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Blakey H, Sun R, Xie L, Russell R, Sarween N, Hodson J, Hargitai B, Marton T, A H Neil D, Wong E, Sheerin NS, Bramham K, Harris CL, Knox E, Drayson M, Lipkin G. Pre-eclampsia is associated with complement pathway activation in the maternal and fetal circulation, and placental tissue. Pregnancy Hypertens 2023; 32:43-49. [PMID: 37088032 DOI: 10.1016/j.preghy.2023.04.001] [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: 09/09/2022] [Revised: 02/21/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Pre-eclampsia (PE) is a leading cause of obstetric morbidity, with no definitive therapy other than delivery. We aimed to compare complement markers in maternal and fetal circulation, and placental tissue, between women with PE and healthy pregnant controls. STUDY DESIGN Maternal and umbilical cord blood was tested for iC3b, C3, C4, properdin, Ba and C5b-9, and placental tissue for C3d, C4d, C9 and C1q, from women with PE (n = 34) and healthy pregnant controls (n = 33). Maternal properdin and Ba tests were repeated in a separate validation cohort (PE n = 35; healthy pregnant controls n = 35). MAIN OUTCOME MEASURES Complement concentrations in maternal and umbilical cord blood, and placental immunohistochemical complement deposition. RESULTS Women with PE had significantly lower concentrations of properdin (mean: 4828 vs 6877 ng/ml, p < 0.001) and C4 (mean: 0.20 vs 0.31 g/l, p < 0.001), and higher Ba (median: 150 vs 113 ng/ml, p = 0.012), compared to controls. After controlling for gestational age at blood draw, average properdin concentration was 1945 ng/ml lower in PE vs controls (95 % CI: 1487-2402, p < 0.001). Of the cord blood markers assessed, only Ba differed significantly between PE and controls (median: 337 vs 233 ng/ml, p = 0.004). C4d staining of the syncytiotrophoblast membrane was increased in PE vs controls (median immunoreactivity score 3 vs 0, p < 0.001). Maternal properdin and C4 were significantly negatively correlated with placental C4d staining. CONCLUSIONS Our data confirm excessive placental complement deposition associated with significant concurrent changes in maternal and fetal circulating complement biomarkers in PE. Inhibition of complement activation is a potential therapeutic target.
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Affiliation(s)
- Hannah Blakey
- Renal Medicine Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Ruyue Sun
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Long Xie
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Rebecca Russell
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Nadia Sarween
- Renal Medicine Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Hodson
- Research Development and Innovation, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Beata Hargitai
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Tamas Marton
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Desley A H Neil
- Renal Medicine Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Edwin Wong
- National Renal Complement Therapeutics Centre, Newcastle, UK
| | - Neil S Sheerin
- National Renal Complement Therapeutics Centre, Newcastle, UK
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, UK
| | - Claire L Harris
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Ellen Knox
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Graham Lipkin
- Renal Medicine Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Isaksson GL, Nielsen LH, Palarasah Y, Jensen DM, Andersen LLT, Madsen K, Bistrup C, Jørgensen JS, Ovesen PG, Jensen BL. Urine excretion of C3dg and sC5b-9 coincide with proteinuria and development of preeclampsia in pregnant women with type-1 diabetes. J Hypertens 2023; 41:223-232. [PMID: 36583350 DOI: 10.1097/hjh.0000000000003288] [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: 12/31/2022]
Abstract
OBJECTIVE Pregnant women with type-1 diabetes have an increased risk of preeclampsia with kidney injury and cardiovascular complications. Urine excretion of plasmin and soluble membrane attack complex (sC5b-9) is elevated in severe preeclampsia. We hypothesized a coupling between these events and that active plasmin promotes intratubular complement activation and membrane deposition. METHODS Stored urine and plasma samples from pregnant women with type-1 diabetes (n = 88) collected at gestational weeks 12, 20, 28, 32, 36 and 38 were used. In the cohort, 14 women developed preeclampsia and were compared with 16 nonpreeclampsia controls. RESULTS Urine C3dg and sC5b-9-associated C9 neoantigen/creatinine ratios increased and were significantly higher in women who developed preeclampsia. Plasma concentrations did not change with gestation. Urine plasmin(ogen) correlated to urine C3dg (r = 0.51, P < 0.001) and C9 neoantigen (r = 0.68, P < 0.001); urine albumin correlated to C3dg (r = 0.44, P < 0.001) and C9 (r = 0.59, P < 0.001). Membrane-associated C3dg and C9 neoantigen was detected in urinary extracellular vesicles from patients but not controls at 36 weeks. Receiver operating characteristic curves showed that C3dg and C9 neoantigen were inferior to albumin as predictive biomarkers for preeclampsia. CONCLUSION In preeclampsia, urinary excretion of activated complement relates significantly to albuminuria and to plasmin(ogen) but not to activation in plasma. Intratubular complement activation in preeclampsia is a postfiltration event tightly related to proteinuria/plasminogenuria and a possible mechanistic link to cellular damage and kidney injury.
