the brain MRI, and arterial ultrasonography findings were collected. Group comparisons were made with continuous variables using an independent t-test or the Mann–Whitney test, and with categorical variables using the chi-square test or Fisher exact test. Multivariate logistic regression analysis was performed to identify the risk factors for ICVD in SLE. Patients with ICVD-SLE were divided into three subgroups according to the gradations of intracranial arterial stenosis (ICAS). The subgroup comparisons were performed by one-way ANOVA test or Kruskal–Wallis test.ResultsOf the 44 patients with ICVD, 45% had a large-vessel ischemic stroke, 50% had a symptomatic lacunar stroke, and 9% had a transient ischemic attack. 2 (4.5%) had both large-vessel ischemic stroke and symptomatic lacunar stroke. Multivariate logistic regression analysis showed that cutaneous vasculitis (OR=7.36, 95% CI=2.11–25.65), anticardiolipin antibody (aCL) (OR=4.38, 95% CI=1.435–13.350), and lupus anticoagulant (LA) (OR=7.543,95% CI=1.789–31.808) were the risk factors, and hydroxychloroquine (HCQ) therapy (OR=0.198, 95% CI=0.078–0.502) was the protective factor, after controlling for confounders. During the analysis of the subgroups, no significant difference was observed between the patients in the group without internal carotid arterial occlusion (ICAS) and those with severe ICAS except for diagnostic delay. However, patients in the moderate ICAS group were older when SLE occurred (P<0.01), had a longer diagnostic delay (P<0.01), a lower percentage of hypocomplementemia (P=0.05) and steroids and HCQ therapy (P=0.01, P=0.05, respectively), a trend toward lower mRS score, but a higher incidence of carotid atherosclerotic plaque (P<0.01), when compared with the other two subgroups.ConclusionCutaneous vasculitis and antiphospholipid antibodies (aPLs) are associated with an increased risk of ICVD, while HCQ therapy may provide protection against ICVD in SLE. The ICVD in younger lupus patients is associated with complement-mediated inflammation and poorer outcome, and require immunosuppressive therapy, whereas the ICVD in elderly patients are characterized by moderate ICAS and carotid atherosclerotic plaques.
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Affiliation(s)
- Li Su
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhigang Qi
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shaochen Guan
- Evidence-Based Medical Center, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lian Wei
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yi Zhao
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yi Zhao,
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28
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Sciascia S, Bloch R, O’Malley T, Kammesheidt A, Alexander RV. Antiphospholipid antibodies are persistently positive at high titers. Additive value of platelet-bound C4d. Front Immunol 2022; 13:949919. [PMID: 36032074 PMCID: PMC9399821 DOI: 10.3389/fimmu.2022.949919] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Classification criteria for antiphospholipid syndrome (APS) require that antiphospholipid antibody (aPL) positivity is confirmed after at least 12 weeks. We tested the hypothesis that aPL at high titers remain positive while low titers fluctuate over time. As both platelet-bound C4d (PC4d) and aPL are associated with thrombosis in systemic lupus erythematosus (SLE), we also evaluated whether PC4d can aid in APS diagnosis. Methods Data from serum or plasma sent to Exagen’s laboratory for routine aPL testing were analyzed. Anti-cardiolipin (aCL) and anti-beta2 glycoprotein-1 antibodies (aB2GP1) were measured by chemiluminescence or ELiA fluorescence enzyme immunoassay; anti-phosphatidylserine/prothrombin complex antibodies (aPS/PT) by ELISA; PC4d by flow cytometry. Statistical analysis included descriptive statistics, logistic regression, and Pearson correlation. Results More than 80% of positive samples with aCL and aB2GP1 at high titers - but not low titers - were positive at a retest. Non-criteria aPL (aPS/PT) followed a similar trend. aCL and aB2GP1 measured with two different technologies were highly correlated. PC4d and IgG of the three aPL were at best moderately correlated even when only positive aPL samples were analyzed (coefficient: 0.1917 to 0.2649). Conclusions High titers aPL are often persistently positive, allowing an earlier diagnosis and risk assessment at the time of the initial screening. Conversely, a retest may be necessary for low titers. The high correlation between two methodologies suggests that these findings are independent of assay platform. The low to moderate correlation between PC4d and aPL might suggest a possible additive value to evaluate association with thrombosis in autoimmune diseases.
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Affiliation(s)
- Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
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29
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Shehata H, Ali A, Silva-Edge M, Haroon S, Elfituri A, Viswanatha R, Jan H, Akolekar R. Thrombophilia screening in women with recurrent first trimester miscarriage: is it time to stop testing? - a cohort study and systematic review of the literature. BMJ Open 2022; 12:e059519. [PMID: 35831047 PMCID: PMC9280906 DOI: 10.1136/bmjopen-2021-059519] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE There are numerous studies reporting a disproportionally high prevalence of thrombophilia in women with a history of recurrent miscarriage (RM), which has led to overdiagnosis and treatment without an improvement in clinical outcomes. The objective of our study was to assess the prevalence of inherited and acquired thrombophilia in a large cohort of women with a history of early RM using internationally agreed diagnostic criteria and inclusion parameters and compare it to the meta-analysis results of existing literature. METHODS DESIGN: Retrospective cohort study and systematic review of literature. SETTING This is a retrospective cohort study set-up in two dedicated tertiary centres for women with RM in Southwest London and Surrey. We reviewed all the available literature related to causes of RMs. We ascertained the prevalence of thrombophilia in the study population and compared it with historical and published prevalence in the general population. PARTICIPANTS 1155 women between 2012 and 2017. All patients had three or more first trimester miscarriages and a full thrombophilia screen. RESULTS The overall prevalence of thrombophilia in our study population is 9.2% (106/1155) with 8.1% (94/1155) of cases positive for inherited thrombophilia, which is similar to the general population; Factor V Leiden (4.9%; 57/1155) and prothrombin gene mutation (2.9%; 34/1155) were the most common inherited thrombophilias, while only 1% (12/1155) tested positive for acquired thrombophilia. Persistent positive lupus anticoagulant (LA) was found in 0.5% (6/1155) and persistent positive anticardiolipin (ACL) antibodies with a value ≥40 U/mL was found in 0.5% (6/1155) of patients. Tests for LA/ACL were performed a minimum of 12 weeks apart thus meeting the revised Sapporo criteria for a diagnosis of antiphospholipid syndrome. CONCLUSION The findings of our study demonstrate that the prevalence of inherited thrombophilia is similar in women with RM to that in the general population. Similarly, the prevalence of acquired thrombophilia, using the revised Sapporo criteria, in the cohort of RMs is similar to that in the general population. Therefore, we do not recommend investigation or treatment of inherited or acquired thrombophilia in women with RM. PROSPERO REGISTRATION NUMBER CRD42020223554.
