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Carrara C, Mataj B, Gastoldi S, Ruggenenti P, Sciascia S, Roccatello D. Case report: Timing of eculizumab treatment in catastrophic antiphospholipid syndrome. Front Immunol 2024; 15:1460317. [PMID: 39318635 PMCID: PMC11419984 DOI: 10.3389/fimmu.2024.1460317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/20/2024] [Indexed: 09/26/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening condition of small-vessel thrombosis with acute multiple-organ involvement and visceral damage. In this report, we present a case of a patient with CAPS who is refractory to conventional therapy. For the first time in a patient with CAPS, marked C5b-9 formation was demonstrated on microvascular endothelial cells, suggesting the usefulness of therapeutic complement inhibition in this setting. Eculizumab, a C5-blocking monoclonal antibody, is remarkably effective in the treatment of different forms of thrombotic microangiopathy by controlling complement system hyperactivation. It halted the "thrombotic storm" and promptly achieved full recovery of thrombocytopenia. However, kidney function did not recover, possibly because eculizumab was administered too late. Conceivably, the timing of treatment is crucial to achieving disease remission before irreversible structural damage occurs in target organs, thereby preventing their complete functional recovery.
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Affiliation(s)
- Camillo Carrara
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - Blerina Mataj
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - Piero Ruggenenti
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - 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, San Giovanni Bosco Hub Hospital ASL Città di Torino and Department of Clinical and Biological Sciences, Turin, Italy
| | - Dario Roccatello
- 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, San Giovanni Bosco Hub Hospital ASL Città di Torino and Department of Clinical and Biological Sciences, Turin, Italy
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2
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024; 106:369-391. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [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: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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3
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Varotto L, Spigolon L, Dotto A, Leonardi D, Bragantini G, Cerrito LF, Deluca C, Hoxha A. Myocardial Involvement in Catastrophic Antiphospholipid Syndrome during Pregnancy or Puerperium: A Case of a Young Breastfeeding Woman and Literature Review. J Clin Med 2024; 13:4732. [PMID: 39200874 PMCID: PMC11355751 DOI: 10.3390/jcm13164732] [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: 07/08/2024] [Revised: 07/27/2024] [Accepted: 07/27/2024] [Indexed: 09/02/2024] Open
Abstract
Catastrophic Antiphospholipid Syndrome (CAPS) is a rare complication that can occur in patients with Antiphospholipid Syndrome (APS). CAPS occurs even more rarely during pregnancy/puerperium and pregnant patients, even less likely to show cardiac involvement without signs of damage on ultrasound and angiography with non-obstructive coronary arteries. We present a case of a 26-year-old breastfeeding woman, the youngest described with CAPS and acute myocardial infarction, whose diagnosis was made with cardiac magnetic resonance imaging (CMRI). A literature review of pregnant patients with similar problems was performed. There are diagnostic and therapeutic difficulties in treating these patients. CMRI demonstrated a transmural late enhancement area. A combination of therapies led to rapid clinical improvement. CMRI is an underused tool that reaffirms the pathophysiology of CAPS and leads clinicians to the possibility of a diffuse thrombotic process. CAPS involves more organs with high mortality rates. CMRI could be optimized in order to reach an early diagnosis and the most effective treatment. This study provides real-world evidence of the feasibility of MRI in a primary care setting during pregnancy/puerperium. Evidence from this study may influence future APS screening and inform policymakers regarding the use of leading MRI technology in the detection of the thrombotic process in a primary care setting.
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Affiliation(s)
- Leonardo Varotto
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Luca Spigolon
- Department of Radiology, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy;
| | - Alberto Dotto
- Department of Medicine—Division of Cardiology, University of Verona, Piazzale A. Stefani 1, 37126 Verona, Italy; (A.D.); (D.L.)
| | - Denis Leonardi
- Department of Medicine—Division of Cardiology, University of Verona, Piazzale A. Stefani 1, 37126 Verona, Italy; (A.D.); (D.L.)
| | - Giulia Bragantini
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Luca Felice Cerrito
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Cristina Deluca
- Department of Neurology, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy;
| | - Ariela Hoxha
- Internal Medicine Unit, Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University of Padua, via Giustiniani 2, 35128 Padova, Italy;
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Zen M, Tonello M, Favaro M, Del Ross T, Calligaro A, Giollo A, Vesentini F, Gennaio IA, Arru F, Ruffatti A, Doria A. Antiphospholipid antibody carriers and patients with quiescent antiphospholipid syndrome show persistent subclinical complement activation. Rheumatology (Oxford) 2024; 63:1733-1738. [PMID: 37774001 DOI: 10.1093/rheumatology/kead517] [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: 07/13/2023] [Revised: 08/20/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVES Complement activation has been advocated as one mechanism by which aPLs can induce thrombosis. In patients with catastrophic APS or re-thrombosis, enhanced complement activation has been shown, even in the quiescent phase of the disease. We aimed to assess complement activation and to investigate its association with clinical variables in aPL-positive patients with a favourable disease course. METHODS Subjects with at least two consecutive positive aPL results obtained ≥12 weeks apart were enrolled. They were subjects without a history of thrombosis or pregnancy morbidity (aPL carriers), patients with pregnancy morbidity alone, i.e. obstetric APS patients (OAPS patients), and/or patients with arterial, venous, or small-vessel thrombotic APS (TAPS patients); for enrolment, all patients were required to have been free of symptoms for ≥2 years. Patients affected with systemic autoimmune diseases were excluded. Healthy age- and sex-matched subjects were included as controls. Plasma C5a and C5b-9 levels were assessed by commercially available ELISA assays. The non-parametric Mann-Whitney test and Spearman's correlation were applied. RESULTS Thirty-seven OAPS patients, 38 TAPS patients, 42 aPL carriers and 30 healthy subjects were enrolled. The median C5a and C5b-9 levels were significantly higher in quiescent aPL-positive patients (OAPS, TAPS, aPL carriers) compared with controls: C5a ng/ml 10.61 [interquartile range (IQR) 6.87-15.46] vs 4.06 (2.66-7.35), P < 0.001; C5b-9 ng/ml 283.95 (175.8-439.40) vs 165.90 (124.23-236.8), P < 0.001. Similar C5a and C5b-9 levels were observed in OAPS and TAPS patients and aPL carriers. A positive correlation between the median C5b-9 levels and the number of aPL-positive tests was found (P = 0.002). CONCLUSION The persistence of aPL antibodies is associated with a persistent subclinical activation of the complement cascade.
