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Foret T, Dufrost V, Lagrange J, Costa P, Mourey G, Lecompte T, Magy-Bertrand N, Regnault V, Zuily S, Wahl D. Thrombin Generation Assay in Antiphospholipid Antibodies Positive Subjects as a Personalized Thrombotic Risk Assessment: State of the Art and Perspectives. Curr Rheumatol Rep 2024; 26:178-187. [PMID: 38372872 DOI: 10.1007/s11926-024-01140-1] [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] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF THE REVIEW Thrombotic risk assessment in antiphospholipid positive (aPL +) subjects is a major challenge, and the study of in vitro thrombin generation (thrombin generation assays (TGA)) could provide useful information. Activated protein C (APC) sensitivity is involved in thrombotic events in antiphospholipid syndrome patients. We summarized methods used to assess APC sensitivity with TGA and evaluated the prognostic role of APC resistance through literature search. RECENT FINDINGS APC resistance induced by aPL is a complex pathway. Several cross-sectional studies assessed APC sensitivity to understand thrombotic event mechanisms in aPL + subjects. Only one prospective cohort had investigated the prognostic impact of APC resistance in aPL + subjects, with a positive and significant correlation between APC sensitivity and the risk of thrombosis during the follow up (hazard ratio, 6.07 [95% CI, 1.69-21.87]). APC resistance assessed with TGA could be associated with thrombotic events in aPL + subjects.
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Affiliation(s)
- Thomas Foret
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France.
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France.
| | - Virginie Dufrost
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Jeremy Lagrange
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Patricia Costa
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France
| | - Guillaume Mourey
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France
- Medical Biology Laboratory, Biological Haemostasis Department, CHU Besançon, F-25000, Besançon, France
| | - Thomas Lecompte
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
- Université de Lorraine, Nancy, France
| | | | - Veronique Regnault
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Denis Wahl
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
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de Laat-Kremers RMW, Wahl D, Zuily S, Ninivaggi M, Regnault V, Musial J, de Groot PG, Devreese KMJ, de Laat B. A thrombin-driven neural net diagnoses the antiphospholipid syndrome without the need for interruption of anticoagulation. Blood Adv 2024; 8:936-946. [PMID: 38163323 PMCID: PMC10877130 DOI: 10.1182/bloodadvances.2023011938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT Thrombosis is an important manifestation of the antiphospholipid syndrome (APS). The thrombin generation (TG) test is a global hemostasis assay, and increased TG is associated with thrombosis. APS is currently diagnosed based on clinical and laboratory criteria, the latter defined as anti-cardiolipin, anti-β2-glycoprotein I antibodies, or lupus anticoagulant (LA). APS testing is often performed after a thrombotic episode and subsequent administration of anticoagulation, which might hamper the interpretation of clotting assays used for LA testing. We set out to develop an artificial neural network (NN) that can diagnose APS in patients who underwent vitamin K antagonist (VKA) treatment, based on TG test results. Five NNs were trained to diagnose APS in 48 VKA-treated patients with APS and 64 VKA-treated controls, using TG and thrombin dynamics parameters as inputs. The 2 best-performing NNs were selected (accuracy, 96%; sensitivity, 96%-98%; and specificity, 95%-97%) and further validated in an independent cohort of VKA-anticoagulated patients with APS (n = 33) and controls (n = 62). Independent clinical validation favored 1 of the 2 selected NNs, with a sensitivity of 88% and a specificity of 94% for the diagnosis of APS. In conclusion, the combined use of TG and NN methodology allowed for us to develop an NN that diagnoses APS with an accuracy of 92% in individuals with VKA anticoagulation (n = 95). After further clinical validation, the NN could serve as a screening and diagnostic tool for patients with thrombosis, especially because there is no need to interrupt anticoagulant therapy.
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Affiliation(s)
- Romy M. W. de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, The Netherlands
| | - Denis Wahl
- Vascular Medicine Division, French National Reference Center for Systemic Autoimmune and Autoinflammatory Disorders (Lupus Erythematosus, Antiphospholipid Antibody Syndrome), CHRU de Nancy, Université de Lorraine, INSERM, Défaillance Cardio-Vasculaire Aigüe et Chronique, Nancy, France
| | - Stéphane Zuily
- Vascular Medicine Division, French National Reference Center for Systemic Autoimmune and Autoinflammatory Disorders (Lupus Erythematosus, Antiphospholipid Antibody Syndrome), CHRU de Nancy, Université de Lorraine, INSERM, Défaillance Cardio-Vasculaire Aigüe et Chronique, Nancy, France
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Véronique Regnault
- Vascular Medicine Division, French National Reference Center for Systemic Autoimmune and Autoinflammatory Disorders (Lupus Erythematosus, Antiphospholipid Antibody Syndrome), CHRU de Nancy, Université de Lorraine, INSERM, Défaillance Cardio-Vasculaire Aigüe et Chronique, Nancy, France
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Jagiellonian University, Krakow, Poland
| | - Philip G. de Groot
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Katrien M. J. Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, The Netherlands
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
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Efthymiou M, Bertolaccini ML, Cohen H. Viewpoint: Lupus anticoagulant detection and interpretation in antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI54-SI63. [PMID: 38320587 DOI: 10.1093/rheumatology/kead623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024] Open
Abstract
Lupus anticoagulant (LA) is a well-established risk factor for the clinical manifestations of antiphospholipid syndrome (APS). Accurate LA detection is an essential prerequisite for optimal diagnosis and management of patients with APS or aPL carriers. Variability remains a challenge in LA testing, with reliable detection influenced by multiple factors, including pre-analytical conditions, anticoagulation treatment, choice of tests and procedures performed, as well as interpretation of results, that can lead to false-positives or negatives. A standardised approach to LA testing, following current guidance, based on published data and international consensus, and with attention to detail, is required to underpin accurate detection of LA. Future work should focus on better characterisation of the nature of LA, which may ultimately lead to improved diagnosis and management of patients with APS and aPL carriers. This article reviews current practice and challenges, providing an overview on detection of LA.
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Affiliation(s)
- Maria Efthymiou
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Mansory EM, Alahwal HM, Bahashwan SM, Radhwi O, Almohammadi AT, Daghistani Y, Al-Mughales J, Barefah AS. Antiphospholipid Antibody Testing: An Audit on Testing Practices in a Public Tertiary Care Center. J Clin Med 2023; 13:243. [PMID: 38202249 PMCID: PMC10780093 DOI: 10.3390/jcm13010243] [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: 12/12/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Antiphospholipid antibodies (aPLs) are antibodies directed against cell membrane components and can be associated with clinical features or be asymptomatic. Testing and interpreting these antibodies is associated with many challenges and pitfalls in clinical practice. OBJECTIVE To review all antiphospholipid antibody testing and describe the testing practices, indications for testing and interpretation of results to infer local challenges with aPL testing and subsequently address ways to overcome those challenges. METHODS This is a retrospective analysis of all aPL testing done in a tertiary center between 2014 and 2018. Characteristics of study patients collected through chart review were described using the mean and standard deviation for continuous variables and proportion for categorical variables. Group differences were compared between patients with any aPL-positive result and those with no positive result using chi-square or Fisher's exact test as appropriate for categorical variables and a simple regression model for numerical variables. RESULTS Among 414 patients undergoing aPL testing, mainly adult females, 62 (14.9%) patients had at least one positive antibody, of those, 26 (42%) had repeat testing done. Testing was mostly done for obstetric indication (107, 25.8%), with 36 patients having one or two early pregnancy losses <10 weeks as their testing indication. A total of 27 (6.5%) patients were labeled with APS/possible APS based on chart review, but on review of the testing of those patients according to classification criteria, only nine patients satisfied the criteria for APS. CONCLUSION This study highlights the clinical challenges associated with aPL testing, including the controversies around indication for testing, the low rates of repeat testing to confirm persistence, and the common misinterpretation of results. Having an aPL testing profile, explicit reference ranges, results commentary, and close interaction between ordering physicians and laboratory staff might be starting points to overcome these challenges.
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Affiliation(s)
- Eman M. Mansory
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hatem M. Alahwal
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Salem M. Bahashwan
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Osman Radhwi
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Abdullah T. Almohammadi
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Yassir Daghistani
- Department of Medicine, College of Medicine, University of Jeddah, Jeddah 23890, Saudi Arabia;
| | - Jamil Al-Mughales
- Department of Clinical Laboratories, Diagnostic Immunology Division, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Clinical Microbiology and Immunology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ahmed S. Barefah
- Hematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (H.M.A.); (S.M.B.); (O.R.); (A.T.A.); (A.S.B.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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Płazak W, Drabik L. SARS-CoV-2 infection and SLE: endothelial dysfunction, atherosclerosis, and thrombosis. Clin Rheumatol 2023; 42:2691-2702. [PMID: 36622519 PMCID: PMC9827021 DOI: 10.1007/s10067-022-06497-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/10/2023]
Abstract
An increased risk of atherosclerotic and thrombotic complications characterizes connective tissue diseases. Endothelial dysfunction is the basis for the initiation and progression of atherosclerosis and thrombosis. We present systemic lupus erythematosus (SLE) as a model rheumatic disease with endothelial dysfunction and discuss its mechanisms, factors that influence the early onset and rapid progression of atherosclerosis, and the increased risk of thromboembolic events. We focus on established methods to improve endothelium function, including statins, antiplatelet, and antithrombotic therapy. Hypercoagulable and hypofibrinolitic states and a hyperinflammatory response characterize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Several pathogenic mechanisms are typical for an acute phase of Covid-19 post-Covid syndrome and connective tissue diseases: endothelial dysfunction, elevated antiphospholipid antibody titer, activation of the complement system, and formation of extracellular neutrophil traps (NET). The current review discusses the mechanisms underlying SLE and the COVID-19 in the context of endothelial function, atherosclerosis, and thrombosis (Graphical abstract). Key Points • The pathophysiology of systemic lupus erythematosus (SLE) and Covid-19 shows some similarities, such as endothelial cell activation and dysfunction, the activation of complementary systems, the presence of antiphospholipid antibodies, and the formation of extracellular neutrophil traps. • Autoimmunity in both diseases creates the basis for hyperinflammatory, hypercoagulable, and hypofibrinolitic states and their thromboembolic complications. • This paper presents our perspective on the mechanisms behind the cardiovascular manifestations of SLE and COVID-19, with a particular emphasis on endothelial dysfunction. Covid-19 and systemic lupus erythematosus-potential similarities in pathophysiology. Figures of the panel illustrate the clinical manifestations of endothelial dysfunction, atherosclerosis, and thromboembolism, including coronary artery disease ([A] coronary angiography with left anterior descending artery stenosis and [B] scintigraphy with reduced perfusion in the myocardial apical segments), stroke ([C] carotid angiography, left carotid artery occlusion) and pulmonary embolism ([D]computed tomography with thrombus in the right pulmonary artery).