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Affiliation(s)
- Gustaf L Isaksson
- Department of Nephrology, Odense University Hospital, Odense
- Department of Molecular Medicine - Cardiovascular and Renal Research, University of Southern Denmark
| | - Lise H Nielsen
- Department of Clinical Medicine - Obstetrics and Gynecology, Aarhus University, Aarhus
| | - Yaseelan Palarasah
- Department of Molecular Medicine - Cancer and Inflammation, University of Southern Denmark
| | - Dorte M Jensen
- Steno Diabetes Center Odense, Odense University Hospital
- Department of Clinical Research, University of Southern Denmark
| | - Lise L T Andersen
- Department of Clinical Research, University of Southern Denmark
- Department of Obstetrics and Gynecology, Odense University Hospital
| | - Kirsten Madsen
- Department of Molecular Medicine - Cardiovascular and Renal Research, University of Southern Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Odense
- Department of Clinical Research, University of Southern Denmark
| | - Jan S Jørgensen
- Department of Clinical Research, University of Southern Denmark
- Department of Obstetrics and Gynecology, Odense University Hospital
| | - Per G Ovesen
- Department of Clinical Medicine - Obstetrics and Gynecology, Aarhus University, Aarhus
| | - Boye L Jensen
- Department of Molecular Medicine - Cardiovascular and Renal Research, University of Southern Denmark
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Smith-Jackson K, Harrison RA. Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events. Immunol Rev 2023; 313:298-319. [PMID: 36377667 PMCID: PMC10100418 DOI: 10.1111/imr.13169] [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: 11/16/2022]
Abstract
During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.
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Affiliation(s)
- Kate Smith-Jackson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Faculty of Medical Science, Newcastle University, Newcastle-upon-Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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Xue Y, Yang N, Ma L, Gu X, Jia K. Predictive value of the complement factors B and H for women with gestational diabetes mellitus who are at risk of preeclampsia. Pregnancy Hypertens 2022; 30:210-214. [DOI: 10.1016/j.preghy.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/18/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
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Ancuța E, Zamfir R, Martinescu G, Crauciuc DV, Ancuța C. The Complement System, T Cell Response, and Cytokine Shift in Normotensive versus Pre-Eclamptic and Lupus Pregnancy. J Clin Med 2021; 10:jcm10245722. [PMID: 34945017 PMCID: PMC8705505 DOI: 10.3390/jcm10245722] [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] [Received: 11/08/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 12/14/2022] Open
Abstract
Successful pregnancy requires an immunological shift with T helper CD4+ bias based on disbalance Th1/Th17 versus Th2/T regulatory (Tregs) required to induce tolerance against the semi-allogeneic fetus and placenta and to support fetal growth. Considered a pregnancy-specific hypertensive disorder, pre-eclampsia is characterized by multifaceted organ involvement related to impaired maternal immune tolerance to paternal antigens triggered by hypoxic placental injury as well as excessive local and systemic anti-angiogenic and inflammatory factor synthesis. Both systemic and local Th1/Th2 shift further expands to Th17 cells and their cytokines (IL-17) complemented by suppressive Treg and Th2 cytokines (IL-10, IL-4); alterations in Th17 and Tregs cause hypertension during pregnancy throughout vasoactive factors and endothelial dysfunction, providing an explanatory link between immunological and vascular events in the pathobiology of pre-eclamptic pregnancy. Apart from immunological changes representative of normotensive pregnancy, lupus pregnancy is generally defined by higher serum pro-inflammatory cytokines, lower Th2 polarization, defective and lower number of Tregs, potential blockade of complement inhibitors by anti-phospholipid antibodies, and similar immune alterations to those seen in pre-eclampsia. The current review underpins the immune mechanisms of pre-eclampsia focusing on local (placental) and systemic (maternal) aberrant adaptive and innate immune response versus normotensive pregnancy and pregnancy in systemic autoimmune conditions, particularly lupus.
