Clinical performance of antibodies to prothrombin and thrombin in Chinese patients with antiphospholipid syndrome: potential interest in discriminating patients with thrombotic events and non-thrombotic events

Clinical phenotype, treatment strategy and pregnancy outcome of non-criteria obstetric antiphospholipid syndrome

PROBLEM

To illustrate the clinical features, treatment strategy, and pregnancy outcome of patients with obstetric antiphospholipid syndrome (OAPS), non-criteria obstetric antiphospholipid syndrome (NC-OAPS) METHOD OF STUDY: A single-center nested case-control study was designed. Patients with a diagnosis of OAPS and NC-OAPS were enrolled. The medical history, coagulation status, and antibody profile data were collected. Patients were given standard anticoagulation therapy with or without glucocorticoids (GC) and/or hydroxychloroquine (HCQ) during pregnancy and were observed for their pregnancy outcome.

RESULTS

A total of 47 patients with OAPS and 120 patients with NC-OAPS were finally included, of whom 55 patients met the clinical criteria (subgroup C) and 65 met the laboratory criteria (subgroup L). Pregnancy morbidity showed significant differences: gravida, pregnancy loss in OAPS versus NC-OAPS. The coagulation function was not significantly different between OAPS and NC-OAPS groups, while TT and FIB were significantly higher in the subgroup C. Thromboelastography (TEG) results showed a significantly lower ANGEL in the NC-OAPS group, a higher ANGEL and lower EPL, LY30 in the subgroup L. No differences between groups were observed in treatment strategy. The pregnancy outcomes were not significantly different between NC-OAPS and OAPS groups.

CONCLUSIONS

Clinical and laboratory differences were found between OAPS and NC-OAPS groups in this study. Patients in different subgroups of NC-OAPS could be identified with different clinical phenotypes. A relatively hypercoagulable status existed in the OAPS group compared to NC-OAPS, and also in the subgroup L.

Neurologic Manifestations of the Antiphospholipid Syndrome - an Update

PURPOSE OF REVIEW

In recent years, the spectrum of neurological manifestations of antiphospholipid syndrome (APS) has been growing. We provide a critical review of the literature with special emphasis on presentation, proposed mechanisms of disease, and treatment of neurological involvement in APS.

RECENT FINDINGS

Although stroke is the most common cause of neurological manifestations in patients with APS, other neurological disorders have been increasingly associated with the disease, including cognitive dysfunction, headache, and epilepsy. Direct oral anticoagulants have failed to show non-inferiority compared to vitamin K antagonists for the prevention of major thrombotic events. Antiphospholipid antibodies are often found in patients with acute COVID-19 but clear evidence supporting an association between these antibodies and the risk of thrombotic events, including stroke and cerebral venous thrombosis, is still lacking. APS patients may present with several distinct neurological manifestations. New criteria will facilitate the classification of patients presenting with increasingly recognized non-criteria neurological manifestations.

Profiles of criteria and non-criteria anti-phospholipid autoantibodies are associated with clinical phenotypes of the antiphospholipid syndrome

Background

Specific anti-phospholipids antibodies (aPLs) are used as classification criteria of the antiphospholipid syndrome (APS). These aPLs, although essential for diagnosis, do not predict disease phenotypes, which may require specific therapies. Non-criteria aPLs are rarely evaluated and their role is yet to be defined. In the current study, we aimed to examine the association between criteria and non-criteria aPLs and APS phenotypes.

Methods

Serum samples from 188 subjects, 130 APS patients and 58 controls were analyzed for the presence of 20 aPLs (IgG and IgM isotypes to cardiolipin (CL), beta2-glycoprotein1 (β2GP1), phosphatidic acid (P-acid), phosphatidylcholine (PC), phosphatidylethanolamine (PE), phosphatidylglycerol (PG), phosphatidylinositol (PI), phosphatidylserine (PS), annexin-5 (AN) and prothrombin (PT) using a line immunoassay (GA Generic Assays, Germany). Sero-positivity to the different aPLs/aPLs profiles was correlated to APS phenotypes (i.e. arterial thrombosis, CNS manifestations, venous thrombosis, relapsing disease, obstetric morbidity).

