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Nevras V, Milaras N, Katsioulis C, Sotiriou Z, Tsalamandris S, Gkounti G, Skevos S. Acute Coronary Syndromes in Antiphospholipid Syndrome-above Suspicion: A Systematic Review. Curr Probl Cardiol 2023; 48:101503. [PMID: 36402221 DOI: 10.1016/j.cpcardiol.2022.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Antiphospholipid syndrome(APS) is an autoimmune disorder characterized clinically by vascular thrombosis and/or pregnancy morbidity, associated with persistently elevated titers of antiphospholipid antibodies on at least two measurements over 12 weeks apart. In this study, we conducted a systematic review of the literature utilizing the Pubmed platform, in order to acquire clinical information about acute coronary syndromes in patients with APS. The obtained articles were reviewed in order to register the clinical characteristics, the rate of occurrence, the prognosis and the therapeutic approach of these patients. APS should be considered in young patients with acute myocardial infarction, even in patients with normal coronary arteries. The pharmaceutical approach is mainly based on the vitamin K antagonists, and in certain occasions aspirin, without any definite guidelines on the subject. Further randomized clinical trials are imperative for a better understanding of the particular characteristics of this group of patients, so that a more complete therapeutic approach to be obtained.
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Affiliation(s)
- Vasileios Nevras
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Nikias Milaras
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece.
| | - Christos Katsioulis
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Zoi Sotiriou
- Pediatrics Department, General Hospital of Karditsa, Karditsa, Karditsa, Greece
| | - Sotirios Tsalamandris
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
| | - Georgia Gkounti
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Sideris Skevos
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
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Sayar Z, Moll R, Isenberg D, Cohen H. Thrombotic antiphospholipid syndrome: A practical guide to diagnosis and management. Thromb Res 2021; 198:213-221. [PMID: 33485122 PMCID: PMC7560059 DOI: 10.1016/j.thromres.2020.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/12/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022]
Abstract
Thrombotic antiphospholipid syndrome (APS) is characterised by venous, arterial and/or small vessel thrombosis in the context of persistently positive antiphospholipid antibodies (aPL). The diagnosis and management of thrombotic APS continues to prove challenging for clinicians. We provide a practical guide to the diagnosis of APS including who to test for aPL and which tests to do. We also consider clinical practice points on the management of venous, arterial and small vessel thrombosis, in the context of first and recurrent thrombotic events. Non-criteria manifestations of APS are reviewed. An approach to recurrent thrombosis and anticoagulant-refractory APS is discussed, with options including increasing the anticoagulation intensity of vitamin K antagonists, switching to low-molecular-weight-heparin, the use of fondaparinux and/or the addition of antiplatelet treatment. Adjunctive options such as vitamin D, hydroxychloroquine and statins are also addressed.
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Affiliation(s)
- Zara Sayar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Haematology, Whittington Health NHS Trust, London, UK.
| | - Rachel Moll
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, Department of Haematology, University College London, London, UK
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3
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Gavriș CM, Nedelcu LD, Pascu AM. Thrombotic risk in antiphospholipidic syndrome: From hypothesis to current evidence (Review). Exp Ther Med 2021; 21:287. [PMID: 33603894 DOI: 10.3892/etm.2021.9718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/08/2020] [Indexed: 11/05/2022] Open
Abstract
Thirty-five years after it was first described, antiphospholipid syndrome (APS) is unanimously recognized as a systemic autoimmune disease, a major acquired thrombophilia, which can affect any arterial or venous vascular territory, explaining the great diversity of clinical manifestations. The current classification criteria updated in the International Consensus Statement for Definite Antiphospholipid Syndrome from Sydney cannot explain alone the unpredictable evolution with thrombotic events of the patients diagnosed with APS. Although the link to genetics and epigenetics has not been clearly defined as in other autoimmune diseases, it is clear that a proper stratification of thrombotic risk in the era of personalized medicine must include classic biological markers (antiphospholipid antibodies, aPL), along with the already recognized phenotypes, non-conventional serological markers, and additional genetic risk factors for thrombosis. Moreover, with advancing age, a patient with APS develops other thrombotic risk factors which include: hypertension and dyslipidemia among others. According to the classification criteria, a patient is considered to have a low, moderate or high thrombotic risk. In clinical practice, patients with the same risk score may have completely different evolutions in terms of the recurrence of thrombosis. Concerning this approach, it appears that new non-conventional serological markers, phenotype-assessment and genetic determinants have an increasing importance and should be reconsidered in a proper thrombotic risk evaluation in patients with APS, compared to the initial concept of APS as first defined.