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Affiliation(s)
- Hassan Shehata
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Amanda Ali
- Women's Health, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | | | - Shahla Haroon
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Abdullatif Elfituri
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Radhika Viswanatha
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Haider Jan
- Women's Helath, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Sutton, UK
| | - Ranjit Akolekar
- Women's Health, Medway Maritime Hospital, Gillingham, Kent, UK
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30
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Gohr M, Jakobsen IM, Helmig RB, Stengaard-Pedersen K, Laurberg TB, Troldborg A. Improved pregnancy outcomes in systemic lupus erythematosus: A retrospective study of pregnancies from a single centre in Denmark from 2010-2020 compared with the period 1990-2010. Lupus 2022; 31:1202-1210. [PMID: 35676102 DOI: 10.1177/09612033221107538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Over the past decades new international guidelines recommend that pregnant Systemic lupus erythematosus (SLE) patients are monitored closely in a multi-professional team throughout pregnancy. The importance of low disease activity before pregnancy and continued treatment during pregnancy has been established. However, there is still a high risk of adverse pregnancy outcome (APO).The APO in a Danish SLE cohort was evaluated and compared with the results in a previous study cohort from the same centre and referral area. METHODS This retrospective cohort study used the local patient registry to identify pregnancies in SLE patients followed at the Department of Rheumatology, Aarhus University Hospital, Denmark, from January 2010 to October 2020. In total, 66 pregnancies were registered in 41 women. Data were compared with a previous retrospective study (1990-2010) from the same hospital. RESULTS Adverse pregnancy outcome occurred in 65% of pregnancies. Forty-seven pregnancies resulted in a live birth, while 15 ended in miscarriages. Compared to the 1990-2010 cohort, a numerical reduction in preterm deliveries (7.58% vs. 17.9%) and emergent caesarean (6.1% vs. 15.5%) was observed, although not reaching statistical significance (p = .07 in both cases). Further, a higher average birth weight (3045 g vs. 2870 g) as well as a higher number of pregnancies and live births per year were observed. Gestational hypertension was significantly reduced from 23.8% to 13.6% (p = .05). Significantly more patients were treated with prednisolone (66.7% vs 35.7%, p = .0002), hydroxychloroquine (6% vs. 73.4%, p < .0001) and acetylsalicylic acid (39.3% vs. 73.1%, p = .0001) in 2010-2020 compared to the 1990-2010. CONCLUSION We observed significant improvements in the frequency of some APOs in the recent 2010-2020 cohort compared with the previous cohort followed from 1990 to 2010. However, even though a specialized multi-professional team closely follows SLE patients through their pregnancies, pregnancy in SLE still carries a high risk of APO.
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Affiliation(s)
- Mette Gohr
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark
| | - Iris Marie Jakobsen
- Department of Rheumatology, 53141Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Bek Helmig
- Department of Gynecology and Obstetrics, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | | | - Trine Bay Laurberg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark
| | - Anne Troldborg
- Department of Rheumatology, 11297Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, 1006Aarhus University, Aarhus, Denmark.,Department of Biomedicine, 1006Aarhus University, Aarhus, Denmark
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31
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Djokovic A, Stojanovich L, Stanisavljevic N, Djokic S, Filipovic B, Matic P, Milanovic M, Apostolovic S, Saponjski J. Cardiac manifestations in primary antiphospholipid syndrome and their association to antiphospholipid antibodies' types and titers-cross-sectional study of Serbian cohort. Clin Rheumatol 2022; 41:1447-1455. [PMID: 35018582 DOI: 10.1007/s10067-022-06056-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 10/28/2021] [Accepted: 01/06/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Antiphospholipid syndrome (APS) is multisystem autoimmune coagulopathy with antiphospholipid antibodies (aPL) in its ground, manifested as a primary disease (PAPS) or in the setting of other conditions, most commonly systemic lupus erythematosus. The objective of this cross-sectional study was to investigate various cardiac manifestations and their possible relation to aPL type and titer in a Serbian cohort of PAPS patients. METHODS A total of 360 PAPS patients were analyzed and aPL analysis included detection of anticardiolipin antibodies (aCL: IgG/IgM), anti-ß2glycoprotein I (ß2GPI: IgG/IgM), and lupus anticoagulant (LA). Cardiac manifestations investigated were valvular lesions (comprehending valvular thickening and dysfunction not related to age and pseudoinfective endocarditis), coronary artery disease (CAD) with specific insight for myocardial infarction (MI), chronic cardiomyopathy (CMP), and acute decompensated heart failure (ADHF) as well as pulmonary hypertension (PH) and intracardiac thrombus presence. RESULTS The prevalence of cardiac manifestations overall was 19.6%. There was a strong association between age and the majority of cardiac manifestations, as well as standard atherosclerotic risk factors. aCL IgG-positive patients had a higher prevalence of valvular lesions (p = 0.042). LA presence was significantly related to MI (p = 0.031) and PH (p = 0.044). CMP and ADHF were significantly related to higher titers of aCl IgG (p = 0.033, p = 0.025 respectively). Age and smoking were independent risk predictors for MI in PAPS with meaningful risk for LA positivity (OR 2.567 CI 0.671-9.820 p = 0.168). CONCLUSIONS Certain cardiac manifestations in PAPS were related to certain aPL type and/or titer levels, imposing confirmation in prospective studies. Preventive actions, comprehending proper anticoagulant/antithrombotic therapy, and intense action against standard atherosclerotic risk factors are of utmost importance in this group of patients. Key Points • In Serbian patients with primary antiphospholipid syndrome (PAPS), prevalence of non-criteria cardiac manifestations was 19.6% and they were significantly related to certain antiphospholipid antibodies and titers. • Lupus anticoagulant was a meaningful predictor of myocardial infarction, enabling possible risk stratification and proper preventive and therapeutical strategies in this subgroup of PAPS patients. • Patients with high titers of aCL IgG are more prone to acute decompensated heart failure occurence, imposing careful follow-up of these patients • Based on the analysis of the Serbian PAPS cohort, even being non-criterial, cardiology manifestations are significantly present and inclusion of cardiologists in treatment and follow-up of these patients should be implied from the diagnosis establishment.
