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Budylowski P, Chau SLL, Banerjee A, Guvenc F, Samson R, Hu Q, Fiddes L, Seifried L, Chao G, Buchholz M, Estacio A, Cheatley PL, Pavenski K, Patriquin CJ, Liu Y, Sheikh-Mohamed S, Crasta K, Yue F, Pasic MD, Mossman K, Gingras AC, Gommerman JL, Ehrhardt GRA, Mubareka S, Ostrowski M. A Significant Contribution of the Classical Pathway of Complement in SARS-CoV-2 Neutralization of Convalescent and Vaccinee Sera. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:1922-1931. [PMID: 38683124 DOI: 10.4049/jimmunol.2300320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 04/09/2024] [Indexed: 05/01/2024]
Abstract
Although high titers of neutralizing Abs in human serum are associated with protection from reinfection by SARS-CoV-2, there is considerable heterogeneity in human serum-neutralizing Abs against SARS-CoV-2 during convalescence between individuals. Standard human serum live virus neutralization assays require inactivation of serum/plasma prior to testing. In this study, we report that the SARS-CoV-2 neutralization titers of human convalescent sera were relatively consistent across all disease states except for severe COVID-19, which yielded significantly higher neutralization titers. Furthermore, we show that heat inactivation of human serum significantly lowered neutralization activity in a live virus SARS-CoV-2 neutralization assay. Heat inactivation of human convalescent serum was shown to inactivate complement proteins, and the contribution of complement in SARS-CoV-2 neutralization was often >50% of the neutralizing activity of human sera without heat inactivation and could account for neutralizing activity when standard titers were zero after heat inactivation. This effect was also observed in COVID-19 vaccinees and could be abolished in individuals who were undergoing treatment with therapeutic anti-complement Abs. Complement activity was mainly dependent on the classical pathway with little contributions from mannose-binding lectin and alternative pathways. Our study demonstrates the importance of the complement pathway in significantly increasing viral neutralization activity against SARS-CoV-2 in spike seropositive individuals.
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Affiliation(s)
- Patrick Budylowski
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Serena L L Chau
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arinjay Banerjee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Furkan Guvenc
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Reuben Samson
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Queenie Hu
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Lindsey Fiddes
- Microscopy Imaging Lab, University of Toronto, Toronto, Ontario, Canada
| | - Laurie Seifried
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Gary Chao
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Megan Buchholz
- Apheresis Unit, Kidney and Metabolism Program, St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Antonio Estacio
- Keenan Research Centre for Biomedical Science of St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Patti Lou Cheatley
- Apheresis Unit, Kidney and Metabolism Program, St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Apheresis Unit, Kidney and Metabolism Program, St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Christopher J Patriquin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Yanling Liu
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | | | - Kimberly Crasta
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - FengYun Yue
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maria D Pasic
- Department of Immunology, Unity Health Toronto, Toronto, Ontario, Canada
| | - Karen Mossman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anne-Claude Gingras
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | | | - Götz R A Ehrhardt
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Samira Mubareka
- Sunnybrook Research Institute, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Mario Ostrowski
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science of St Michael's Hospital, Unity Health, Toronto, Ontario, Canada
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Govender S, David M, Naicker T. Is the Complement System Dysregulated in Preeclampsia Comorbid with HIV Infection? Int J Mol Sci 2024; 25:6232. [PMID: 38892429 PMCID: PMC11172754 DOI: 10.3390/ijms25116232] [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: 05/02/2024] [Revised: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 06/21/2024] Open
Abstract
South Africa is the epicentre of the global HIV pandemic, with 13.9% of its population infected. Preeclampsia (PE), a hypertensive disorder of pregnancy, is often comorbid with HIV infection, leading to multi-organ dysfunction and convulsions. The exact pathophysiology of preeclampsia is triggered by an altered maternal immune response or defective development of maternal tolerance to the semi-allogenic foetus via the complement system. The complement system plays a vital role in the innate immune system, generating inflammation, mediating the clearance of microbes and injured tissue materials, and a mediator of adaptive immunity. Moreover, the complement system has a dual effect, of protecting the host against HIV infection and enhancing HIV infectivity. An upregulation of regulatory proteins has been implicated as an adaptive phenomenon in response to elevated complement-mediated cell lysis in HIV infection, further aggravated by preeclamptic complement activation. In light of the high prevalence of HIV infection and preeclampsia in South Africa, this review discusses the association of complement proteins and their role in the synergy of HIV infection and preeclampsia in South Africa. It aims to identify women at elevated risk, leading to early diagnosis and better management with targeted drug therapy, thereby improving the understanding of immunological dysregulation.