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Affiliation(s)
| | | | - Alina Mihaela Pascu
- Faculty of Medicine, 'Transilvania University' of Braşov, 500036 Brasov, Romania
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Barinotti A, Radin M, Cecchi I, Foddai SG, Rubini E, Roccatello D, Sciascia S, Menegatti E. Genetic Factors in Antiphospholipid Syndrome: Preliminary Experience with Whole Exome Sequencing. Int J Mol Sci 2020; 21:E9551. [PMID: 33333988 PMCID: PMC7765384 DOI: 10.3390/ijms21249551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 12/18/2022] Open
Abstract
As in many autoimmune diseases, the pathogenesis of the antiphospholipid syndrome (APS) is the result of a complex interplay between predisposing genes and triggering environmental factors, leading to a loss of self-tolerance and immune-mediated tissue damage. While the first genetic studies in APS focused primarily on the human leukocytes antigen system (HLA) region, more recent data highlighted the role of other genes in APS susceptibility, including those involved in the immune response and in the hemostatic process. In order to join this intriguing debate, we analyzed the single-nucleotide polymorphisms (SNPs) derived from the whole exome sequencing (WES) of two siblings affected by APS and compared our findings with the available literature. We identified genes encoding proteins involved in the hemostatic process, the immune response, and the phospholipid metabolism (PLA2G6, HSPG2, BCL3, ZFAT, ATP2B2, CRTC3, and ADCY3) of potential interest when debating the pathogenesis of the syndrome. The study of the selected SNPs in a larger cohort of APS patients and the integration of WES results with the network-based approaches will help decipher the genetic risk factors involved in the diverse clinical features of APS.
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Affiliation(s)
- Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, 10125 Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
| | - Silvia Grazietta Foddai
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, 10125 Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, 10154 Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, 10154 Turin, Italy
| | - Elisa Menegatti
- Center of Research of Immunopathology and Rare Diseases—Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, 10154 Turin, Italy; (A.B.); (M.R.); (I.C.); (S.G.F.); (E.R.); (D.R.); (E.M.)
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, 10125 Turin, Italy
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Linge P, Arve S, Olsson LM, Leonard D, Sjöwall C, Frodlund M, Gunnarsson I, Svenungsson E, Tydén H, Jönsen A, Kahn R, Johansson Å, Rönnblom L, Holmdahl R, Bengtsson A. NCF1-339 polymorphism is associated with altered formation of neutrophil extracellular traps, high serum interferon activity and antiphospholipid syndrome in systemic lupus erythematosus. Ann Rheum Dis 2020; 79:254-261. [PMID: 31704719 DOI: 10.1136/annrheumdis-2019-215820] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES: A single nucleotide polymorphism in the NCF1 gene (NCF1-339, rs201802880), encoding NADPH oxidase type II subunit NCF1/p47phox, reducing production of reactive oxygen species (ROS) is strongly associated with the development of systemic lupus erythematosus (SLE). This study aimed at characterising NCF1-339 effects on neutrophil extracellular trap (NET) formation, type I interferon activity and antibody profile in patients with SLE. METHODS: Neutrophil NET-release pathways (n=31), serum interferon (n=141) and finally antibody profiles (n=305) were investigated in SLE subjects from Lund, genotyped for NCF1-339. Then, 1087 SLE subjects from the rheumatology departments of four Swedish SLE centres, genotyped for NCF1-339, were clinically characterised to validate these findings. RESULTS: Compared with patients with normal-ROS NCF1-339 genotypes, neutrophils from patients with SLE with low-ROS NCF1-339 genotypes displayed impaired NET formation (p<0.01) and increased dependence on mitochondrial ROS (p<0.05). Low-ROS patients also had increased frequency of high serum interferon activity (80% vs 21.4%, p<0.05) and positivity for anti-β2 glycoprotein I (p<0.01) and anticardiolipin antibodies (p<0.05) but were not associated with other antibodies. We confirmed an over-representation of having any antiphospholipid antibody, OR 1.40 (95% CI 1.01 to 1.95), anti-β2 glycoprotein I, OR 1.82 (95% CI 1.02 to 3.24) and the antiphospholipid syndrome (APS), OR 1.74 (95% CI 1.19 to 2.55) in all four cohorts (n=1087). CONCLUSIONS: The NCF1-339 SNP mediated decreased NADPH oxidase function, is associated with high interferon activity and impaired formation of NETs in SLE, allowing dependence on mitochondrial ROS. Unexpectedly, we revealed a striking connection between the ROS deficient NCF1-339 genotypes and the presence of phospholipid antibodies and APS.