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Affiliation(s)
- Margherita Zen
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Marta Tonello
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Maria Favaro
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Teresa Del Ross
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Antonia Calligaro
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Alessandro Giollo
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Filippo Vesentini
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Ilenia Anna Gennaio
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Federico Arru
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Amelia Ruffatti
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Andrea Doria
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
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Jacobs L, Wauters N, Lablad Y, Morelle J, Taghavi M. Diagnosis and Management of Catastrophic Antiphospholipid Syndrome and the Potential Impact of the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Antibodies (Basel) 2024; 13:21. [PMID: 38534211 DOI: 10.3390/antib13010021] [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: 12/31/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and life-threatening condition characterized by the persistence of antiphospholipid antibodies and occurrence of multiple vascular occlusive events. CAPS currently remains a diagnostic challenge and requires urgent treatment. The diagnosis of CAPS is made difficult by classification criteria used as diagnostic criteria in clinical practice, knowledge derived from retrospective data and case reports, confounding clinical and biological features, and its rapid onset and mortality. The absence of prospective studies of CAPS limits the strength of evidence for guideline treatment protocols. This comprehensive review summarizes the current understanding of the disease, and discusses how the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria impact the definition and therapeutic management of CAPS, which is considered the most severe form of APS. The correct integration of 2023 ACR/EULAR APS classification criteria is poised to facilitate CAPS diagnosis, particularly in critical situations, offering a promising avenue for improved outcomes.
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Affiliation(s)
- Lucas Jacobs
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Nader Wauters
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Yahya Lablad
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Namur University Hospitals (CHU UCL Namur), 5000 Namur, Belgium
| | - Maxime Taghavi
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
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6
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Raschi E, Borghi MO, Tedesco F, Meroni PL. Antiphospholipid syndrome pathogenesis in 2023: an update of new mechanisms or just a reconsideration of the old ones? Rheumatology (Oxford) 2024; 63:SI4-SI13. [PMID: 38320591 DOI: 10.1093/rheumatology/kead603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/27/2023] [Indexed: 02/08/2024] Open
Abstract
Antibodies against phospholipid (aPL)-binding proteins, in particular, beta 2 glycoprotein I (β2GPI), are diagnostic/classification and pathogenic antibodies in antiphospholipid syndrome (APS). β2GPI-aPL recognize their target on endothelium and trigger a pro-thrombotic phenotype which is amplified by circulating monocytes, platelets and neutrophils. Complement activation is required as supported by the lack of aPL-mediated effects in animal models when the complement cascade is blocked. The final result is a localized clot. A strong generalized inflammatory response is associated with catastrophic APS, the clinical variant characterized by systemic thrombotic microangiopathy. A two-hit hypothesis was suggested to explain why persistent aPL are associated with acute events only when a second hit allows antibody/complement binding by modulating β2GPI tissue presentation. β2GPI/β2GPI-aPL are also responsible for obstetric APS, being the molecule physiologically present in placental/decidual tissues. Additional mechanisms mediated by aPL with different characteristics have been reported, but their diagnostic/prognostic value is still a matter of research.
