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Liu X, Qiu Y, Yu ED, Xiang S, Meng R, Niu KF, Zhu H. Comparison of therapeutic interventions for recurrent pregnancy loss in association with antiphospholipid syndrome: A systematic review and network meta‐analysis. Am J Reprod Immunol 2020; 83:e13219. [PMID: 31872490 DOI: 10.1111/aji.13219] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/10/2019] [Accepted: 12/10/2019] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xiang Liu
- Department of Gynecology and Obstetrics West China Second University Hospital Sichuan University Chengdu China
- West China School of Medicine Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu China
| | - Yuxuan Qiu
- Department of Thyroid & Parathyroid Surgery West China Hospital Sichuan University Chengdu China
| | | | - Shang Xiang
- West China School of Medicine Sichuan University Chengdu China
| | - Rui Meng
- West China School of Medicine Sichuan University Chengdu China
| | - Kai fan Niu
- West China School of Medicine Sichuan University Chengdu China
| | - Huili Zhu
- Department of Gynecology and Obstetrics West China Second University Hospital Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Chengdu China
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2
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Tabacco S, Giannini A, Garufi C, Botta A, Salvi S, Del Sordo G, Benedetti Panici P, Lanzone A, De Carolis S. Complementemia in pregnancies with antiphospholipid syndrome. Lupus 2019; 28:1503-1509. [PMID: 31623520 DOI: 10.1177/0961203319882507] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Prognosis of pregnancies in women with antiphospholipid syndrome has dramatically improved over the past two decades using conventional treatment with low molecular weight heparin and low-dose aspirin. However, despite this regimen, 10-15% of antiphospholipid syndrome patients experience pregnancy losses. Several studies have been performed in order to identify risk factors predictive of complications. Thrombosis has been generally accepted as the key pathogenetic mechanism underlying pregnancy morbidity. However, the thrombogenic state alone is not able to explain all the different mechanisms leading to pregnancy failure. In fact, emerging evidence shows that complement pathway could play an important role in mediating clinical events in antiphospholipid syndrome. However, the exact mechanism through which complement mediates antiphospholipid syndrome complications remains unknown. Low complement levels (C3 and C4) are associated with poor pregnancy outcome in women with antiphospholipid syndrome in different studies. Hypocomplementemia could be indicated as an early predictor of adverse pregnancy outcome, available at the beginning of pregnancy for starting, if necessary, additional treatment to conventional therapy. However, future studies need to better understand the impact of low complement level on antiphospholipid syndrome pregnancy outcome.
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Affiliation(s)
- S Tabacco
- Department of Gynaecology Obstetrics and Urology, "Sapienza" University of Rome, Rome, Italy
| | - A Giannini
- Department of Gynaecology Obstetrics and Urology, "Sapienza" University of Rome, Rome, Italy
| | - C Garufi
- Lupus Clinic, "Sapienza" University of Rome, Rome, Italy
| | - A Botta
- UOC di Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - S Salvi
- UOC di Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - G Del Sordo
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - P Benedetti Panici
- Department of Gynaecology Obstetrics and Urology, "Sapienza" University of Rome, Rome, Italy
| | - A Lanzone
- UOC di Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - S De Carolis
- UOC di Patologia Ostetrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
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Eid MI, Abdelhafez MS, El-Refaie W, El-Zayadi AA, Samir K, Abdelrazik MM, Thabet M, Wageh A, Fyala EA, Abdeldayem Y, Badawy A. Timing of initiation of low-molecular-weight heparin administration in pregnant women with antiphospholipid syndrome: a randomized clinical trial of efficacy and safety. Int J Womens Health 2019; 11:41-47. [PMID: 30666167 PMCID: PMC6336021 DOI: 10.2147/ijwh.s193293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We aimed to evaluate the effect of different timing of initiation of low-molecular-weight heparin (LMWH) administration on the pregnancy outcomes in women with antiphospholipid syndrome (APS). Materials and methods A randomized controlled study was conducted on women with obstetrical APS. All participants were randomly divided at documentation of positive pregnancy test into two groups; early initiation group in which LMWH therapy was started once positive pregnancy test was established (in the fifth week of gestation), and later initiation group in which LMWH therapy was started after sonographic confirmation of fetal cardiac pulsation (in the seventh week of gestation). In both groups, LMWH (enoxaparin) was given at a dose of 40 mg/day subcutaneously and the therapy continued until end of pregnancy. The primary outcome measure was ongoing pregnancy rate and the secondary outcome measures were fetal loss, live birth rate, preterm labor before 34 weeks of gestation, intrauterine growth restriction (IUGR), and congenital fetal malformations. Results Ninety-four women (48 in the early initiation group and 46 in the later initiation group) were subjected to final analysis. The ongoing pregnancy rate was significantly higher in the early initiation group than in the later initiation group (81.2% vs 60.9%; P=0.040). However, both groups were similar in the incidences of fetal loss, preterm labor before 34 weeks of gestation, and IUGR, and live birth rate. No recorded congenital fetal malformations in both groups. Conclusion Early administration of LMWH for pregnant women with obstetrical APS reduces early pregnancy loss, but does not affect the incidence of late obstetrical complications.