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Affiliation(s)
| | | | - Thajasvarie Naicker
- Optics and Imaging Centre, Doris Duke Medical Research Institute, College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa; (S.G.); (M.D.)
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Cole MA, Ranjan N, Gerber GF, Pan XZ, Flores-Guerrero D, Chaturvedi S, Sperati CJ, McCrae KR, Brodsky RA. Complement Biosensors Identify a Classical Pathway Stimulus in Complement-Mediated Hemolytic Uremic Syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.29.596475. [PMID: 38854038 PMCID: PMC11160691 DOI: 10.1101/2024.05.29.596475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Complement-mediated hemolytic uremic syndrome (CM-HUS) is a thrombotic microangiopathy characterized by germline variants or acquired antibodies to complement proteins and regulators. Building upon our prior experience with the modified Ham (mHam) assay for ex vivo diagnosis of complementopathies, we have developed an array of cell-based complement "biosensors'' by selective removal of complement regulatory proteins (CD55 and CD59, CD46, or a combination thereof) in an autonomously bioluminescent HEK293 cell line. These biosensors can be used as a sensitive method for diagnosing CM-HUS and monitoring therapeutic complement blockade. Using specific complement pathway inhibitors, this model identifies IgM-driven classical pathway stimulus during both acute disease and in many patients during clinical remission. This provides a potential explanation for ~50% of CM-HUS patients who lack an alternative pathway "driving" variant and suggests at least a subset of CM-HUS is characterized by a breakdown of IgM immunologic tolerance. Key Points CM-HUS has a CP stimulus driven by polyreactive IgM, addressing the mystery of why 40% of CM-HUS lack complement specific variantsComplement biosensors and the bioluminescent mHam can be used to aid in diagnosis of CM-HUS and monitor complement inhibitor therapy.
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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Barbey C, Wolf H, Wagner R, Pauly D, Breunig M. A shift of paradigm: From avoiding nanoparticular complement activation in the field of nanomedicines to its exploitation in the context of vaccine development. Eur J Pharm Biopharm 2023; 193:119-128. [PMID: 37838145 DOI: 10.1016/j.ejpb.2023.10.008] [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: 07/27/2023] [Revised: 10/01/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
The complement system plays a central role in our innate immunity to fight pathogenic microorganisms, foreign and altered cells, or any modified molecule. Consequences of complement activation include cell lysis, release of histamines, and opsonization of foreign structures in preparation for phagocytosis. Because nanoparticles interact with the immune system in various ways and can massively activate the complement system due to their virus-mimetic size and foreign texture, detrimental side effects have been described after administration like pro-inflammatory responses, inflammation, mild to severe anaphylactic crisis and potentially complement activated-related pseudoallergy (CARPA). Therefore, application of nanotherapeutics has sometimes been observed with restraint, and avoiding or even suppressing complement activation has been of utmost priority. In contrast, in the field of vaccine development, particularly protein-based immunogens that are attached to the surface of nanoparticles, may profit from complement activation regarding breadth and potency of immune response. Improved transport to the regional lymph nodes, enhanced antigen uptake and presentation, as well as beneficial effects on immune cells like B-, T- and follicular dendritic cells may be exploited by strategic nanoparticle design aimed to activate the complement system. However, a shift of paradigm regarding complement activation by nanoparticular vaccines can only be achieved if these beneficial effects are accurately elicited and overshooting effects avoided.