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Affiliation(s)
- Aleksandra Djokovic
- Department of Cardiology, Division of Interventional Cardiology, University Hospital Medical Center Bezanijska Kosa, Belgrade, Serbia. .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Ljudmila Stojanovich
- Department of Rheumatology, University Hospital Medical Center Bezanijska Kosa, Belgrade, Serbia
| | - Natasa Stanisavljevic
- Department of Hematology, University Hospital Medical Center Bezanijska Kosa, Belgrade, Serbia
| | - Sandra Djokic
- Clinical Center of Serbia, Pulmonology Clinic, Belgrade, Serbia
| | - Branka Filipovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Gastroenterology, University Hospital Medical Center Dr Dragisa Misovic - Dedinje, Belgrade, Serbia
| | - Predrag Matic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Vascular Surgery, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milomir Milanovic
- Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia
| | - Svetlana Apostolovic
- Department of Professional and Scientific Training, Cardiology Clinic, Clinical Center of Nis, Nis, Serbia.,School of Medicine, University of Nis, Nis, Serbia
| | - Jovica Saponjski
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Interventional Cardiology, Emergency Room, Clinical Center of Serbia, Belgrade, Serbia
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Al-Mughales JA. Anti-Nuclear Antibodies Patterns in Patients With Systemic Lupus Erythematosus and Their Correlation With Other Diagnostic Immunological Parameters. Front Immunol 2022; 13:850759. [PMID: 35359932 PMCID: PMC8964090 DOI: 10.3389/fimmu.2022.850759] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background Antinuclear antibodies (ANA) are major immunodiagnostic tools in systemic lupus erythematosus (SLE); however, their clinical and pathogenic roles are not yet elucidated and are a subject of controversy. Objectives The aim of the study is to explore the pathogenic significance of ANA patterns among SLE patients, by analyzing their association with ANA titers, complement levels and other pathogenic immune markers, namely, anti-double-stranded DNA (anti-dsDNA), complements C3 and C4, rheumatoid factor (RF), anticardiolipin antibodies IgG (ACL IgG) and IgM (ACL IgM), Beta-2 Glycoprotein 1 Antibodies (β2-GP) IgG (β2-IgM) and IgM (β2-IgM), and lupus anticoagulant (LA). Method A comparative cross-sectional study was conducted among 495 SLE patients, who were diagnosed and classified by consultant rheumatologists according to the new European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 criteria. SLE immunodiagnostic profiles were analyzed including the following parameters: ANA antibody titers and staining patterns, anti-dsDNA, C3 and C4 levels, aCL, and anti-β2-GP and LA. Result The most frequently observed ANA patterns were the speckled (52.1%) and homogeneous (35.2%) patterns, while other patterns were rare representing less than 7% of the patients each. ANA titers were highest in patients with mixed pattern followed by the speckled pattern. Of all the investigated patterns, the peripheral pattern showed the most pathogenic immune profile, namely, highest levels of anti-dsDNA, lowest levels of C4, and highest levels of aCL and β2-GP IgG and IgM. Conclusion This retrospective study showed that speckled followed by homogeneous ANA patterns were predominant accounting for 52.1 and 35.2% of the patients. The ANA pattern showed several associations with other immune markers that are documented to have significant clinical implications in SLE. Peripheral, mixed, and speckled patterns were associated with higher profiles of immune markers indicative of a potential prognostic value of these patterns in SLE.
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Affiliation(s)
- Jamil A. Al-Mughales
- Department of Medical Microbiology and Parasitology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Clinical Laboratory Medicine, Diagnostic Immunology Division, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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Neuropsychiatric Manifestations of Antiphospholipid Syndrome—A Narrative Review. Brain Sci 2022; 12:brainsci12010091. [PMID: 35053834 PMCID: PMC8773877 DOI: 10.3390/brainsci12010091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a common autoimmune pro-thrombotic condition characterised by thrombosis and pregnancy morbidity. There are a broad range of neuropsychiatric manifestations associated with APS, from focal symptoms to more global dysfunction. Patients commonly present with transient ischaemic attacks and ischaemic strokes, with identifiable lesions on brain imaging. However, the underlying pathogenesis remains uncertain in other manifestations, such as cognitive dysfunction, seizures, headache and chorea. The aim is to provide a comprehensive review of the various neuropsychiatric manifestations associated with APS. A detailed literature search was applied to PubMed, including citations from 1983 to December 2021.