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Affiliation(s)
- Mohamed Ibrahem Eid
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | | | - Waleed El-Refaie
- Department of Obstetrics and Gynecology, Port Said University, Port Said, Egypt
| | - Ahmed A El-Zayadi
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Khaled Samir
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | | | - Mahmoud Thabet
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Alaa Wageh
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Emad Ahmed Fyala
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Yasser Abdeldayem
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
| | - Ahmed Badawy
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt,
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Ruffatti A, Favaro M, Calligaro A, Zambon A, Del Ross T. Management of pregnant women with antiphospholipid antibodies. Expert Rev Clin Immunol 2019; 15:347-358. [DOI: 10.1080/1744666x.2019.1565995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Alessandra Zambon
- Obstetrics and Gynecology Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
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Ruffatti A, Hoxha A, Favaro M, Tonello M, Colpo A, Cucchini U, Banzato A, Pengo V. Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:28-39. [PMID: 27342460 DOI: 10.1007/s12016-016-8571-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Most investigators currently advocate prophylactic-dose heparin plus low-dose aspirin as the preferred treatment of otherwise healthy women with obstetric antiphospholipid syndrome, whilst women with a history of vascular thrombosis alone or associated with pregnancy morbidity are usually treated with therapeutic heparin doses in association with low-dose aspirin in an attempt to prevent both thrombosis and pregnancy morbidity. However, the protocols outlined above fail in about 20 % of pregnant women with antiphospholipid syndrome. Identifying risk factors associated with pregnancy failure when conventional therapies are utilized is an important step in establishing guidelines to manage these high-risk patients. Some clinical and laboratory risk factors have been found to be related to maternal-foetal complications in pregnant women on conventional therapy. However, the most efficacious treatments to administer to high-risk antiphospholipid syndrome women in addition to conventional therapy in order to avoid pregnancy complications are as yet unestablished. This is a comprehensive review on this topic and an invitation to participate in a multicentre study in order to identify the best additional treatments to be used in this subset of antiphospholipid syndrome patients.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
- Reumatologia, Policlinico Universitario, Via Giustiniani, 2-35128, Padova, Italy.
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Anna Colpo
- Blood Transfusion Unit, University-Hospital of Padua, Padua, Italy
| | - Umberto Cucchini
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandra Banzato
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Vittorio Pengo
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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6
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Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
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Bao SH, Sheng SL, Liao H, Zhou Q, Frempong ST, Tu WY. Use of D-dimer measurement to guide anticoagulant treatment in recurrent pregnancy loss associated with antiphospholipid syndrome. Am J Reprod Immunol 2017; 78. [PMID: 29024233 DOI: 10.1111/aji.12770] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 09/12/2017] [Indexed: 11/26/2022] Open
Affiliation(s)
- Shi Hua Bao
- Department of Reproductive Immunology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Shi Le Sheng
- Department of Nuclear Medicine; School of Medicine; Renji Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Hong Liao
- Department of Cervical Diseases; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Qian Zhou
- Department of Reproductive Immunology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Sophia Twum Frempong
- Department of Reproductive Immunology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Wei Yan Tu
- Department of Reproductive Immunology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
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9
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Khamashta M, Taraborelli M, Sciascia S, Tincani A. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2016; 30:133-48. [DOI: 10.1016/j.berh.2016.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chighizola CB, Gerosa M, Trespidi L, Di Giacomo A, Rossi F, Acaia B, Meroni PL. Update on the current recommendations and outcomes in pregnant women with antiphospholipid syndrome. Expert Rev Clin Immunol 2014; 10:1505-17. [DOI: 10.1586/1744666x.2014.968129] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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11