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Affiliation(s)
- Eugen Ancuța
- Research Department, “Elena Doamna” Obstetrics and Gynecology Clinical Hospital, 700398 Iași, Romania; (E.A.); (G.M.)
| | - Radu Zamfir
- Fundeni Clinical Institute, 022328 București, Romania;
| | - Gabriel Martinescu
- Research Department, “Elena Doamna” Obstetrics and Gynecology Clinical Hospital, 700398 Iași, Romania; (E.A.); (G.M.)
| | - Dragoș Valentin Crauciuc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Correspondence: (D.V.C.); or (C.A.); Tel.: +40-740036387 (C.A.)
| | - Codrina Ancuța
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, 700661 Iași, Romania
- Correspondence: (D.V.C.); or (C.A.); Tel.: +40-740036387 (C.A.)
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Kikine P, Pillay Y, Naicker T. THE ROLE OF HUMAN COMPLEMENT PROTEIN FACTOR B AND FACTORP/PROPERDIN IN HIV-ASSOCIATED PRE-ECLAMPSIA. Hypertens Pregnancy 2021; 41:9-14. [PMID: 34781830 DOI: 10.1080/10641955.2021.2001819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objectives: This study seeks to discover how the concentration of complement proteins, factors B and P are affected in HIV-associated PE.Methods: This study included 72 pregnant women: 36 preeclamptic and 36 normotensive. Serum concentrations of factors B and P were measured using a Bioplex immunoassay.Results: A significant decrease of factor B in the HIV+ compared to the HIV- group was noted. No significant difference across all groups for both analytes was observed.Conclusion Our results suggest the alternative pathway (AP) is inhibited by HIV evading immune detection. The AP is not excessively activated in PE during the third trimester.
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Affiliation(s)
- Phumelele Kikine
- Department of Optics and Imaging, University of Kwa-Zulu Natal, Durban, South Africa
| | - Yazira Pillay
- Department of Optics and Imaging, University of Kwa-Zulu Natal, Durban, South Africa
| | - Thajasvarie Naicker
- Department of Optics and Imaging, University of Kwa-Zulu Natal, Durban, South Africa
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HIV Associated Preeclampsia: A Multifactorial Appraisal. Int J Mol Sci 2021; 22:ijms22179157. [PMID: 34502066 PMCID: PMC8431090 DOI: 10.3390/ijms22179157] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: This review explores angiogenesis, vascular dysfunction, the complement system, RAAS, apoptosis and NETosis as potential pathways that are dysregulated during preeclampsia, HIV infection and ART usage. Results: HIV-1 accessory and matrix proteins are protagonists for the elevation of oxidative stress, apoptosis, angiogenesis, and elevation of adhesion markers. Despite the immunodeficiency during HIV-1 infection, HIV-1 exploits our cellular defence arsenal by escaping cell-mediated lysis, yet HIV-1 infectivity is enhanced via C5a release of TNF-α and IL-6. This review demonstrates that PE is an oxidatively stressed microenvironment associated with increased apoptosis and NETosis, but with a decline in angiogenesis. Immune reconstitution in the duality of HIV-1 and PE by protease inhibitors, HAART and nucleoside reverse transcriptase, affect similar cellular pathways that eventuate in loss of endothelial cell integrity and, hence, its dysfunction. Conclusions: HIV-1 infection, preeclampsia and ARTs differentially affect endothelial cell function. In the synergy of both conditions, endothelial dysfunction predominates. This knowledge will help us to understand the effect of HIV infection and ART on immune reconstitution in preeclampsia.