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Affiliation(s)
- Wojciech Płazak
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - Leszek Drabik
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
- Department of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
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Erez O, Gotsch F, Jung E, Chaiworapongsa T, Gudicha DW, Suksai M, Gallo DM, Chaemsaithong P, Bosco M, Al Qasem M, Meyyazhagan A, Than NG, Romero R. Perturbations in kinetics of the thrombin generation assay identify women at risk of preeclampsia in the first trimester and provide the rationale for a preventive approach. Am J Obstet Gynecol 2023; 228:580.e1-580.e17. [PMID: 36368431 PMCID: PMC10149548 DOI: 10.1016/j.ajog.2022.11.1276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Activation of the coagulation system and increased thrombin generation have been implicated in the pathophysiology of preeclampsia, and this rationale supports the administration of low-molecular-weight heparin to prevent this syndrome in patients at risk. Yet, randomized trials of this prophylactic measure have yielded contradictory results. A possible explanation is that only a subset of patients with preeclampsia have excessive thrombin generation and would benefit from the administration of low-molecular-weight heparin. Therefore, the key questions are whether and when patients who subsequently develop preeclampsia present evidence of abnormal thrombin generation. OBJECTIVE This study aimed to determine (1) the kinetics of thrombin generation throughout gestation in women with a normal pregnancy and in those with early and late preeclampsia, and (2) the diagnostic performance of in vivo thrombin generation parameters to predict the development of preeclampsia. STUDY DESIGN This retrospective, nested case-control study was based on a prospective longitudinal cohort of singleton gestations. Cases comprised women who developed preeclampsia (n=49), and controls consisted of patients with a normal pregnancy (n=45). Preeclampsia was classified into early-onset (n=24) and late-onset (n=25). Longitudinal changes in the parameters of the thrombin generation assay (lag time, time to peak thrombin concentration, peak thrombin concentration, endogenous thrombin generation, and velocity index) throughout gestation were compared between the study groups, and normal pregnancy percentiles were derived from the control group. We tested whether a single parameter or a combination of parameters, derived from the kinetics of thrombin generation, could identify patients who subsequently developed preeclampsia. Time-related parameters <10th percentile were considered short, and concentration-related parameters >90th percentile were considered high. RESULTS (1) Patients who developed preeclampsia (early- and late-onset) had abnormal thrombin generation kinetics as early as 8 to 16 weeks of pregnancy; (2) patients with a combination of a short lag time and high peak thrombin concentration at 8 to 16 weeks of pregnancy had an odds ratio of 43.87 for the subsequent development of preeclampsia (area under the curve, 0.79; sensitivity, 56.8%; specificity, 92.7%; positive likelihood ratio, 7.76); (3) at 16 to 22 weeks of gestation, patients with a combination of a short lag time and a high velocity index had an odds ratio of 16 for the subsequent development of preeclampsia (area under the curve, 0.78; sensitivity, 62.2%; specificity, 92.5%; positive likelihood ratio, 8.29). CONCLUSION During early pregnancy, the thrombin generation assay can identify the subset of patients at a greater risk for the development of preeclampsia owing to accelerated and enhanced production of thrombin. This observation provides a rationale for testing the efficacy of low-molecular-weight heparin in this subset of patients. We propose that future research on the efficacy of low-molecular-weight heparin and other interventions targeting the coagulation system to prevent preeclampsia should be focused on patients with abnormal kinetics of thrombin generation.
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Affiliation(s)
- Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Francesca Gotsch
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dereje W Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dahiana M Gallo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mariachiara Bosco
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Malek Al Qasem
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arun Meyyazhagan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Nandor Gabor Than
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Systems Biology of Reproduction Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary; Maternity Private Clinic, Budapest, Hungary; First Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI.
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Gehlen R, Vandevelde A, de Laat B, Devreese KMJ. Application of the thrombin generation assay in patients with antiphospholipid syndrome: A systematic review of the literature. Front Cardiovasc Med 2023; 10:1075121. [PMID: 37057100 PMCID: PMC10089302 DOI: 10.3389/fcvm.2023.1075121] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/20/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThe antiphospholipid syndrome (APS) is classified by the presence of antiphospholipid antibodies (aPL) and thrombotic and/or adverse obstetric outcomes. The diagnosis and risk assessment of APS is challenging. This systematic review investigated if the thrombin generation (TG) assay could be helpful for APS diagnosis and risk assessment.MethodsA systemic review was performed by searching two databases (MEDLINE and Embase) until March 31, 2022, using a search strategy with two concepts: APS and TG, and related keywords. Two reviewers independently screened the articles based on predefined inclusion and exclusion criteria. Data extraction and quality assessment with the Newcastle-Ottawa Scale (NOS) were performed independently. Synthesis Without Meta-analysis guidelines were followed for data synthesis reporting.ResultsFourteen studies with 677 APS and 1,349 control subjects were included with variable quality according to the NOS. Twelve studies measured TG via the calibrated automated thrombogram (CAT) method using a fluorogenic substrate, whereas two used a chromogenic substrate-based TG assay. One study compared the CAT assay to the fully-automated ST Genesia® (Stago, France). Two studies initiated TG using platelet-rich plasma, whereas the rest of the studies used platelet-poor plasma. Resistance to activated protein C (aPC) was examined in ten studies. They reported a significant increase in aPC-resistance in APS patients compared to healthy controls, aPL-carriers, and thrombotic controls. Based on two studies, the prevalence of aPC-resistance was higher in APS patients compared to healthy controls and thrombotic controls with odds ratios of 5.9 and 6.8–12.8, respectively (p < 0.05). In contrast, no significant difference in aPC-resistance was found between APS patients and autoimmune disease controls. Furthermore, 7/14 studies reported TG-parameters including peak height, endogenous thrombin potential, lag time, and time to peak, but these outcomes were highly variable between studies. Furthermore, TG methodology between studies differed greatly, impacting the comparability of the studies.ConclusionaPC-resistance measured with TG was increased in APS patients compared to healthy and thrombotic controls, but the diagnostic and prognostic value is unclear compared to current diagnostic strategies. Studies of other TG-parameters were heterogeneous and more research is needed to identify their potential added value in APS diagnosis.Systematic Review Registrationhttps://www.PROSPERO/, identifier: CRD42022308363
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Affiliation(s)
- Rachel Gehlen
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Arne Vandevelde
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Katrien M. J. Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Correspondence: Katrien M. J. Devreese
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Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
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9
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Vandevelde A, Devreese KMJ. Laboratory Diagnosis of Antiphospholipid Syndrome: Insights and Hindrances. J Clin Med 2022; 11:jcm11082164. [PMID: 35456258 PMCID: PMC9025581 DOI: 10.3390/jcm11082164] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 12/11/2022] Open
Abstract
Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Currently, laboratory criteria aPL consist of lupus anticoagulant (LAC), anticardiolipin antibodies (aCL) IgG/IgM, and anti-β2 glycoprotein I antibodies (aβ2GPI) IgG/IgM. Diagnosis and risk stratification of APS are complex and efforts to standardize and optimize laboratory tests have been ongoing since the initial description of the syndrome. LAC detection is based on functional coagulation assays, while aCL and aβ2GPI are measured with immunological solid-phase assays. LAC assays are especially prone to interference by anticoagulation therapy, but strategies to circumvent this interference are promising. Alternative techniques such as thrombin generation for LAC detection and to estimate LAC pathogenicity have been suggested, but are not applicable yet in routine setting. For aCL and aβ2GPI, a lot of different assays and detection techniques such as enzyme-linked immunosorbent and chemiluminescent assays are available. Furthermore, a lack of universal calibrators or standards results in high variability between the different solid-phase assays. Other non-criteria aPL such as anti-domain I β2 glycoprotein I and antiphosphatidylserine/prothrombin antibodies have been suggested for risk stratification purposes in APS, while their added value to diagnostic criteria seems limited. In this review, we will describe laboratory assays for diagnostic and risk evaluation in APS, integrating applicable guidelines and classification criteria. Current insights and hindrances are addressed with respect to both laboratory and clinical implications.
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Affiliation(s)
- Arne Vandevelde
- Department of Diagnostic Sciences, Ghent University, 9000 Gent, Belgium;
- Coagulation Laboratory, Ghent University Hospital, 9000 Gent, Belgium
| | - Katrien M. J. Devreese
- Department of Diagnostic Sciences, Ghent University, 9000 Gent, Belgium;
- Coagulation Laboratory, Ghent University Hospital, 9000 Gent, Belgium
- Correspondence:
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10
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Khanna A, Periwal P, Talwar D. Double trouble - Catastrophic antiphospholipid antibody syndrome with dengue fever. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_408_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Binder NB, Depasse F, Mueller J, Wissel T, Schwers S, Germer M, Hermes B, Turecek PL. Clinical use of thrombin generation assays. J Thromb Haemost 2021; 19:2918-2929. [PMID: 34592058 PMCID: PMC9292855 DOI: 10.1111/jth.15538] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
Determining patient's coagulation profile, i.e. detecting a bleeding tendency or the opposite, a thrombotic risk, is crucial for clinicians in many situations. Routine coagulation assays and even more specialized tests may not allow a relevant characterization of the hemostatic balance. In contrast, thrombin generation assay (TGA) is a global assay allowing the dynamic continuous and simultaneous recording of the combined effects of both thrombin generation and thrombin inactivation. TGA thus reflects the result of procoagulant and anticoagulant activities in blood and plasma. Because of this unique feature, TGA has been widely used in a wide array of settings from both research, clinical and pharmaceutical perspectives. This includes diagnosis, prognosis, prophylaxis, and treatment of inherited and acquired bleeding and thrombotic disorders. In addition, TGA has been shown to provide relevant information for the diagnosis of coagulopathies induced by infectious diseases, comprising also disturbance of the coagulation system in COVID-19, or for the assessment of early recurrence in breast cancer. This review article aims to document most clinical applications of TGA.