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Su Z, Huang Z, Zhao J, Li M, Hu J, Zeng X, Hu C, Yang B. Detection of IgA Antiphospholipid Antibodies Does not Improve Thrombotic Antiphospholipid Syndrome Classification: A two-Center Study. Clin Appl Thromb Hemost 2022; 28:10760296221081129. [PMID: 35379020 PMCID: PMC8988664 DOI: 10.1177/10760296221081129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Thrombotic antiphospholipid syndrome (APS) is a systemic autoimmune disease; its diagnosis requires meeting both clinical and laboratory criteria. Prevalence rates of immunoglobulin (Ig) A anticardiolipin antibodies (aCL) and IgA anti-β2 glycoprotein I antibodies (aβ2GPI) remain unknown, and the clinical value of these antibodies to APS classification remains controversial. Therefore, we aimed to examine both items in the Chinese population. Methods Using chemiluminescence immunoassay, antiphospholipid antibodies (aPL) were quantified in 12,582 hospital-based general population, 278 thrombotic APS patients, and 233 healthy controls. Results In the general population, the positive rates of IgA aCL and IgA aβ2GPI antibodies were 2.87% and 1.99%, respectively. Furthermore, isolated IgA aPL-positivity rate was 0.72% in patients with APS, which was comparable to those in the general population (0.68%, p = 1) and in healthy controls (0.43%, p = 1). Among the IgA aPL-positive individuals in the general population, isolated IgA-positive individuals had lower serum levels of IgA antibodies (p = 0.007 for IgA aCL and p = 0.059 for IgA aβ2GPI). Regarding to APS classification, adding IgA aPL into conventional aPL assays may not improve and may even deteriorate the net reclassification index for APS; besides, no association between thrombosis and IgA aPL was observed. Conclusions this study assessed the prevalence of various aPL in Chinese population. IgA aPL may not enhance the classification ability of established laboratory criteria for thrombotic APS. Our data do not support the addition of IgA aPL to conventional aPL assays.
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Affiliation(s)
- Zhenzhen Su
- 34753West China Hospital of Sichuan University, Chengdu, China
| | - Zhuochun Huang
- 34753West China Hospital of Sichuan University, Chengdu, China
| | - Jiuliang Zhao
- 34732Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology & Clinical Immunology, Ministry of Education, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Mengtao Li
- 34732Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology & Clinical Immunology, Ministry of Education, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Jing Hu
- 34753West China Hospital of Sichuan University, Chengdu, China
| | - Xiaofeng Zeng
- 34732Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology & Clinical Immunology, Ministry of Education, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Chaojun Hu
- 34732Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology & Clinical Immunology, Ministry of Education, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China
| | - Bin Yang
- 34753West China Hospital of Sichuan University, Chengdu, China
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Rodríguez CM, Velásquez-Berrío M, Rúa C, Viana M, Abrahams VM, Cadavid AP, Alvarez AM. Antiphospholipid Antibodies From Women With Pregnancy Morbidity and Vascular Thrombosis Induce Endothelial Mitochondrial Dysfunction, mTOR Activation, and Autophagy. Front Physiol 2021; 12:706743. [PMID: 34912234 PMCID: PMC8667788 DOI: 10.3389/fphys.2021.706743] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/18/2021] [Indexed: 01/09/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by thrombosis and pregnancy morbidity (PM) obstetric events together with persistent high titers of circulating antiphospholipid antibodies (aPL). Several mechanisms that explain the development of thrombosis and PM in APS include the association of aPL with alterations in the coagulation cascade and inflammatory events. Other mechanisms disturbing cellular homeostases, such as mitochondrial dysfunction, autophagy, and cell proliferation, have been described in other autoimmune diseases. Therefore, the objective of this study was to investigate the impact of aPL from different patient populations on endothelial cell mitochondrial function, activation of the mammalian target of rapamycin (mTOR) and autophagy pathways, and cellular growth. Using an in vitro model, human umbilical vein endothelial cells (HUVECs) were treated with polyclonal immunoglobulin G (IgG) purified from the serum of women with both PM and vascular thrombosis (PM/VT), with VT only (VT), or with PM and non-criteria aPL (seronegative-obstetric APS, SN-OAPS). We included IgG from women with PM without aPL (PM/aPL-) and healthy women with previous uncomplicated pregnancies (normal human serum, NHS) as control groups. Mitochondrial function, mTOR activation, autophagy, and cell proliferation were evaluated by Western blotting, flow cytometry, and functional assays. IgG from women with PM/VT increased HUVEC mitochondrial hyperpolarization and activation of the mTOR and autophagic pathways, while IgG from patients with VT induced endothelial autophagy and cell proliferation in the absence of elevated mTOR activity or mitochondrial dysfunction. IgG from the SN-OAPS patient group had no effect on any of these HUVEC responses. In conclusion, aPL from women with PM and vascular events induce cellular stress evidenced by mitochondrial hyperpolarization and increased activation of the mTOR and autophagic pathways which may play a role in the pathogenesis of obstetric APS.
