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Gris JC, Chéa M, Bouvier S, Pereira FR. Antiphospholipid Antibodies in Mental Disorders. Semin Thromb Hemost 2024. [PMID: 39047993 DOI: 10.1055/s-0044-1788696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Thrombotic events striking the central nervous system are clinical criteria for the antiphospholipid syndrome (APS). Besides these, neuropsychiatric non-APS criteria manifestations are increasingly described in patients with persistently positive antiphospholipid antibodies (aPL). Among these are psychiatric manifestations. Animal models mainly describe hyperactive behavior and anxiety associated with hippocampal abnormalities. Cases of associations with psychosis, mood disorders, bipolarity, anxiety, obsessive-compulsive behavior, and depression have been reported but are still rare. Systematic human clinical association studies are concordant with a risk of psychosis, depression (simple to major), and anxiety disorders, but these are limited and of inconstant methodological quality. Brain imaging in patients, also insufficiently investigated, shows early signs of hypoperfusion and of subtle diffuse white matter changes compatible with an alteration of the axonal structure and changes in the myelin sheath. Direct interactions of aPL with the brain cells, both on cell lines and on animal and human brain biopsies, targeting both glial cells, astrocytes, and neurons, can be demonstrated. These clusters of arguments make the association between psychiatric diseases and aPL increasingly plausible. However, a considerable amount of clinical research must still be performed in accordance with the highest standards of methodological quality. The therapeutic management of this association, in terms of both prevention and cure, currently remains unresolved.
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Affiliation(s)
- Jean-Christophe Gris
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Debrest Institute of Epidemiology and Public Health, Univ Montpellier, INSERM, Montpellier, France
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Mathias Chéa
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Debrest Institute of Epidemiology and Public Health, Univ Montpellier, INSERM, Montpellier, France
| | - Sylvie Bouvier
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Debrest Institute of Epidemiology and Public Health, Univ Montpellier, INSERM, Montpellier, France
| | - Fabricio R Pereira
- Department of Radiology and Medical Imaging, CHU Nîmes, Nîmes, France
- MIPA, University of Nîmes, Nîmes, France
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2
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Rhein AK, Rabinovich A, Abuhasira R, Lubaton-Barshishat S, Erez O. Obstetric antiphospholipid syndrome carries an increased lifetime risk for obstetric and thrombotic complications-a population-based study. Res Pract Thromb Haemost 2024; 8:102430. [PMID: 38798792 PMCID: PMC11127162 DOI: 10.1016/j.rpth.2024.102430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/13/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Background Antiphospholipid syndrome (APS) can present with either a thromboembolic event (thrombotic APS, TAPS) or an obstetric complication (obstetric APS, OAPS). Data on long-term complications in the different APS phenotypes are limited. Objectives We aimed to compare obstetric history, antiphospholipid antibody profiles, obstetric and thromboembolic complications, and pregnancy outcomes between TAPS and OAPS. Methods This retrospective cohort study included women who delivered singleton pregnancies between 1998 and 2020. One hundred sixteen thousand four hundred nine women were included, resulting in 320,455 deliveries. Among the included patients, 71 were diagnosed with APS, 49 were classified as OAPS, and 22 as TAPS. The demographics, obstetric, neonatal, and thrombotic outcomes were compared among TAPS, OAPS, and the general obstetric population. Results OAPS patients had an increased risk of thrombotic events compared with the general obstetric population (odds ratio [OR] 18.0; 95% CI, 8.7-37.2). In pregnancies following the diagnosis of APS, despite standard antithrombotic treatment, OAPS patients exhibited an elevated risk of placenta-related and neonatal complications compared with the general obstetric population (late fetal loss [adjusted OR {aOR}, 15.3; 95% CI, 0.5-27.5], stillbirth [aOR, 5.9; 95% CI, 2.2-15.4], placental abruption [aOR, 4.8; 95% CI, 1.5-15.3], preeclampsia [aOR, 4.4; 95% CI, 2.5-7.7], fetal growth restriction [aOR, 4.3; 95% CI, 8.5-27.5], small for gestational age neonate [aOR, 4.0; 95% CI, 2.4-6.6], and low Apgar scores [Apgar'1: aOR, 2.6; 95% CI, 1.3-10.4; Apgar'5: aOR, 3.7; 95% CI, 1.3-10.4]). TAPS patients exhibited increased risk of preeclampsia (aOR, 3.1; 95% CI, 1.2-8). Conclusion OAPS patients exhibit a heightened risk of thrombotic events compared with the general obstetric population. Despite treatment, OAPS and TAPS still presented obstetric complications. These findings, after confirmation in prospective studies, need to be taken into consideration when planning the treatment approach for these patients.