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Del Ross T, Ruffatti A, Visentin MS, Tonello M, Calligaro A, Favaro M, Hoxha A, Punzi L. Treatment of 139 pregnancies in antiphospholipid-positive women not fulfilling criteria for antiphospholipid syndrome: a retrospective study. J Rheumatol 2013; 40:425-9. [PMID: 23418380 DOI: 10.3899/jrheum.120576] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The effect of low-dose aspirin (LDA) on pregnancy outcome in antiphospholipid (aPL)-positive women not fulfilling the criteria for antiphospholipid antibody syndrome (APS) was evaluated retrospectively. METHODS We evaluated 139 pregnancies of 114 aPL-positive women not fulfilling the Sydney classification criteria for definite APS (104 treated with LDA, 35 untreated). Inclusion criteria consisted of (1) any titer of aPL and no previous pregnancy or no pregnancy losses (defined as aPL carriers); (2) any titer of aPL and 1 or 2 pregnancy losses before the 10th gestational week. No women had previous thrombosis. The rate of pregnancy loss, gestational age at delivery, and birth weight percentile were compared in the treated and untreated patients. Associations between clinical and laboratory characteristics and pregnancy outcomes were investigated. RESULTS The rate of pregnancy loss was low in both treated and untreated groups (7.7% vs 2.9%, respectively). There were no statistically significant differences in the rate of pregnancy loss, gestational age at birth, or birth weight percentile in the treated and untreated groups. There were significant associations between gestational age at birth ≤ 34th week and positivity for lupus anticoagulant (p = 0.025) and anti-ß2-glycoprotein I IgG antibodies at titers > 99th (p = 0.016). CONCLUSION LDA treatment does not appear to improve pregnancy outcome in low-risk women not fulfilling the criteria for APS. Because antibody profile seems to influence pregnancy outcome, further studies of patients stratified according to their antibody profile are warranted.
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Affiliation(s)
- Teresa Del Ross
- Rheumatology Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy.
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Cappelletti M, Giannelli S, Martinelli A, Cetin I, Colombo E, Calcaterra F, Mavilio D, Della Bella S. Lack of activation of peripheral blood dendritic cells in human pregnancies complicated by intrauterine growth restriction. Placenta 2012. [PMID: 23182380 DOI: 10.1016/j.placenta.2012.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The state of activation of dendritic cells (DCs) at the feto-maternal interface critically contributes to optimal decidual immune responses needed to support fetal-placental development. We recently demonstrated that during healthy pregnancy also peripheral blood DCs (PBDCs), which are easily accessible, are activated as well. In this study, to investigate a possible involvement of DCs in intrauterine growth restriction (IUGR), we evaluated whether PBDCs in pregnancy complicated by IUGR may be altered compared with PBDCs in healthy pregnancy. METHODS PBDCs from 12 pregnant women with primary IUGR, 21 healthy pregnant and 19 nonpregnant women were analyzed by flow cytometric analysis of whole-blood samples collected at a single time point. RESULTS The number of plasmacytoid PBDCs was significantly reduced in women with IUGR pregnancy. Myeloid and plasmacytoid PBDCs in IUGR lacked the state of activation (assessed as CD80, CD86, CD40 expression) and the shift to a proinflammatory pattern of cytokine production occurring during healthy pregnancy. DISCUSSION To our knowledge, this is the first study investigating the state of PBDC activation in IUGR pregnancy. Our results are in accordance with a previous study reporting a lower expression of activation and maturation markers by decidual DCs in IUGR placentas. CONCLUSIONS The reduced activation of PBDCs in IUGR pregnancy may possibly reflect a reduced activation of decidual DCs. If confirmed at the feto-maternal interface, the alterations of DCs described in IUGR pregnancy have the potential to negatively impact on vascular development during gestation. These observations may therefore broaden our understanding of IUGR pathogenesis.
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Affiliation(s)
- M Cappelletti
- Lab of Immunology, Department of Biomedical Sciences and Technologies, University of Milan, Italy
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Abstract
The antiphospholipid syndrome (APS) is the most common acquired thrombophilia. It is characterized by venous and arterial thrombosis, recurrent pregnancy loss, and various other clinical manifestations in the presence of antiphospholipid antibodies (aPL). Like other autoimmune diseases, the etiology of APS derives from a combination of genetic and environmental factors. The most significant environmental factors in APS are infectious agents, followed by trauma and drugs. Infections can induce aPL and, in the catastrophic variant of APS, about one-third of cases are associated with a clear recent infection. On their formation, aPL have been clearly shown to be pathogenic, because they influence all arms of the coagulation system and because passive transfer and active immunization protocols have demonstrated. Therefore, in a genetically susceptible individual, exposure to one or more infectious agent can cause a molecular mimicry and result in the production of pathogenic aPL that can induce thrombosis and pregnancy loss. Identification of the epitopes within the beta-2-glycoprotein-I molecule that serves as the target for autoantibodies makes them the target for immunomodulation of the syndrome.