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Affiliation(s)
- Petrus Linge
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Sabine Arve
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Lina M Olsson
- Department of Medical Biochemistry and Biophysics, Division of Medical Inflammation Research, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Dag Leonard
- Department of Medical Sciences, Science for Life Laboratories, Rheumatology Unit, Uppsala University, Uppsala, Uppland, Sweden
| | - Christopher Sjöwall
- Department of Clinical and Experimental Medicine, Rheumatology/AIR, Linköping University, Linkoping, Ostergotland, Sweden
| | - Martina Frodlund
- Department of Clinical and Experimental Medicine, Rheumatology/AIR, Linköping University, Linkoping, Ostergotland, Sweden
| | - Iva Gunnarsson
- Department of Medicine Solna, Unit of Rheumatology, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Elisabet Svenungsson
- Department of Medicine Solna, Unit of Rheumatology, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Helena Tydén
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Robin Kahn
- Department of Clinical Sciences Lund, Section of Pediatrics, Lund University, Lund, Skane, Sweden
- Wallenberg Center for Molecular Medicin, Lund University, Lund, Skane, Sweden
| | - Åsa Johansson
- Division for Hematology and Transfusion Medicine, Department of laboratory medicine, Lund University, Lund, Skane, Sweden
- Regional Laboratories Region Skane, Department of Clinical Immunology and Transfusion Medicine, Skanes universitetssjukhus Lund Labmedicin Skane, Lund, Skane, Sweden
| | - Lars Rönnblom
- Department of Medical Sciences, Science for Life Laboratories, Rheumatology Unit, Uppsala University, Uppsala, Uppland, Sweden
| | - Rikard Holmdahl
- Department of Medical Biochemistry and Biophysics, Division of Medical Inflammation Research, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Anders Bengtsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
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Wirestam L, Arve S, Linge P, Bengtsson AA. Neutrophils-Important Communicators in Systemic Lupus Erythematosus and Antiphospholipid Syndrome. Front Immunol 2019; 10:2734. [PMID: 31824510 PMCID: PMC6882868 DOI: 10.3389/fimmu.2019.02734] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/07/2019] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are two autoimmune diseases that can occur together or separately. Insights into the pathogenesis have revealed similarities, such as development of autoantibodies targeting subcellular antigens as well as a shared increased risk of cardiovascular morbidity, potentially due to mutual pathologic mechanisms. In this review, we will address the evidence implicating neutrophils in the pathogenesis of these conditions, highlighting their shared features. The neutrophil is the most abundant leukocyte, recognized for its role in infectious and inflammatory diseases, but dysregulation of neutrophil effector functions, including phagocytosis, oxidative burst and formation of neutrophil extracellular traps (NETs) may also contribute to an autoimmune process. The phenotype of neutrophils in SLE and APS differs from neutrophils of healthy individuals, where neutrophils in SLE and APS are activated and prone to aggregate. A specific subset of low-density neutrophils with different function compared to normal-density neutrophils can also be found within the peripheral blood mononuclear cell (PBMC) fraction after density gradient centrifugation of whole blood. Neutrophil phagocytosis is required for regular clearance of cell remnants and nuclear material. Reactive oxygen species (ROS) released by neutrophils during oxidative burst are important for immune suppression and impairment of ROS production is seen in SLE. NETs mediate pathology in both SLE and APS via several mechanisms, including exposure of autoantigens, priming of T-cells and activation of autoreactive B-cells. NETs are also involved in cardiovascular events by forming a pro-thrombotic scaffolding surface. Lastly, neutrophils communicate with other cells by producing cytokines, such as Interferon (IFN) -α, and via direct cell-cell contact. Physiological neutrophil effector functions are necessary to prevent autoimmunity, but in SLE and APS these are altered.
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Affiliation(s)
- Lina Wirestam
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Sabine Arve
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Petrus Linge
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Anders A Bengtsson
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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HLA DRB1 and HLA DQB1 Alleles in Bulgarian Patients with Primary and Secondary Antiphospholipid Syndrome. ACTA MEDICA BULGARICA 2019. [DOI: 10.2478/amb-2019-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease with multifactorial and polygenic pathogenesis. Recently, the genetic predisposition in APS has been subjected to wide discussion. The aim of this study is to determine the prevalence of DRB1 and DQB1 loci in Bulgarian population of healthy persons and patients with primary (PAPS) and secondary (SAPS) APS. Patients are divided in 5 groups: I-29 patents with systemic lupus erythematosus (SLE) with SAPS, II-35 patients with PAPS, III-32 women with spontaneous abortions without aPL, IV-15 patients with different thrombosis (deep venous thromboses, pulmonary embolism, mesenterial thrombosis, myocardial infarction, stroke) without laboratory data for APS, and V-16 SLE patients without clinical and laboratory data for APS. SAPS patients have more frequently DRB1*03 and DQB1*02 and more rarely DRB1*11 and DQB1*03 in comparison with healthy subjects and patients with PAPS. Patents with PAPS, those with spontaneous abortions and patients with thrombotic events but without antiphospholipid antibodies (aPL) have DRB1*03, DRB1*11, DQB1*02 and DQB1*03 alleles similar to the general population. There are no differences between group I (SLE+APS) and group V (SLE) in DRB1* and DQB1*alleles.