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Affiliation(s)
- Ariel Katherine Rhein
- The Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran Abuhasira
- The Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Shir Lubaton-Barshishat
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Offer Erez
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women's Hospital, Wayne State University, Detroit, Michigan, USA
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Kontovazainitis CG, Gialamprinou D, Katsaras GN, Pouliakis A, Theodoridis T, Mitsiakos G. Combined Anticoagulant Therapy for Prevention of Preeclampsia and Small for Gestational Age Neonates: A Systematic Review and Meta-analysis. Am J Perinatol 2023; 40:1745-1764. [PMID: 35235957 DOI: 10.1055/a-1785-9032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis (SRMA) aims to compare the efficacy of combining low molecular weight heparin (LMWH) and aspirin against aspirin alone in preventing preeclampsia (PE) and small for gestational age (SGA) neonates in women at moderate and high risks. STUDY DESIGN The included studies were nonrandomized and randomized clinical trials (RCTs) enrolling women at moderate and high risks for developing preeclampsia. PubMed/Medline, Cochrane Library, Embase, and Grey literature (including ClinicalTrials.gov) were searched. RESULTS Out of 4,762 records, 7 nonrandomized studies and 12 RCTs (enrolling 545 and 1,677 women, respectively) were selected. Although the studies were clinically heterogeneous, the conduction of quantitative analysis was feasible. Regarding RCTs, the odds of early-onset preeclampsia was reduced by 89% (pooled odds ratio [OR] = 0.11, 95% confidence interval [CI]: 0.01-0.93, p = 0.04) in women with thrombophilia, the incidence of SGA neonates below the 5th percentile by 48% (pooled OR = 0.52, 95% CI: 0.28-0.96, p = 0.04) in women with a history of preeclampsia and/or SGA neonates, and the incidence of SGA neonates below the 10th percentile by 31% (pooled OR = 0.69, 95% CI: 0.50-0.96, p = 0.03) in the whole population. CONCLUSION Concerning the whole studied population, combined anticoagulant therapy is not superior to aspirin alone. However, it may be more effective in preventing early-onset preeclampsia regarding women with thrombophilia, SGA neonates below the 5th percentile regarding women with a history of preeclampsia and/or SGA, and SGA neonates below the 10th percentile in moderate- or high-risk women. The above mixed but promising results need to be envisaged with caution due to the clinical heterogeneity of the included studies which is the main limitation of our research. Nevertheless, the strict and narrow inclusion search criteria, and the appropriate subgroup analysis are its main strengths. More RCTs with homogeneous populations and stricter inclusion criteria are needed to confirm these results. KEY POINTS · Combined therapy is not superior to aspirin alone.. · Combined therapy in women with thrombophilia may protect against early-onset preeclampsia.. · Combined therapy in moderate/high-risk women may protect against SGA <10th percentile neonates..