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Affiliation(s)
- Elena Raschi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Maria Orietta Borghi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesco Tedesco
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
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7
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Bitsadze V, Yakubova F, Khizroeva J, Lazarchuk A, Salnikova P, Vorobev A, Tretyakova M, Degtyareva N, Grigoreva K, Gashimova N, Kvaratskheliia M, Makatsariya N, Kudryavtseva E, Tomlenova A, Gris JC, Elalamy I, Ay C, Makatsariya A. Catastrophic Antiphospholipid Syndrome. Int J Mol Sci 2024; 25:668. [PMID: 38203837 PMCID: PMC10779422 DOI: 10.3390/ijms25010668] [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: 11/24/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Unlike classic APS, CAPS causes multiple microthrombosis due to an increased inflammatory response, known as a "thrombotic storm". CAPS typically develops after infection, trauma, or surgery and begins with the following symptoms: fever, thrombocytopenia, muscle weakness, visual and cognitive disturbances, abdominal pain, renal failure, and disseminated intravascular coagulation. Although the presence of antiphospholipid antibodies in the blood is one of the diagnostic criteria, the level of these antibodies can fluctuate significantly, which complicates the diagnostic process and can lead to erroneous interpretation of rapidly developing symptoms. Triple therapy is often used to treat CAPS, which includes the use of anticoagulants, plasmapheresis, and high doses of glucocorticosteroids and, in some cases, additional intravenous immunoglobulins. The use of LMWH is recommended as the drug of choice due to its anti-inflammatory and anticoagulant properties. CAPS is a multifactorial disease that requires not only an interdisciplinary approach but also highly qualified medical care, adequate and timely diagnosis, and appropriate prevention in the context of relapse or occurrence of the disease. Improved new clinical protocols and education of medical personnel regarding CAPS can significantly improve the therapeutic approach and reduce mortality rates.
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Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nataliya Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Ekaterina Kudryavtseva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Anna Tomlenova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, 34093 Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, 75012 Paris, France
- Hospital Tenon, 4 Rue de la Chine, 75020 Paris, France
| | - Cihan Ay
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, 1080 Vienna, Austria
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
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8
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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9
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Pengo V, Denas G. Antiphospholipid Syndrome in Patients with Venous Thromboembolism. Semin Thromb Hemost 2023; 49:833-839. [PMID: 35728601 DOI: 10.1055/s-0042-1749590] [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: 10/18/2022]
Abstract
Unprovoked (or provoked by mild risk factors) venous thromboembolism (VTE) in young patients, VTE in uncommon sites, or cases of unexplained VTE recurrence may be positive for antiphospholipid antibodies (aPL) and thus may be diagnosed with antiphospholipid syndrome (APS). The evaluation of aPL is standardized using immunological tests for anticardiolipin and anti-β2-glycoprotein I. The determination of functional antibodies (lupus anticoagulant) is less standardized, especially in patients on anticoagulant treatment. Patients positive for all the three tests are at high risk of recurrence, which, in turn, might lead to chronic obstruction of pulmonary vessels (chronic thromboembolic pulmonary hypertension). Randomized clinical trials have shown that triple-positive patients should be treated with vitamin K antagonists maintaining an international normalized ratio between 2 and 3. Whether patients with VTE and incomplete aPL profile can be treated with direct oral anticoagulants should be further investigated.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Gentian Denas
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
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10
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Capolla S, Colombo F, De Maso L, Mauro P, Bertoncin P, Kähne T, Engler A, Núñez L, Spretz R, Larsen G, Dal Bo M, Toffoli G, Macor P. Surface antibody changes protein corona both in human and mouse serum but not final opsonization and elimination of targeted polymeric nanoparticles. J Nanobiotechnology 2023; 21:376. [PMID: 37838659 PMCID: PMC10576379 DOI: 10.1186/s12951-023-02134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Nanoparticles represent one of the most important innovations in the medical field. Among nanocarriers, polymeric nanoparticles (PNPs) attracted much attention due to their biodegradability, biocompatibility, and capacity to increase efficacy and safety of encapsulated drugs. Another important improvement in the use of nanoparticles as delivery systems is the conjugation of a targeting agent that enables the nanoparticles to accumulate in a specific tissue. Despite these advantages, the clinical translation of therapeutic approaches based on nanoparticles is prevented by their interactions with blood proteins. In fact, the so-formed protein corona (PC) drastically alters the biological identity of the particles. Adsorbed activated proteins of the complement cascade play a pivotal role in the clearance of nanoparticles, making them more easily recognized by macrophages, leading to their rapid elimination from the bloodstream and limiting their efficacy. Since the mouse is the most used preclinical model for human disease, this work compared human and mouse PC formed on untargeted PNPs (uPNPs) and targeted PNPs (tPNPs), paying particular attention to complement activation. RESULTS Mouse and human serum proteins adsorbed differently to PNPs. The differences in the binding of mouse complement proteins are minimal, whereas human complement components strongly distinguish the two particles. This is probably due to the human origin of the Fc portion of the antibody used as targeting agent on tPNPs. tPNPs and uPNPs mainly activate complement via the classical and alternative pathways, respectively, but this pattern did not affect their binding and internalization in macrophages and only a limited consumption of the activity of the human complement system was documented. CONCLUSIONS The results clearly indicate the presence of complement proteins on PNPs surface but partially derived from an unspecific deposition rather than an effective complement activation. The presence of a targeting antibody favors the activation of the classical pathway, but its absence allows an increased activation of the alternative pathway. This results in similar opsonization of both PNPs and similar phagocytosis by macrophages, without an impairment of the activity of circulating complement system and, consequently, not enhancing the susceptibility to infection.