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Affiliation(s)
- Clara Barbey
- Department of Pharmaceutical Technology, University Regensburg, Regensburg, Germany
| | - Hannah Wolf
- Department of Experimental Ophthalmology, University Marburg, Marburg, Germany
| | - Ralf Wagner
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany; Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Diana Pauly
- Department of Experimental Ophthalmology, University Marburg, Marburg, Germany
| | - Miriam Breunig
- Department of Pharmaceutical Technology, University Regensburg, Regensburg, Germany.
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Rajasekaran A, Green TJ, Renfrow MB, Julian BA, Novak J, Rizk DV. Current Understanding of Complement Proteins as Therapeutic Targets for the Treatment of Immunoglobulin A Nephropathy. Drugs 2023; 83:1475-1499. [PMID: 37747686 PMCID: PMC10807511 DOI: 10.1007/s40265-023-01940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and a frequent cause of kidney failure. Currently, the diagnosis necessitates a kidney biopsy, with routine immunofluorescence microscopy revealing IgA as the dominant or co-dominant immunoglobulin in the glomerular immuno-deposits, often with IgG and sometimes IgM or both. Complement protein C3 is observed in most cases. IgAN leads to kidney failure in 20-40% of patients within 20 years of diagnosis and reduces average life expectancy by about 10 years. There is increasing clinical, biochemical, and genetic evidence that the complement system plays a paramount role in the pathogenesis of IgAN. The presence of C3 in the kidney immuno-deposits differentiates the diagnosis of IgAN from subclinical glomerular mesangial IgA deposition. Markers of complement activation via the lectin and alternative pathways in kidney-biopsy specimens are associated with disease activity and are predictive of poor outcome. Levels of select complement proteins in the circulation have also been assessed in patients with IgAN and found to be of prognostic value. Ongoing genetic studies have identified at least 30 loci associated with IgAN. Genes within some of these loci encode complement-system regulating proteins that can interact with immune complexes. The growing appreciation for the central role of complement components in IgAN pathogenesis highlighted these pathways as potential treatment targets and sparked great interest in pharmacological agents targeting the complement cascade for the treatment of IgAN, as evidenced by the plethora of ongoing clinical trials.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd J Green
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew B Renfrow
- Department of Biochemistry and Molecular Genetics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bruce A Julian
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jan Novak
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Hardy MP, Mansour M, Rowe T, Wymann S. The Molecular Mechanisms of Complement Receptor 1-It Is Complicated. Biomolecules 2023; 13:1522. [PMID: 37892204 PMCID: PMC10605242 DOI: 10.3390/biom13101522] [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: 09/25/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Human complement receptor 1 (CR1) is a membrane-bound regulator of complement that has been the subject of recent attempts to generate soluble therapeutic compounds comprising different fragments of its extracellular domain. This review will focus on the extracellular domain of CR1 and detail how its highly duplicated domains work both separately and together to mediate binding to its main ligands C3b and C4b, and to inhibit the classical, lectin, and alternative pathways of the complement cascade via the mechanisms of decay acceleration activity (DAA) and co-factor activity (CFA). Understanding the molecular basis of CR1 activity is made more complicated by the presence not only of multiple ligand binding domains within CR1 but also the fact that C3b and C4b can interact with CR1 as both monomers, dimers, and heterodimers. Evidence for the interaction of CR1 with additional ligands such as C1q will also be reviewed. Finally, we will bring the mechanistic understanding of CR1 activity together to provide an explanation for the differential complement pathway inhibition recently observed with CSL040, a soluble CR1-based therapeutic candidate in pre-clinical development.