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Affiliation(s)
- Christos-Georgios Kontovazainitis
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, "Papageorgiou" Hospital, Thessaloniki, Greece
| | - Dimitra Gialamprinou
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, "Papageorgiou" Hospital, Thessaloniki, Greece
| | - Georgios N Katsaras
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, "Papageorgiou" Hospital, Thessaloniki, Greece
| | - Abraham Pouliakis
- Second Department of Pathology, National and Kapodistrian University of Athens, "ATTIKON" University Hospital, Athens, Greece
| | - Theodoros Theodoridis
- First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece, "Papageorgiou" Hospital, Thessaloniki, Greece
| | - Georgios Mitsiakos
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, "Papageorgiou" Hospital, Thessaloniki, Greece
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Windisch S, Ash JY, Frishman WH. Antiphospholipid Syndrome: Thrombotic and Vascular Complications. Cardiol Rev 2023:00045415-990000000-00143. [PMID: 37607079 DOI: 10.1097/crd.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Antiphospholipid syndrome is a rare, autoimmune thrombophilia defined by vascular thrombosis and pregnancy morbidity, in the setting of documented persistent antiphospholipid antibodies including the lupus anticoagulant, anticardiolipin antibodies, or anti-β2 glycoprotein I antibodies. The presence of antiphospholipid antibodies can be completely asymptomatic, or they can lead to clinical manifestations as severe as catastrophic antiphospholipid syndrome, which involves widespread coagulopathy over a very short period of time. The degree of risk associated with antiphospholipid syndrome depends on the characteristics of the antiphospholipid antibody profile and on the presence of additional thrombotic risk factors. The current standard treatment for unprovoked thrombosis is long-term warfarin. Treatment to prevent recurrent obstetric complications is low-dose aspirin and prophylactic heparin in pregnant patients. The use of direct oral anticoagulants in patients with antiphospholipid syndrome is still being debated. Their use is generally contraindicated, especially in high-risk patients, such as those with all 3 antiphospholipid antibodies present, but they may potentially be of some use in some low-risk patients.
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Affiliation(s)
- Stephen Windisch
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Julia Y Ash
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
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Gris JC, Guillotin F, Chéa M, Bourguignon C, Nouvellon É, Bouvier S. Antiphospholipid Antibodies in Pregnancy: Maternal and Neonatal Implications. Semin Thromb Hemost 2022; 49:337-347. [PMID: 36108650 DOI: 10.1055/s-0042-1756193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractAntiphospholipid antibodies (aPL Abs) have long been associated with the occurrence of certain specific pregnancy morbidities, affecting both mother and fetus. Antithrombotic-based prophylactic regimens are the standard of care. Their intensity is modulated by the thrombotic history and has greatly improved the prognosis related to spontaneous morbidity. Observational studies show that this treatment is still associated with the persistence of excess of late-pregnancy placental diseases, calling for new or complementary developments, yet to be validated. Rigorous prospective multicentric validation of clinical and laboratory parameters capable of identifying those women and fetuses at a risk of pejorative evolution, thus early prognosis, is a priority issue. These will make it possible to develop customized treatments and test them. Furthermore, there are still concerns, particularly neurodevelopmental ones, about children born to aPL Ab-positive mothers, and clarification based on regular, more systematic evaluations is required. Even after pregnancy, women with a pure obstetrical antiphospholipid syndrome are at a greater risk of venous and arterial thrombosis over time, and prevention needs to be improved. These women also appear to develop more psychiatric and mood disorders. Central nervous system imaging using high-resolution techniques has shown subtle impairments in the white matter, associated with the most pathogenic aPL Abs and the clinical significance of this is under investigation. These mothers also seem to develop an excess of cancers. The systemic impact of aPL Abs is gradually being suspected, although this requires further evidence, and prevention should be envisaged.