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Collier ARY, Smith LA, Karumanchi SA. Review of the immune mechanisms of preeclampsia and the potential of immune modulating therapy. Hum Immunol 2021; 82:362-370. [PMID: 33551128 DOI: 10.1016/j.humimm.2021.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/23/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022]
Abstract
Successful pregnancy relies on maternal immunologic tolerance mechanisms limit maladaptive immune responses against the semi-allogeneic fetus and placenta and support fetal growth. Preeclampsia is a common disorder of pregnancy that affects 4-10% of pregnancies and is a leading cause of maternal and neonatal morbidity and mortality. Preeclampsia clinically manifests as maternal hypertension, proteinuria, and progressive multi-organ injury likely triggered by hypoxic injury to the placenta, resulting in local and systemic anti-angiogenic and inflammatory factor production. Despite the steady rising rates of preeclampsia in the United States, effective treatment options are limited to delivery, which improves maternal status often at the cost of prematurity in the newborn. Preeclampsia also increases the lifelong risk of cardiovascular disease for both mother and infant. Thus, identifying new therapeutic targets is a high priority area to improve maternal, fetal, and infant health outcomes. Immune abnormalities in the placenta and in the maternal circulation have been reported to precede the clinical onset of disease. In particular, excessive systemic and placental complement activation and impaired adaptive T cell tolerance with Th1/Th2/Th17/Treg imbalance has been reported in humans and in animal models of preeclampsia. In this review, we focus on the evidence for the immune origins of preeclampsia, discuss the promise of immune modulating therapy for prevention or treatment, and highlight key areas for future research.
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Affiliation(s)
- Ai-Ris Y Collier
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA; Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Laura A Smith
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - S Ananth Karumanchi
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Camacho CA, Santos GDO, Caballeros JE, Cazales N, Ramirez CJ, Vidigal PMP, Ramos HJDO, Barros E, Mattos RC. Uterine infusion of conceptus fragments changes the protein profile from cyclic mares. Anim Reprod 2020; 17:e20200552. [PMID: 33791032 PMCID: PMC7995263 DOI: 10.1590/1984-3143-ar2020-0552] [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] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/22/2022] Open
Abstract
This experiment aimed to compare at day seven after ovulation, the protein profile of uterine fluid in cyclic mares with mares infused two days before with Day 13 conceptus fragments. Experimental animals were ten healthy cyclic mares, examined daily to detect ovulation (Day 0) as soon as estrus was confirmed. On day seven, after ovulation, uterine fluid was collected, constituting the Cyclic group (n = 10). The same mares were examined in the second cycle until ovulation was detected. On day five, after ovulation, fragments from a previously collected concepti were infused into each mare's uterus. Two days after infusion, uterine fluid was collected, constituting the Fragment group (n = 10). Two-dimensional electrophoresis technique processed uterine fluid samples. A total of 373 spots were detected. MALDI-TOF/TOF and NanoUHPLC-QTOF mass spectrometry identified twenty spots with differences in abundance between the Cyclic and Fragment group. Thirteen proteins were identified, with different abundance between groups. Identified proteins may be related to embryo-maternal communication, which involves adhesion, nutrition, endothelial cell proliferation, transport, and immunological tolerance. In conclusion, conceptus fragments signalized changes in the protein profile of uterine fluid seven days after ovulation in comparison to the observed at Day 7 in the same cyclic mares.