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8
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The H1 haplotype of the endothelial protein C receptor protects against arterial thrombosis in patients with antiphospholipid syndrome. Thromb Res 2018; 169:128-134. [PMID: 30048851 DOI: 10.1016/j.thromres.2018.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/15/2018] [Accepted: 07/03/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Genetic variants in the endothelial protein C receptor gene (PROCR) may contribute to the thrombosis risk by regulating levels of the soluble form of this protein (sEPCR). We evaluated whether PROCR polymorphisms and sEPCR levels play a role in the thrombotic manifestations of antiphospholipid syndrome. MATERIALS AND METHODS One hundred and seventy-five patients (62 with primary antiphospholipid syndrome, 30 with antiphospholipid syndrome associated with systemic lupus erythematosus, 40 with systemic lupus erythematosus without antiphospholipid antibodies and 43 with systemic lupus erythematosus and antiphospholipid antibodies) and 66 healthy controls were included. PROCR H1 and H3 haplotypes were determined by genotyping 7014G/C and 1651C/G tag-polymorphisms, respectively. sEPCR levels were determined by enzyme-linked immunosorbent assay. RESULTS PROCR haplotype distribution was similar among groups of patients and controls. PROCR H1 and H3 haplotypes were less prevalent in antiphospholipid syndrome patients with arterial thrombosis than those without arterial thrombosis, but statistical significance was only reached for the H1 haplotype (58.0% vs. 85.7%, p = 0.003; odds ratio: 0.23 [95% CI 0.08-0.65]). No relationship between the PROCR H1 and H3 haplotypes and venous thrombosis was found. sEPCR levels were higher in H3 than in H1 carriers (175.5 [95% CI 60.9-290.1] ng/ml vs. 69.1 [95% CI 61.5-76.9] ng/ml, p < 0.01). No relationship of sEPCR with arterial or venous thrombosis was found. CONCLUSION The PROCR H1 haplotype was less frequently found in APS patients with arterial thrombosis, suggesting a protective effect of PROCR H1 against arterial thrombosis in these patients. No relationship between sEPCR and thrombosis was found.
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Hinojosa CA, Anaya-Ayala JE, Bermudez-Serrato K, García-Alva R, Laparra-Escareno H, Torres-Machorro A, Lizola R. Surgical Interventions for Organ and Limb Ischemia Associated With Primary and Secondary Antiphospholipid Antibody Syndrome With Arterial Involvement. Vasc Endovascular Surg 2017; 51:550-554. [PMID: 28920529 DOI: 10.1177/1538574417729273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The association of antiphospholipid antibody syndrome (APS) and hypercoagulability is well known. Arterial compromise leading to ischemia of organs and/or limbs in patients with APS is uncommon, frequently unrecognized, and rarely described. We evaluated our institutional experience. METHODS Retrospective review was conducted. From August 2007 to September 2016, 807 patients with diagnosis of APS were managed in our Institution. Patients with primary and secondary APS who required interventions were examined. Demographics, comorbidities, manifestations, procedures, complications, and other factors affecting outcomes were recorded. RESULTS Fourteen patients (mean age 35 years old, standard deviation ±14) were evaluated and treated by our service. Six (43%) of them had primary APS and 8 (57%) had secondary APS; 11 (79%) were female. Two (14%) experienced distal aorta and iliac arteries involvement, 3 (21%) visceral vessels disease, 2 (14%) in upper and 7 (50%) in the lower extremity vasculatures. Thirteen (93%) patients underwent direct open revascularization and 1 with hand ischemia (Raynaud disease) underwent sympathectomy. During the mean follow-up period of 48 months, reinterventions included a revision of the proximal anastomosis of an aortobifemoral bypass graft, 1 (7%) abdominal exploration for bleeding, 1 (7%) graft thrombectomy, and 4 (29%) amputations (2 below the knee, 1 above the knee, and 1 transmetatarsal). One (7%) death occurred secondary to sepsis in a patient who had acute mesenteric ischemia. Significant differences in clinical manifestations and outcomes were not observed among patients with primary and secondary APS. All patients remained on systemic anticoagulation. CONCLUSION APS is a prothrombotic disorder that may lead to arterial involvement with less frequency than the venous circulation but has significant morbidity and limb loss rate. Arterial reconstruction seems feasible in an attempt to salvage organs and limbs; however, research is necessary to establish the optimal anticoagulation regime and long-term management following surgical interventions.