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Affiliation(s)
| | | | | | | | | | | | - Björn Hermes
- DIN e.V. – DIN Standards Committee Medicine (NAMed)
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12
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Devreese KM, Zuily S, Meroni PL. Role of antiphospholipid antibodies in the diagnosis of antiphospholipid syndrome. J Transl Autoimmun 2021; 4:100134. [PMID: 34816113 PMCID: PMC8592860 DOI: 10.1016/j.jtauto.2021.100134] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 01/07/2023] Open
Abstract
The diagnosis of antiphospholipid syndrome (APS) relies on the detection of antiphospholipid antibodies (aPL). Currently, lupus anticoagulant (LA), anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are included as laboratory criteria, if persistently present. LAC measurement remains a complicated procedure with many pitfalls and interfered by anticoagulant therapy. Solid-phase assays for aCL and aβ2GPI show interassay differences. These methodological issues make the laboratory diagnosis of APS challenging. In the interpretation of aPL results, antibody profiles help in identifying patients at risk. Other aPL, such as antibodies against the domain I of beta2-glycoprotein (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies have been studied in the last years and may be useful in risk stratification of APS patients. Because of the methodological shortcomings of immunological and clotting assays, these non-criteria aPL may be useful in patients with incomplete antibody profiles to confirm or exclude the increased risk profile. This manuscript will focus on the laboratory aspects, the clinical relevance of assays and interpretation of aPL results in the diagnosis of APS. The presence of antiphospholipid antibodies (aPL) define the diagnosis of the antiphospholipid syndrome (APS). Laboratory criteria are lupus anticoagulant, anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG/IgM. Lupus anticoagulant measurement, as well as solid phase assays for aCL and aβ2GPI, show methodological challenges. Antibodies against domain I of β2GPI (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies are non-criteria aPL. aDI and aPS/PT may be useful in risk stratification of APS patients.
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Affiliation(s)
- Katrien M.J. Devreese
- Coagulation Laboratory, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Corresponding author. Coagulation Laboratory, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Gent, Belgium.
| | - Stéphane Zuily
- Université de Lorraine, Inserm, DCAC, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Regional Universitaire de Nancy, 54000, Nancy, France
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano–Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
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13
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Szabó G, Antal-Szalmás P, Kerényi A, Pénzes K, Bécsi B, Kappelmayer J. Laboratory Approaches to Test the Function of Antiphospholipid Antibodies. Semin Thromb Hemost 2021; 48:132-144. [PMID: 34261151 DOI: 10.1055/s-0041-1730357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder caused by the presence of aPLs (antiphospholipid antibodies, i.e., anti-β2-glycoprotein I and anti-cardiolipin). Everyday practice in terms of laboratory diagnostics of APS includes determination of aPLs and well-known functional assays assessing for lupus anticoagulant (LA), in turn using various tests. According to recent guidelines, the recommended method for LA identification or exclusion is based on the Russell Viper Venom test and a sensitive activated partial thromboplastin time assay. Despite the fact that LA can be quantified in laboratory practice in this way, LA is still used as a binary parameter that is just one of the risk factors of thrombosis in APS. As of today, there are no other functional assays to routinely assess the risk of thrombosis in APS. It is well-known that APS patients display a wide range of clinical outcomes although they may express very similar laboratory findings. One way to solve this dilemma, could be if antibodies could be further delineated using more advanced functional tests. Therefore, we review the diagnostic approaches to test the function of aPLs. We further discuss how thrombin generation assays, and rotational thromboelastometry tests can be influenced by LA, and how experimental methods, such as flow cytometric platelet activation, surface plasmon resonance, or nano differential scanning fluorimetry can bring us closer to the puzzling interaction of aPLs with platelets as well as with their soluble protein ligand. These novel approaches may eventually enable better characterization of aPL, and also provide a better linkage to APS pathophysiology.
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Affiliation(s)
- Gábor Szabó
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Thrombosis, Haemostasis and Vascular Biology Programme, Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Adrienne Kerényi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Krisztina Pénzes
- Division of Medical Laboratory Sciences, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Bálint Bécsi
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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14
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de Laat-Kremers RMW, Wahl D, Zuily S, Ninivaggi M, Chayouâ W, Regnault V, Musial J, de Groot PG, Devreese KMJ, de Laat B. Deciphered coagulation profile to diagnose the antiphospholipid syndrome using artificial intelligence. Thromb Res 2021; 203:142-151. [PMID: 34022673 DOI: 10.1016/j.thromres.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
The antiphospholipid syndrome (APS) is diagnosed by the presence of lupus anticoagulant and/or antibodies against cardiolipin or β2-glycoprotein-1 and the occurrence of thrombosis or pregnancy morbidity. The assessment of overall coagulation is known to differ in APS patients compared to normal subjects. The accelerated production of key factor thrombin causes a prothrombotic state in APS patients, and the reduced efficacy of the activated protein C pathway promotes this effect. Even though significant differences exist in the coagulation profile between normal controls and APS patients, it is not possible to rely on a single test result to diagnose APS. A neural network is a computing system inspired by the human brain that can be trained to distinguish between healthy subjects and patients based on subject specific data. In a first cohort of patients, we developed a neural networking that diagnoses APS. We clinically validated this neural network in a separate cohort consisting of APS patients, normal controls, controls visiting the hospital for other indications and two diseased control groups (thrombosis patients and auto-immune disease patients). The positive predictive value ranged from 62% in the hospital controls to 91% in normal controls and the negative predictive value of the neural network ranged from 86% in the thrombosis control group to 95% in the hospital controls. The sensitivity of the neural network was higher than 90% in all control groups. In conclusion, we developed a neural network that accurately diagnoses APS in the validation cohort. After further clinical validation in newly diagnosed patients, this neural network could possibly be clinically implemented to diagnose APS based on thrombin generation data.
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Affiliation(s)
- Romy M W de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, the Netherlands; Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands
| | - Denis Wahl
- Vascular Medicine Division, CHU de Nancy, Nancy, France
| | | | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands
| | - Walid Chayouâ
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands; Department of Biochemistry, CARIM, Maastricht University, Maastricht, the Netherlands
| | | | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Jagiellonian University, Krakow, Poland
| | - Philip G de Groot
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, the Netherlands; Department of Functional Coagulation, Synapse Research Institute, Maastricht, the Netherlands
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15
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Pontara E, Cattini MG, Cheng C, Bison E, Denas G, Pengo V. Insight into the hypercoagulable state of high-risk thrombotic APS patients: Contribution of aβ2GPI and aPS/PT antibodies. J Thromb Haemost 2021; 19:805-813. [PMID: 33249717 DOI: 10.1111/jth.15199] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Most high-risk thrombotic antiphospholipid syndrome (APS) patients test positive for anti-β2-glycoprotein I (aβ2GPI) and anti-phosphatidylserine/prothrombin (aPS/PT) antibodies. Information on the influence of these antibodies on thrombin generation and activated protein C resistance (aPCr) is still sparse and contradictory. METHODS Plasma of 16 patients poured into a β2GPI affinity column allowed the perfect separation of aβ2GPI and aPS/PT antibodies. aPS/PT antibodies were further purified through a prothrombin affinity column. Obtained material was spiked into normal pooled plasma (NPP) and tested in the thrombin generation assay in the absence or presence of aPC. RESULTS aPS/PT antibodies showed a marked anticoagulant effect. Affinity purified aPS/PT and aβ2GPI antibodies from five patients were compared. aPS/PT antibodies showed significantly prolonged lag time and time to peak (5.0 minutes [interquartile range (IQR)3.5-6.1] versus 2.7 minutes [IQR2.2-3.5], P = .03 and 8.7 minutes [IQR6.7-10.3] versus 5.7 minutes [IQR4.5-6.2], P = .05, respectively) and significantly lower peak and velocity index (143 nmol/L [IQR131-163] versus 171 nmol/L [IQR157-182], P = .03 and 35 nmol/L/min [IQR32-59] versus 72 nmol/L/min [IQR54-77], P = .03, respectively). When aPC was added to the system, aPCr was significantly increased compared to controls for both aβ2GPI and aPS/PT antibodies. However, it was significantly stronger using aPS/PT antibodies. Median inhibition of endogenous thrombin potential was 22% (IQR16-33) with aPS/PT compared to 52% (IQR46-56) with aβ2GPI antibodies (P = .002). CONCLUSIONS Aβ2GPI antibodies show a mild anticoagulant and moderate procoagulant effect in thrombin generation and moderate aPC resistance. Conversely, aPS/PT antibodies show a strong anticoagulant effect and a strong aPCr.
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Affiliation(s)
- Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Chunyan Cheng
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
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16
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The antiphospholipid syndrome may induce non-thrombotic internal jugular vein stenosis: two cases report. BMC Neurol 2021; 21:9. [PMID: 33413173 PMCID: PMC7789703 DOI: 10.1186/s12883-020-02035-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is associated with a high incidence of thrombotic events, either arterial thrombosis or venous thrombosis. However, APS-related non-thrombotic venous stenosis is rarely reported. CASE PRESENTATION This study described two cases of young women with APS-related internal jugular vein stenosis (IJVS) and reviewed current literature on this issue, including clinical features, diagnosis, and treatment. CONCLUSIONS IJVS is a rather rare complication of APS. Two cases were reported for the first time that high titer of antiphospholipid antibodies (aPL) might mediate direct vessel wall damage and further induce venous stenosis despite long-term standardized anticoagulation to prevent thrombus formation. Therefore, dynamic monitoring of autoantibodies and concomitant use of anticoagulants and corticosteroids may be necessary to the management of APS and its complications.