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Affiliation(s)
- Cesar Augusto Camacho
- Laboratório de Reprodução Animal, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Gabriel de Oliveira Santos
- Laboratório de Reprodução Animal, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Jorge Emilio Caballeros
- Laboratório de Reprodução Animal, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Nicolas Cazales
- Laboratório de Reprodução Animal, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
- Facultad de Veterinária, Universidad de la República - UDELAR, Montevideo, Uruguay
| | - Camilo José Ramirez
- Núcleo de Análise de Biomoléculas, Universidade Federal de Viçosa, Viçosa, MG, Brasil
| | | | | | - Edvaldo Barros
- Núcleo de Análise de Biomoléculas, Universidade Federal de Viçosa, Viçosa, MG, Brasil
| | - Rodrigo Costa Mattos
- Laboratório de Reprodução Animal, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Plasma CD59 concentrations are increased in preeclampsia with severe features and correlate with laboratory measures of end-organ injury. Pregnancy Hypertens 2020; 22:204-209. [PMID: 33091682 DOI: 10.1016/j.preghy.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Dysregulation of CD59 may lead to increased complement-mediated end-organ injury in preeclampsia. We sought to determine if soluble CD59 concentrations are altered in preeclampsia with severe features. STUDY DESIGN Observational case-control study, which enrolled subjects prospectively from six centers in Colombia from 2015 to 2016. Cases had preeclampsia with severe features and controls were either healthy or had chronic hypertension, gestational hypertension, or preeclampsia without severe features. Trained coordinators collected clinical data, blood and urine. Analyses were by test of medians and Spearman's correlation. MAIN OUTCOME MEASURES Soluble CD59 concentration in plasma and urine, using enzyme linked immunosorbent assays. RESULTS In total, 352 subjects were enrolled (104 cases; 248 controls). Compared to healthy women or those with other hypertensive disorders of pregnancy, women with preeclampsia with severe features had increased concentration of CD59 in plasma (P < 0.001) and decreased CD59 in urine (P = 0.01). In sub-group analyses, plasma CD59 concentrations were increased in preeclampsia with severe features compared to healthy controls (P < 0.001) or controls with either chronic hypertension (P = 0.002) or gestational hypertension (P = 0.02). Increased plasma CD59 concentrations correlated with decreased platelet count and increased lactate dehydrogenase, creatinine, aspartate transaminase, urine protein/creatinine ratio, systolic blood pressure and diastolic blood pressure (P < 0.01, all correlations). CONCLUSION In women with preeclampsia with severe features, soluble CD59 concentrations were increased in plasma and decreased in urine, and plasma levels correlated with increased blood pressure and end-organ injury. Soluble CD59 concentrations may help identify a subset of women with preeclampsia that have altered regulation of terminal complement proteins.
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Abstract
PURPOSE OF REVIEW This review summarizes recent research in the field of systemic lupus erythematosus (SLE) and pregnancy with focus on clinical and biochemical predictors of adverse pregnancy outcomes (APOs), accumulating evidence for the safety and efficacy of hydroxychloroquine (HCQ) in pregnancy, and the importance of preconception counseling. RECENT FINDINGS Ongoing research from PROMISSE investigators (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus) adds to the understanding of risk factors for APOs in SLE pregnancies, including aberrant complement activation, incomplete downregulation of lupus-associated transcription factors, and lower socioeconomic status. Evidence supporting numerous advantages for continuing HCQ in pregnancy, as well as support for low-dose aspirin in preeclampsia prevention is reviewed. Practice gaps exist among rheumatologists in ensuring effective contraception when women of childbearing age are undergoing therapy with potentially fetotoxic medications. The publication of organizational guidelines provides evidence-based recommendations on lupus pregnancy management. SUMMARY Outcomes of lupus pregnancies continue to improve with understanding of risk factors that predict APOs as well as improvements in disease management. Rheumatologists caring for women with SLE should be familiar with the most up-to-date research in order to optimize pregnancy outcomes in this population.
