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Salter BM, Crowther MA. Catastrophic antiphospholipid syndrome: a CAPS-tivating hematologic disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:214-221. [PMID: 39644034 DOI: 10.1182/hematology.2024000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare but life-threatening form of antiphospholipid syndrome (APS) defined by the rapid onset of large and small vessel thrombosis occurring simultaneously across multiple sites, resulting in multiorgan dysfunction. The presence of underlying immune dysfunction causing activation of coagulation and, in many cases, abnormal complement regulation predisposes these patients to thrombotic events. CAPS is often preceded by triggering factors such as infection, surgery, trauma, anticoagulation discontinuation, and malignancy. Given the high mortality rate, which may exceed 50%, prompt recognition and initiation of management is required. The detection of antiphospholipid antibodies and the histopathologic identification of microvascular ischemia via tissue biopsy are required to diagnose CAPS. However, these patients are often too unwell to obtain results and wait for them. As such, investigations should not delay CAPS therapy, especially if there is strong clinical suspicion. Management of CAPS requires "triple therapy" with glucocorticoids, intravenous heparin, therapeutic plasma exchange, and/or intravenous immunoglobulin. Treatment for refractory disease is based on poor-quality evidence but includes anti-CD20 (rituximab) or anticomplement (eculizumab) monoclonal antibodies and other immunosuppressant agents, either alone or in combination. The rarity of this syndrome and the subsequent lack of randomized clinical trials have led to a paucity of high-quality evidence to guide management. Continued international collaboration to expand ongoing CAPS registries will allow a better understanding of the response to newer targeted therapy.
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Affiliation(s)
- Brittany M Salter
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Zen M, Tonello M, Favaro M, Del Ross T, Calligaro A, Giollo A, Vesentini F, Gennaio IA, Arru F, Ruffatti A, Doria A. Antiphospholipid antibody carriers and patients with quiescent antiphospholipid syndrome show persistent subclinical complement activation. Rheumatology (Oxford) 2024; 63:1733-1738. [PMID: 37774001 DOI: 10.1093/rheumatology/kead517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/20/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVES Complement activation has been advocated as one mechanism by which aPLs can induce thrombosis. In patients with catastrophic APS or re-thrombosis, enhanced complement activation has been shown, even in the quiescent phase of the disease. We aimed to assess complement activation and to investigate its association with clinical variables in aPL-positive patients with a favourable disease course. METHODS Subjects with at least two consecutive positive aPL results obtained ≥12 weeks apart were enrolled. They were subjects without a history of thrombosis or pregnancy morbidity (aPL carriers), patients with pregnancy morbidity alone, i.e. obstetric APS patients (OAPS patients), and/or patients with arterial, venous, or small-vessel thrombotic APS (TAPS patients); for enrolment, all patients were required to have been free of symptoms for ≥2 years. Patients affected with systemic autoimmune diseases were excluded. Healthy age- and sex-matched subjects were included as controls. Plasma C5a and C5b-9 levels were assessed by commercially available ELISA assays. The non-parametric Mann-Whitney test and Spearman's correlation were applied. RESULTS Thirty-seven OAPS patients, 38 TAPS patients, 42 aPL carriers and 30 healthy subjects were enrolled. The median C5a and C5b-9 levels were significantly higher in quiescent aPL-positive patients (OAPS, TAPS, aPL carriers) compared with controls: C5a ng/ml 10.61 [interquartile range (IQR) 6.87-15.46] vs 4.06 (2.66-7.35), P < 0.001; C5b-9 ng/ml 283.95 (175.8-439.40) vs 165.90 (124.23-236.8), P < 0.001. Similar C5a and C5b-9 levels were observed in OAPS and TAPS patients and aPL carriers. A positive correlation between the median C5b-9 levels and the number of aPL-positive tests was found (P = 0.002). CONCLUSION The persistence of aPL antibodies is associated with a persistent subclinical activation of the complement cascade.