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17
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Devreese KMJ. Testing for antiphospholipid antibodies: Advances and best practices. Int J Lab Hematol 2021; 42 Suppl 1:49-58. [PMID: 32543059 DOI: 10.1111/ijlh.13195] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
The diagnosis of antiphospholipid syndrome (APS) relies on the detection of circulating antiphospholipid antibodies (aPL). Currently, lupus anticoagulant (LAC), anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are included as laboratory criteria if persistently present. Progress has been made on the standardization of tests as guidelines on LAC testing and immunological assays for aCL and aβ2GPI are published. However, LAC measurement remains a complicated procedure with many pitfalls and interfered by anticoagulant therapy. Solid-phase assays for aCL and aβ2GPI still show interassay differences. These methodological issues make the laboratory diagnosis of APS challenging. In the interpretation of aPL results, antibody profiles help in identifying patients at risk. Noncriteria aPL, such as antibodies against the domain I of beta2-glycoprotein (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies have been studied in the last years and may be useful in risk stratification of APS patients. But, aDI and aPS/PT are not included in the current diagnostic criteria and testing in daily practice is not recommended as these antibodies have no added value in the diagnosis of APS. This review will focus on the technical aspects of the laboratory methods, the clinical relevance of assays and interpretation of aPL results in the diagnosis of APS.
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Affiliation(s)
- Katrien M J Devreese
- Department of Laboratory Medicine, Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
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18
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Antibody profiles comprising anti phosphatidylserine/prothrombin differently affect thrombin generation and protein C resistance in antiphospholipid antibody carriers. Clin Chim Acta 2020; 510:796-801. [DOI: 10.1016/j.cca.2020.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/04/2020] [Accepted: 09/18/2020] [Indexed: 12/27/2022]
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19
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Zuily S, de Laat B, Guillemin F, Kelchtermans H, Magy-Bertrand N, Desmurs-Clavel H, Lambert M, Poindron V, de Maistre E, Dufrost V, Risse J, Shums Z, Norman GL, de Groot PG, Lacolley P, Lecompte T, Regnault V, Wahl D. Anti–Domain I β2-Glycoprotein I Antibodies and Activated Protein C Resistance Predict Thrombosis in Antiphospholipid Syndrome: TAC(I)T Study. J Appl Lab Med 2020; 5:1242-1252. [DOI: 10.1093/jalm/jfaa072] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/24/2020] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Antibodies binding to domain I of β2-glycoprotein I (aDI) and activated protein C (APC) resistance are associated with an increased risk of thrombosis in cross-sectional studies. The objective of this study was to assess their predictive value for future thromboembolic events in patients with antiphospholipid antibodies (aPL) or antiphospholipid syndrome.
Methods
This prospective multicenter cohort study included consecutive patients with aPL or systemic lupus erythematosus. We followed 137 patients (43.5 ± 15.4 year old; 107 women) for a mean duration of 43.1 ± 20.7 months.
Results
We detected aDI IgG antibodies by ELISA in 21 patients. An APC sensitivity ratio (APCsr) was determined using a thrombin generation–based test. The APCsr was higher in patients with anti–domain I antibodies demonstrating APC resistance (0.75 ± 0.13 vs 0.48 ± 0.20, P < 0.0001). In univariate analysis, the hazard ratio (HR) for thrombosis over time was higher in patients with aDI IgG (3.31 [95% CI, 1.15–9.52]; P = 0.03) and patients with higher APC resistance (APCsr >95th percentile; HR, 6.07 [95% CI, 1.69–21.87]; P = 0.006). A sensitivity analysis showed an increased risk of higher aDI IgG levels up to HR 5.61 (95% CI, 1.93–16.31; P = 0.01). In multivariate analysis, aDI IgG (HR, 3.90 [95% CI, 1.33–11.46]; P = 0.01) and APC resistance (HR, 4.98 [95% CI, 1.36–18.28]; P = 0.02) remained significant predictors of thrombosis over time.
Conclusions
Our study shows that novel tests for antibodies recognizing domain I of β2-glycoprotein I and functional tests identifying APC resistance are significant predictors of thrombosis over time and may be useful for risk stratification.
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Affiliation(s)
- Stephane Zuily
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
| | - Bas de Laat
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Francis Guillemin
- University of Lorraine, Nancy, France
- Inserm, CIC-EC CIE1433, Nancy, France
| | - Hilde Kelchtermans
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Marc Lambert
- CHRU de Lille, Department of Internal Medicine, Lille, France
| | - Vincent Poindron
- CHU de Strasbourg, Internal Medicine and Clinical Immunology Department, Strasbourg, France
| | | | - Virginie Dufrost
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
| | - Jessie Risse
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
| | - Zakera Shums
- CHU de Dijon, Hematology Department, Dijon, France
| | | | - Philip G de Groot
- Synapse Research Institute, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Clinical Chemistry and Haematology, University Medical Centre (UMC) Utrecht, Utrecht, The Netherlands
| | - Patrick Lacolley
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
| | - Thomas Lecompte
- Nancy University Hospital, Hematology Laboratory, Nancy, France
| | - Véronique Regnault
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
| | - Denis Wahl
- Nancy University Hospital, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
- Inserm, U1116, Nancy, France
- Nancy University, Nancy, France
- University of Lorraine, Nancy, France
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20
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Abstract
PURPOSE OF THE REVIEW This review focuses on the laboratory tests necessary for the diagnosis of antiphospholipid syndrome (APS). For the interpretation of the results of the tests for antiphospholipid antibodies (aPL), understanding of all pitfalls and interferences is necessary. RECENT FINDINGS Progress has been made on the standardization of aPL tests and current guidelines for detection of lupus anticoagulant (LAC), anticardiolipin antibodies (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) are useful tools. LAC measurement remains a complex procedure with many pitfalls and interference by anticoagulant therapy. Solid phase assays for aCL and aβ2GPI still show inter-assay differences. Measuring LAC, aCL, and aβ2GPI allows making antibody profiles that help in identifying patients at risk. Other aPL, such as antibodies against domain I of beta2-glycoprotein I (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies, may be useful in risk stratification of APS patients, but are not included in the current diagnostic criteria as no added value in the diagnosis of APS has been illustrated so far. The laboratory diagnosis of APS remains challenging. LAC, aCL, aβ2GPI IgG, and IgM should be performed to increase diagnostic efficacy, with an integrated interpretation of all results and an interpretative comment. A close interaction between clinical pathologists and clinicians is mandatory.
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Affiliation(s)
- Katrien M J Devreese
- Department of Laboratory Medicine, Coagulation Laboratory, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
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21
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Lopez-Pedrera C, Barbarroja N, Patiño-Trives AM, Collantes E, Aguirre MA, Perez-Sanchez C. New Biomarkers for Atherothrombosis in Antiphospholipid Syndrome: Genomics and Epigenetics Approaches. Front Immunol 2019; 10:764. [PMID: 31040845 PMCID: PMC6476988 DOI: 10.3389/fimmu.2019.00764] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 03/22/2019] [Indexed: 01/08/2023] Open
Abstract
Antiphospholipid Syndrome (APS) is an autoimmune disorder, characterized by pregnancy morbidity and/or a hyper coagulable state involving the venous or the arterial vasculature and associated with antiphospholipid antibodies (aPL), including anti-cardiolipin antibodies (aCL), anti-beta2-glycoprotein I (anti-ß2GPI), and Lupus anticoagulant (LA). In recent years there have been many advances in the understanding of the molecular basis of vascular involvement in APS. APS is of multifactorial origin and develops in genetically predisposed individuals. The susceptibility is determined by major histocompatibility complex (MHC). Different HLA-DR and HLA-DQ alleles have been reported in association with APS. Moreover, MHC II alleles may determine the autoantibody profile and, as such, the clinical phenotype of this disease. Besides, polymorphisms in genes related to the vascular system are considered relevant factors predisposing to clinical manifestations. Antiphospholipid antibodies (aPL) induce genomic and epigenetic alterations that support a pro- thrombotic state. Thus, a specific gene profile has been identified in monocytes from APS patients -related to aPL titres in vivo and promoted in vitro by aPL- explaining their cardiovascular involvement. Regarding epigenetic approaches, we previously recognized two miRNAs (miR-19b/miR-20a) as potential modulators of tissue factor, the main receptor involved in thrombosis development in APS. aPLs can further promote changes in the expression of miRNA biogenesis proteins in leukocytes of APS patients, which are translated into an altered miRNA profile and, consequently, in the altered expression of their protein targets related to thrombosis and atherosclerosis. MicroRNAs are further released into the circulation, acting as intercellular communicators. Accordingly, a specific signature of circulating miRNAs has been recently identified in APS patients as potential biomarkers of clinical features. Genomics and epigenetic biomarkers might also serve as indices for disease progression, clinical pharmacology, or safety, so that they might be used to individually predict disease outcome and guide therapeutic decisions. In that way, in the setting of a clinical trial, novel and specific microRNA–mRNA regulatory networks in APS, modified by effect of Ubiquinol treatment, have been identified. In this review, current and previous studies analyzing genomic/epigenetic changes related to the clinical profile of APS patients, and their modulation by effect of specific therapies, are discussed.