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Jia K, Ma L, Wu S, Yang W. Serum Levels of Complement Factors C1q, Bb, and H in Normal Pregnancy and Severe Pre-Eclampsia. Med Sci Monit 2019; 25:7087-7093. [PMID: 31541546 PMCID: PMC6767947 DOI: 10.12659/msm.915777] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to determine the diagnostic role of serum levels of complement C1q, Bb, and H in nonpregnant women, women with normal pregnancy, and women with severe pre-eclampsia. Material/Methods Healthy nonpregnant women (n=30), women with early, middle, and late normal pregnancy (n=30, respectively), and women with severe pre-eclampsia (n=73) were studied. The pre-eclampsia study group included early-onset cases (n=43) and late-onset cases (n=30). Serum levels of Bb were determined by enzyme-linked immunosorbent assay (ELISA), and C1q and H were tested by a turbidimetric immunoassay method. Results In the pre-eclampsia study group, compared with women with normal pregnancy, serum levels of C1q remained stable throughout pregnancy, and Bb levels declined from mid-pregnancy (p=0.250). Serum levels of factor H increased in the middle and late stages of pregnancy, and C1q and H were lower in early-onset severe pre-eclampsia (p<0.001, p=0.009, respectively) and late-onset severe pre-eclampsia (p<0.001, p=0.031, respectively) compared with the early-onset control and late-onset control groups. Serum levels of Bb increased in early-onset severe pre-eclampsia (p=0.001) and late-onset severe pre-eclampsia (p=0.003) compared with early-onset control and late-onset control groups. The area under the receiver operator curve (ROC) for serum C1q, Bb, and H for the diagnosis of early-onset severe pre-eclampsia were 0.814 (95% CI, 0.712–0.917), 0.743 (95% CI, 0.638–0.859), and 0.681(95% CI, 0.556–0.806), and late-onset severe pre-eclampsia were 0.805 (95% CI, 0.694–0.913), 0.796 (95% CI, 0.680–0.911), and 0.662 (95% CI, 0.524–0.800). Conclusions The classical and alternative pathways of complement were activated in patients with severe pre-eclampsia. Serum levels of C1q, Bb, and H should be studied further as potential diagnostic markers for severe pre-eclampsia.
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Affiliation(s)
- Keke Jia
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China (mainland)
| | - Lijuan Ma
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China (mainland)
| | - Siyi Wu
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China (mainland)
| | - Wang Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China (mainland)
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Pillay Y, Moodley J, Naicker T. The role of the complement system in HIV infection and preeclampsia. Inflamm Res 2019; 68:459-469. [PMID: 31028431 DOI: 10.1007/s00011-019-01240-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The complement system is a key component of the innate immune system that plays a vital role in host defense, maintains homeostasis and acts as a mediator of the adaptive immune response. The complement system could possibly play a role in the pathogenesis of HIV infection and preeclampsia (PE), both of which represent major causes of maternal death in South Africa. RECENT FINDINGS The relationship between PE and HIV infection is unclear as PE represents an exaggerated immune response, while HIV infection is associated with a decline in immune activity. Although the complement system works to clear and neutralize HIV, it could also enhance the infectivity of HIV by various other mechanisms. It has been suggested that the dysregulation of the complement system is associated with the development of PE. CONCLUSION There is currently a paucity of information on the combined effect of the complement system in HIV-associated PE. This review highlights the role of the complement system in the duality of HIV infection and PE and provides new insights into this relationship whilst also elucidating potential therapeutic targets.
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Affiliation(s)
- Yazira Pillay
- Optics and Imaging Centre, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thajasvarie Naicker
- Optics and Imaging Centre, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Complement Activation During Early Pregnancy and Clinical Predictors of Preterm Birth in African American Women. J Perinat Neonatal Nurs 2019; 33:E15-E26. [PMID: 31651632 PMCID: PMC6818745 DOI: 10.1097/jpn.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complement activation is essential for select physiologic processes during pregnancy; however, excess activation has been associated with an increased risk for preterm birth (PTB). African American (AA) women experience disproportionately higher rates of inflammation-associated PTB than other groups of women; thus, the purpose of this study was to explore the relationship between complement activation and perinatal outcomes among AA women. A plasma sample was collected between 8 and 14 weeks' gestation from a cohort of healthy AA women (N = 144) enrolled in a larger PTB cohort study. Medical record review was conducted to collect information on clinical factors (cervical length, health behaviors, gestational age at delivery). Multiple regression analysis was used to explore the relationships between complement marker (C3a/Bb) concentrations and the outcomes of interest after adjusting for baseline characteristics. C3a/Bb concentrations were not significant predictors of the gestational age at delivery, cervical length, or behavioral risk factors for PTB in this sample. Complement markers may not influence pregnancy outcomes among AA women in the same way as in predominantly white populations; however, more studies are needed to define complement dysregulation and the relationship with outcomes among AA women.