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Affiliation(s)
- Margherita Zen
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Marta Tonello
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Maria Favaro
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Teresa Del Ross
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Antonia Calligaro
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Alessandro Giollo
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Filippo Vesentini
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Ilenia Anna Gennaio
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Federico Arru
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Amelia Ruffatti
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
| | - Andrea Doria
- Department of Medicine, Rheumatology Unit, University of Padua, Padova, Italy
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Jacobs L, Wauters N, Lablad Y, Morelle J, Taghavi M. Diagnosis and Management of Catastrophic Antiphospholipid Syndrome and the Potential Impact of the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Antibodies (Basel) 2024; 13:21. [PMID: 38534211 DOI: 10.3390/antib13010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and life-threatening condition characterized by the persistence of antiphospholipid antibodies and occurrence of multiple vascular occlusive events. CAPS currently remains a diagnostic challenge and requires urgent treatment. The diagnosis of CAPS is made difficult by classification criteria used as diagnostic criteria in clinical practice, knowledge derived from retrospective data and case reports, confounding clinical and biological features, and its rapid onset and mortality. The absence of prospective studies of CAPS limits the strength of evidence for guideline treatment protocols. This comprehensive review summarizes the current understanding of the disease, and discusses how the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria impact the definition and therapeutic management of CAPS, which is considered the most severe form of APS. The correct integration of 2023 ACR/EULAR APS classification criteria is poised to facilitate CAPS diagnosis, particularly in critical situations, offering a promising avenue for improved outcomes.
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Affiliation(s)
- Lucas Jacobs
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Nader Wauters
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Yahya Lablad
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Namur University Hospitals (CHU UCL Namur), 5000 Namur, Belgium
| | - Maxime Taghavi
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
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Neurologic Manifestations of Catastrophic Antiphospholipid Syndrome. Curr Neurol Neurosci Rep 2022; 22:589-600. [PMID: 36040563 DOI: 10.1007/s11910-022-01228-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Understanding of antiphospholipid antibody syndrome (APS), associated neurological manifestations, and disease-directed treatment has grown considerably over the last decade. Herein, we critically review the current and high-yield literature related to the pathophysiology, neurological presentations, and management of APS with particular emphasis on the rare and more fatal subset of APS, catastrophic antiphospholipid syndrome (CAPS). RECENT FINDINGS APS may manifest with a variety of neurologic syndromes, with cerebrovascular disease representing the most commonly encountered presentation. Diagnostic evaluation and treatment are often tailored to the specific presentation, with suspicion and testing for antiphospholipid antibodies recommended when neurologic presentations occur atypically or in younger individuals. In CAPS, which is more rapidly progressive with multiorgan involvement, potential alternative microangiopathic syndromes should be carefully considered in the differential diagnosis. To date, anticoagulation with vitamin K antagonists remains the mainstay of therapy in APS while triple therapy with anticoagulation, corticosteroids, and plasma exchange is standard of care in CAPS. Immunotherapy has shown early promise in refractory cases. APS is an autoimmune clinical syndrome with neurologic presentations classically characterized by vascular thrombosis, though recent understandings suggest additional direct immune-mediated phenomena. Our understanding of the underlying pathogenic mechanisms of APS continues to grow and will continue to influence our therapeutic approaches.
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
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Quintana-López G, Rodríguez-Pintó I, Maldonado-Cañón K, Gerard Espinosa, Diaz-Rojas J, Cervera R. Cost-effectiveness analysis of treatments for the first episode of catastrophic antiphospholipid syndrome: A study based on the catastrophic antiphospholipid syndrome registry. Lupus 2022; 31:194-201. [PMID: 35037492 DOI: 10.1177/09612033211070973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatments for catastrophic antiphospholipid syndrome (CAPS) rose from recommendations and consensus of international experts based on case series or case reports. We aimed to evaluate the treatment scheme with the best cost-effectiveness ratio associated with lower mortality as a high-impact clinical benefit. METHODS The CAPS Registry was used as our source of structured data on the different therapeutic strategies, their frequency, and their effectiveness (survival). Starting from around 50 different schemes, we identified those with a mortality of less than 33% within the 18 most frequently utilized. After applying the efficiency frontier method, we included two schemes to conduct a cost-effectiveness analysis from the Colombian healthcare sector perspective. Scheme 1 (Glucocorticoids + Anticoagulation + Anti-aggregation + Intravenous IgG immunoglobulin) and scheme 2 (Glucocorticoids + Anticoagulation + Anti-aggregation + Plasma exchange) were compared in terms of costs and survival. Deterministic and probabilistic sensitivity analyses (Monte Carlo simulation) were conducted to evaluate model robustness and uncertainty. RESULTS Our analysis uses the information corresponding to 427 cases from the CAPS registry, the majority being women (68.8%), with a mean age of 45.7 years and bearing general mortality of 38.17% (female: 38.4%, male: 37.5%). Scheme 2 was the cost-effective strategy over scheme 1. The results were robust on discrete sensitivity analysis and probability sensitivity analysis (Monte Carlo simulation). CONCLUSION To our knowledge, this is the first economic evaluation focused on the treatment of CAPS. For the Colombian health system, schemes 1 and 2 have similar behavior; nevertheless, scheme 2 represents the best cost-effectiveness ratio. This treatment approach is highly susceptible to the allocation of resources by the system and beneficial in terms of health outcomes.