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Affiliation(s)
- Jean-Christophe Gris
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France
- UMR UA11 INSERM IDESP - Montpellier University, France
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | | | - Mathias Chéa
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chloé Bourguignon
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP - Montpellier University, France
| | - Éva Nouvellon
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP - Montpellier University, France
| | - Sylvie Bouvier
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France
- UMR UA11 INSERM IDESP - Montpellier University, France
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6
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Gris JCR, Bouguignon C, Bouvier S, Cochery-Nouvellon E, Laurent J, Perez-Martin A, Mousty E, Nikolaeva M, Khizroeva J, Bitsadze V, Makatsariya A. PREGNANCY AFTER COMBINED ORAL CONTRACEPTIVE-ASSOCIATED VENOUS THROMBOEMBOLISM: AN INTERNATIONAL RETROSPECTIVE STUDY OF OUTCOMES. Thromb Haemost 2022; 122:1779-1793. [PMID: 35472708 DOI: 10.1055/a-1835-8808] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Few data are available on thrombotic outcomes during pregnancy and puerperium occurring after an initial provoked venous thromboembolic event (VTE). OBJECTIVES To describe thrombotic outcomes during pregnancy after a first combined oral contraceptive (COC)-associated VTE and the factors associated with recurrence Methods. This was an international multicentric retrospective study on patients referred for thrombophilia screening from January 1st 2010 to January 1st 2021 following a first COC-associated VTE, including women with neither inherited thrombophilia nor antiphospholipid antibodies and focusing on those who had a subsequent pregnancy under the same thromboprophylaxis treatment. Thrombotic recurrences during pregnancy and puerperium as well as risk factors for recurrence were analysed. RESULTS We included 2,145 pregnant women. A total of 88 thrombotic events, 58 antenatal and 29 postnatal, occurred, mostly during the first trimester of pregnancy and the first two weeks of puerperium. Incidence rates were 49.6 (37-62) per 1,000 patient-years during pregnancy and 118.7 (78-159) per 1,000 patient-years during puerperium. Focusing on pulmonary embolism, incidence rates were 1.68 (1-4) per 1,000 patient-years during pregnancy and 65.5 (35-97) per 1,000 patient-years during puerperium. Risk factors for antenatal recurrences were maternal hypercholestorolaemia and birth of a very small-for-gestational-age neonate. A risk factor for postnatal recurrence was the incidence of preeclampsia. Conclusions Our multicentric retrospective data show significant rates of VTE recurrence during pregnancy and puerperium in women with a previous VTE event associated with COC, despite a unique LMWH-based thromboprophylaxis. These results may provide benchmarks and valuable information for designing future randomized controlled trials.
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7
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Killian M, van Mens TE. Risk of Thrombosis, Pregnancy Morbidity or Death in Antiphospholipid Syndrome. Front Cardiovasc Med 2022; 9:852777. [PMID: 35299976 PMCID: PMC8921454 DOI: 10.3389/fcvm.2022.852777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
The antiphospholipid syndrome is an autoimmune disease characterized by thrombosis and pregnancy morbidity. The manifestations are caused by antibodies targeting cell membrane phospholipids and/or associated proteins. The triggers leading to these antibodies' production are unknown but recent work suggests cross-reactivity between the autoantigens and peptides produced by the intestinal microbiome. Work on how the autoantibodies could cause clinical manifestations implicates different mechanisms. Binding to surface proteins of different cell types can induce intracellular signaling leading to cell activation and tissue factor expression. Complement activation and neutrophil extracellular-traps are also involved, and recent evidence implicates endothelial protein C receptor-lysobisphosphatidic acid complex. Pregnancy is a high-risk situation for antiphospholipid syndrome patients due to the increased risk of thrombosis and obstetric complications. Epidemiological and clinical research on APS is hampered by heterogeneity in populations, testing and treatment strategies. About one in 10 to one in fifty APS pregnancies is complicated by thrombosis, despite treatment. Pregnant patients with prior thrombosis are prescribed therapeutic dose heparins and low dose aspirin. Without prior thrombosis a prophylactic dose is used. The most frequent obstetrical manifestation is recurrent early pregnancy loss. The association of APS antibodies with late pregnancy loss is stronger, however. Prevention of recurrence is achieved with aspirin and prophylactic dose heparin, although the evidence is of low certainty. The third obstetrical classifying manifestation comprises preterm delivery due to placenta-mediated complications and is treated in subsequent pregnancies with aspirin with or without prophylactic dose heparin, again based on low quality evidence. New therapies are under investigation.