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Affiliation(s)
- Carlos A Hinojosa
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Javier E Anaya-Ayala
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Karla Bermudez-Serrato
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Ramón García-Alva
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Hugo Laparra-Escareno
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Adriana Torres-Machorro
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Rene Lizola
- 1 Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
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10
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Alijotas-Reig J, Ferrer-Oliveras R, Esteve-Valverde E, Ruffatti A, Tincani A, Lefkou E, Bertero MT, Espinosa G, Coloma E, de Carolis S, Rovere-Querini P, Canti V, Picardo E, Fredi M, Mekinian A. Inherited thrombophilia in women with poor aPL-related obstetric history: prevalence and outcomes. Survey of 208 cases from the European Registry on Obstetric Antiphospholipid Syndrome cohort. Am J Reprod Immunol 2016; 76:164-71. [DOI: 10.1111/aji.12534] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/31/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit; Department of Internal Medicine; Vall d'Hebron University Hospital; Barcelona Spain
- Department of Medicine; Universitat Autonoma; Barcelona Spain
| | - Raquel Ferrer-Oliveras
- Obstetric and Gynaecolgy Department; Vall d'Hebron University Hospital; Universitat Autonoma; Barcelona Spain
| | - Enrique Esteve-Valverde
- Systemic Autoimmune Disease Unit; Department of Internal Medicine; Vall d'Hebron University Hospital; Barcelona Spain
- Internal Medicine Department; Althaia Healthcare Network of Manresa; Barcelona Spain
| | - Amelia Ruffatti
- Rheumatology Unit; Department of Clinical and Experimental Medicine Azienda Ospedaliera; University of Padua; Padua Italy
| | - Angela Tincani
- Rheumatology and Clinial Immunology Unit; Ospedale Civile; Brescia Italy
| | - Elmina Lefkou
- Haematology Unit; Hippokration Hospital of Thessaloniki; Thessaloniki Greece
| | | | - Gerard Espinosa
- Systemic Autoimmune Diseases Service; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Emmanuel Coloma
- Systemic Autoimmune Diseases Service; Hospital Clinic; Universitat de Barcelona; Barcelona Spain
| | - Sara de Carolis
- Depatment of Gynaecology; Gemmeli Hospital; Catholic University; Roma Italy
| | - Patrizia Rovere-Querini
- Pregnancy and Rheumatic Diseases Clinic Unit of Medicine and Clinical Immunology IRCCS Ospedale San Raffaele Università Vita-Salute San Raffaele; Milano Italy
| | - Valentina Canti
- Pregnancy and Rheumatic Diseases Clinic Unit of Medicine and Clinical Immunology IRCCS Ospedale San Raffaele Università Vita-Salute San Raffaele; Milano Italy
- Laboratorio Autoimmunità e Inflammazione Voscolare - San Raffaele DIBIT; Milano Italy
| | - Elisa Picardo
- Department of Obstetrics and Gynaecology; University of Turin; Turin Italy
| | - Micaela Fredi
- Rheumatology and Clinial Immunology Unit; Ospedale Civile; Brescia Italy
| | - Arsene Mekinian
- Department of Medicine; Hôpital Saint-Antoine; Universite Est Parisien; Paris France
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11
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Ho YC, Ahuja KDK, Körner H, Adams MJ. β 2GP1, Anti-β 2GP1 Antibodies and Platelets: Key Players in the Antiphospholipid Syndrome. Antibodies (Basel) 2016; 5:E12. [PMID: 31557993 PMCID: PMC6698853 DOI: 10.3390/antib5020012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 12/21/2022] Open
Abstract
Anti-beta 2 glycoprotein 1 (anti-β2GP1) antibodies are commonly found in patients with autoimmune diseases such as the antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE). Their presence is highly associated with increased risk of vascular thrombosis and/or recurrent pregnancy-related complications. Although they are a subtype of anti-phospholipid (APL) antibody, anti-β2GP1 antibodies form complexes with β2GP1 before binding to different receptors associated with anionic phospholipids on structures such as platelets and endothelial cells. β2GP1 consists of five short consensus repeat termed "sushi" domains. It has three interchangeable conformations with a cryptic epitope at domain 1 within the molecule. Anti-β2GP1 antibodies against this cryptic epitope are referred to as 'type A' antibodies, and have been suggested to be more strongly associated with both vascular and obstetric complications. In contrast, 'type B' antibodies, directed against other domains of β2GP1, are more likely to be benign antibodies found in asymptomatic patients and healthy individuals. Although the interactions between anti-β2GP1 antibodies, β2GP1, and platelets have been investigated, the actual targeted metabolic pathway(s) and/or receptor(s) involved remain to be clearly elucidated. This review will discuss the current understanding of the interaction between anti-β2GP1 antibodies and β2GP1, with platelet receptors and associated signalling pathways.
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Affiliation(s)
- Yik C Ho
- School of Health Sciences, University of Tasmania, Locked Bag 1322, Launceston, Tasmania 7250, Australia.
| | - Kiran D K Ahuja
- School of Health Sciences, University of Tasmania, Locked Bag 1322, Launceston, Tasmania 7250, Australia.
| | - Heinrich Körner
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania 7001, Australia.
| | - Murray J Adams
- School of Health Sciences, University of Tasmania, Locked Bag 1322, Launceston, Tasmania 7250, Australia.