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Affiliation(s)
- Sara Capolla
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico (CRO) di Aviano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, 33081, Italy
| | - Federico Colombo
- Institute for Molecular Systems Engineering and Advanced Materials (IMSEAM), Ruprecht-Karls-Universität Heidelberg, Im Neuenheimer Feld 225, 69120, Heidelberg, Germany
- Department of Life Sciences, University of Trieste, via L. Giorgieri n. 5, Trieste, 34127, Italy
| | - Luca De Maso
- Department of Life Sciences, University of Trieste, via L. Giorgieri n. 5, Trieste, 34127, Italy
| | - Prisca Mauro
- Department of Life Sciences, University of Trieste, via L. Giorgieri n. 5, Trieste, 34127, Italy
| | - Paolo Bertoncin
- Department of Life Sciences, University of Trieste, via L. Giorgieri n. 5, Trieste, 34127, Italy
| | - Thilo Kähne
- Institute of Exptl. Internal Medicine, Medical Faculty, Otto von Guericke University, Magdeburg, 39120, Germany
| | - Alexander Engler
- Institute of Exptl. Internal Medicine, Medical Faculty, Otto von Guericke University, Magdeburg, 39120, Germany
| | - Luis Núñez
- BioTarget Inc, Chicago, IL, USA
- Natural Science Department, Concordia University, 7400 Augusta St, River Forest, IL, 60305, USA
- LNK Chemsolutions LLC, Lincoln, NE, USA
| | - Ruben Spretz
- BioTarget Inc, Chicago, IL, USA
- LNK Chemsolutions LLC, Lincoln, NE, USA
| | - Gustavo Larsen
- BioTarget Inc, Chicago, IL, USA
- LNK Chemsolutions LLC, Lincoln, NE, USA
- Department of Chemical and Biochemical Engineering, University of Nebraska Lincoln, Lincoln, NE, USA
| | - Michele Dal Bo
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico (CRO) di Aviano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, 33081, Italy
| | - Giuseppe Toffoli
- Experimental and Clinical Pharmacology Unit, Centro di Riferimento Oncologico (CRO) di Aviano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, 33081, Italy
| | - Paolo Macor
- Department of Life Sciences, University of Trieste, via L. Giorgieri n. 5, Trieste, 34127, Italy.
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11
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Tarzia V, Bagozzi L, Ponzoni M, Pradegan N, Banchelli F, Bortolussi G, Bellanti E, Bianco R, Zanella F, Bottio T, Gregori D, Gerosa G. Prognosticating Mortality of Primary Cardiogenic Shock Requiring Extracorporeal Life Support: The RESCUE Score. Curr Probl Cardiol 2023; 48:101554. [PMID: 36529235 DOI: 10.1016/j.cpcardiol.2022.101554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
We aimed to identify prognostic laboratory markers during extracorporeal life support (ECLS) in patients with primary refractory cardiogenic shock (RCS) and to create a preliminary specific mortality score. All 208 consecutive subjects admitted for primary RCS and treated with ECLS between January-2009 and December-2018 were retrospectively analyzed. Multivariate regression analysis on laboratory markers during the first nine days of ECLS was used to develop a "Refractory End-stage Shock CUred with Ecls" (RESCUE) score. Serum creatinine (OR = 3.72, 95%CI: 2.01-6.88), direct bilirubin (OR = 1.40, 95%CI: 1.05-1.8), and platelet count (OR = 0.62, 95%CI: 0.42-0.94) were independent predictors of in-hospital mortality and were included in the score. The mean AUC was 0.763 (95%CI: 0.698-0.828) in the development cohort and 0.729 (95%CI: 0.664-0.794) in the bootstrap internal validation cohort. The RESCUE score represents a novel promising instrument to predict early mortality during the first critical days of ECLS and to help in properly guiding the therapeutic decision-making process.
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Affiliation(s)
- Vincenzo Tarzia
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy.
| | - Lorenzo Bagozzi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Matteo Ponzoni
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Federico Banchelli
- Statistics Unit, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giacomo Bortolussi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Ermanno Bellanti
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Roberto Bianco
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Fabio Zanella
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Tomaso Bottio
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
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12
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Tarzia V, Ponzoni M, Pittarello D, Gerosa G. Planned Combo Strategy for LVAD Implantation in ECMO Patients: A Proof of Concept to Face Right Ventricular Failure. J Clin Med 2022; 11:jcm11237062. [PMID: 36498641 PMCID: PMC9740870 DOI: 10.3390/jcm11237062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/20/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022] Open
Abstract
We propose a patient-tailored strategy that considers the risk for postoperative right heart failure, utilizing the percutaneous ProtekDuo cannula (Livanova, London, UK) in an innovative way to perform cardiopulmonary bypass during LVAD implantation in ECMO patients. Our novel protocol is based on the early intra-operative use of the ProtekDuo cannula, adopting the distal lumen as the pulmonary vent and the proximal lumen as the venous inflow cannula during cardiopulmonary bypass. This configuration is rapidly switched to the standard fashion to provide planned postoperative temporary right ventricular support, in selected patients at high risk of right ventricular failure. From September 2020 to June 2022, six patients were supported with the ProtekDuo cannula during and after an intracorporeal LVAD implantation (five of which were minimally invasive): four HeartMate III (Abbott, U.S.A.) and two HVAD (Medtronic Inc, MN). In all cases, the ProtekDuo cannula was correctly positioned and removed without complications after a median period of 8 days. Non-fatal bleeding (bronchial hemorrhage) occurred in one patient (17%) during biventricular support. Thirty-day mortality was 0%. From this preliminary work, our novel strategy demonstrated to be a feasible solution for planned minimally invasive right ventricular support in ECMO patients scheduled for a durable LVAD implantation.