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Affiliation(s)
- Chary Lopez-Pedrera
- Instituto Maimonides de Investigación Biomédica de Cordoba, Reina Sofia Hospital, Córdoba, Spain.,Hospital Universitario Reina Sofía, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
| | - Nuria Barbarroja
- Hospital Universitario Reina Sofía, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
| | - Alejandra Mª Patiño-Trives
- Instituto Maimonides de Investigación Biomédica de Cordoba, Reina Sofia Hospital, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
| | - Eduardo Collantes
- Hospital Universitario Reina Sofía, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
| | - Mª Angeles Aguirre
- Hospital Universitario Reina Sofía, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
| | - Carlos Perez-Sanchez
- Hospital Universitario Reina Sofía, Córdoba, Spain.,Inflammatory and Systemic Autoimmune Diseases' Group, Instituto Maimonides de Investigacion Biomédica de Córdoba, Cordova, Spain.,Department of Medicine, Universidad de Córdoba, Córdoba, Spain
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22
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D'Angelo C, Franch O, Fernández-Paredes L, Oreja-Guevara C, Núñez-Beltrán M, Comins-Boo A, Reale M, Sánchez-Ramón S. Antiphospholipid Antibodies Overlapping in Isolated Neurological Syndrome and Multiple Sclerosis: Neurobiological Insights and Diagnostic Challenges. Front Cell Neurosci 2019; 13:107. [PMID: 30941020 PMCID: PMC6433987 DOI: 10.3389/fncel.2019.00107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/04/2019] [Indexed: 01/19/2023] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis, pregnancy morbidity and fetal loss caused by pathogenic autoantibodies directed against phospholipids (PL) and PL-cofactors. Isolated neurological APS may represent a significant diagnostic challenge, as epidemiological, clinical and neuroimaging features may overlap with those of multiple sclerosis (MS). In an open view, MS could be considered as an organ-specific anti-lipid (phospholipid and glycosphingolipid associated proteins) disease, in which autoreactive B cells and CD8+ T cells play a dominant role in its pathophysiology. In MS, diverse autoantibodies against the lipid-protein cofactors of the myelin sheath have been described, whose pathophysiologic role has not been fully elucidated. We carried out a review to select clinical studies addressing the prevalence of antiphospholipid (aPL) autoantibodies in the so-called MS-like syndrome. The reported prevalence ranged between 2% and 88%, particularly aCL and aβ2GPI, with predominant IgM isotype and suggesting worse MS prognosis. Secondarily, an updated summary of current knowledge on the pathophysiological mechanisms and events responsible for these conditions is presented. We draw attention to the clinical relevance of diagnosing isolated neurological APS. Prompt and accurate diagnosis and antiaggregant and anticoagulant treatment of APS could be vital to prevent or at least reduce APS-related morbidity and mortality.
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Affiliation(s)
- Chiara D'Angelo
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain.,Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Oriol Franch
- Department of Neurology, Hospital Ruber Internacional, Madrid, Spain
| | - Lidia Fernández-Paredes
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
| | | | - María Núñez-Beltrán
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Alejandra Comins-Boo
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
| | - Marcella Reale
- Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Silvia Sánchez-Ramón
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain.,Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
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23
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Prothrombin conversion is accelerated in the antiphospholipid syndrome and insensitive to thrombomodulin. Blood Adv 2019; 2:1315-1324. [PMID: 29895622 DOI: 10.1182/bloodadvances.2018018036] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/25/2018] [Indexed: 12/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a condition in which the presence of antibodies against phospholipid-binding proteins is associated with thrombophilia and/or pregnancy morbidity. Although antiphospholipid antibodies have anticoagulant characteristics in vitro, they are associated with thromboembolic complications. Thrombin generation (TG) is a sensitive global test of coagulation, and elevated TG is associated with thrombosis. Increased TG can be caused by increased prothrombin conversion, decreased thrombin inactivation, or a combination of both. In this study, we measured TG in APS patients and healthy controls with and without vitamin K antagonist (VKA) treatment at 1 and 5 pM tissue factor and with thrombomodulin. Prothrombin conversion and thrombin inactivation were determined by thrombin dynamics analysis. The TG peak was increased in nontreated APS patients at 1 pM TF compared with nontreated controls. Prothrombin conversion was significantly increased in nontreated APS patients. In contrast, prothrombin conversion did not differ in controls and patients that were on VKA therapy. Thrombin inactivation was comparable between controls and APS patients in the presence and absence of VKAs. Both TG (peak and ETP) and prothrombin conversion were significantly higher in APS patients with prior thrombosis compared with patients without a history of thrombosis. In this study, we demonstrate that in APS, the hemostatic balance shifts toward a more prothrombotic phenotype due to elevated prothrombin conversion but unchanged thrombin inactivation rates. Within the group of APS patients, increased TG and prothrombin conversion are associated with a history of thrombosis.
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24
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Cohen H, Efthymiou M, Isenberg DA. Use of direct oral anticoagulants in antiphospholipid syndrome. J Thromb Haemost 2018; 16:1028-1039. [PMID: 29624847 DOI: 10.1111/jth.14017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 12/20/2022]
Abstract
The direct oral anticoagulants (DOACs) are therapeutic alternatives to warfarin and other vitamin K antagonists (VKAs), and constitute the standard of care for many indications. VKAs constitute the conventional therapy for the treatment and secondary thromboprophylaxis of thrombotic antiphospholipid syndrome (APS), but are often problematic, owing to the variable sensitivity of thromboplastins to lupus anticoagulant. Thus, the International Normalized Ratio may not accurately reflect anticoagulation intensity, or be clinically effective. Definition of the current role of DOACs in the treatment of APS is based on limited clinical trial data and information from other sources, including manufacturers' data, case series or cohort studies, and expert consensus. The Rivaroxaban in Antiphospholipid Syndrome (RAPS) randomized controlled trial (RCT), which had a laboratory surrogate primary outcome measure, suggests that rivaroxaban has the potential to be an effective and convenient alternative to warfarin in thrombotic APS patients with a single venous thromboembolism event requiring standard-intensity anticoagulation. However, further studies, in particular to provide better long-term efficacy and safety data, are needed before it can be widely recommended. APS patients are clinically heterogeneous, with the risk of recurrent thrombosis and the intensity of anticoagulation being influenced by their clinical phenotype and risk profile. DOAC trials involving homogeneous thrombotic APS populations, with the antiphospholipid antibody status well defined, will help to optimize the appropriate treatment in APS patient subgroups. Ongoing and emerging DOAC RCTs should provide further information to guide the use of DOACs in APS patients. Optimal identification of APS patients is a key step in working towards improved therapeutic strategies in these individuals.
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Affiliation(s)
- H Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - D A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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25
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Influence of autoimmunity and inflammation on endothelial function and thrombosis in systemic lupus erythematosus patients. Clin Rheumatol 2018; 37:2087-2093. [PMID: 29675623 DOI: 10.1007/s10067-018-4104-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
The aim of this study is to assess the relationship between autoimmunity and endothelial activation/damage (ICAM-1 and vWF serum levels) and the degree of prothrombotic activity (thrombin-antithrombin complexes-TAT serum levels) in SLE. In 60 clinically stable SLE patients, levels of the following parameters were estimated in their serum: lupus anticoagulant (LA), anticardiolipin antibodies in both IgG and IgM classes (aCL-IgG and aCL-IgM, respectively), antiβ2GPI antibodies in both IgG and IgM classes (antiβ2GPI-IgG and antiβ2GPI-IgM, respectively), ICAM, von Willebrand factor (vWF), TAT, CRP, C3c, C4, and IL-6. ICAM-1 values exceeded the upper reference limit in 9 (15%) patients. vWF levels were increased in 21 (35%) patients. In all patients with elevated ICAM-1 values, vWF were also increased. TAT concentrations were elevated in 12 (20%) people. ICAM-1 were significantly higher in patients with elevated aCL-IgM (> 30 MPL vs ≤ 30 MPL; p < 0.05). Similarly, ICAM-1 were significantly higher in patients with elevated antiβ2-GPI-IgM (> 20 SMU vs ≤ 20 SMU; p < 0.05). There was no significant difference in ICAM-1 levels in relation to LA-positivity. vWF were not significantly different in relation to antiphospholipid antibodies nor the inflammation marker levels. TAT were significantly higher in patients with elevated aCL-IgM (> 30 MPL vs ≤ 30 MPL; p < 0.05). In one third of young patients with stable SLE, signs of endothelial activation/damage were found, as shown by elevated plasma ICAM-1 or vWF. Increased prothrombotic tendency manifested by elevated TAT was found in one fifth of the patients. Elevated anticardiolipin (IgM) and anti-β2-glycoprotein I (IgM) antibodies influence endothelial dysfunction and enhance prothrombotic state.
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26
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Chaturvedi S, McCrae KR. Clinical Risk Assessment in the Antiphospholipid Syndrome: Current Landscape and Emerging Biomarkers. Curr Rheumatol Rep 2018; 19:43. [PMID: 28711993 DOI: 10.1007/s11926-017-0668-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Laboratory criteria for the classification of antiphospholipid syndrome include the detection of a lupus anticoagulant and/or anticardiolipin and anti-β2-glycoprotein I antibodies. However, the majority of patients who test positive in these assays do not have thrombosis. Current risk-stratification tools are largely limited to the antiphospholipid antibody profile and traditional thrombotic risk factors. RECENT FINDINGS Novel biomarkers that correlate with disease activity and potentially provide insight into future clinical events include domain 1 specific anti-β2GPI antibodies, antibodies to other phospholipids or phospholipid/protein antigens (such as anti-PS/PT), and functional/biological assays such as thrombin generation, complement activation, levels of circulating microparticles, and annexin A5 resistance. Clinical risk scores may also have value in predicting clinical events. Biomarkers that predict thrombosis risk in patients with antiphospholipid antibodies have been long sought, and several biomarkers have been proposed. Ultimately, integration of biomarkers with established assays and clinical characteristics may offer the best chance of identifying patients at highest risk of APS-related complications.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37235, USA
| | - Keith R McCrae
- Department of Cellular and Molecular Medicine, Taussig Cancer Institute, Cleveland Clinic, CA6-154, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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27
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Devreese KMJ, Ortel TL, Pengo V, de Laat B. Laboratory criteria for antiphospholipid syndrome: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16:809-813. [PMID: 29532986 DOI: 10.1111/jth.13976] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 01/16/2023]
Affiliation(s)
- K M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - T L Ortel
- Departments of Medicine and Pathology, Duke University Medical Center, Durham, NC, USA
| | - V Pengo
- Cardiology Department, University of Padova, Padova, Italy
| | - B de Laat
- Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
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28
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Valor L, Hernández-Flórez D, Martínez-Barrio J, López Longo FJ. A reflection on how we define, determine and interpret the finding of lupus anticoagulant. REUMATOLOGIA CLINICA 2018; 14:120-122. [PMID: 28599869 DOI: 10.1016/j.reuma.2017.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/28/2017] [Accepted: 04/29/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Lara Valor
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Biomédica, Hospital Gregorio Marañón, Madrid, España.