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Affiliation(s)
- Martin Killian
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, Saint-Étienne, France.,Internal Medicine Department, Saint-Etienne University Hospital, Saint-Étienne, France
| | - Thijs E van Mens
- Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
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Udry S, Peréz SM, Belizna C, Aranda F, Esteve-Valverde E, Wingeyer SP, Fernández-Romero DS, Latino JO, de Larrañaga G, Alijotas-Reig J. Clinical and therapeutic value of the adjusted Global Antiphospholipid Syndrome Score in primary obstetric antiphospholipid syndrome. Lupus 2022; 31:354-362. [PMID: 35157809 DOI: 10.1177/09612033221078223] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) To assess the clinical utility of the adjusted global antiphospholipid syndrome score (aGAPSS) to predict new obstetric events during follow-up in primary obstetric antiphospholipid syndrome (POAPS) patients under standard-of-care treatment (SC) based on the use of low-dose aspirin (LDA) + heparin and (2) to study the risk of a first thrombotic event and to evaluate whether stratification according to this score could help to identify POAPS patients who would benefit from long-term thromboprophylaxis. METHODS This is a retrospective, multicentre study. 169 women with POAPS were evaluated for the presence of a new obstetric event and/or a first thrombotic event during follow-up [time period: 2008-2020, median: 7 years (6-12 years)]. The outcomes of 107 pregnancies from these POAPS patients with SC were studied to evaluate relapses. Simple and multivariable logistic regression analyses were performed. RESULTS Regarding obstetric morbidity, only triple positivity for antiphospholipid antibodies (aPLs) [OR = 8.462 (95% CI: 2.732-26.210); p < 0.0001] was found to be a strong risk factor independently associated with treatment failure. On the other hand, triple positivity for aPLs [OR=10.44 (95% CI: 2.161-50.469), p = 0.004] and an aGAPSS ≥7 [OR = 1.621 (95% CI: 1.198-2.193), p = 0.002] were independent risk factors associated with a first thrombotic event. LDA was marginally associated with a decrease in the risk of thrombosis only in patients with aGAPSS ≥ 7 (p = 0.048). CONCLUSION aGAPSS appears to be useful in predicting the occurrence of a first thrombotic event in POAPS patients, and these stratification of patients could be helpful in selecting patients who would benefit from thromboprophylaxis with LDA.
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Affiliation(s)
- Sebastián Udry
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Ringgold:62886Acute Hospital "Dr. Carlos G. Durand", City of Buenos Aires, Argentina.,Haemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", City of Buenos Aires, Argentina
| | - Stephanie Morales Peréz
- Internal Medicine Department, Althaia Healthcare University Network of Manresa, Systemic Autoimmune Disease Unit, Manresa, Barcelona
| | - Cristina Belizna
- Internal Medicine Department Clinique de l'Anjou, Angers, Vascular and Coagulation Department, University Hospital Angers, Angers, France.,UMR CNRS 6015, INSERM U1083, University of Angers, Angers, France
| | - Federico Aranda
- Haemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", City of Buenos Aires, Argentina
| | - Enrique Esteve-Valverde
- Internal Medicine Department, Althaia Healthcare University Network of Manresa, Systemic Autoimmune Disease Unit, Manresa, Barcelona
| | - Silvia Perés Wingeyer
- Haemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", City of Buenos Aires, Argentina
| | - Diego S Fernández-Romero
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Ringgold:62886Acute Hospital "Dr. Carlos G. Durand", City of Buenos Aires, Argentina
| | - José O Latino
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Ringgold:62886Acute Hospital "Dr. Carlos G. Durand", City of Buenos Aires, Argentina
| | - Gabriela de Larrañaga
- Haemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", City of Buenos Aires, Argentina
| | - Jaume Alijotas-Reig
- Systemic Autoimmune Disease Unit, Department of Internal Medicine, and Vall d'Hebron Research Unit, Vall d'Hebron University Hospital Campus, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:jcm11030675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
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Was Antiphospholipid Syndrome a Risk Factor of Stroke? A Systemic Review and Meta-Analysis of Cohort Studies. DISEASE MARKERS 2021; 2021:4431907. [PMID: 34956419 PMCID: PMC8702362 DOI: 10.1155/2021/4431907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022]
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis. This systemic review and meta-analysis was to verify the hypothesis that APS might increase the risk of stroke. Studies were identified after literature searching of PubMed, Embase, and Cochrane. Newcastle-Ottawa Quality Assessment Scale Cohort Studies (NOQAS-C) was used to assess the quality of studies. The pooled effect with 95% confidence interval (95% CI) was calculated by random-effect model. I-square (I2) was used to test heterogeneity. Funnel plot was used to evaluate publication bias. A total of 17 cohort studies with overall high quality were included. There was no publication bias. Pooled hazard ratio of stroke occurrence in APS patients was 1.76 (1.39-2.21) with low heterogenicity and stable result from sensitivity analysis. In the analysis of subgroups, pooled risk ratios of stroke occurrence in patients with only positive antibodies of APS diagnosis were 1.75 (0.99-3.09), which for the APS patients with other autoimmune diseases were 14.70 (7.56-28.56). APS might be a risk factor of stroke, especially in patients with other autoimmune diseases.