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Affiliation(s)
- Gerardo Quintana-López
- Reumavance Group, Rheumatology section, Department of Internal Medicine, 173061Fundación Santa Fe de Bogotá University Hospital, Bogota, Colombia.,Department of Internal Medicine, School of Medicine, 28021Universidad Nacional de Colombia, Bogota, Colombia.,Department of Internal Medicine, School of Medicine, Universidad de Los Andes, Bogota, Colombia
| | - Ignasi Rodríguez-Pintó
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, 58955Hospital Mútua de Terrassa, Terrassa, Spain
| | - Kevin Maldonado-Cañón
- Reumavance Group, Rheumatology section, Department of Internal Medicine, 173061Fundación Santa Fe de Bogotá University Hospital, Bogota, Colombia
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, 146245Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Jorge Diaz-Rojas
- Department of Autoimmune Diseases, Hospital Clínic, 146245Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.,Facultad de Ciencias, Departamento de Farmacia, Universidad Nacional de Colombia, Bogota, Colombia
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, 146245Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Stanescu C, Andronesi AG, Jurcut C, Gherghiceanu M, Vornicu A, Burcea FA, Andronesi TD, Lupusoru GE, Iliuta L, Sorohan BM, Obrisca B, Ismail G. Successful Treatment of Catastrophic Antiphospholipid Syndrome Using Rituximab: Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:912. [PMID: 34577835 PMCID: PMC8470109 DOI: 10.3390/medicina57090912] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Kidney involvement is a frequent complication of systemic lupus erythematosus (SLE) and kidney biopsy is essential in differentiating lupus nephritis (LN) from thrombotic microangiopathy (TMA) secondary to antiphospholipid autoantibodies (aPL). Association between antiphospholipid syndrome (APS) and acquired hemophilia due to inhibitors was very rarely described in SLE patients. CASE PRESENTATION We present the case of a 61-year-old male diagnosed with SLE who acquired deficiency of clotting factor VIII due to circulating inhibitors, admitted for acute kidney injury (AKI), microangiopathic hemolytic anemia, thrombocytopenia, and diplopia. Kidney biopsy showed TMA due to APS, but no signs of LN. Head computed tomography identified low dense areas in the white matter, suggesting small blood vessels' involvement. A diagnosis of probable catastrophic antiphospholipid syndrome (CAPS) was established and treatment with low molecular weight heparin, intravenous methylprednisolone, plasmapheresis, and rituximab was initiated, followed by resolution of AKI, diplopia, and TMA with complete depletion of CD19+B-lymphocytes (CD19+B-Ly) after one month. We further review the current knowledge regarding pathogenesis and management of CAPS in SLE patients. CONCLUSIONS Targeted therapy was possible after kidney biopsy, improving renal and general prognosis. CD19+B-Ly repopulation preceded biological relapse, so monitoring of CD19+B-Ly may serve as a tool to predict relapses and guide rituximab therapy.