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Di Simone N, Meroni PL, D'Asta M, Di Nicuolo F, D'Alessio MC, Caruso A. Pathogenic role of anti-β2-glycoprotein I antibodies on human placenta: functional effects related to implantation and roles of heparin. Hum Reprod Update 2006; 13:189-96. [PMID: 17099207 DOI: 10.1093/humupd/dml051] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Most of the clinical manifestations of the antiphospholipid syndrome (APS) can be related to thrombotic events; however, placental thrombosis cannot explain all of the pregnancy complications that occur in women with this syndrome. In this regard, it has been hypothesized that antiphospholipid (aPL) antibodies can directly attack trophoblasts, but it is still unclear what pathogenetic mechanisms play a role and which aPL antibodies subpopulations are involved. Although it has been assumed that aPL antibodies are directed against anionic phospholipids (PLs), current advances in the field suggest that antibodies to PL-binding plasma protein such as beta2-glycoprotein-I (beta2-GPI) are the clinically relevant aPL antibodies. It appears that following the attachment of beta2-GPI to PLs, both molecules undergo conformational changes that result in the exposure of cryptic epitopes within the structure of beta2-GPI allowing the subsequent binding of antibodies. aPL antibodies detected by anti-beta2-GPI assays are associated with fetal loss. However, there is still debate on how the antibodies might induce the obstetrical manifestations. The significantly improved outcome of pregnancies treated with heparin has stimulated interest in the drug's mechanisms of action. Several mechanisms could explain its beneficial effects, because in addition to a direct effect of heparin on the coagulation cascade, it might protect pregnancies by reducing the binding of aPL antibodies, reducing inflammation, facilitating implantation and/or inhibiting complement activation. Further investigations are needed to better understand how aPL antibodies induce obstetric complications and to better clarify the functional role of heparin in the human placenta leading to more successful therapeutic options.
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Affiliation(s)
- N Di Simone
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome.
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15
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Benson EM. Immunologic manipulation for the threatened fetus. Thromb Res 2004; 114:427-34. [PMID: 15507274 DOI: 10.1016/j.thromres.2004.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Revised: 06/10/2004] [Accepted: 06/23/2004] [Indexed: 12/14/2022]
Abstract
Management of the pregnant woman with the antiphospholipid syndrome (APLS) has improved over the last 10 years. The recurrent pregnancy loss that is associated with this disease is managed with prophylactic low dose aspirin and heparin therapy. This therapy leads to a 40% absolute risk reduction in pregnancy loss. However, many women still fail to deliver a live infant despite this therapy so immunologic manipulation of the mother's disease in this group needs to be considered. Intravenous immunoglobulin and plasma exchange may have a role. New immunosuppressive drugs such as tacrolimus have yet to be tried. Monoclonal antibodies to B cells, B-cell growth factors, complement proteins and integrin molecules, all of which appear to play a role in the disease process, may also offer patients some hope. Similarly, biologics such as C1 esterase inhibitor protein, cell surface complement regulator proteins or interleukin-3 need to be tried given their efficacy in models of antibody-induced cell injury.
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Affiliation(s)
- Elizabeth M Benson
- Department of Immunopathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Australia.
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Abstract
Antiphospholipid antibodies (aPL) are autoantibodies that are associated with recurrent reproductive failure and thrombotic disease. There are two well-characterised aPL, lupus anticoagulant and anticardiolipin antibodies. aPL were originally thought to bind to negatively-charged phospholipids but it is now clear that the title aPL is a misnomer and that the antigens for these autoantibodies are actually phospholipid-binding proteins. Chief amongst these phospholipid-binding proteins are prothrombin and beta(2) glycoprotein I. This review concentrates on the role of beta(2) glycoprotein I in the reproductive failure caused by aPL. Exactly how aPL cause reproductive failure remains unknown but there is emerging evidence that the antibodies may have several different adverse effects on trophoblasts. There is also evidence questioning the traditional hypothesis that fetal demise is secondary to thrombosis of the utero-placental circulation. Heparin is commonly used to treat pregnant women with aPL but if these antibodies do not cause fetal demise primarily by a thrombotic mechanism a question must be raised over the role of heparin. However, heparin binds to many proteins including beta(2) glycoprotein I and it is possible that the reported beneficial effects of heparin in aPL-affected pregnancies may be due to the ability of heparin to prevent the interaction of aPL and beta(2) glycoprotein I.