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Affiliation(s)
- Vincenzo Tarzia
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-0498212412; Fax: +39-0498212409
| | - Matteo Ponzoni
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
| | - Demetrio Pittarello
- Anaesthesia and Intensive Care Unit, University of Padova, 35128 Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, 35128 Padova, Italy
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13
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Hubben A, McCrae KR. Emerging Therapies in Antiphospholipid Syndrome. Transfus Med Rev 2022; 36:195-203. [PMID: 36272841 PMCID: PMC10162403 DOI: 10.1016/j.tmrv.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022]
Abstract
The antiphospholipid syndrome (APS) is the most common cause of acquired immune-mediated thrombophilia. This syndrome is broadly defined by the presence of arterial or venous thrombosis, or pregnancy morbidity, in the presence of high levels of antiphospholipid antibodies. Despite recognition of this disorder more than 50 years ago, a fundamental unifying pathogenesis has not been determined. Due to this, mechanism-based therapies for APS are not available, and current management following thrombotic events suggests anticoagulation of indeterminate duration, or for obstetric complications, heparin/low molecular weight heparin and aspirin. However, APS is an autoimmune disorder, and several approaches focused on modulating the immune response or its effectors have been employed. Those which have been most extensively studied include hydroxychloroquine, rituximab and eculizumab, an inhibitor of complement C5. In this report, we review in depth, and critique, key clinical studies of these agents. Since all of these studies are small, our conclusions are qualified. However, it appears that hydroxychloroquine may enhance the anticoagulant efficacy of vitamin K antagonists in APS patients, and that rituximab may ameliorate some of the "non-criteria" manifestations of APS. The catastrophic antiphospholipid syndrome (CAPS) is associated with diffuse thrombosis, multi-organ dysfunction, and ∼30% mortality. A high incidence of complement regulatory gene mutations, and compelling data concerning the efficacy of eculizumab in CAPS, suggests an important role for complement in this disorder. However, additional work is needed to clarify the role of complement in non-catastrophic APS, though emerging data suggests that complement inhibition may be effective in preventing thrombosis in these patients as well.
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Affiliation(s)
- Anne Hubben
- Department of Cardiovascular and Metabolic Sciences, Taussig Cancer Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith R McCrae
- Department of Cardiovascular and Metabolic Sciences, Taussig Cancer Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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14
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Ponce A, Rodríguez-Pintó I, Basauli JM, Espinosa G, Erkan D, Shoenfeld Y, Cervera R. The clinical significance of low complement levels in patients with catastrophic antiphospholipid syndrome: A descriptive analysis of 73 patients from the "Catastrophic antiphospholipid syndrome registry". Lupus 2022; 31:1218-1225. [PMID: 35686348 DOI: 10.1177/09612033221107583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To explore the prevalence and clinical significance of low complement levels in patients with catastrophic antiphospholipid syndrome (CAPS). METHODS We reviewed data from the "CAPS Registry" on C3 and/or C4 complement plasma protein levels during acute CAPS episodes. Patients were classified into those with low and normal complement levels. Data on clinical presentation, with special focus on thrombotic microangiopathy (TMA) features, diagnosis of systemic lupus erythematosus (SLE), and antiphospholipid antibody (aPL) profile were reviewed. The chi-square exact test was performed to evaluate differences between categorical data. RESULTS The "CAPS Registry" includes 566 patients with a total of 578 episodes of CAPS. Data on complement plasma protein levels was available in 73 episodes from the same number of patients. Low levels of C3 and/or C4 complement plasma proteins were detected in 42 (58%) CAPS episodes. Low complement levels were more common in SLE patients (55% SLE vs. 19% No SLE; p<0.001). The frequencies of clinical TMA (72% vs. 80%; p=0.4) or TMA syndrome (86% vs. 84%, p=0.9), frequency of triple aPL triple positivity (67% vs 33%; p=0.3), or the mortality (35% vs. 31%; p=0.7) were similar between low and normal complement groups. CONCLUSION In our study, low levels of C3 and C4 plasma proteins are detected in 58% episodes of CAPS, which were not associated with clinical presentation including TMA features, aPL triple positivity, or mortality.
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Affiliation(s)
- Ana Ponce
- Autoimmune Diseases Unit, 16496Hospital de Viladecans, Viladecans, Spain
| | - Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, 58955Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - José M Basauli
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, 26744Sheba Medical Center, Tel-Hashomer, Israel.,Ariel University, Ariel, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
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15
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Eculizumab for Refractory Thrombosis in Antiphospholipid Syndrome. Blood Adv 2022; 6:1271-1277. [PMID: 35051999 PMCID: PMC8864643 DOI: 10.1182/bloodadvances.2021005657] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
Recurrent thrombosis can present in antiphospholipid syndrome despite anticoagulation, antiplatelet, and immunosuppressive therapies. Complement inhibition may be a therapeutic option for recurrent thrombosis associated with antiphospholipid syndrome.
Antiphospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis with antiphospholipid antibodies. Dysregulation of the complement pathway has been implicated in APS pathophysiology. We report the successful use of eculizumab, an anti-C5 monoclonal antibody, in controlling and preventing recurrent thrombosis in a refractory case of APS. An 18-year-old female was diagnosed with APS after developing extensive, unprovoked deep vein thrombosis (DVT) of axillary, inferior vena cava, and brachiocephalic veins. Thrombophilia evaluation revealed triple-positive lupus anticoagulant, β-2 glycoprotein IgM, IgA, and anticardiolipin antibodies (each >40 U/mL) with persistently positive titers after 12 weeks. She was refractory to multiple anticoagulants alone (enoxaparin, fondaparinux, apixaban, rivaroxaban, and warfarin) with antiplatelet (aspirin and clopidogrel) and adjunctive therapies (hydroxychloroquine, immunosuppression with steroids and rituximab, and plasmapheresis). Despite these, she continued to develop recurrent thrombosis and additionally developed hepatic infarction and pulmonary embolism with failure to decrease titers after 6 weeks of plasma exchange. Following this event, eculizumab (600 mg weekly × 4 weeks followed by 900 mg every 2 weeks) was initiated in combination with fondaparinux, aspirin, clopidogrel, and hydroxychloroquine. She has remained on this regimen without recurrence of thrombosis. Our case suggests that eculizumab may have a role as a therapeutic option in refractory thrombosis in APS.
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16
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Eculizumab use in catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis from the “CAPS Registry”. Clin Exp Rheumatol 2022; 21:103055. [DOI: 10.1016/j.autrev.2022.103055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/21/2022] [Indexed: 02/07/2023]
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17
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 780] [Impact Index Per Article: 260.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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18
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Macor P, Durigutto P, Mangogna A, Bussani R, De Maso L, D’Errico S, Zanon M, Pozzi N, Meroni PL, Tedesco F. Multiple-Organ Complement Deposition on Vascular Endothelium in COVID-19 Patients. Biomedicines 2021; 9:1003. [PMID: 34440207 PMCID: PMC8394811 DOI: 10.3390/biomedicines9081003] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 01/08/2023] Open
Abstract
Increased levels of circulating complement activation products have been reported in COVID-19 patients, but only limited information is available on complement involvement at the tissue level. The mechanisms and pathways of local complement activation remain unclear. The aim of this study was to investigate the deposition of complement components in the lungs, kidneys, and liver in patients with COVID-19 patients and to determine the pathway/s of complement activation. We performed immunofluorescence analyses of autopsy specimens of lungs, kidney, and liver from 12 COVID-19 patients who died of acute respiratory failure. Snap-frozen samples embedded in OCT were stained with antibodies against complement components and activation products, IgG, and spike protein of SARS-CoV-2. Lung deposits of C1q, C4, C3, and C5b-9 were localized in the capillaries of the interalveolar septa and on alveolar cells. IgG displayed a similar even distribution, suggesting classical pathway activation. The spike protein is a potential target of IgG, but its uneven distribution suggests that other viral and tissue molecules may be targeted by IgG. FB deposits were also seen in COVID-19 lungs and are consistent with activation of the alternative pathway, whereas MBL and MASP-2 were hardly detectable. Analysis of kidney and liver specimens mirrored findings observed in the lung. Complement deposits were seen on tubules and vessels of the kidney with only mild C5b-9 staining in glomeruli, and on the hepatic artery and portal vein of the liver. Complement deposits in different organs of deceased COVID-19 patients caused by activation of the classical and alternative pathways support the multi-organ nature of the disease and the contribution of the complement system to inflammation and tissue damage.
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Affiliation(s)
- Paolo Macor
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Paolo Durigutto
- Laboratory of Immuno-Rheumatology, Istituto Auxologico Italiano, IRCCS, 20095 Milan, Italy; (P.D.); (P.L.M.)
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy;
| | - Rossana Bussani
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (R.B.); (S.D.); (M.Z.)
| | - Luca De Maso
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (R.B.); (S.D.); (M.Z.)
| | - Martina Zanon
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (R.B.); (S.D.); (M.Z.)
| | - Nicola Pozzi
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA;
| | - Pier Luigi Meroni
- Laboratory of Immuno-Rheumatology, Istituto Auxologico Italiano, IRCCS, 20095 Milan, Italy; (P.D.); (P.L.M.)
| | - Francesco Tedesco
- Laboratory of Immuno-Rheumatology, Istituto Auxologico Italiano, IRCCS, 20095 Milan, Italy; (P.D.); (P.L.M.)
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Markers of complement activation in plasma during quiescent phases in patients with catastrophic antiphospholipid syndrome. Blood 2021; 137:2989-2992. [PMID: 33649771 DOI: 10.1182/blood.2020010575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022] Open
Abstract
Accumulating evidence suggests that complement activation is a critical contributor to catastrophic antiphospholipid syndrome (CAPS). While complement activation and C5b-9 levels have been documented in acute CAPS, Ruffati et al report that patients with a history of CAPS have higher levels of C5a and C5b-9 even in the quiescent phase, suggesting an underlying defect in complement regulation.