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Affiliation(s)
- Cristina Stanescu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Andreea Gabriella Andronesi
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Ciprian Jurcut
- Internal Medicine Department, “Carol Davila” Military Emergency Hospital, 010225 Bucharest, Romania;
| | - Mihaela Gherghiceanu
- “Victor Babes” National Institute for Research and Development in Pathology and Biomedical Sciences, 050097 Bucharest, Romania;
| | - Alexandra Vornicu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Florentina Andreea Burcea
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Toader Danut Andronesi
- Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania;
| | - Gabriela Elena Lupusoru
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Luminita Iliuta
- Department of Biostatistics, Marketing and Medical Technology, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania;
| | - Bogdan Marian Sorohan
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Bogdan Obrisca
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Gener Ismail
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
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Barros VIPVLD, Igai AMK, Oliveira ALMLD, Teruchkin MM, Orsi FA. Obstetric antiphospholipid syndrome. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:495-501. [PMID: 34318477 PMCID: PMC10411138 DOI: 10.1055/s-0041-1732382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
| | - Ana Maria Kondo Igai
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Nasonov EL, Beketova TV, Reshetnyak TM, Lila AM, Ananieva LP, Lisitsyna TA, Soloviev SK. Coronavirus disease 2019 (COVID-19) and immune-mediated inflammatory rheumatic diseases: at the crossroads of thromboinflammation and autoimmunity. RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.47360/1995-4484-2020-353-367] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammation and coagulation are key basic mechanism of protection against all potentially pathogenic mechanical and biological factors targeting human organism from inner and outer environment. On the other hand, uncontrolled inflammation results in hypercoagulation, inhibition of anticoagulation and alteration of mechanisms responsible for resolution of inflammation, while production of “procoagulant” mediators (thrombin, tissue factor and others), activation of platelets and of vascular endothelial cells maintains inflammation. All factors taken together serve as the basis for a pathological process called thromboinflammation or immunothrombosis. Currently thromboinflammation is considered in the broad sense as a universal pathogenetic mechanism of numerous widespread acute and chronic conditions, including immune-mediated (autoimmune) inflammatory rheumatic diseases, oftentimes complicated by severe irreversible damage to vital organs. Thromboinflammation gained specific attention during СОVID-19 (coronavirus disease 2019) pandemic, caused by SARS-Cov-2 (severe acute respiratory syndrome Coronavirus-2). COVID-19 is considered currently as systemic thromboinflammation syndrome, manifesting via generalized thrombosis of arterial and venous macro- and microvasculature, termed as COVID-19-coagulopathy. The paper discusses common pathogenetic coagulopathy mechanisms in COVID-19 and immune-mediated (autoimmune) inflammatory rheumatic diseases (IMRDs), associated with overproduction of antiphospholipid antibodies, activation of the complement system, and dis-regulated synthesis of proinflammatory cytokines, etc. Delineating the autoimmune subtype of thromboinflammation, identification of genetic (i.e., genes encoding the complement system and others) and molecular-biologic biomarkers associated with higher occurrence of COVID-19-coagulopathy are the most relevant undertakings for the current practice. Gaining insights into mechanisms of thromboinflammation and converting them into potential pharmacotherapies of IMDs would facilitate and accelerate the drafting of effective therapeutic strategies for COVID-19.
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Affiliation(s)
- E. L. Nasonov
- VA Nasonova Research Institute of Rheumatology;
I.M. Sechenov First Moscow State Medical University, MOH (Sechenov University)
| | | | - T. M. Reshetnyak
- VA Nasonova Research Institute of Rheumatology;
Russian Medical Academy of Continuing Prefessional Education, Ministry of Health of Russia
| | - A. M. Lila
- VA Nasonova Research Institute of Rheumatology
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Cervera R, Rodríguez-Pintó I, Legault K, Erkan D. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Catastrophic Antiphospholipid Syndrome. Lupus 2020; 29:1594-1600. [DOI: 10.1177/0961203320951260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Task Force on Catastrophic Antiphospholipid Syndrome (CAPS) met again on occasion of the 16th International Congress on Antiphospholipid Antibodies (aPL) that was held in Manchester, England, in September 2019. Its aims were to assess the up-to-date knowledge on pathogenesis, clinical and laboratory features, diagnosis and classification, precipitating factors, and treatment of CAPS. This article summarizes the main aspects that were presented during the Task Force meeting at that Congress.