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Affiliation(s)
- L W Chamley
- Department of Obstetrics and Gynaecology, University of Auckland, National Women's Hospital, Epsom, New Zealand.
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Chapman J, Shoenfeld Y. Neurological and neuroendocrine-cytokine inter-relationship in the antiphospholipid syndrome. Ann N Y Acad Sci 2002; 966:415-24. [PMID: 12114299 DOI: 10.1111/j.1749-6632.2002.tb04242.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although many neurological deficits have been described in the antiphospholipid syndrome (APS), only stroke is well established and accepted as a diagnostic criterion in the disease. We presently review clinical data obtained from large series of cases regarding stroke, dementia, epilepsy, chorea, migraine, white-matter disease, and behavioral changes in APS, or linked-to-laboratory criteria such as antiphospholipid antibodies (aPL). The contribution of animal models to our understanding of these manifestations of APS is stressed, especially regarding the cognitive and behavioral aspects for which we have established model systems in the mouse. These models utilize immunization of mice with beta(2)-glycoprotein1, a central autoantigen in APS, which induces persistent high levels of aPLs. These mice develop hyperactive behavior after a period of four months, as well as deficits in learning and memory, and are potentially valuable as a system in which to study the pathogenesis and treatment of cognitive and behavioral aspects of APS. We have developed another model, in which IgGs from APS patients induce depolarization of brain synaptoneurosomes, and which may serve as a model for the pathogenesis of epilepsy in APS. Hormonal changes are another potential CNS manifestation of APS and this may be potentially linked to the systemic and central effects of cytokines such as interleukin-3. Better understanding of the link between APS and neurological or neuroendocrine manifestations other than stroke will reveal whether they can be used as clinical criteria for the diagnosis of APS and, it is hoped, lead to better treatment.
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Affiliation(s)
- Joab Chapman
- Neuroimmunology Service, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Bowen JM, Chamley L, Mitchell MD, Keelan JA. Cytokines of the placenta and extra-placental membranes: biosynthesis, secretion and roles in establishment of pregnancy in women. Placenta 2002; 23:239-56. [PMID: 11969335 DOI: 10.1053/plac.2001.0781] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Virtually all known cytokines have been demonstrated to be expressed in the placenta and associated fetal and maternal membranes during normal gestation. In addition to playing their traditional roles as modulators of immunological function, cytokines derived from the placenta and extraplacental membranes, together with other locally-derived growth factors, appear to be implicated in various aspects of implantation and placental development. Imbalances in the intrauterine cytokine milieu around the time of implantation and invasion may play a causative role in disorders associated with early pregnancy failure, and are also associated with the abnormal trophoblast development seen in gestational trophoblastic disease. Cytokines thus appear to be an important component of a paracrine/autocrine communication network operating within the feto-maternal interface to ensure the successful establishment of pregnancy.
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Affiliation(s)
- J M Bowen
- The Liggins Institute, Division of Pharmacology and Clinical Pharmacology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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19
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Chamley LW, Konarkowska B, Duncalf AM, Mitchell MD, Johnson PM. Is interleukin-3 important in antiphospholipid antibody-mediated pregnancy failure? Fertil Steril 2001; 76:700-6. [PMID: 11591401 DOI: 10.1016/s0015-0282(01)01984-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the effect of interleukin-3 (IL-3) on trophoblast proliferation and expression of beta2-glycoprotein I. DESIGN In vitro cell culture using primary trophoblasts and the cell lines Jeg-3, Jar, and BeWo. SETTING Department of Obstetrics and Gynaecology, University of Auckland. PATIENT(S) Women with normal pregnancies. INTERVENTION(S) Increasing amounts of IL-3 were added to cultures of primary human trophoblasts, cell lines, or cells treated with a proliferation inhibiting antiphospholipid-like antibody. RNA was extracted from primary human trophoblasts or cell lines. MAIN OUTCOME MEASURE(S) We examined basal and IL-3-stimulated cellular proliferation by [3H] thymidine incorporation assay and secretion of beta2-glycoprotein I into culture medium by semiquantitative immunoblot analysis. Reverse transcriptase-polymerase chain reaction analysis was used to demonstrate the presence of IL-3 receptor transcripts. RESULT(S) The IL-3 treatment did not induce proliferation of highly purified primary trophoblast cultures or cell lines but did induce proliferation of contaminating CD45+ cells in trophoblast cultures. The IL-3 did not overcome the antiproliferative effect of an antiphospholipid-like monoclonal antibody on trophoblast. Secretion of beta2-glycoprotein I by trophoblast cultures was time dependent but unaltered by IL-3 treatment. CONCLUSION(S) Our results question the proposed importance of IL-3 in antiphospholipid antibody-mediated fetal death.