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Systems-Pharmacology Dissection of Traditional Chinese Medicine Compound Saffron Formula Reveals Multi-scale Treatment Strategy for Cardiovascular Diseases. Sci Rep 2016; 6:19809. [PMID: 26813334 PMCID: PMC4728400 DOI: 10.1038/srep19809] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 12/14/2015] [Indexed: 11/22/2022] Open
Abstract
Cardiovascular diseases (CVDs) have been regarding as “the world’s first killer” of human beings in recent years owing to the striking morbidity and mortality, the involved molecular mechanisms are extremely complex and remain unclear. Traditional Chinese medicine (TCM) adheres to the aim of combating complex diseases from an integrative and holistic point of view, which has shown effectiveness in CVDs therapy. However, system-level understanding of such a mechanism of multi-scale treatment strategy for CVDs is still difficult. Here, we developed a system pharmacology approach with the purpose of revealing the underlying molecular mechanisms exemplified by a famous compound saffron formula (CSF) in treating CVDs. First, by systems ADME analysis combined with drug targeting process, 103 potential active components and their corresponding 219 direct targets were retrieved and some key interactions were further experimentally validated. Based on this, the network relationships among active components, targets and diseases were further built to uncover the pharmacological actions of the drug. Finally, a “CVDs pathway” consisted of several regulatory modules was incorporated to dissect the therapeutic effects of CSF in different pathological features-relevant biological processes. All this demonstrates CSF has multi-scale curative activity in regulating CVD-related biological processes, which provides a new potential way for modern medicine in the treatment of complex diseases.
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13
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Peterson LK, Willis R, Harris EN, Branch WD, Tebo AE. Antibodies to Phosphatidylserine/Prothrombin Complex in Antiphospholipid Syndrome: Analytical and Clinical Perspectives. Adv Clin Chem 2016; 73:1-28. [PMID: 26975968 DOI: 10.1016/bs.acc.2015.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thrombosis and/or pregnancy-related morbidity accompanied by persistently positive antiphospholipid antibodies (aPL). Current laboratory criteria for APS classification recommend testing for lupus anticoagulant as well as IgG and IgM anticardiolipin, and beta-2 glycoprotein I (anti-β2GPI) antibodies. However, there appears to be a subset of patients with classical APS manifestations who test negative for the recommended criteria aPL tests. While acknowledging that such patients may have clinical features that are not of an autoimmune etiology, experts also speculate that these "seronegative" patients may test negative for relevant autoantibodies as a result of a lack of harmonization and/or standardization. Alternatively, they may have aPL that target other antigens involved in the pathogenesis of APS. In the latter, autoantibodies that recognize a phosphatidylserine/prothrombin (PS/PT) complex have been reported to be associated with APS and may have diagnostic relevance. This review highlights analytical and clinical attributes associated with PS/PT antibodies, taking into consideration the performance characteristics of criteria aPL tests in APS with specific recommendations for harmonization and standardization efforts.
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Affiliation(s)
- Lisa K Peterson
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Rohan Willis
- Rheumatology/Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Ware D Branch
- Maternal Fetal Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Anne E Tebo
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA; ARUP Laboratories, Institute of Clinical and Experimental Pathology, Salt Lake City, Utah, USA.
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van den Hoogen LL, van Roon JAG, Radstake TRDJ, Fritsch-Stork RDE, Derksen RHWM. Delineating the deranged immune system in the antiphospholipid syndrome. Autoimmun Rev 2015; 15:50-60. [PMID: 26318678 DOI: 10.1016/j.autrev.2015.08.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 08/24/2015] [Indexed: 12/16/2022]
Abstract
The antiphospholipid syndrome (APS) is a systemic autoimmune disease that is characterized serologically by the presence of antiphospholipid antibodies (aPL) and clinically by vascular thrombosis and obstetric complications. The protein β2 glycoprotein I (β2GPI) is identified as the most important autoantigen in this syndrome. Activation of endothelial cells, thrombocytes and placental tissue by anti-β2GPI antibodies relates to the clinical manifestations of APS. This review describes genetic and environmental factors in relation to APS and summarizes the current knowledge on abnormalities in components of both the innate and adaptive immune system in APS. The role of dendritic cells, T-cells, B-cells, monocytes, neutrophils and NK-cells as well as the complement system in APS are discussed. Several gaps in our knowledge on the pathophysiology of APS are identified and a plea is made for future extensive immune cell profiling by a systems medicine approach in order to better unravel the pathogenesis of APS, to gain more insight in the role of the immune system in APS as well as having the potential to reveal biomarkers or novel therapeutic targets.