Results

In this cohort, arterial thrombosis was associated with accumulative number of ≥ 7/20 aPLs evaluated (OR 4.1; CI 95% 1.9–96, p = 0.001) as well as the sole presence of aPT (IgG) (OR 2.3;CI 95% 1.1–5.1, p = 0.03). CNS manifestations were linked with a profile of 4 aPLs (IgG): aPT, aPG, aPI and aAN (OR 2.6;CI 95% 1.1–6.3, p = 0.03). Symptom-free period of ≥ 3 years was linked with lower number of aPLs and the presence of aPI (IgG) (OR 3.0;CI 95% 1.08–8.1, p < 0.05) or aAN (IgG) (OR 3.4;CI 95% 1.08–10.9, p < 0.05). APS related pregnancy morbidity correlated with a profile of 2 aPLs (IgG): aCL and aPS (OR 2.9; CI 95% 1.3–6.5, p < 0.05) or the sole presence of aAN (IgG) (OR 2.8; CI 95% 1.02–8, p = 0.05).

Conclusion

In this study, we observed an association between specific criteria/non-criteria aPLs or aPLs profiles and clinical phenotypes of APS. Our data suggest that examination of a wider variety of aPLs may allow better characterization of APS.

Characteristics of pregnancy complications and treatment in obstetric antiphospholipid syndrome in China

OBJECTIVES

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by obstetric complications and thrombotic events associated with antiphospholipid antibodies (aPL). We aimed to compare the clinical characteristics and treatment of primary APS (PAPS) and secondary APS (systemic lupus erythematosus-APS, SAPS) patients and investigate risk factors associated with obstetric complications in Shanghai, China.

METHODS

We retrospectively collected and analyzed the data of obstetric APS (OAPS) patients from 2000 to 2017 in the APS-Shanghai (APS-SH) database.

RESULTS

One hundred eighty OAPS patients with a total of 450 pregnancies were included in this study. Two hundred twenty-one (49.11%) pregnancies resulted in miscarriage, and 161 (35.77%) pregnancies resulted in intrauterine death. In our cohort, when women were treated, 57 out of 66 pregnancies resulted in live births (86%). Of the 9 treated patients who failed to have live births, 3 had intrauterine deaths, 3 had fetal growth restriction, 2 had pneumorrhagia of the newborn, and 1 had a miscarriage. OAPS patients were divided into two groups: PAPS and SAPS. More SAPS patients than PAPS patients used glucocorticoids (GCs) and hydroxychloroquine (both p < 0.001). However, there was no significant difference in the GC dosage between SAPS and PAPS patients (p = 0.188). Lupus anticoagulant (LAC) and IgG aβ2GPI were risk factors for miscarriage (odds ratio (OR) = 2.398, 95% confidence interval (CI) = 1.276-4.505, p = 0.002; OR = 2.907, 95% CI = 1.558-5.405, p = 0.001, respectively) and intrauterine death (OR = 2.439, 95% CI = 1.299-4.580, p = 0.006; OR = 2.060, 95% CI = 1.089-3.897, p = 0.026, respectively).

CONCLUSIONS

The live birth rate of OAPS patients in Shanghai was 86%. Even if OAPS patients were treated, pregnancy complications could occur, and these patients might need further second-line treatment. Key Points • This is the first study to report data on Chinese OAPS patients. The live birth rate was 86%. • Lupus anticoagulant and IgG aβ2GPI were risk factors for miscarriage and intrauterine death in our cohort. • Despite active treatment, 9 patients had obstetric complications. Therefore, further second-line treatment is still needed.

Clinical performance of non-criteria antibodies to phospholipids in Chinese patients with antiphospholipid syndrome

BACKGROUND

Increasing evidence suggests the role of non-criteria aPLs as important supplements to the current criteria aPLs in APS. In this study, we evaluated the clinical performance of a panel of non-criteria antibodies to phospholipid antigens, including, phosphatidylserine (aPS), phosphatidylinositol (aPI), sphingomyelin (aSM), phosphatidylcholine (aPC) and phosphatidylethanolamine (aPE) in a well-defined Chinese APS cohort.