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Affiliation(s)
| | | | - Tony Rowe
- CSL, Bio21 Institute, Melbourne, VIC 3052, Australia
| | - Sandra Wymann
- CSL, CSL Biologics Research Centre, 1066 Bern, Switzerland
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8
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Dani R, Oroszlán G, Martinusz R, Farkas B, Dobos B, Vadas E, Závodszky P, Gál P, Dobó J. Quantification of the zymogenicity and the substrate-induced activity enhancement of complement factor D. Front Immunol 2023; 14:1197023. [PMID: 37283768 PMCID: PMC10239819 DOI: 10.3389/fimmu.2023.1197023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
Abstract
Complement factor D (FD) is a serine protease present predominantly in the active form in circulation. It is synthesized as a zymogen (pro-FD), but it is continuously converted to FD by circulating active MASP-3. FD is a unique, self-inhibited protease. It has an extremely low activity toward free factor B (FB), while it is a highly efficient enzyme toward FB complexed with C3b (C3bB). The structural basis of this phenomenon is known; however, the rate enhancement was not yet quantified. It has also been unknown whether pro-FD has any enzymatic activity. In this study, we aimed to measure the activity of human FD and pro-FD toward uncomplexed FB and C3bB in order to quantitatively characterize the substrate-induced activity enhancement and zymogenicity of FD. Pro-FD was stabilized in the proenzyme form by replacing Arg25 (precursor numbering) with Gln (pro-FD-R/Q). Activated MASP-1 and MASP-3 catalytic fragments were also included in the study for comparison. We found that the complex formation with C3b enhanced the cleavage rate of FB by FD approximately 20 million-fold. C3bB was also a better substrate for MASP-1, approximately 100-fold, than free FB, showing that binding to C3b renders the scissile Arg-Lys bond in FB to become more accessible for proteolysis. Though easily measurable, this cleavage by MASP-1 is not relevant physiologically. Our approach provides quantitative data for the two-step mechanism characterized by the enhanced susceptibility of FB for cleavage upon complex formation with C3b and the substrate-induced activity enhancement of FD upon its binding to C3bB. Earlier MASP-3 was also implicated as a potential FB activator; however, MASP-3 does not cleave C3bB (or FB) at an appreciable rate. Finally, pro-FD cleaves C3bB at a rate that could be physiologically significant. The zymogenicity of FD is approximately 800, i.e., the cleavage rate of C3bB by pro-FD-R/Q was found to be approximately 800-fold lower than that by FD. Moreover, pro-FD-R/Q at approximately 50-fold of the physiological FD concentration could restore half-maximal AP activity of FD-depleted human serum on zymosan. The observed zymogen activity of pro-FD might be relevant in MASP-3 deficiency cases or during therapeutic MASP-3 inhibition.
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9
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Xiao F, Guo J, Tomlinson S, Yuan G, He S. The role of the complosome in health and disease. Front Immunol 2023; 14:1146167. [PMID: 36969185 PMCID: PMC10036758 DOI: 10.3389/fimmu.2023.1146167] [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: 01/17/2023] [Accepted: 02/28/2023] [Indexed: 03/12/2023] Open
Abstract
The complement system is one of the immune system's oldest defense mechanisms and is historically regarded as a liver-derived and serum-active innate immune system that 'complements' cell-mediated and antibody-mediated immune responses against pathogens. However, the complement system is now recognized as a central component of both innate and adaptive immunity at both the systemic and local tissue levels. More findings have uncovered novel activities of an intracellularly active complement system-the complosome-that have shifted established functional paradigms in the field. The complosome has been shown to play a critical function in regulating T cell responses, cell physiology (such as metabolism), inflammatory disease processes, and cancer, which has amply proved its immense research potential and informed us that there is still much to learn about this system. Here, we summarize current understanding and discuss the emerging roles of the complosome in health and disease.
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Affiliation(s)
- Fang Xiao
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jixu Guo
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Guandou Yuan
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning, China
- Guangxi Key Laboratory of Immunology and Metabolism for Liver Diseases, Nanning, Guangxi, China
| | - Songqing He
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning, China
- Guangxi Key Laboratory of Immunology and Metabolism for Liver Diseases, Nanning, Guangxi, China
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10
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Harrison RA, Harris CL, Thurman JM. The complement alternative pathway in health and disease-activation or amplification? Immunol Rev 2023; 313:6-14. [PMID: 36424888 DOI: 10.1111/imr.13172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Joshua M Thurman
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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