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Affiliation(s)
- Carlos M. Rodríguez
- Grupo Reproducción, Facultad de Medicina, Departamento de Microbiología y Parasitología, Universidad de Antioquia (UdeA), Medellín, Colombia
| | - Manuela Velásquez-Berrío
- Grupo Reproducción, Facultad de Medicina, Departamento de Microbiología y Parasitología, Universidad de Antioquia (UdeA), Medellín, Colombia
| | - Carolina Rúa
- Grupo de Investigación en Trombosis, Facultad de Medicina, Universidad de Antioquia (UdeA), Medellín, Colombia
| | - Marta Viana
- Grupo de Metabolismo y Función Vascular, Departamento de Química y Bioquímica, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
- Red Iberoamericana de Alteraciones Vasculares Asociadas a Transtornos del Embarazo (RIVATREM), Chillán, Chile
| | - Vikki M. Abrahams
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Angela P. Cadavid
- Grupo Reproducción, Facultad de Medicina, Departamento de Microbiología y Parasitología, Universidad de Antioquia (UdeA), Medellín, Colombia
- Red Iberoamericana de Alteraciones Vasculares Asociadas a Transtornos del Embarazo (RIVATREM), Chillán, Chile
| | - Angela M. Alvarez
- Grupo Reproducción, Facultad de Medicina, Departamento de Microbiología y Parasitología, Universidad de Antioquia (UdeA), Medellín, Colombia
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Arora S, Nair S, Prabhu R, Avanthika C, Jhaveri S, Samayam S, Katta MR, Agarwal P. Role of Direct Oral Anticoagulation Agents as Thromboprophylaxis in Antiphospholipid Syndrome. Cureus 2021; 13:e19009. [PMID: 34824926 PMCID: PMC8610415 DOI: 10.7759/cureus.19009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 01/13/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that causes venous, arterial and small-vessel thrombosis, pregnancy loss, and premature birth. Cardiac valvular disease, renal thrombotic microangiopathy, thrombocytopenia, hemolytic anemia, and cognitive impairment are some of its other clinical symptoms. Antiphospholipid antibodies cause endothelial cells, monocytes, and platelets to become activated, as well as an increase in tissue factor and thromboxane A2. Complement activation might play a key function in pathogenesis. Long-term oral anticoagulation is used to treat thrombosis, and individuals having arterial episodes should be treated quickly. Patients with systemic lupus erythematosus (SLE), as well as those with solely obstetric antiphospholipid syndrome, should get primary thromboprophylaxis. Obstetric care is based on a combination of medical and obstetric high-risk management, as well as aspirin and heparin therapy. Possible supplementary therapy for this condition is hydroxychloroquine. Statins, rituximab, and novel anticoagulant medicines are all potential future treatments for non-pregnant individuals with antiphospholipid syndrome. We aim to review the role of direct-acting oral anticoagulants (DOACs) as thromboprophylactic drugs in the treatment of APS in this article. The treatment of venous thromboembolism has been transformed by a new class of DOACs. These drugs, such as rivaroxaban, function by inhibiting factor Xa directly. Not only do they have known anticoagulant actions, but they also obviate the need for dosage monitoring and modification, in contrast to warfarin. We conducted an exhaustive literature search of PubMed/MEDLINE and Google Scholar Indexes using the keywords "Antiphospholipid syndrome," "thromboprophylaxis," and "oral anticoagulants" up to September 2021. We found that DOACs have been shown to be non-inferior to warfarin in a variety of anticoagulation situations in a number of high-powered clinical studies. In many hypercoagulable conditions such as APS, DOACs are quickly establishing themselves as first-line therapy. This article is focused on comprehensively reviewing the mechanism of action of DOACs, their role as thromboprophylactic drugs, risks and complications of DOACs, and comparing their efficacy with the standard treatment protocol and warfarin.
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Affiliation(s)
- Shreya Arora
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Shaalina Nair
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Rishab Prabhu
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Chaithanya Avanthika
- Medicine and Surgery, Karnataka Institute of Medical Sciences, Hubli, IND.,Pediatrics, Karnataka Institute of Medical Sciences, Hubli, IND
| | - Sharan Jhaveri
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Shilpa Samayam
- Internal Medicine, Government Medical College Siddipet, Siddipet, IND
| | - Maanya R Katta
- Internal Medicine, Gandhi Medical College, Hyderabad, IND
| | - Pahel Agarwal
- Internal Medicine, Bhaskar Medical College, Hyderabad, IND
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Connelly K, Morand EF. Systemic lupus erythematosus: a clinical update. Intern Med J 2021; 51:1219-1228. [PMID: 34423550 DOI: 10.1111/imj.15448] [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: 10/17/2020] [Revised: 03/11/2021] [Accepted: 04/25/2021] [Indexed: 12/21/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease known for its complexity and heterogeneity. Striking diversity can be observed between individual patients, in terms of clinical manifestations, serological abnormalities, disease progression and response to therapy. Furthermore, dysfunction of a broad range of immune pathways underlies disease development and expression. An appreciation of this diversity is vital in order to diagnose accurately and appropriately treat patients with SLE as there is no one-size-fits-all diagnostic test or treatment. Optimal management involves identifying affected organs, assessing severity, differentiating activity from irreversible damage and tailoring immunosuppressive treatment accordingly. Non-pharmacological interventions, attention to disease and treatment-related comorbidities and addressing the significant impact on health-related quality of life are also crucial to maximising patient outcomes.
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Affiliation(s)
- Kathryn Connelly
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia.,School for Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric F Morand
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia.,School for Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Demir S, Li J, Magder LS, Petri M. Antiphospholipid patterns predict risk of thrombosis in systemic lupus erythematosus. Rheumatology (Oxford) 2021; 60:3770-3777. [PMID: 33331921 DOI: 10.1093/rheumatology/keaa857] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We evaluated which aPL combinations increase the risk of future thrombosis in patients with SLE. METHODS This prospective cohort study consisted of SLE patients who had been tested for all seven aPL (LA, aCL isotypes IgM, IgG and IgA, and anti-β2-glycoprotein I isotypes IgM, IgG and IgA). Pooled logistic regression was used to assess the relationship between aPL and thrombosis. RESULTS There were 821 SLE patients with a total of 75 048 person-months of follow-up. During the follow-up we observed 88 incident cases of thrombosis: 48 patients with arterial, 37 with venous and 3 with both arterial and venous thrombosis. In individual models, LA was the most predictive of any [age-adjusted rate ratio 3.56 (95% CI 2.01, 6.30), P < 0.0001], venous [4.89 (2.25, 10.64), P < 0.0001] and arterial [3.14 (1.41, 6.97), P = 0.005] thrombosis. Anti-β2-glycoprotein I IgA positivity was a significant risk factor for any [2.00 (1.22, 3.3), P = 0.0065] and venous [2.8 (1.42, 5.51), P = 0.0029] thrombosis. Only anti-β2-glycoprotein I IgA appeared to add significant risk to any [1.73 (1.04, 2.88), P = 0.0362] and venous [2.27 (1.13, 4.59), P = 0.0218] thrombosis among those with LA. We created an interaction model with four categories based on combinations of LA and other aPL to look at the relationships between combinations and the risk of thrombosis. In this model LA remained the best predictor of thrombosis. CONCLUSION Our study demonstrated that in SLE, LA remained the best predictor of thrombosis and adding additional aPL did not add to the risk, with the exception of anti-β2-glycoprotein I IgA.