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20
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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21
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Patients with refractory catastrophic antiphospholipid syndrome respond inconsistently to eculizumab. Blood 2020; 136:2473-2477. [DOI: 10.1182/blood.2020007499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
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22
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Chighizola CB, Sciascia S, Andreoli L, Meroni PL. Beyond current concepts in anti-phospholipid syndrome: The 16th International Congress on Anti-phospholipid Antibodies (ICAPA) in Manchester. Autoimmun Rev 2020; 19:102615. [PMID: 32663623 DOI: 10.1016/j.autrev.2020.102615] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/06/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy; Unit of Allergology, Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases/Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy; Unit of Allergology, Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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23
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Hermel M, Hermel D, Azam S, Shinbane J, Sarcon A, Jones E, Mehta A, Grazette L, Liebman H, Weitz I. Acute dilated cardiomyopathy in the setting of catastrophic antiphospholipid syndrome and thrombotic microangiopathy: A case series and review. EJHAEM 2020; 1:44-50. [PMID: 35847716 PMCID: PMC9175940 DOI: 10.1002/jha2.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/25/2022]
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) is a rare form of antiphospholipid syndrome, an autoimmune condition characterized by vascular thromboses, pregnancy loss, and antiphospholipid (aPL) antibodies. Diagnosis of CAPS relies on thrombosis of at least three different organs systems over 1 week, histopathological evidence of small vessel occlusion, and high aPL antibody titers. In a subset of precipitating circumstances, activation or disruption of endothelial cells in the microvasculature may occur along with cardiomyopathy. We present two cases of CAPS-associated dilated cardiomyopathy at our institution, focusing on disease management, pathophysiology, and treatment. These patients were of Southeastern Asian descent, raising the possibility of genetic polymorphisms contributing to the development of cardiomyopathy. Both met CAPS criteria and both demonstrated clinicopathologic thrombotic microangiopathy (TMA) and complement activation and developed severe dilated cardiomyopathy with shock. Complement activation plays an important role in the development of CAPS and may be important in the pathogenesis of CAPS-associated cardiomyopathy. Clinical suspicion for TMA as a pathophysiologic mechanism of unexplained heart failure in CAPS is important and increased awareness of cardiac side effects is necessary so that early treatment can be initiated to halt further cardiac and systemic complications.
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Affiliation(s)
- Melody Hermel
- Department of MedicineKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - David Hermel
- Department of MedicineKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Saif Azam
- Department of MedicineKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Jerold Shinbane
- Department of CardiologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Annahita Sarcon
- Department of CardiologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Erika Jones
- Department of CardiologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Arjun Mehta
- Department of PathologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Luanda Grazette
- Department of CardiologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Howard Liebman
- Jane Anne Nohl Division of HematologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
| | - Ilene Weitz
- Jane Anne Nohl Division of HematologyKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCalifornia
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Skoczynska M, Crowther MA, Chowaniec M, Ponikowska M, Chaturvedi S, Legault K. Thrombotic microangiopathy in the course of catastrophic antiphospholipid syndrome successfully treated with eculizumab: case report and systematic review of the literature. Lupus 2020; 29:631-639. [DOI: 10.1177/0961203320917460] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective The purpose of this study was to characterize the role of eculizumab, a monoclonal antibody against the terminal complement component C5, in patients with catastrophic antiphospholipid syndrome (CAPS). Methods We present a case report of a patient with systemic lupus erythematosus (SLE) and CAPS treated with eculizumab, as well as results of a systematic review of the literature. Results Including our patient, we identified 11 case reports of patients with CAPS treated with eculizumab. All of them had partial or total remission of symptoms. Conclusion Data on eculizumab efficacy in CAPS are promising but are limited to single case reports. More studies are needed to develop evidence-based recommendations for eculizumab use in CAPS.
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Affiliation(s)
- Marta Skoczynska
- Department and Clinic of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Malgorzata Chowaniec
- Department of Rheumatology and Internal Medicine, Wroclaw University Hospital, Wroclaw, Poland
- Department of Hygiene, Wroclaw Medical University, Wroclaw, Poland
| | - Monika Ponikowska
- Department of Rheumatology and Internal Medicine, Wroclaw University Hospital, Wroclaw, Poland
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Abstract
PURPOSE OF REVIEW The purpose of this report is to review recent research findings on APS in children and neonates. RECENT FINDINGS European evidence-based recommendations for diagnosis and treatment of pediatric APS has recently been published by the SHARE Initiative. Recent studies have shown a high prevalence of non-thrombotic manifestations in children with aPL, domains 4/5 specificity of 'innocent' anti-β2GPI antibodies in infants, and a higher risk for developmental delays and learning disabilities, hence, the need for neurodevelopmental monitoring in children born to mothers with APS. An International effort on creating a new diagnostic criteria for APS is underway. Pediatric APS is a rare disease with significant differences from the APS in adults. Majority of the children with persistently positive aPL do not develop thrombotic events; however, relatively higher proportion of thrombosis in children is related to aPL positivity compared to adults; this may partly be due to the absence of common pro-thrombotic "second-hit" risk factors of adults such as atherosclerosis and cigarette smoking. Diagnosis of APS in children may be delayed or missed when adult APS criteria are used, because in pediatric APS, non-thrombotic clinical manifestations such as thrombocytopenia, hemolytic anemia, and neurological disorders such as migraine, epilepsy, and chorea may precede thrombotic manifestations. Around 20% of the children initially diagnosed with primary APS eventually develop SLE. Neonatal APS is rare; however, the offspring of mothers with APS are at a higher risk for developmental delays and learning disabilities; prematurity and IUGR may increase this risk. Regular assessment of neurodevelopmental status of these children should be performed. Thrombosis is a rare event in the offspring of mothers with APS; anticoagulation of such infants is not recommended. An international effort to create a new diagnostic criteria for APS is underway.