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Affiliation(s)
- Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Ignasi Rodríguez-Pintó
- Systemic Autoimmune Diseases Unit, Hospital Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Kim Legault
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
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Sevim E, Willis R, Erkan D. Is there a role for immunosuppression in antiphospholipid syndrome? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:426-432. [PMID: 31808842 PMCID: PMC6913487 DOI: 10.1182/hematology.2019000073] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by thrombosis, pregnancy morbidity, or nonthrombotic manifestations in patients with persistently positive antiphospholipid antibodies (aPL). Conventional APS treatment focuses on antithrombotic strategies, which are usually ineffective for the microvascular and nonthrombotic manifestations of aPL. Using a case-based presentation, this review focuses on the role of immunosuppression in nonobstetric APS, including B-cell inhibition (rituximab, belimumab, and bortezomib), complement inhibition (eculizumab), mechanistic target of rapamycin inhibition (sirolimus), vascular endothelial cell modulation (defibrotide), statins, and traditional rheumatologic disease-modifying agents (hydroxychloroquine, mycophenolate mofetil, azathioprine, and cyclophosphamide).
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Affiliation(s)
- Ecem Sevim
- Division of Rheumatology, Hospital for Special Surgery, New York, NY
| | - Rohan Willis
- Division of Rheumatology, University of Texas Medical Branch, Galveston, TX; and
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 810] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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13
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Mezhov V, Segan JD, Tran H, Cicuttini FM. Antiphospholipid syndrome: a clinical review. Med J Aust 2019; 211:184-188. [PMID: 31271468 DOI: 10.5694/mja2.50262] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome is characterised by recurrent thrombosis (arterial, venous, microvascular) and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (lupus anticoagulant, anti-β2-glycoprotein 1 and anticardiolipin). It can be a primary disease or associated with another autoimmune disease (especially systemic lupus erythematosis). Testing for antiphospholipid antibodies should be considered in patients < 50 years of age with unprovoked venous or arterial thromboembolism, thrombosis at unusual sites or pregnancy complications. The mainstay of treatment is antithrombotic therapy and recommendations vary based on arterial, venous or pregnancy complications. If associated with systemic lupus erythematosis, hydroxychloroquine is recommended both as primary and secondary prophylaxis. Antithrombotic treatment is gold standard and effective.
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Affiliation(s)
| | | | - Huyen Tran
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
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14
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Neilan TG, Price MC, Sanborn DY, Gainor JF, Chen A. Case 33-2018: A 57-Year-Old Man with Confusion, Fever, Malaise, and Weight Loss. N Engl J Med 2018; 379:1658-1669. [PMID: 30354952 DOI: 10.1056/nejmcpc1802830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tomas G Neilan
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Melissa C Price
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Danita Y Sanborn
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Justin F Gainor
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Athena Chen
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
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15
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Signorelli F, Balbi GGM, Domingues V, Levy RA. New and upcoming treatments in antiphospholipid syndrome: A comprehensive review. Pharmacol Res 2018; 133:108-120. [PMID: 29715499 DOI: 10.1016/j.phrs.2018.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 02/23/2018] [Accepted: 04/15/2018] [Indexed: 12/11/2022]
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16
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Diószegi Á, Tarr T, Nagy-Vincze M, Nánásy-Vass M, Veisz R, Bidiga L, Dezső B, Balla J, Szodoray P, Szekanecz Z, Soltész P. Microthrombotic renal involvement in an SLE patient with concomitant catastrophic antiphospholipid syndrome: the beneficial effect of rituximab treatment. Lupus 2018; 27:1552-1558. [DOI: 10.1177/0961203318768890] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiphospholipid syndrome is characterized by multiple arterial and/or venous thrombotic events, recurrent fetal losses in the presence of antiphospholipid antibodies (aPL). Catastrophic antiphospholipid syndrome is a life-threatening, rare subset of antiphospholipid syndrome when the thrombotic events affect at least three organs, and clinical manifestations develop simultaneously or within a week. Diagnostically, small vessel occlusions can be detected by histopathology in the presence of aPL. Our case report describes an 18-year-old man who has been treated for antiphospholipid syndrome associated with systemic lupus erythematosus (SLE) since 2011. The clinical findings were dominated by recurrent deep vein thrombosis, and severe proteinuria caused by lupus nephritis, accompanied by mild serological and laboratory findings. The patient was hospitalized in March 2014 because of severe thrombocytopenia and infective diarrhoea. At this time the renal functions deteriorated rapidly. Simultaneously, left upper extremity paresis was observed; computed tomography showed ischaemic lesions in the territory of the middle cerebral artery. Abdominal discomfort and pain occurred. On computed tomography scan ischaemic lesions were seen in the spleen, the right kidney and the coeliac trunk. Laboratory and serological findings verified the presence of aPL and anti-DNA antibodies, anaemia and thrombocytopenia. Based on the above-mentioned clinical and laboratory findings, the diagnosis of catastrophic antiphospholipid syndrome was established. Anticoagulation, corticosteroids and plasma exchange treatment, as well as haemodiafiltration were initiated. Although the thrombotic cascade decelerated following these interventions, we could not see an improvement in the renal function. Rituximab treatment was started, leading to a significant improvement in renal function. After 5 weeks of treatment the patient was discharged from hospital.