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Affiliation(s)
- Lucas L van den Hoogen
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Laboratory of Translational Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | - Joël A G van Roon
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Laboratory of Translational Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Timothy R D J Radstake
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Laboratory of Translational Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ruth D E Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ronald H W M Derksen
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Willis R, Gonzalez EB. Pathogenetic mechanisms of antiphospholipid antibody production in antiphospholipid syndrome. World J Rheumatol 2015; 5:59-68. [DOI: 10.5499/wjr.v5.i2.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/11/2014] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Antiphospholiipid syndrome (APS) is an autoimmune disease characterized by the pathological action of antiphospholipid antibodies (aPL), that leads to recurrent pregnancy loss and thrombosis. Despite limited evidence, it is clear that there are both inherited and acquired components of the ontogeny of these antibodies. Animal genetic studies and human familial and population studies highlight the influence of genetic factors in APS, particularly human leukocyte antigen associations. Similarly, both animal and human studies have reported the importance of acquired factors in APS development and infectious agents in particular have a great impact on aPL production. Bacterial and viral agents have been implicated in the induction of autoimmune responses by various mechanisms including molecular mimicry, cryptic autoantigens exposure and apoptosis. In this review we highlight the latest updates with regards to inherited and acquired factors leading to the manufacturing of pathogenic antibodies and APS.
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Familial antiphospholipid syndrome presenting as bivessel arterial occlusion in a 17-year-old girl. Rheumatol Int 2013; 33:1359-62. [DOI: 10.1007/s00296-011-2300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 12/10/2011] [Indexed: 10/14/2022]
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Abstract
Monozygotic twins, 27 years old, with primary anti-phospholipid syndrome have been described. The first of the twins had obstetric morbidities (one miscarriage at 12 weeks and premature birth of a growth-restricted fetus at 27 weeks secondary to pre-eclampsia) and the second had venous thrombosis. Lupus anticoagulant was present in both and anti-cardiolipin antibodies were present in high titres when re-tested at appropriate intervals. Development of clinical features of APS in monozygotic twins points to an underlying genetic basis in the pathogenesis of anti-phospholipid syndrome.
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Affiliation(s)
- V Ravindran
- Department of Rheumatology, MES Medical College, Perinthalmanna, India
| | - S Rajendran
- Department of Vascular Surgery, MES Medical College, Perinthalmanna, India
| | - G Elias
- Department of Internal Medicine, PVS Hospital, Kozhikode, India
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Increased activity of interleukin-23/interleukin-17 cytokine axis in primary antiphospholipid syndrome. Immunobiology 2012; 218:186-91. [PMID: 22559912 DOI: 10.1016/j.imbio.2012.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 03/20/2012] [Indexed: 01/09/2023]
Abstract
The aim of the study was to investigate serum concentrations of interleukin (IL)-17 and IL-17-inducing cytokines IL-23 and transforming growth factor (TGF)-β, as well as IL-17 single nucleotide polymorphism (SNP) rs2275913 in patients with primary antiphospholipid syndrome (PAPS). We studied fifty patients with PAPS and fifty age- and sex-matched healthy controls. The cytokine levels were measured by ELISA, while the rs2275913 SNP located in promoter region of IL-17 gene was genotyped using real-time PCR. The significantly higher levels of IL-17 (p=0.002), IL-23 (p<0.001) and TGF-β (p=0.042) were found in PAPS patients (median 13.1, 9.4, and 125.6 pg/ml, respectively) compared to the control group (6.8, 4.9 and 44.4 pg/ml). There was a significant positive correlation between concentrations of IL-17 and IL-23 (r=0.540, p<0.001), but not between those of IL-17 and TGF-β. No statistically significant differences were observed in the distribution of genotypes and alleles of the IL-17 rs2275913 variants in patients with PAPS compared to healthy subjects. The blood concentrations of IL-17 did not differ in subjects with different rs2275913 genotypes or patients with or without antiphospholipid antibodies. Finally, a trend toward higher IL-17 levels (p=0.063) and the significantly higher IL-17 concentrations (p=0.012) were observed in PAPS patients with deep vein thrombosis and thrombocytopenia, respectively. These data demonstrate that IL-23/IL-17 axis, stimulated independently of TGF-β increase IL-17A gene polymorphism and antiphospholipid antibody production, might contribute to vascular manifestations of PAPS.