METHODS

A total of 229 subjects were tested, including 86 patients with APS, 104 disease controls (DCs) and 39 healthy controls (HCs). Serum IgG/IgM aCL, IgG/IgM aβ2GP1, IgG/IgM aPS, IgG/IgM aPI, IgG/IgM aSM, IgG/IgM aPC, and IgG/IgM aPE were tested by ELISA.

RESULTS

The presence of aPE, aPS, aPI, aPC, and aSM in patients with APS and Disease Controls were 8.1% (7/86) and 1.0% (1/104), 37.2% (32/86) and 9.6% (10/104), 50.0% (43/86) and 8.7% (9/104), 23.3% (20/86) and 1.0% (1/104), and 18.6% (16/86) and 1.9% (2/104), respectively. In criteria aPLs, aCL IgG demonstrated the highest positive likelihood ratio (LR+) of 35.75, followed by LA (LR+ of 13.51) and aCL IgM (LR+ of 11.64). In non-criteria aPLs, aPC IgG demonstrated the highest LR+ of 24.94 followed by aSM IgM (LR+ of 14.97). Importantly, the non-criteria aPLs were detected in 18.8% (3/16) of seronegative APS patients. The criteria aPLs, including LA, IgG aCL and IgG aβ2GPI, were significantly correlated with both arterial thrombosis and venous thrombosis, while the non-criteria aPLs, including IgG aPS, IgM aPS, IgG aPI and IgG aPC were significantly associated with arterial thrombosis but not venous thrombosis.

CONCLUSIONS

In summary, our findings indicate that those non-criteria aPLs may be particularly helpful for patients in whom APS is highly suspected, but conventional aPLs are repeatedly negative as well as for predicting APS patients with arterial thrombosis.

Antibodies to phosphatidylserine/prothrombin (aPS/PT) enhanced the diagnostic performance in Chinese patients with antiphospholipid syndrome

Background:

Increasing evidence has highlighted the role of non-criteria antiphospholipid antibodies (aPLs) as important supplements to the current criteria aPLs for the diagnosis of antiphospholipid syndrome (APS). In this retrospective study, we evaluated the clinical relevance of antibodies to phosphatidylserine/prothrombin (aPS/PT) in Chinese patients with APS.

Methods:

A total of 441 subjects were tested, including 101 patients with primary APS (PAPS), 140 patients with secondary APS (SAPS), 161 disease controls (DCs) and 39 healthy controls (HCs). Serum IgG/IgM aPS/PT was determined by ELISA.

Results:

The levels of IgG/IgM aPS/PT were significantly increased in patients with APS compared with DCs and HCs. IgG and IgM aPS/PT were present in 29.7% and 54.5% of PAPS, and 42.1% and 53.6% of SAPS, respectively. For diagnosis of APS, IgG aCL exhibited the highest positive likelihood ratio (LR+) of 21.60, followed by LA (13.84), IgG aβ2GP1 (9.19) and IgG aPS/PT (8.49). aPS/PT was detected in 13.3% of seronegative PAPS patients and 31.3% of seronegative SAPS patients. LA exhibited the highest OR of 3.64 in identifying patients with thrombosis, followed by IgG aCL (OR, 2.63), IgG aPS/PT (OR, 2.55) and IgG aβ2GP1 (OR, 2.33). LA and IgG aCL were correlated with both arterial and venous thrombosis, whereas IgG aPS/PT and IgG aβ2GP1 correlated with venous or arterial thrombosis, respectively.

Conclusions:

Our findings suggest that the inclusion of IgG/IgM aPS/PT may enhance the diagnostic performance for APS, especially in those in whom APS is highly suspected, but conventional aPLs are repeatedly negative. In addition, IgG aPS/PT may contribute to identify patients at risk of thrombosis.