| | - Diana Hernández-Flórez
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Biomédica, Hospital Gregorio Marañón, Madrid, España
| | - Julia Martínez-Barrio
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Biomédica, Hospital Gregorio Marañón, Madrid, España
| | - Francisco Javier López Longo
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Biomédica, Hospital Gregorio Marañón, Madrid, España
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29
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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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30
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Kumano O, Moore GW. Lupus anticoagulant mixing tests for multiple reagents are more sensitive if interpreted with a mixing test-specific cut-off than index of circulating anticoagulant. Res Pract Thromb Haemost 2018; 2:105-113. [PMID: 30046711 PMCID: PMC6055558 DOI: 10.1002/rth2.12069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Lupus anticoagulant (LA) is classified in the antibody family that is recognized as antiphospholipid antibodies. Guidelines for LA detection recommend mixing test interpretation with either a mixing test specific cut-off (MTC) or index of circulating anticoagulant (ICA). We previously evidenced that MTC was superior to ICA in detecting the in vitro inhibition of LA with a single dilute APTT (activated partial thromboplastin time) and dRVVT (diluted Russell's viper venom time) pairing. OBJECTIVES The objective in the present study was to compare the LA diagnostic effectiveness of MTC and ICA by multiple APTT and dRVVT reagents. METHODS One hundred-five samples from non-anticoagulated patients positive for LA in the dilute APTT (dAPTT) and dRVVT reagent pairing employed for diagnostic examination were performed by undiluted and in a 1:1 mix with normal pooled plasma with four additional APTT reagents and another dRVVT reagent (dRVVT B). RESULTS Frequencies of MTC and ICA positivity were determined from samples LA positive in undiluted plasma. MTC positivity in mixing test were 63%, 77%, 80%, 84%, 46%, 81%, and 72% in 4 APTT, dAPTT and 2 dRVVT, respectively. ICA positivity were 47%, 67%, 58%, 54%, 42%, 47%, and 29%, respectively. There were no samples of ICA-positive/MTC-negative with any reagent. CONCLUSIONS The data indicate that MTC is superior to ICA for LA detection in mixing tests in multiple reagents and reagent types. Although mixing tests may make weak LA samples appear negative, the efficacy of LA detection can be improved by the method to interpret the results.
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Affiliation(s)
| | - Gary W. Moore
- Department of Haemostasis and ThrombosisViapath AnalyticsGuy's & St. Thomas’ HospitalsLondonUK
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31
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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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32
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Chaturvedi S, McCrae KR. Diagnosis and management of the antiphospholipid syndrome. Blood Rev 2017; 31:406-417. [PMID: 28784423 DOI: 10.1016/j.blre.2017.07.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 06/22/2017] [Accepted: 07/28/2017] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (APLA). Laboratory diagnosis of APLA depends upon the detection of a lupus anticoagulant, which prolongs phospholipid-dependent anticoagulation tests, and/or anticardiolipin (aCL) and anti-β2-glycoprotein-1 (β2GPI) antibodies. APLA are primarily directed toward phospholipid binding proteins. Pathophysiologic mechanisms underlying thrombosis and pregnancy loss in APS include APLA induced cellular activation, inhibition of natural anticoagulant and fibrinolytic systems, and complement activation, among others. There is a high rate of recurrent thrombosis in APS, especially in triple positive patients (patients with lupus anticoagulant, aCL and anti-β2GPI antibodies), and indefinite anticoagulation with a vitamin K antagonist is the standard of care for thrombotic APS. There is currently insufficient evidence to recommend the routine use of direct oral anticoagulants (DOAC) in thrombotic APS. Aspirin with low molecular weight or unfractionated heparin may reduce the incidence of pregnancy loss in obstetric APS. Recent insights into the pathogenesis of APS have led to the identification of new potential therapeutic interventions, including anti-inflammatory and immunomodulatory therapies. Additional research is needed to better understand the effects of APLA on activation of signaling pathways in vascular cells, to identify more predictive biomarkers that define patients at greatest risk for a first or recurrent APLA-related clinical event, and to determine the safety and efficacy of DOACs and novel anti-inflammatory and immune-modulatory therapies for refractory APS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Keith R McCrae
- Department of Hematology and Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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33
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Bai A. β2-glycoprotein I and its antibodies involve in the pathogenesis of the antiphospholipid syndrome. Immunol Lett 2017; 186:15-19. [DOI: 10.1016/j.imlet.2017.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/05/2017] [Accepted: 03/23/2017] [Indexed: 11/26/2022]
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34
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Posch F, Gebhart J, Rand JH, Koder S, Quehenberger P, Pengo V, Ay C, Pabinger I. Cardiovascular risk factors are major determinants of thrombotic risk in patients with the lupus anticoagulant. BMC Med 2017; 15:54. [PMID: 28279213 PMCID: PMC5345189 DOI: 10.1186/s12916-017-0807-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/06/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with the lupus anticoagulant (LA) are at an increased risk of thrombotic events, which in turn increase the risk of death. Understanding the determinants of thrombotic risk in patients with LA may pave the way towards targeted thromboprophylaxis. In the Vienna Lupus Anticoagulant and Thrombosis Study (LATS), we systematically evaluate risk factors for thrombotic events in patients with LA. METHODS We followed 150 patients (mean age: 41.3 years, female gender: n = 122 (81.3%), history of thrombosis or pregnancy complications: n = 111 (74.0%)), who tested repeatedly positive for LA until development of thrombosis, death, or censoring. The primary endpoint was a composite of arterial or venous thrombotic events (TEs). RESULTS During a median follow-up of 9.5 years (range: 12 days-13.6 years) and 1076 person-years, 32 TEs occurred (arterial: n = 16, venous: n = 16; cumulative 10-year TE incidence: 24.3%). A prolonged lupus-sensitive activated partial thromboplastin time (aPTT-LA) (adjusted subdistribution hazard ratio (SHR) = 2.31, 95% CI: 1.07--5.02), diabetes (adjusted SHR = 4.39, 95% CI: 1.42-13.57), and active smoking (adjusted SHR = 2.31, 95% CI: 1.14-5.02) emerged as independent risk factors of both arterial and venous thrombotic risk. A risk model that includes a prolonged lupus-sensitive aPTT, smoking, and diabetes enabled stratification of LA patients into subgroups with a low, intermediate, and high risk of thrombosis (5-year TE risk of 9.7% (n = 77), 30.9% (n = 51), and 56.8% (n = 22). CONCLUSIONS Long-term thrombotic risk in patients with LA is clustered within subjects harboring typical cardiovascular risk factors in addition to a prolonged lupus-sensitive aPTT, whereas patients with none of these risk factors represent a large subgroup with a low risk of thrombosis.
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Affiliation(s)
- Florian Posch
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria.,Division of Oncology, Department of Internal Medicine, Medical University of Graz, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Jacob H Rand
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Silvia Koder
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Vittorio Pengo
- Division of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria.
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Naik SN, Raghavendra Y. Antiphospholipid antibody syndrome - A case report. Ayu 2017; 38:62-65. [PMID: 29861595 PMCID: PMC5954263 DOI: 10.4103/ayu.ayu_57_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Anti-phospholipid antibody (APLA) syndrome is defined by the presence of thrombo-embolic complications and pregnancy morbidity in the presence of persistently increased titers of APLA syndrome. Its clinical presentation can be diverse and any organ can be involved with a current impact in the most surgical and medical specialties. Here, the case of a 34-year-old young lady with APLA syndrome presented with the cerebral venous thrombosis and subsequently deep vein thrombosis of the left leg veins. Three classes of APLAs (IgG, IgM and activated protein C) were elevated. There were no clinical or laboratory evidence for other autoimmune or systemic illnesses. The patient is under treatment of Ruksha Tikshna Virechana (purgation) with Haritaki (Terminalia chebula Retz.) and Goarka (extract of cow’s urine) with the concept of Kaphaja Shotha (nonpitting edema) and got significant result in both subjective and objective parameters.
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Affiliation(s)
- Sameer N Naik
- Department of Kayachikitsa, PG Studies and Research Center, Kleu's Shri B M K Ayurveda Mahavidyalaya, Belgaum, India
| | - Y Raghavendra
- Shri Dhanvantari Ayurveda College Hospital and Research Centre, Uttara Kannada, Karnataka, India
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36
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Moore GW. Current Controversies in Lupus Anticoagulant Detection. Antibodies (Basel) 2016; 5:E22. [PMID: 31558003 PMCID: PMC6698846 DOI: 10.3390/antib5040022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 01/19/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune, acquired thrombophilia diagnosed when vascular thrombosis or pregnancy morbidity are accompanied by persistent antiphospholipid antibodies. Lupus anticoagulants (LA) are one of the criteria antibodies but calibration plasmas are unavailable and they are detected by inference based on antibody behaviour in a medley of coagulation-based assays. Elevated screening tests suggest the presence of a LA, which is confirmed with mixing tests to evidence inhibition and confirmatory tests to demonstrate phospholipid-dependence. At least two screening tests of different principle must be used to account for antibody heterogeneity and controversy exists on whether assays, in addition to dilute Russell's viper venom time and activated partial thromboplastin time, should be employed. A variety of approaches to raw data manipulation and interpretation attract debate, as does inclusion or exclusion of mixing studies in circumstances where the presence of a LA is already evident from other results. Therapeutic anticoagulation compromises coagulation-based assays but careful data interpretation and use of alternative reagents can detect or exclude LA in specific circumstances, and this aspect of LA detection continues to evolve. This review focuses on the main areas of debate in LA detection.