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11
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Kaneko K, Ozawa N, Murashima A. Obstetric anti-phospholipid syndrome: from pathogenesis to treatment. Immunol Med 2021; 45:79-93. [PMID: 34470570 DOI: 10.1080/25785826.2021.1969116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by clinical manifestations such as thrombosis and obstetric complications with documented persistence of antiphospholipid antibodies (aPLs). Recent studies have revealed that the cause of aPL-related obstetric complications is dysfunction of placental trophoblasts and inflammation of the maternal-fetal interface induced by aPLs, not thrombosis. Although aPLs are associated with recurrence of serious complications during pregnancy, appropriate combination therapy with heparin and low-dose aspirin can improve the course of 70-80% of subsequent pregnancies. Preconception counseling and patient-tailored treatment are fundamental to improving maternal and fetal outcomes. Non-anticoagulant treatments such as hydroxychloroquine and statins are being developed for cases refractory to conventional treatment. Risk factors for thrombosis after pregnancy complications were identified based on the analysis of large databases of obstetric APS.
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Affiliation(s)
- Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuaki Ozawa
- Division of Reproductive Medicine and Maternal Care/Immunology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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12
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Pregnolato F, Gerosa M, Raimondo MG, Comerio C, Bartoli F, Lonati PA, Borghi MO, Acaia B, Ossola MW, Ferrazzi E, Trespidi L, Meroni PL, Chighizola CB. EUREKA algorithm predicts obstetric risk and response to treatment in women with different subsets of anti-phospholipid antibodies. Rheumatology (Oxford) 2021; 60:1114-1124. [PMID: 32441742 DOI: 10.1093/rheumatology/keaa203] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/30/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES aPL, the serum biomarkers of APS, are the most common acquired causes of pregnancy morbidity (PM). This study investigates the impact of aPL positivity fulfilling classification criteria ('criteria aPL') and at titres lower than thresholds considered by classification criteria ('low-titre aPL') on PM and assesses the effectiveness of low-dose aspirin (LDASA), low molecular weight heparin (LMWH) and HCQ in reducing the probability of PM (PPM). METHODS Longitudinal data on 847 pregnancies in 155 women with persistent aPL at any titre and 226 women with autoimmune diseases and negative aPL were retrospectively collected. A generalized estimating equations model for repeated measures was applied to quantify PPM under different clinical situations. RESULTS EUREKA is a novel algorithm that accurately predicts the risk of aPL-associated PM by considering aPL titres and profiles. aPL significantly impact PPM when at low titres and when fulfilling classification criteria. PPM was further stratified upon the aPL tests: aCL IgG/IgM and anti-β2-glycoprotein I (β2GPI) IgM, alone or combined, do not affect the basal risks of PPM, an increase occurs in case of positive LA or anti-β2GPI IgG. LDASA significantly affects PPM exclusively in women with low-titre aPL without anti-β2GPI IgG. The LDASA + LMWH combination significantly reduces PPM in all women with low-titre aPL and women with criteria aPL, except those carrying LA and anti-β2GPI IgG. In this group, the addition of HCQ further reduces PPM, although not significantly. CONCLUSION EUREKA allows a tailored therapeutic approach, impacting everyday clinical management of aPL-positive pregnant women.