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Affiliation(s)
- Arzu Soybilgic
- Pediatric Rheumatology, Children's Hospital of University of Illinois, 840 S. Wood St, 1206 CSB, Chicago, 60612, USA.
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center, Faculty of Medicine, University of Ljubljana, Bohoriceva 20, 1525, Ljubljana, Slovenia
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26
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McDonnell T, Wincup C, Buchholz I, Pericleous C, Giles I, Ripoll V, Cohen H, Delcea M, Rahman A. The role of beta-2-glycoprotein I in health and disease associating structure with function: More than just APS. Blood Rev 2020; 39:100610. [PMID: 31471128 PMCID: PMC7014586 DOI: 10.1016/j.blre.2019.100610] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/09/2019] [Accepted: 08/15/2019] [Indexed: 12/22/2022]
Abstract
Beta-2-Glycoprotein I (β2GPI) plays a number of essential roles throughout the body. β2GPI, C-reactive protein and thrombomodulin are the only three proteins that possess the dual capability to up and down regulate the complement and coagulation systems depending upon external stimulus. Clinically, β2GPI is the primary antigen in the autoimmune condition antiphospholipid syndrome (APS), which is typically characterised by pregnancy morbidity and vascular thrombosis. This protein is also capable of adopting at least two distinct structural forms, but it has been argued that several other intermediate forms may exist. Thus, β2GPI is a unique protein with a key role in haemostasis, homeostasis and immunity. In this review, we examine the genetics, structure and function of β2GPI in the body and how these factors may influence its contribution to disease pathogenesis. We also consider the clinical implications of β2GPI in the diagnosis of APS and as a potentially novel therapeutic target.
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Affiliation(s)
- Thomas McDonnell
- Rheumatology, Division of Medicine, Rayne Institute, University College London, UK.
| | - Chris Wincup
- Rheumatology, Division of Medicine, Rayne Institute, University College London, UK
| | - Ina Buchholz
- Nanostructure Group, Institute of Biochemistry, University of Greifswald, Germany
| | - Charis Pericleous
- Imperial College London, Imperial College Vascular Sciences, National Heart & Lung Institute, ICTEM, Hammersmith Campus, Du Cane Road, London, UK
| | - Ian Giles
- Rheumatology, Division of Medicine, Rayne Institute, University College London, UK
| | - Vera Ripoll
- Rheumatology, Division of Medicine, Rayne Institute, University College London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mihaela Delcea
- Nanostructure Group, Institute of Biochemistry, University of Greifswald, Germany
| | - Anisur Rahman
- Rheumatology, Division of Medicine, Rayne Institute, University College London, UK
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27
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Ruffatti A, Calligaro A, Lacognata CS, D'Odorico A, Colpo A, Cardin F, Calabrese F. Insights into the pathogenesis of catastrophic antiphospholipid syndrome. A case report of relapsing catastrophic antiphospholipid syndrome and review of the literature on ischemic colitis. Clin Rheumatol 2019; 39:1347-1355. [PMID: 31853731 DOI: 10.1007/s10067-019-04888-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/28/2022]
Abstract
We present the case of a woman with a severe clinical history of antiphospholipid syndrome and persistent positivity for lupus anticoagulant, IgG anticardiolipin and IgG anti-β2Glycoprotein I antibodies. An acute clinical onset characterized by severe abdominal pain immediately followed by circulatory shock and histological colonic small vessel thrombosis pattern pointed to a diagnosis of ischemic colitis. The subsequent rapid onset of pulmonary alveolitis and heart failure associated to subendocardial hypoperfusion led to a diagnosis of definite catastrophic antiphospholipid syndrome (CAPS). Conventional triple therapy together with a broad-spectrum preventive antibiotic therapy were quickly initiated, and the outcome was favorable. We evaluated the patients with ischemic colitis in CAPS described in the literature between 1992 and May 2019 and our CAPS case. In accordance with the "two-hit" hypothesis and on the basis of the patients' data, we would like to speculate that the colonic wall necrosis related to ischemic colitis damaged the intestinal barrier causing loss of resistance to bacteria and leading to endotoxemia and bacteremia with bacteria translocation through the circulatory stream to the lungs and heart. The bacteria acted as the priming factor which favored the binding of β2Glycoprotein I to the endothelium vessels in the colon, lungs, and heart following activation of anti-β2Glycoprotein I antibodies which attached to the domain I of β2Glycoprotein I. This was followed by complement activation which triggered the thrombotic and cytokine storm. If further clinical studies confirm this hypothesis, the treatment of CAPS could be more targeted and effective.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Carmelo S Lacognata
- Radiology Unit, Department of Diagnostic Imaging and Interventional Radiology, University Hospital of Padua, Padua, Italy
| | - Anna D'Odorico
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Anna Colpo
- Apheresis Unit, Department of Transfusion Medicine, University Hospital of Padua, Padua, Italy
| | - Fabrizio Cardin
- Endoscopic Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua, Padua, Italy
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