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Affiliation(s)
- L W Chamley
- Department of Obstetrics and Gynaecology, University of Auckland, National Women's Hospital, Epsom, Auckland, New Zealand.
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Vinatier D, Dufour P, Cosson M, Houpeau JL. Antiphospholipid syndrome and recurrent miscarriages. Eur J Obstet Gynecol Reprod Biol 2001; 96:37-50. [PMID: 11311759 DOI: 10.1016/s0301-2115(00)00404-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sixty percent of recurrent spontaneous abortions are unexplained. Antiphospholipid syndrome is a multisystem disease with the predominant features of venous and arterial thrombosis, recurrent pregnancy loss, foetal death and the presence of antiphospholipid antibodies. Many epidemiological studies focus on antiphospholipid autoantibodies syndrome (APS) as a cause of recurrent spontaneous abortion (RSA). It is found that 7-25% of RSA would have APS as the main risk factor. 'Association not being synonymous with cause', the proportion of abortions due to the APS is difficult to estimate for several reasons: definition of recurrent abortion is variable, the assays for antiphospholipid antibodies are not well standardised, inclusion of patients in the study group according to the antibodies titre is author dependent. Recent studies suggest association of antiphospholipid antibodies syndrome not only with recurrent abortions but also with infertility. New mechanisms are described by which antiphospholipid antibodies could cause placental thrombosis and infarction, acting directly on the surface anticoagulant expressed on trophoblastic cells. Only lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) assays are sufficiently standardised to be usable in routine. Testing for other antiphospholipid antibodies (aPLs) should remain investigational. Several treatments have been proposed: low doses of aspirin, low or immunosuppressive doses of corticosteroids, and preventive or effective dose of heparin, intravenous immunoglobulin.
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Affiliation(s)
- D Vinatier
- Hôpital Jeanne de Flandre, Clinique de Gynécologie Obstétrique et Néonatalogie, Centre Hospitalier Universitaire de Lille, F59037 Cedex, Lille, France.
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21
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Di Simone N, Caliandro D, Castellani R, Ferrazzani S, Caruso A. Interleukin-3 and human trophoblast: in vitro explanations for the effect of interleukin in patients with antiphospholipid antibody syndrome. Fertil Steril 2000; 73:1194-200. [PMID: 10856482 DOI: 10.1016/s0015-0282(00)00533-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To examine the effect of interleukin (IL)-3 on in vitro trophoblast differentiation, hormone production, and invasiveness affected by antiphospholipid antibodies. DESIGN Primary cytotrophoblast cell cultures. SETTING Obstetrics and Gynecology Department of the Catholic University, Rome, Italy. PATIENT(S) Five normal pregnant women underwent uncomplicated vaginal delivery at 36 weeks of gestation. INTERVENTION(S) Immunoglobulin (Ig) G antibodies were isolated from the plasma of two patients with antiphospholipid syndrome and two normal control subjects with the use of protein-G Sepharose columns. Cytotrophoblast cells were dispersed in Ringer's bicarbonate buffer containing trypsin and DNAseI, filtered, and layered over a Percoll gradient in Hank's balanced salt solution. MAIN OUTCOME MEASURE(S) We investigated the effects of IL-3 and antiphospholipid antibodies on trophoblast cell invasiveness, differentiation, and hormone secretion. RESULT(S) IgG obtained from patients with antiphospholipid syndrome bound to trophoblast cells, with inhibitory effects on the cells' invasiveness, differentiation, and hCG secretion. IL-3 was able to restore in vitro placental functions. CONCLUSION(S) These results imply that IL-3 favorably affects human trophoblast implantation and development.