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Affiliation(s)
- Francesca Pregnolato
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Division of Rheumatology, ASST G. Pini & CTO, Milan, Italy
| | - Maria Gabriella Raimondo
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Division of Rheumatology, ASST G. Pini & CTO, Milan, Italy
| | - Chiara Comerio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Bartoli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Division of Rheumatology, ASST G. Pini & CTO, Milan, Italy
| | - Paola A Lonati
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy
| | - Maria Orietta Borghi
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Barbara Acaia
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Manuela Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Enrico Ferrazzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Cecilia B Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano, IRCCS, Cusano Milanino, Milan, Italy.,Immunology and Rheumatology Unit, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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13
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Jiang H, Wang CH, Jiang N, Li J, Wu CY, Wang Q, Li MT, Tian XP, Zhao JL, Zhao Y, Zeng XF. Clinical characteristics and prognosis of patients with isolated thrombotic vs. obstetric antiphospholipid syndrome: a prospective cohort study. Arthritis Res Ther 2021; 23:138. [PMID: 33964976 PMCID: PMC8105941 DOI: 10.1186/s13075-021-02515-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies suggested that thrombotic and obstetric antiphospholipid syndromes could be independent identities, but few have systematically compared their clinical characteristics and prognosis. OBJECTIVE The objective of this study is to identify key differences between thrombotic APS (tAPS) and obstetric APS (oAPS). METHODS This single-center, prospective study included consecutive patients with primary antiphospholipid syndrome (APS) receiving treatment at the Peking Union Medical College Hospital during a period from 2013 to 2020. RESULTS Screening of the database yielded a total of 244 women with positive antiphospholipid antibody (aPL). Among the 105 women with primary APS, 39 (37.14%) had isolated tAPS (ItAPS), 44 (41.90%) had isolated oAPS (IoAPS), and 9 (8.57%) had both tAPS and tAPS+oAPS. In comparison to those with IoAPS, patients with ItAPS had older age (41.92 ± 11.97 vs. 33.16 ± 4.22 years, P < 0.01), higher rate of cardiovascular risk (at least one positive of coronary heart disease, hypertension, obesity, diabetes, and hyperlipidemia) (41.03% vs. 6.82%, P < 0.01), and higher frequency of thrombocytopenia (43.59% vs. 20.45%, P < 0.05). Antibody profiles were generally similar among the groups, but isolated anti-β2GPI positivity was more common in patients with IoAPS (52.27% vs. 17.94% for ItAPS, P = 0.01). Triple aPL positivity was more common in patients with both tAPS and oAPS (66.67% vs. 46.15% for ItAPS vs. 25% for IoAPS, P = 0.022). Blood homocysteine was higher in patients with ItAPS (11.20 vs. 9.90 μmol/L for IoAPS, P < 0.05), but there were no differences in inflammatory markers or complements. Recurrence rate of thrombosis was higher in patients with ItAPS (33.33% vs. 2.27% for IoAPS, P ≤ 0.001) with a mean follow-up of 61 months. CONCLUSION Despite generally similar antibody and biochemical profiles, patients with ItAPS had much higher risk of recurrent thrombosis than IoAPS, supporting distinct mechanisms of pathogenesis.