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Affiliation(s)
- Selcan Demir
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatric Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Jessica Li
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michelle Petri
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Chen FY, Chen CF, Tan AC, Chan CH, Chen FA, Liu WS, Chen TH, Ou SM, Li SY, Tsai MT, Chen YT, Lin CC. Long-term prognosis of vascular access in hemodialysis patients with systemic lupus erythematosus: a retrospective cohort study. Sci Rep 2021; 11:12519. [PMID: 34131224 PMCID: PMC8206131 DOI: 10.1038/s41598-021-92005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/27/2021] [Indexed: 11/09/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) have a higher risk of vascular complications. This retrospective cohort study aimed to analyze the differences in the risk of arteriovenous fistula or graft (AVF/AVG) dysfunction in hemodialysis patients with and without SLE from Taiwan's National Health Insurance Database over a 10-year period. AVF/AVG dysfunction is defined as the occurrence of the first episode of intervention after vascular access creation. A total of 1366 HD patients with SLE had higher incidence rates of AVF/AVG dysfunction than 4098 non-SLE HD patients in the following 4 periods: (1) after 1 year (incidence rates = 15.21% and 13.01%, respectively; subdistribution hazard ratio (SHR) = 1.16; P = 0.007), (2) 1st-to-10th-year period (15.36% and 13.25%; SHR = 1.16; P = 0.007), (3) 5th-to-10th-year period (11.91% and 8.1%; SHR = 1.42; P = 0.003), and (4) overall period (23.53% and 21.66%; SHR = 1.09; P = 0.027). In conclusion, there were significantly higher incidence rates of AVF/AVG dysfunction in SLE patients during the long-term follow-up period. Vascular access function should be monitored regularly by clinical examinations, especially after 1 year and during 5 to 10 years, to improve AVF/AVG patency and dialysis adequacy in SLE patients undergoing maintenance hemodialysis.
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Affiliation(s)
- Fan-Yu Chen
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Chun-Fan Chen
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan, Taiwan
| | - Ann Charis Tan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Chia-Hao Chan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Fu-An Chen
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan, Taiwan
| | - Wen-Sheng Liu
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei City Hospital Zhongxing Branch, Taipei, Taiwan.,Institute of Food Safety and Health Risk Assessment, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,Institute of Food Safety and Health Risk Assessment, National Yang-Ming University, Taipei, Taiwan.,College of Science and Engineering, Fu Jen Catholic University, New Taipei City, Taiwan.,University of Taipei, Taipei, Taiwan
| | - Tz-Heng Chen
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Fenglin Branch, Taipei Veterans General Hospital, Hualien, Taiwan
| | - Shuo-Ming Ou
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Szu-Yuan Li
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Ming-Tsun Tsai
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Yung-Tai Chen
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,University of Taipei, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Fuyou Branch, Taipei City Hospital Heping, Taipei, Taiwan
| | - Chih-Ching Lin
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan.
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Systematic review of observational studies reporting antiphospholipid antibodies in patients with solid tumors. Blood Adv 2021; 4:1746-1755. [PMID: 32337583 DOI: 10.1182/bloodadvances.2020001557] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/25/2020] [Indexed: 01/01/2023] Open
Abstract
This review summarizes the evidence on antiphospholipid (aPL) antibodies and related thromboembolic events in patients with solid tumors. Data sources included Medline, EMBASE, Web of Science, PubMed ePubs, and the Cochrane Central Register of Controlled Trials through August 2019 without restrictions. Observational studies that evaluated patients with solid tumors for the presence of aPL antibodies were included. Data were extracted and quality was assessed by one reviewer and cross-checked by another. Thirty-three studies were identified. Gastrointestinal (GI) and genitourinary (GU) cancers were the most frequently reported. Compared with healthy patients, patients with GI cancer were more likely to develop anticardiolipin antibodies (risk ratio [RR], 5.1; 95% confidence interval [CI], 2.6-9.95), as were those with GU (RR, 7.3; 95% CI, 3.3-16.2) and lung cancer (RR, 5.2; 95% CI, 1.3-20.6). The increased risk for anti-β2-glycoprotein I or lupus anticoagulant was not statistically significant. Patients with lung cancer who had positive aPL antibodies had higher risk of developing thromboembolic events than those who had negative antibodies (RR, 3.8%; 95% CI, 1.2-12.2), while the increased risk in patients with GU cancer was not statistically significant. Deaths due to thromboembolic events were more common among patients with lung cancer who had elevated aPL antibodies. A limitation of this review is that the results are contingent on the reported information. We found an increased risk of developing aPL antibodies in patients with GI, GU, and lung cancers resulting in thromboembolic events and death. Further studies are needed to better understand the pathogenesis and development of aPL antibodies in cancer.
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How I treat anticoagulant-refractory thrombotic antiphospholipid syndrome. Blood 2021; 137:299-309. [PMID: 32898856 DOI: 10.1182/blood.2020004942] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022] Open
Abstract
The standard treatment of thrombotic antiphospholipid syndrome (APS) is lifelong oral anticoagulation with a vitamin K antagonist (VKA), generally warfarin. A minority of patients with APS rethrombose despite seemingly adequate anticoagulation. These patients are deemed anticoagulant refractory. The management of anticoagulant-refractory APS is largely empirical and extrapolated from other clinically similar situations. Further options include increased VKA anticoagulation intensity or alternative antithrombotic strategies, including low-molecular-weight heparin, fondaparinux, the addition of antiplatelet therapy, and consideration of vascular options. Patients with anticoagulant-refractory thrombotic APS may have APS-associated thrombocytopenia, which necessitates balancing the risk of recurrent thrombosis vs bleeding to achieve adequate anticoagulation. The multiple mechanisms involved in the generation of the thrombotic phenotype in APS suggest that anticoagulation alone may not control thrombosis. Thus, other modalities, including adjunctive treatment (hydroxychloroquine, statins, and vitamin D) for APS-related thrombosis, merit consideration, as do immunomodulatory therapy and complement inhibition. Patients with APS may have coexistent systemic lupus erythematosus, which adds to the complexity of managing their thromboembolic disease. However, with attention to detail and judicious application of the limited data, it is possible to minimize the morbidity resulting from anticoagulant-refractory thrombotic APS. Multicenter studies are required to guide the sequence of interventions and their comparative efficacy in patients with anticoagulant-refractory thrombotic APS.