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Affiliation(s)
- Á Diószegi
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - T Tarr
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - M Nagy-Vincze
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - M Nánásy-Vass
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - R Veisz
- Department of Radiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - L Bidiga
- Department of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - B Dezső
- Department of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - J Balla
- Division of Nephrology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - P Szodoray
- Institute of Immunology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Z Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - P Soltész
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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17
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Dobrowolski C, Erkan D. Treatment of antiphospholipid syndrome beyond anticoagulation. Clin Immunol 2018; 206:53-62. [PMID: 29510235 DOI: 10.1016/j.clim.2018.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder marked by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). At the present time, treatment is primarily focused on anticoagulation. However, there is increasing awareness of the mechanisms involved in APS pathogenesis, which has led to the trial of novel therapies targeting those mechanisms. Following a brief review of the etiopathogenesis of and current management strategies in APS, this paper focuses on the evidence for these potential, targeted APS treatments, e.g., hydroxychloroquine, statins, rituximab, belimumab, eculizumab, defibrotide, sirolimus, and peptide therapy.
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Affiliation(s)
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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18
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Özgür G, Beyan C. Therapeutic apheresis in the treatment of catastrophic antiphospholipid syndrome. Transfus Apher Sci 2018; 57:13-15. [PMID: 29478799 DOI: 10.1016/j.transci.2018.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Catastrophic thrombotic syndrome is characterized by occurrence of several thromboembolic occlusions which affect a variety of vascular beds over a short period of time. Catastrophic Antiphospholipid syndrome (CAPS) (1%) is regarded as a rare but severe variant of Antiphospholipid Syndrome. Treatment with anticoagulants, steroids and therapeutic plasma exchange has been shown to give the best results. However, to treat CAPS, the best substitute for plasma is still a debatable issue because there are no standard methods.
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Affiliation(s)
- Gökhan Özgür
- Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkey.
| | - Cengiz Beyan
- TOBB University of Economics and Technology, Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey
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19
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Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare but life-threatening condition that may be precipitated by pregnancy. The condition can be hard to diagnose since it mimics other thrombotic microangiopathies that are associated with pregnancy. Accurate and timely diagnosis is critical for effective treatment. In this review, we highlight pertinent clinical features of CAPS so that obstetricians will be able to recognize and treat the condition.
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Affiliation(s)
- Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Room 2B200 SOM, 50 North Medical Dr, Salt Lake City, UT 84132.
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20
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Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein 1 antibodies. APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature as well as obstetrical complications. The pathophysiological hallmark is thrombosis, but other factors such as complement activation might be important. Prevention of thrombotic manifestations associated with APS includes lifestyle changes and, in individuals at high risk, low-dose aspirin. Prevention and treatment of thrombotic events are dependent mainly on the use of vitamin K antagonists. Immunosuppression and anticomplement therapy have been used anecdotally but have not been adequately tested. Pregnancy morbidity includes unexplained recurrent early miscarriage, fetal death and late obstetrical manifestation such as pre-eclampsia, premature birth or fetal growth restriction associated with placental insufficiency. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low-molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.
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21
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Wang CR, Weng CT, Liu MF. Monocentric experience of the rituximab therapy in systemic lupus erythematosus-associated antiphospholipid syndrome with warfarin therapy failure. Semin Arthritis Rheum 2017; 47:e7-e8. [DOI: 10.1016/j.semarthrit.2017.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 12/19/2022]
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