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15
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Lokki AI, Heikkinen-Eloranta JK, Laivuori H. The Immunogenetic Conundrum of Preeclampsia. Front Immunol 2018; 9:2630. [PMID: 30483272 PMCID: PMC6243043 DOI: 10.3389/fimmu.2018.02630] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022] Open
Abstract
Pregnancy is an immunological challenge to the mother. The fetal tissues including the placenta must be protected from activation of the maternal immune system. On the other hand, the placental tissue sheds into the maternal circulation and must be adequately identified and phagocytized by the maternal immune system. During a healthy pregnancy, numerous immunosuppressive processes take place that allow the allograft fetus to thrive under exposure to humoral and cellular components of the maternal immune system. Breakdown of immune tolerance may result in sterile inflammation and cause adverse pregnancy outcomes such as preeclampsia, a vascular disease of the pregnancy with unpredictable course and symptoms from several organs. Immunological incompatibility between mother and fetus is strongly indicated in preeclampsia. Recently, genetic factors linking immunological pathways to predisposition to preeclampsia have been identified. In this mini-review genetic variation in immunological factors are discussed in the context of preeclampsia. Specifically, we explore immunogenetic and immunomodulary mechanisms contributing to loss of tolerance, inflammation, and autoimmunity in preeclampsia.
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Affiliation(s)
- A Inkeri Lokki
- Research Programs Unit, Immunobiology Research Program, University of Helsinki, Helsinki, Finland.,Bacteriology and Immunology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Hannele Laivuori
- Medical and Clinical genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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16
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Vaught AJ, Braunstein EM, Jasem J, Yuan X, Makhlin I, Eloundou S, Baines AC, Merrill SA, Chaturvedi S, Blakemore K, Sperati CJ, Brodsky RA. Germline mutations in the alternative pathway of complement predispose to HELLP syndrome. JCI Insight 2018; 3:99128. [PMID: 29563339 DOI: 10.1172/jci.insight.99128] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/07/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is a severe variant of hypertensive disorders of pregnancy affecting approximately 1% of all pregnancies, and has significant maternal and fetal morbidity. Previously, we showed that upregulation of the alternative pathway of complement (APC) plays a role in HELLP syndrome. We hypothesize that HELLP syndrome follows a 2-hit disease model similar to atypical hemolytic uremic syndrome (aHUS), requiring both genetic susceptibility and an environmental risk factor. Our objective was to perform a comparative analysis of the frequency of APC activation and germline mutations in affected women and to create a predictive model for identifying HELLP syndrome. METHODS Pregnant women with HELLP syndrome, and healthy controls after 23 weeks of gestation were recruited, along with aHUS and thrombotic thrombocytopenic purpura participants. We performed a functional assay, the mHam, and targeted genetic sequencing in all groups. RESULTS Significantly more participants with rare germline mutations in APC genes were present in the HELLP cohort compared with controls (46% versus 8%, P = 0.01). In addition, significantly more HELLP participants were positive for the mHam when compared with controls (62% versus 16%, P = 0.009). Testing positive for both a germline mutation and the mHam was highly predictive for the diagnosis of HELLP syndrome. CONCLUSION HELLP syndrome is characterized by both activation of the APC and frequent germline mutations in APC genes. Similar to aHUS, treatment via complement inhibition to mitigate maternal and fetal morbidity and mortality may be possible. FUNDING National Heart Lung and Blood Institute grants T32HL007525 and R01HL133113.