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Ding X, Ren Y, He X. IFN-I Mediates Lupus Nephritis From the Beginning to Renal Fibrosis. Front Immunol 2021; 12:676082. [PMID: 33959133 PMCID: PMC8093624 DOI: 10.3389/fimmu.2021.676082] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Lupus nephritis (LN) is a common complication of systemic lupus erythematosus (SLE) and a major risk factor for morbidity and mortality. The abundant cell-free nucleic (DNA/RNA) in SLE patients, especially dsDNA, is a key substance in the pathogenesis of SLE and LN. The deposition of DNA/RNA-immune complexes (DNA/RNA-ICs) in the glomerulus causes a series of inflammatory reactions that lead to resident renal cell disturbance and eventually renal fibrosis. Cell-free DNA/RNA is the most effective inducer of type I interferons (IFN-I). Resident renal cells (rather than infiltrating immune cells) are the main source of IFN-I in the kidney. IFN-I in turn damages resident renal cells. Not only are resident renal cells victims, but also participants in this immunity war. However, the mechanism for generation of IFN-I in resident renal cells and the pathological mechanism of IFN-I promoting renal fibrosis have not been fully elucidated. This paper reviews the latest epidemiology of LN and its development process, discusses the mechanism for generation of IFN-I in resident renal cells and the role of IFN-I in the pathogenesis of LN, and may open a new perspective for the treatment of LN.
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Affiliation(s)
- Xuewei Ding
- Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China.,Laboratory of Pediatric Nephrology, Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Ren
- Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China.,Laboratory of Pediatric Nephrology, Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China.,Pediatric Internal Medicine Department, Haikou Maternal and Child Health Hospital, Haikou, China
| | - Xiaojie He
- Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China.,Laboratory of Pediatric Nephrology, Institute of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
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Non-Criteria Manifestations of Juvenile Antiphospholipid Syndrome. J Clin Med 2021; 10:jcm10061240. [PMID: 33802787 PMCID: PMC8002433 DOI: 10.3390/jcm10061240] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 01/07/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder mainly characterised by increased risks of thrombosis and pregnancy morbidity and persistent positive test results for antiphospholipid antibodies (aPLs). The criteria for diagnosing juvenile APS have yet to be validated, while the Sydney classification criteria do not contain several non-thrombotic clinical manifestations associated with the presence of aPLs. As such, difficulties have been encountered in the diagnosis of patients who have no certain thrombotic occlusions. Moreover, extra-criteria manifestations (i.e., clinical manifestations not listed in the classification criteria), including neurologic manifestations (chorea, myelitis and migraine), haematologic manifestations (thrombocytopenia and haemolytic anaemia), livedo reticularis, nephropathy and valvular heart disease have been reported, which suggests that the clinical spectrum of aPL-related manifestations extends beyond that indicated in the classification criteria. Studies have demonstrated that more than 40% of children with aPLs demonstrated non-thrombotic aPL-related clinical manifestations alone. Moreover, our results showed that the pathogenesis of non-criteria manifestations is characterised by “APS vasculopathy”. The present review introduces the characteristics and findings of non-criteria manifestations observed in juvenile APS.
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Dieudonné Y, Guffroy A, Poindron V, Sprauel PS, Martin T, Korganow AS, Gies V. B cells in primary antiphospholipid syndrome: Review and remaining challenges. Autoimmun Rev 2021; 20:102798. [PMID: 33722752 DOI: 10.1016/j.autrev.2021.102798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 02/03/2023]
Abstract
It is now widely accepted that antiphospholipid antibodies (aPL) have direct pathogenic effects and that B cells, notably through aPL production, play a key role in the development of antiphospholipid syndrome (APS). Recent findings strengthened the implication of B cells with the description of specific B cell phenotype abnormalities and inborn errors of immunity involving B cell signaling in APS patients. In addition, it has been shown in preclinical models that cross-reactivity between APS autoantigens and mimotopes expressed by human gut commensals can lead to B cell tolerance breakdown and are sufficient for APS development. However, B cell targeting therapies are surprisingly not as effective as expected in APS compared to other autoimmune diseases. Elucidation of the B cell tolerance breakdown mechanisms in APS patients may help to develop and guide the use of novel therapeutic agents that target B cells or specific immune pathway.
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Affiliation(s)
- Yannick Dieudonné
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France.
| | - Aurélien Guffroy
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Poindron
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Pauline Soulas Sprauel
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
| | - Thierry Martin
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Anne-Sophie Korganow
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Gies
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
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Comparison of patients with transient and sustained increments of antiphospholipid antibodies after acute ischemic stroke. J Neurol 2021; 268:2541-2549. [PMID: 33547954 DOI: 10.1007/s00415-021-10432-w] [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: 12/14/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Antiphospholipid syndrome (APS) is one of the uncommon causes of ischemic stroke, and is associated with young and female patients. However, the significance of antiphospholipid antibody (aPL) in older ischemic stroke patients is uncertain. We aimed to examine the significance of aPLs in ischemic stroke in these older patients. MATERIALS AND METHODS A total of 739 patients with acute ischemic stroke within 7 days of initial symptoms were collected consecutively. Clinical and laboratory data were obtained from medical records. aPLs (lupus anticoagulant, anti-cardiolipin antibody, anti-β2glycoprotein-I antibody) were measured the day after admission and the presence of at least one antibody was regarded as positive aPL. Patients with positive aPL were rechecked after at least 12 weeks for confirmation of APS. RESULT Of the 739 patients, 103 (13.9%) had at least one aPL initially. These patients were older, had more atrial fibrillation and higher levels of inflammatory markers. Among the 103 aPL positive patients, 41 remained positive at 3 months, 23 showed negative conversion, and 39 were not available for follow-up. Patients diagnosed with APS had higher numbers of aPL and had specifically anti-β2glycoprotein-I IgG antibody. The patients with aPLs did not differ significantly from the others in terms of stroke subtype. CONCLUSION aPL was rather common in ischemic stroke patients regardless of age. Although the influence of transient positive aPL on ischemic stroke remains uncertain, two or more aPLs and the presence of anti-β2glycoprotein-I IgG may predict a diagnosis of APS.