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Affiliation(s)
- Gary W Moore
- Diagnostic Haemostasis & Thrombosis Laboratories, Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' NHS Foundation Hospitals Trust, 4th floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.
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37
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Matsumoto T, Nogami K, Shima M. A combined approach using global coagulation assays quickly differentiates coagulation disorders with prolonged aPTT and low levels of FVIII activity. Int J Hematol 2016; 105:174-183. [PMID: 27730530 DOI: 10.1007/s12185-016-2108-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/03/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Abstract
Patients with mild/moderate hemophilia (H)A, acquired HA (AHA) and lupus anticoagulants (LA), have prolonged aPTTs with low levels of factor (F)VIII activity, but the differentiation of these disorders is complex and time consuming. We established an approach to quickly differentiate these disorders using comprehensive coagulation tests. Patients' plasmas with mild/moderate HA, AHA, LA without anti-phospholipid syndrome [LA-APS(-)], and LA with APS [LA-APS(+)] were examined using clot waveform analysis (CWA) and thrombin generation test (TGT). Activated protein C (APC) sensitivity was assessed by TGT. CWA revealed similarly prolonged clot times in all groups [NP/mild/moderate HA/AHA/LA-APS(-)/LA-APS(+); 33 ± 1/82 ± 12/116 ± 44/90 ± 29/96 ± 15 s] but significantly different decreased maximal coagulation velocity (3.1 ± 0.1/1.3 ± 0.3/0.9 ± 0.5/1.6 ± 0.3/2.2 ± 0.5). In TGT, AHA group demonstrated severely reduced peak-thrombin levels (362 ± 23/170 ± 27/49 ± 21/158 ± 75/158 ± 99 nM), whilst both LA groups markedly prolonged lag times (4.5 ± 0.3/5.0 ± 0.4/4.7 ± 0.8/12.5 ± 7.7/28.8 ± 11.8 min), suggesting that AHA could be readily identified, but the different LA sub-types failed to be classified. An APC sensitivity demonstrated that 'normalized' APC-induced levels of peak thrombin in LA-APS(+) were significantly lower relative to LA-APS(-) (normalized %inhibition; 5 ± 7/42 ± 39 %). Our studies confirmed that %inhibition by APC was significantly decreased in NP preincubated with purified IgGs from LA-APS(+) compared to LA-APS(-), facilitating differentiation between LA groups. A combined approach using CWA and TGT could be a useful means of differentiating coagulation disorders with prolonged aPTT.
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Affiliation(s)
- Tomoko Matsumoto
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Course of Hemophilia Treatment and Pathology, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Course of Hemophilia Treatment and Pathology, Nara Medical University, Kashihara, Japan
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Novel enzyme immunoassay system for simultaneous detection of six subclasses of antiphospholipid antibodies for differential diagnosis of antiphospholipid syndrome. Blood Coagul Fibrinolysis 2016; 28:316-322. [PMID: 27676644 DOI: 10.1097/mbc.0000000000000599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Antiphospholipid syndrome, which often complicates systemic lupus erythematosus (SLE), features high occurrence of arterial and/or venous thrombosis and recurrent fetal loss. However, which antibody subclass contributes to which clinical event remains uncertain. We newly developed an up-to-date enzyme immunoassay system using the AcuStar automated analyzer (Instrumentation Laboratory, Bedford, Massachusetts, USA) for parallel detection of six subclasses of antiphospholipid antibodies (aPLs): anticardiolipin antibodies (aCL) of IgG, IgM, and IgA and anti-β2-glycoprotein I antibodies (aβ2GPI) of IgG, IgM, and IgA. They were measured in 276 healthy volunteers and 138 patients with SLE: 45 with thromboembolic complications (29 arterial; 16 venous) and 93 without. Lupus anticoagulant activity in their plasma was measured according to the guidelines recommended by the Subcommittee on Lupus Anticoagulant/Phospholipid-Dependent Antibodies. aCL/β2GPI was measured with a standard ELISA kit commonly used in Japan. The positive results of IgG aCL, IgA aCL, and IgG aβ2GPI were closely associated with thromboembolic complications, whereas IgM aCL and IgM aβ2GPI were not. receiver operating characteristic analysis revealed that the accuracy of predicting thromboembolic complications based on the composite test results of the former three antibodies were obviously higher than by each alone. Regarding agreement with the test results of lupus anticoagulant activity, IgG aβ2GPI showed the closest match. Patients with SLE frequently possess various combinations of the six aPL subclasses, and this antibody spectrum is closely associated with thromboembolic events in these patients. This new automated enzyme immunoassay system allows simultaneous analysis of the profile of aPL subclasses for the differential diagnosis of antiphospholipid antibody syndrome in its early stage.
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Amengual O, Forastiero R, Sugiura-Ogasawara M, Otomo K, Oku K, Favas C, Delgado Alves J, Žigon P, Ambrožič A, Tomšič M, Ruiz-Arruza I, Ruiz-Irastorza G, Bertolaccini ML, Norman GL, Shums Z, Arai J, Murashima A, Tebo AE, Gerosa M, Meroni PL, Rodriguez-Pintó I, Cervera R, Swadzba J, Musial J, Atsumi T. Evaluation of phosphatidylserine-dependent antiprothrombin antibody testing for the diagnosis of antiphospholipid syndrome: results of an international multicentre study. Lupus 2016; 26:266-276. [PMID: 27510605 DOI: 10.1177/0961203316660203] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective A task force of scientists at the International Congress on Antiphospholipid Antibodies recognized that phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT) might contribute to a better identification of antiphospholipid syndrome (APS). Accordingly, initial and replication retrospective, cross-sectional multicentre studies were conducted to ascertain the value of aPS/PT for APS diagnosis. Methods In the initial study (eight centres, seven countries), clinical/laboratory data were retrospectively collected. Serum/plasma samples were tested for IgG aPS/PT at Inova Diagnostics (Inova) using two ELISA kits. A replication study (five centres, five countries) was carried out afterwards. Results In the initial study ( n = 247), a moderate agreement between the IgG aPS/PT Inova and MBL ELISA kits was observed ( k = 0.598). IgG aPS/PT were more prevalent in APS patients (51%) than in those without (9%), OR 10.8, 95% CI (4.0-29.3), p < 0.0001. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratio of IgG aPS/PT for APS diagnosis were 51%, 91%, 5.9 and 0.5, respectively. In the replication study ( n = 214), a moderate/substantial agreement between the IgG aPS/PT results obtained with both ELISA kits was observed ( k = 0.630). IgG aPS/PT were more prevalent in APS patients (47%) than in those without (12%), OR 6.4, 95% CI (2.6-16), p < 0.0001. Sensitivity, specificity, LR + and LR- for APS diagnosis were 47%, 88%, 3.9 and 0.6, respectively. Conclusions IgG aPS/PT detection is an easily performed laboratory parameter that might contribute to a better and more complete identification of patients with APS.
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Affiliation(s)
- O Amengual
- 1 Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - R Forastiero
- 2 Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMeTTyB), Universidad Favaloro-CONICET, Departamento de Fisiologia, Hemostasia y Trombosis, Buenos Aires, Argentina
| | - M Sugiura-Ogasawara
- 3 Department of Obstetrics and Gynecology, Nagoya City University, Graduated School of Medical Sciences, Nagoya, Japan
| | - K Otomo
- 1 Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - K Oku
- 1 Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - C Favas
- 4 Department of Medicine IV, Fernando Fonseca Hospital, Amadora and CEDOC/NOVA Medical School, Lisbon, Portugal
| | - J Delgado Alves
- 4 Department of Medicine IV, Fernando Fonseca Hospital, Amadora and CEDOC/NOVA Medical School, Lisbon, Portugal
| | - P Žigon
- 5 Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - A Ambrožič
- 5 Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Tomšič
- 5 Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - I Ruiz-Arruza
- 6 Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of The Basque Country, Spain
| | - G Ruiz-Irastorza
- 6 Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Health Research Institute, Hospital Universitario Cruces, University of The Basque Country, Spain
| | - M L Bertolaccini
- 7 Academic Department of Vascular Surgery, Cardiovascular Division, King's College London, UK
| | - G L Norman
- 8 Inova Diagnostics Inc., San Diego, CA, USA
| | - Z Shums
- 8 Inova Diagnostics Inc., San Diego, CA, USA
| | - J Arai
- 9 Medical and Biological Laboratories, Co. Ltd, Nagano, Japan
| | - A Murashima
- 10 Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - A E Tebo
- 11 Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, UT, USA
| | - M Gerosa
- 12 Department of Clinical Sciences and Community Health, Istituto Auxologico Italiano, University of Milan, Milan, Italy
| | - P L Meroni
- 12 Department of Clinical Sciences and Community Health, Istituto Auxologico Italiano, University of Milan, Milan, Italy
| | - I Rodriguez-Pintó
- 13 Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - R Cervera
- 13 Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - J Swadzba
- 14 Department of Medicine Jagiellonian University, Cracow, Poland
| | - J Musial
- 14 Department of Medicine Jagiellonian University, Cracow, Poland
| | - T Atsumi
- 1 Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Taipan snake venom time coupled with ecarin time enhances lupus anticoagulant detection in nonanticoagulated patients. Blood Coagul Fibrinolysis 2016; 27:477-80. [DOI: 10.1097/mbc.0000000000000486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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41
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Moore GW, Culhane AP, Daw CR, Noronha CP, Kumano O. Mixing test specific cut-off is more sensitive at detecting lupus anticoagulants than index of circulating anticoagulant. Thromb Res 2016; 139:98-101. [DOI: 10.1016/j.thromres.2016.01.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/05/2016] [Accepted: 01/26/2016] [Indexed: 01/20/2023]
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Alpay N, Hançer VS, Erer B, İnanç M, Diz-Küçükkaya R. The Relationship between P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome: A Pilot Case-Control Study. Turk J Haematol 2015; 31:357-62. [PMID: 25541651 PMCID: PMC4454049 DOI: 10.4274/tjh.2013.0091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The selectins are cell adhesion molecules that mediate the interactions among leukocytes, activated platelets, and endothelial cells. We aimed to investigate whether P-selectin polymorphisms are associated with thrombosis in patients with antiphospholipid syndrome (APS). MATERIALS AND METHODS The diagnosis and classification of APS were based on the report of an international workshop. Genomic DNA was extracted from citrated blood samples of all subjects. Three single nucleotide polymorphisms associated with the P-selectin coding region (S290N, c.1087G>A; N562D, c.1902G>A; T715P, c.2363A>C) were assessed. RESULTS There were 26 APS (65%) patients with thrombosis. The number of patients without thrombosis was 14 (35%). The frequency of the N562D-DN genotype was significantly higher in patients with APS than in healthy controls (p=0.003). The frequency of this genotype was significantly higher in patients with APS with thrombosis compared with patients with no thrombosis (p=0.03). The N562D-NN genotype was found at a higher frequency in patients with APS than in healthy controls (p=0.004). CONCLUSION Our results suggest that the N562D polymorphism of the DN genotype of P-selectin is associated with an increased risk of thrombosis in patients with APS.