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Affiliation(s)
- N Di Simone
- Department of Obstetrics and Gynecology, Università Cattolica del S. Cuore, Rome, Italy
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22
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Cadavid A, Peña B, García G, Botero J, Sánchez F, Ossa J, Beer A. Heparin plus aspirin as a "single" therapy for recurrent spontaneous abortion associated with both allo- and autoimmunity. Am J Reprod Immunol 1999; 41:271-8. [PMID: 10374704 DOI: 10.1111/j.1600-0897.1999.tb00438.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PROBLEM The aim of this study was to contribute to the study of the pathogenesis and the treatment of recurrent spontaneous abortion (RSA) associated with immune alterations. METHOD OF STUDY This is a prospective clinical trial with 11 patients with RSA associated with allo- and autoimmunity not receiving lymphocyte immunizations but only heparin and aspirin preconceptionally and through pregnancy. A concurrent group of 8 patients receiving a complete therapy (lymphocyte immunizations, heparin, and aspirin) but not receiving heparin and aspirin preconceptionally is also included in this report. RESULTS The rate of pregnancy success in these patients was 90.9% (10/11), and the rate of success of the concurrent group was 75.0% (6/8). CONCLUSIONS The results are in agreement with the working hypothesis regarding the possible final common mechanism in the pathogenesis of abortion associated with allo- and autoimmunity. The "single" therapy with heparin and aspirin was effective, less costly, and logistically simpler to provide than a complete therapy including lymphocyte immunizations.
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Affiliation(s)
- A Cadavid
- Reproduction Program, School of Medicine, University of Antioquia, Medellin, Colombia
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24
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Griesshammer M, Bergmann L, Pearson T. Fertility, pregnancy and the management of myeloproliferative disorders. BAILLIERE'S CLINICAL HAEMATOLOGY 1998; 11:859-74. [PMID: 10640221 DOI: 10.1016/s0950-3536(98)80043-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The management of pregnant patients with chronic myeloproliferative disorders (MPD) is a difficult problem. Patients with essential thrombocythaemia (ET), and, less frequently, those with chronic myeloid leukaemia (CML) or polycythaemia vera (PV), present at a childbearing age. Pregnancy itself does not appear to affect adversely the natural course and prognosis of the MPD. However, fertility might be reduced, and an adverse outcome of pregnancy due to thrombotic or bleeding complications is a matter of concern. It ET, first-trimester abortion is the most frequent complication but increased perinatal mortality and premature delivery are also observed. Placental infarction due to thrombosis seems to be the most consistent event. Maternal thrombotic or haemorrhagic complications are rare but are more common than seen in normal pregnancy. The outcome of pregnancy seems to be positively influenced by aspirin, at least in some cases. The value of cytoreduction and/or heparin prophylaxis has not been established but may have a role in selected cases. In CML, the potential adverse effects of hyperleukocytosis, and sometimes thrombocytosis, generally make myelosuppressive treatment essential. In PV, the number of reported pregnancies is low. Maintaining the PCV below 0.45 is of the utmost importance relating to the outcome of pregnancy. Although cytoreductive drugs should generally be avoided, if possible, until at least after the first trimester of pregnancy, interferon-alpha seems to be the drug of choice when myelosuppression is indicated. In summary, the available information about pregnancy occurring during the course of an MPD indicates that successful management of pregnancy is possible. However, optimal management of these patients is poorly defined and agreed protocols are not available. In view of these problems, it is timely to consider the establishment of a national or European registry to monitor prospectively the management offered to pregnant women found to have an MPD.