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Tung ML, Tan B, Cherian R, Chandra B. Anti-phospholipid syndrome and COVID-19 thrombosis: connecting the dots. Rheumatol Adv Pract 2021; 5:rkaa081. [PMID: 33615129 PMCID: PMC7882149 DOI: 10.1093/rap/rkaa081] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is spreading rapidly worldwide, it has emerged as a leading cause of mortality, resulting in >1 million deaths over the past 10 months. The pathophysiology of COVID-19 remains unclear, posing a great challenge to the medical management of patients. Recent studies have reported an unusually high prevalence of thromboembolic events in COVID-19 patients, although the mechanism remains elusive. Several studies have reported the presence of aPLs in COVID-19 patients. We have noticed similarities between COVID-19 and APS, which is an autoimmune prothrombotic disease that is often associated with an infective aetiology. Molecular mimicry and endothelial dysfunction could plausibly explain the mechanism of thrombogenesis in acquired APS. In this review, we discuss the clinicopathological similarities between COVID-19 and APS, and the potential role of therapeutic targets based on the anti-phospholipid model for COVID-19 disease.
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Affiliation(s)
- Moon Ley Tung
- Department of Hematology and Oncology, National University Cancer Institute
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Bryce Tan
- Department of Medicine, National University Hospital
| | - Robin Cherian
- Yong Loo Lin School of Medicine, National University of Singapore
- Department of Cardiology, National University Heart Centre Singapore
| | - Bharatendu Chandra
- Yong Loo Lin School of Medicine, National University of Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
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Muelleman TJ, Alonso J, Barnard ZR, Maxwell AK, Mahboubi H, Stefan M, Lekovic GP, Slattery WH, Brackmann DE. Hypercoagulability in Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e222-e226. [PMID: 33065597 DOI: 10.1097/mao.0000000000002934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature. PATIENTS Two patients who underwent resection of vestibular schwannomas. INTERVENTIONS Surgical resection and diagnostic testing. MAIN OUTCOME MEASURES Postoperative venous thromboses. RESULTS One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course. CONCLUSIONS In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.
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Affiliation(s)
- Thomas J Muelleman
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Jose Alonso
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Anne K Maxwell
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Hossein Mahboubi
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Gregory P Lekovic
- Division of Neurosurgery, House Ear Institute, Los Angeles, California
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Htut TW, Milne D, Khan MM, Watson HG. Outcomes in patients with nontriple antiphospholipid syndrome (APS) anticoagulated with rivaroxaban. Int J Lab Hematol 2021; 43:e252-e253. [PMID: 33470532 DOI: 10.1111/ijlh.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/21/2020] [Accepted: 12/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Thura Win Htut
- Department Haematology, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Denis Milne
- Department Haematology, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Mohammed M Khan
- Department Haematology, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Henry G Watson
- Department Haematology, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
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Gairing SJ, Kloeckner R, Pitton MB, Baumgart J, von Auer-Wegener C, Lang H, Galle PR, Foerster F, Schattenberg JM. Multidisciplinary approach to the complex treatment for non-cirrhotic portal hypertension - case-report-based discussion. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:43-49. [PMID: 33429449 DOI: 10.1055/a-1330-9827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Non-cirrhotic portal vein thrombosis (PVT) in patients with antiphospholipid syndrome (APS) is a rare complication, and the management has to be determined individually based on the extent and severity of the presentation. We report on a 37-year-old male patient with non-cirrhotic chronic PVT related to a severe thrombophilia, comprising APS, antithrombin-, factor V- and factor X-deficiency. Three years after the initial diagnosis of non-cirrhotic PVT, the patient presented with severe hemorrhagic shock related to acute bleeding from esophageal varices, requiring an emergency transjugular intrahepatic portosystemic stent shunt (TIPSS). TIPSS was revised after a recurrent bleeding episode due to insufficient reduction of the portal pressure. Additionally, embolization of the dilated V. coronaria ventriculi led to the regression of esophageal varices but resulted simultaneously in a left-sided portal hypertension (LSPH) with development of stomach wall and perisplenic varices. After a third episode of acute esophageal varices bleeding, a surgical distal splenorenal shunt (Warren shunt) was performed to reduce the LSPH. Despite anticoagulation with low molecular weight heparin and antithrombin substitution, endoluminal thrombosis led to a complete Warren shunt occlusion, aggravating the severe splenomegaly and pancytopenia. Finally, a partial spleen embolization (PSE) was performed. In the postinterventional course, leukocyte and platelet counts increased rapidly and the patient showed no further bleeding episodes. Overall, this complex course demonstrates the need for individual assessment of multimodal treatment options in non-cirrhotic portal hypertension. This young patient required triple modality porto-systemic pressure reduction (TIPSS, Warren shunt, PSE) and involved finely balanced anticoagulation and bleeding control.
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Affiliation(s)
- Simon J Gairing
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Roman Kloeckner
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Michael B Pitton
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Janine Baumgart
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Charis von Auer-Wegener
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Hauke Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Peter R Galle
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Friedrich Foerster
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Jörn M Schattenberg
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
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Abstract
Liver involvement in rheumatic diseases may occur as a primary liver disease, primary rheumatic disease with hepatic manifestations or antirheumatic drug-induced liver disease. The aim of our article is to underline the importance of monitoring and control of the level of aminotransferases and cholestatic enzymes in rheumatic disorders. Some of the rheumatic diseases with constantly elevated liver enzymes need to be investigated in consideration of concomitant primary autoimmune liver disease (such as autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis) or drug hepatotoxicity. Also, we should be aware of hepatitis B reactivation or hepatitis C flare when immunosuppressants are used.
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