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Affiliation(s)
- Arthur J Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics
| | | | - Jagar Jasem
- Division of Hematology, Department of Medicine, and
| | - Xuan Yuan
- Division of Hematology, Department of Medicine, and
| | - Igor Makhlin
- Division of Hematology, Department of Medicine, and
| | - Solange Eloundou
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics
| | | | | | | | - Karin Blakemore
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics
| | - C John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Kim MY, Guerra MM, Kaplowitz E, Laskin CA, Petri M, Branch DW, Lockshin MD, Sammaritano LR, Merrill JT, Porter TF, Sawitzke A, Lynch AM, Buyon JP, Salmon JE. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis 2018; 77:549-555. [PMID: 29371202 DOI: 10.1136/annrheumdis-2017-212224] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/07/2017] [Accepted: 12/10/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Studies in mouse models implicate complement activation as a causative factor in adverse pregnancy outcomes (APOs). We investigated whether activation of complement early in pregnancy predicts APOs in women with systemic lupus erythematosus (SLE) and/or antiphospholipid (aPL) antibodies. METHODS The PROMISSE Study enrolled pregnant women with SLE and/or aPL antibodies (n=487) and pregnant healthy controls (n=204) at <12 weeks gestation and evaluated them monthly. APOs were: fetal/neonatal death, preterm delivery <36 weeks because of placental insufficiency or preeclampsia and/or growth restriction <5th percentile. Complement activation products were measured on serial blood samples obtained at each monthly visit. RESULTS APO occurred in 20.5% of SLE and/or aPL pregnancies. As early as 12-15 weeks, levels of Bb and sC5b-9 were significantly higher in patients with APOs and remained elevated through 31 weeks compared with those with normal outcomes. Moreover, Bb and sC5b-9 were significantly higher in patients with SLE and/or aPL without APOs compared with healthy controls. In logistic regression analyses, Bb and sC5b-9 at 12-15 weeks remained significantly associated with APO (ORadj=1.41 per SD increase; 95% CI 1.06 to 1.89; P=0.019 and ORadj=1.37 per SD increase; 95% CI 1.05 to 1.80; P=0.022, respectively) after controlling for demographic and clinical risk factors for APOs in PROMISSE. When analyses were restricted to patients with aPL (n=161), associations between Bb at 12-15 weeks and APOs became stronger (ORadj=2.01 per SD increase; 95% CI 1.16 to 3.49; P=0.013). CONCLUSION In pregnant patients with SLE and/or aPL, increased Bb and sC5b-9 detectable early in pregnancy are strongly predictive of APOs and support activation of complement, particularly the alternative pathway, as a contributor to APOs.
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Affiliation(s)
- Mimi Y Kim
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marta M Guerra
- Medicine, Hospital for Special Surgery, New York, New York, USA
| | | | - Carl A Laskin
- Medicine, Mount Sinai Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Michelle Petri
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - D Ware Branch
- Obstetrics and Gynecology, University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael D Lockshin
- Medicine, Hospital for Special Surgery, New York, New York, USA.,Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Lisa R Sammaritano
- Medicine, Hospital for Special Surgery, New York, New York, USA.,Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Joan T Merrill
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - T Flint Porter
- Obstetrics and Gynecology, University of Utah Health Sciences Center and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Allen Sawitzke
- Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Anne M Lynch
- Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jill P Buyon
- Medicine, New York University School of Medicine, New York, New York, USA
| | - Jane E Salmon
- Medicine, Hospital for Special Surgery, New York, New York, USA.,Medicine, Weill Cornell Medicine, New York, New York, USA
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18
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Dunn AB, Dunlop AL, Hogue CJ, Miller A, Corwin EJ. The Microbiome and Complement Activation: A Mechanistic Model for Preterm Birth. Biol Res Nurs 2017; 19:295-307. [PMID: 28073296 DOI: 10.1177/1099800416687648] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Preterm birth (PTB, <37 completed weeks' gestation) is one of the leading obstetrical problems in the United States, affecting approximately one of every nine births. Even more concerning are the persistent racial disparities in PTB, with particularly high rates among African Americans. There are several recognized pathophysiologic pathways to PTB, including infection and/or exaggerated systemic or local inflammation. Intrauterine infection is a causal factor linked to PTB thought to result most commonly from inflammatory processes triggered by microbial invasion of bacteria ascending from the vaginal microbiome. Trials to treat various infections have shown limited efficacy in reducing PTB risk, suggesting that other complex mechanisms, including those associated with inflammation, may be involved in the relationship between microbes, infection, and PTB. The complement system, a key mediator of the inflammatory response, is an innate defense mechanism involved in both normal physiologic processes that occur during pregnancy implantation and processes that promote the elimination of pathogenic microbes. Recent research has demonstrated an association between this system and PTB. The purpose of this article is to present a mechanistic model of inflammation-associated PTB, which hypothesizes a relationship between the microbiome and dysregulation of the complement system. Exploring the relationships between the microbial environment and complement biomarkers may elucidate a potentially modifiable biological pathway to PTB.
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Affiliation(s)
- Alexis B Dunn
- 1 Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Anne L Dunlop
- 1 Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Carol J Hogue
- 2 Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Andrew Miller
- 3 School of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Elizabeth J Corwin
- 1 Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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