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MESH Headings
- Abnormalities, Drug-Induced/etiology
- Abnormalities, Drug-Induced/prevention & control
- Abortion, Spontaneous/etiology
- Abortion, Spontaneous/prevention & control
- Alkylating Agents/therapeutic use
- Animals
- Aspirin/therapeutic use
- Bone Marrow Transplantation
- Case Management
- Contraindications
- Disease Progression
- Female
- Hematocrit
- Hemorrhage/etiology
- Hemorrhage/prevention & control
- Heparin/therapeutic use
- Humans
- Infarction/etiology
- Infarction/prevention & control
- Infertility, Female/chemically induced
- Infertility, Female/etiology
- Infertility, Male/chemically induced
- Infertility, Male/etiology
- Interferon-alpha/therapeutic use
- Interferon-alpha/toxicity
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Male
- Mice
- Myeloproliferative Disorders/complications
- Myeloproliferative Disorders/therapy
- Placenta/blood supply
- Platelet Aggregation Inhibitors/therapeutic use
- Pregnancy
- Pregnancy Complications, Neoplastic/therapy
- Pregnancy Outcome
- Thrombosis/etiology
- Thrombosis/prevention & control
- Transplantation Conditioning/adverse effects
- Transplantation, Homologous
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Affiliation(s)
- M Griesshammer
- Department of Haematology and Oncology, University of Ulm, Germany
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25
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Shoenfeld Y, Sherer Y, Fishman P. Interleukin-3 and pregnancy loss in antiphospholipid syndrome. Scand J Rheumatol Suppl 1998; 107:19-22. [PMID: 9759126 DOI: 10.1080/03009742.1998.11720701] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cytokines play an important role in the progression of autoimmune diseases, and therefore it is not surprising that their levels may be altered in some of these diseases. Interleukin-3 (IL-3), which is an hematopoietic growth factor as well as an important factor that aids in embryo implantation and placental development, was found to be decreased both in pregnant women with antiphospholipid syndrome (APS) compared with a control group, and in animal models of APS. Treatment of animals having APS with IL-3 succeeded in prevention of disease manifestations. In this communication we review IL-3 and APS interrelationship, and discuss the role of aspirin and other commonly used drugs, with respect to IL-3 levels in APS.
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Affiliation(s)
- Y Shoenfeld
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel
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26
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Blank M, George J, Fishman P, Levy Y, Toder V, Savion S, Barak V, Koike T, Shoenfeld Y. Ciprofloxacin immunomodulation of experimental antiphospholipid syndrome associated with elevation of interleukin-3 and granulocyte-macrophage colony-stimulating factor expression. ARTHRITIS AND RHEUMATISM 1998; 41:224-32. [PMID: 9485080 DOI: 10.1002/1529-0131(199802)41:2<224::aid-art6>3.0.co;2-w] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the immunomodulatory potential of ciprofloxacin in mice with experimental antiphospholipid syndrome (APS). METHODS Ciprofloxacin or ceftazidime (control antibiotic) was given to mice with experimentally induced APS. The titers of autoantibodies, levels of cytokines, and number of cytokine-producing cells were determined by enzyme-linked immunosorbent assay. Myeloid progenitor cells were determined by granulocyte-macrophage colony-forming unit, and interleukin-3 (IL-3) messenger RNA (mRNA) was tested by Northern analysis. RESULTS A decrease in the incidence of pregnancy loss and an improvement in the clinical manifestations of APS were noted in the mice treated with ciprofloxacin, compared with the mice given ceftazidime. The effect of ciprofloxacin was found to be associated with increased serum levels of IL-3 and with increased IL-3 mRNA transcription in the splenocytes. Expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) was documented by elevated titers in the sera and elevated numbers of colony-forming cells in the bone marrow. CONCLUSION Ciprofloxacin prevents the manifestations of experimental APS. This effect may be associated with increased IL-3 levels and GM-CSF expression.
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Affiliation(s)
- M Blank
- Sheba Medical Center, Tel-Hashomer, Israel
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27
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Abstract
Endothelial and/or platelet activation likely initiates thrombus formation. Whether antiphospholipid antibody (aPL) is an activator, a toxic response, or a protective response is not clear, nor is it certain whether aPL is germ-line encoded or antigen-driven. The pregnancy model is particularly informative. Alternative hypotheses about thrombogenicity which relegate aPL to the role of bystander have not yet been excluded.
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Affiliation(s)
- M D Lockshin
- Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USA
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28
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Abstract
During the last few years several murine models for APS have been described. These include spontaneous occurring disease, or APS induced by immunization with pathogenic autoantibodies. Employing those models, several treatment modalities, in different stages of the disease, were studied. Treatments which showed promising potential for application in patients with APS include immunomodulation with specific anti-idiotypic or anti-CD4 antibodies, treatment with IL-3, high-dose intravenous immunoglobulins, ciprofloxacin or bromocriptine, as well as antithrombotic and anticoagulant treatments using aspirin and/or low-molecular-weight heparin. Bone-marrow transplantation was also found to improve clinical and serological manifestations of the disease. These studies might promote the handling of controlled clinical trials assessing their efficacy in APS patients.
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Affiliation(s)
- I Krause
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel
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