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Lee YH, Choi SJ, Ji JD, Song GG. Association between the valine/leucine247 polymorphism of β2-glycoprotein I and susceptibility to anti-phospholipid syndrome: a meta-analysis. Lupus 2012; 21:865-71. [DOI: 10.1177/0961203312440348] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The objective of this paper is to explore whether the valine/leucine247 (Val/Leu247) polymorphism of β2-glycoprotein I (β2GPI) confers susceptibility to anti-phospholipid syndrome (APS) and thrombosis and predicts positivity for anti-β2GPI antibodies. Methods: A meta-analysis was conducted on the associations between the β2GPI Val/Leu247 polymorphism and susceptibility to APS and thrombosis and positivity for anti-β2GPI. Results: A total of 1507 patients with APS and 1450 controls in 12 comparative studies were included in this meta-analysis. Meta-analysis of the β2GPI Val/Leu247 polymorphism showed significant associations between the β2GPI Val allele and APS, thrombosis, and anti-β2GPI positivity (odds ratio (OR) 1.316, 95% confidence interval (CI) 1.068–1.621, p = 0.010; OR 1.908, 95% CI 1.195–3.046, p = 0.007; OR 1.630, 95% CI 1.018–2.609, p = 0.042, respectively). A direct comparison between anti-β2GPI-positive and -negative patients revealed that the frequency of the Val allele was significantly higher in anti-β2GPI-positive patents (OR 1.514, 95% CI 1.017–1.253, p = 0.041). Furthermore, a direct comparison between thrombosis-positive and -negative patients also indicated that the Val/Val + Val/Leu and the Val/Val vs. Leu/Leu genotypes of the β2GPI polymorphism were significantly elevated in patients with thrombosis (OR 2.817, 95% CI 1.200–6.610, p = 0.017; OR 3.312, 95% CI 1.338–8.200, p = 0.010, respectively). Conclusion: This meta-analysis shows that the β2GPI Val/Leu247 polymorphism is associated with susceptibility to APS and thrombosis and with anti-β2GPI positivity.
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Affiliation(s)
- YH Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - SJ Choi
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - JD Ji
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - GG Song
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Willis R, Pierangeli SS. Pathophysiology of the antiphospholipid antibody syndrome. AUTOIMMUNITY HIGHLIGHTS 2011; 2:35-52. [PMID: 26000118 PMCID: PMC4389016 DOI: 10.1007/s13317-011-0017-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 01/24/2011] [Indexed: 12/16/2022]
Abstract
Antiphospholipid antibodies (aPL) are associated with the recurrent pregnancy loss and thrombosis that characterizes the antiphospholipid antibody syndrome (APS). Although the ontogeny of these pathogenic antibodies has not been fully elucidated, there is evidence that indicates the involvement of both genetic and environmental factors. The ability of aPL to induce a procoagulant phenotype in APS patients plays a central role in the development of arterial and venous thrombotic manifestations typical of the disease. Inflammation serves as a necessary link between this procoagulant phenotype and actual thrombus development and is an important mediator of the placental injury seen in APS patients with obstetric complications. Recent evidence has indicated a role for abnormal cellular proliferation and differentiation in the pathophysiology of APS, especially in those patients with pregnancy morbidity and other more atypical manifestations that have no identifiable thrombotic cause. The interplay of genetic and environmental factors responsible for aPL development and the mechanisms by which these antibodies produce disease in APS patients is the focus of this review.
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Affiliation(s)
- Rohan Willis
- Department of Microbiology, University of the West Indies, Mona Campus, Kingston, Jamaica, West Indies
| | - Silvia S Pierangeli
- Division of Rheumatology/Internal Medicine, University of Texas Medical Branch, Brackenridge Hall 2.108 301 University Boulevard, Galveston, TX 77555-0883 USA
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Abstract
Abstract
Background: The antiphospholipid syndrome (APS) is an important cause of acquired thromboembolic complications and pregnancy morbidity. Its diagnosis is based on clinical and laboratory criteria, defined by strict guidelines. The original clinical and laboratory criteria for the identification of APS patients were published in 1999, in the so-called Sapporo criteria. In 2006 these criteria were revised, and recently more precise guidelines for analysis of the lupus anticoagulant have been provided. However, several questions related to the diagnosis of APS remain unanswered.
Content: In addition to providing a historical perspective, this review covers several challenges in the diagnosis of APS with respect to clinical and laboratory features, while highlighting pathogenic pathways of the syndrome. We discuss ongoing dilemmas in the diagnosis of this complex disease. Although antiphospholipid antibodies are found in association with various clinical manifestations, the older established clinical criteria were not substantively altered in the 2006 update. Several laboratory tests recommended in the latest criteria, including phospholipid-dependent coagulation tests for the detection of the lupus anticoagulant and ELISAs for measuring anticardiolipin and β2-glycoprotein I antibodies, still show methodological and diagnostic shortcomings. In addition, antiphospholipid antibodies have been described against other antigens, but their clinical role remains uncertain.
Conclusions: Despite updated APS criteria, diagnosis of this syndrome remains challenging. Further research on clinically relevant antibodies and standardization of their detection are needed to improve clinical risk assessment in APS.
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Affiliation(s)
- Katrien Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - Marc F Hoylaerts
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
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