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Affiliation(s)
- Nilüfer Alpay
- İstanbul University İstanbul Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, İstanbul, Turkey. E-ma-il:
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43
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Devreese KMJ, de Laat B. Mixing studies in lupus anticoagulant testing are required at least in some type of samples. J Thromb Haemost 2015; 13:1475-8. [PMID: 26017873 DOI: 10.1111/jth.13020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/24/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND According to the ISTH guidelines for lupus anticoagulant (LAC) testing, the second step in the three-step procedure (screening, mixing, and confirmation) is the mixing test, which improves the discrimination between the presence of an inhibitor and coagulation factor deficiencies such as those occurring in patients receiving vitamin K antagonists (VKAs). OBJECTIVES From a retrospective analysis of dilute Russell viper venom (dRVVT) results, we evaluated the impact of the mixing test result on the interpretation of LAC positivity. METHODS We interpreted the dRVVT clotting times with and without taking into account the results of the mixing test in a patient population with prolonged screening test (n = 267) with special attention to the patients receiving VKAs. RESULTS AND CONCLUSIONS The number of samples classified as 'LAC positive' differed substantially depending on the method of interpretation; 170 and 235 of 267 samples were classified as LAC positive with the three- and two-step procedure, respectively. Discrepancy between the two-step (without mixing step) and the three-step procedure was due to not including a mixing test and was more pronounced in the VKA patient population. Screen/confirm ratios carried out on a 1:1 mix of patient and normal pooled plasma (NPP) gave a lower incidence of 59 of 267. We advise continuing to perform mixing test to avoid false-positives. In patients with discrepant results between the two- and three-step dRVVT interpretation, mainly observed in VKA-treated patients, we advise retesting of the patients preferable beyond the period of anticoagulant therapy and additional testing for anti-beta2GPI and/or anti-cardiolipin antibodies.
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Affiliation(s)
- K M J Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - B de Laat
- Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
- Synapse B.V., Maastricht, the Netherlands
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Efthymiou M, Lawrie AS, Mackie I, Arachchillage D, Lane PJ, Machin S, Cohen H. Thrombin generation and factor X assays for the assessment of warfarin anticoagulation in thrombotic antiphospholipid syndrome. Thromb Res 2015; 135:1191-7. [DOI: 10.1016/j.thromres.2015.03.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/12/2015] [Accepted: 03/30/2015] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by recurrent thrombosis and/or obstetrical morbidity in the presence of persistently positive antiphospholipid antibodies. Recent insights into the pathogenesis of APS have begun to elucidate pathophysiology and led to the identification of potential therapeutic interventions. The objective of this review is to examine the advances in this field and highlight the areas of further investigation. RECENT FINDINGS Several mechanisms of thrombosis and pregnancy loss in APS have been proposed. These include activation of endothelial cells, monocytes, and platelets, and/or inhibition of natural anticoagulant and fibrinolytic systems by antiphospholipid antibodies. However, in many cases the underlying molecular mechanisms and their relevance to the human disorder remain uncertain. New therapeutic agents such as statins, hydroxychloroquine, rituximab, complement inhibitors, and interventions aimed at disruption of intracellular signaling pathways have shown promise in preclinical and clinical studies. SUMMARY Indefinite anticoagulation remains the mainstay of treatment for thrombotic APS. Despite advances in diagnostic techniques, it remains difficult to predict thrombotic risk in asymptomatic patients with antiphospholipid antibodies. Further mechanistic and clinical studies are needed to predict thrombotic risk and develop improved therapies for this devastating illness.
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Chaturvedi S, McCrae KR. The antiphospholipid syndrome: still an enigma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:53-60. [PMID: 26637701 PMCID: PMC4877624 DOI: 10.1182/asheducation-2015.1.53] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Antiphospholipid syndrome (APS) is defined by clinical manifestations that include thrombosis and/or fetal loss or pregnancy morbidity in patients with antiphospholipid antibodies (aPL). Antiphospholipid antibodies are among the most common causes of acquired thrombophilia, but unlike most of the genetic thrombophilias are associated with both venous and arterial thrombosis. Despite an abundance of clinical and basic research on aPL, a unified mechanism that explains their prothrombotic activity has not been defined; this may reflect the heterogeneity of aPL and/or the fact that they may influence multiple pro- and/or antithrombotic pathways. Antiphospholipid antibodies are directed primarily toward phospholipid binding proteins rather than phospholipid per se, with the most common antigenic target being β2-glycoprotein 1 (β2GPI) although antibodies against other targets such as prothrombin are well described. Laboratory diagnosis of aPL depends upon the detection of a lupus anticoagulant (LA), which prolongs phospholipid-dependent anticoagulation tests, and/or anticardiolipin and anti-β2-glycoprotein 1 antibodies. Indefinite anticoagulation remains the mainstay of therapy for thrombotic APS, although new strategies that may improve outcomes are emerging. Preliminary reports suggest caution in the use of direct oral anticoagulants in patients with APS-associated thrombosis. Based on somewhat limited evidence, aspirin and low molecular weight heparin are recommended for obstetrical APS. There remains a pressing need for better understanding of the pathogenesis of APS in humans, for identification of clinical and laboratory parameters that define patients at greatest risk for APS-related events, and for targeted treatment of this common yet enigmatic disorder.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Vanderbilt University Medical Center, Nashville, TN
| | - Keith R. McCrae
- Hematology and Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH
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Krilis SA, Giannakopoulos B. Laboratory methods to detect antiphospholipid antibodies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:321-328. [PMID: 25696873 DOI: 10.1182/asheducation-2014.1.321] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This chapter reviews several important themes pertaining to the antiphospholipid syndrome (APS), including a description of the clinical features, a discussion of the main autoantigen, beta 2-glycoprotein I (β2GPI), and insights into the characteristics of the pathogenic anti-β2GPI autoantibodies. Evidence-based considerations for when to test for APS are explored, along with the clinical significance of patients testing positive on multiple APS assays, so-called triple positivity. A detailed review of recently published laboratory guidelines for the detection of lupus anticoagulant and the solid-phase anticardiolipin and anti-β2GPI ELISAs is undertaken. Finally, a brief review of nonclassification criteria laboratory assays with potential future diagnostic utility is presented.
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Affiliation(s)
- Steven A Krilis
- Department of Infectious Diseases, Immunology, and Sexual Health and Department of Medicine, St George Clinical School, University of New South Wales, Kogarah, New South Wales, Australia
| | - Bill Giannakopoulos
- Department of Infectious Diseases, Immunology, and Sexual Health and Department of Rheumatology, St George Hospital, Kogarah, New South Wales, Australia; and Department of Medicine, St George Clinical School, University of New South Wales, Kogarah, New South Wales, Australia
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48
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Devreese KMJ. Antiphospholipid antibody testing and standardization. Int J Lab Hematol 2014; 36:352-63. [PMID: 24750682 DOI: 10.1111/ijlh.12234] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/12/2014] [Indexed: 11/28/2022]
Abstract
The laboratory criteria that define patients with antiphospholipid syndrome (APS) include lupus anticoagulant (LAC), anticardiolipin antibodies and anti-β2 glycoprotein I antibodies (aβ2GPI). All assays show methodological shortcomings and the combination of the three tests, each with different sensitivity and specificity, and hence, differences in clinical utility make the laboratory diagnosis of APS challenging. Consensus guidelines and proposals for antiphospholipid antibodies (aPL) testing have been published in the last 20 years and have led to a substantial improvement. Despite efforts so far, standardization is not reached yet, but progress has been made. On-going efforts to reduce the interlaboratory/interassay variations remain important; even an absolute standardization cannot be feasibly achieved. Taking into account the methodological shortcomings of the means we have available, more detailed guidelines may help in adequate performance of aPL testing. This review will focus on the efforts and achievements in standardization and on the weaknesses and strengths of the current available laboratory methods.
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Affiliation(s)
- K M J Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Nojima J, Motoki Y, Aoki N, Tsuneoka H, Ichihara K. A novel ELISA system for simultaneous detection of six subclasses of anti-phospholipid antibodies for prediction of thrombotic complications among SLE patients. Thromb Res 2014; 133:1135-40. [DOI: 10.1016/j.thromres.2014.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/05/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
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The lupus anticoagulant: results from 2257 patients attending a high-risk pregnancy clinic. Blood 2013; 122:341-7; quiz 466. [DOI: 10.1182/blood-2013-02-485839] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Key Points
Only 62 (2.7%) of 2257 high-risk patients tested positive for LAC over 6 years; only 5 (0.02%) with early recurrent miscarriage tested positive. The 2 assays recommended by ISTH guidelines were less effective than our 4-assay panel at capturing and describing LAC-positive patients.
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