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Affiliation(s)
- Hui Jiang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chu-Han Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Nan Jiang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Jing Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chan-Yuan Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin-Ping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiu-Liang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Xiao-Feng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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14
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Bettiol A, Emmi G, Finocchi M, Silvestri E, Urban ML, Mattioli I, Scalera A, Lupoli R, Vannacci A, Di Minno MND, Prisco D. Obstetric antiphospholipid syndrome is not associated with an increased risk of subclinical atherosclerosis. Rheumatology (Oxford) 2020; 59:3709-3716. [PMID: 32388557 DOI: 10.1093/rheumatology/keaa116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/18/2020] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVES The persistent positivity of aPLs, either isolated or associated with thrombotic and/or obstetric events (APS), has been associated with the increase of intima-media thickness (IMT) and carotid plaques. Despite the fact that aPLs can promote both thrombotic and obstetric complications, some pathogenic differences have been documented between the two entities. This study aimed to evaluate whether the atherosclerotic risk differs between subjects with obstetric and thrombotic APS. METHODS A total of 167 APS women (36 obstetric and 131 thrombotic) were compared with 250 aPLs negative controls. IMT of the common carotid artery (CCA) and of the bulb and the prevalence of carotid plaques were assessed. RESULTS CCA- and bulb-IMT were significantly higher in women with thrombotic APS, while being similar between the obstetric APS and the controls [CCA-IMT: mean (s.d.) 0.97 (0.49), 0.78 (0.22) and 0.81 (0.12) mm for the thrombotic, obstetric and control groups, respectively, P < 0.001 between thrombotic and controls, P = 0.002 between thrombotic and obstetric; bulb-IMT: mean (s.d.) 1.38 (0.79), 0.96 (0.27) and 0.96 (0.51) mm for the thrombotic, obstetric and control groups, P < 0.001]. Women with thrombotic APS had significantly increased risk of presenting carotid plaques. This risk was significantly lower in obstetric APS. CONCLUSION Unlike thrombotic APS, obstetric APS is not associated with an increase of markers of subclinical atherosclerosis. If confirmed on wider populations, these results could suggest different pathogenetic role of aPLs in promoting atherosclerosis in vascular and obstetric APS, and raise questions on the risk-benefit profile of thromboprophylaxis in obstetric APS outside pregnancy periods.
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Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Martina Finocchi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Irene Mattioli
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze
| | - Antonella Scalera
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Roberta Lupoli
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
| | | | - Domenico Prisco
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA)
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15
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Gaspar P, Cohen H, Isenberg DA. The assessment of patients with the antiphospholipid antibody syndrome: where are we now? Rheumatology (Oxford) 2020; 59:1489-1494. [PMID: 32359070 DOI: 10.1093/rheumatology/keaa172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 11/14/2022] Open
Abstract
The antiphospholipid antibody syndrome (APS), a chronic autoimmune thrombophilia with an increased mortality and morbidity, has been recognized for more than three decades. Unlike other autoimmune rheumatic conditions such as systemic lupus erythematosus, myositis and Sjögren's syndrome, relatively few attempts have been made to develop activity, damage or disease-specific quality of life indices for APS. In this review of the literature, we consider those attempts that have been made to develop assessment tools for patients with APS, but also reflect upon the nature of the condition, to discuss, in particular, whether an activity index is appropriate for this disease.
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Affiliation(s)
- Pedro Gaspar
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Internal Medicine, Hospital de Santa Maria, Lisbon, Portugal
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust.,Haemostasis Research Unit, Department of Haematology, University College London
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.,Centre for Rheumatology, Division of Medicine, University College London, London, UK
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16
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Cohen H, Cuadrado MJ, Erkan D, Duarte-Garcia A, Isenberg DA, Knight JS, Ortel TL, Rahman A, Salmon JE, Tektonidou MG, Williams DJ, Willis R, Woller SC, Andrade D. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Antiphospholipid Syndrome Treatment Trends. Lupus 2020; 29:1571-1593. [PMID: 33100166 PMCID: PMC7658424 DOI: 10.1177/0961203320950461] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS), an acquired autoimmune thrombophilia, is characterised by thrombosis and/or pregnancy morbidity in association with persistent antiphospholipid antibodies. The 16th International Congress on Antiphospholipid Antibodies Task Force on APS Treatment Trends reviewed the current status with regard to existing and novel treatment trends for APS, which is the focus of this Task Force report. The report addresses current treatments and developments since the last report, on the use of direct oral anticoagulants in patients with APS, antiplatelet agents, adjunctive therapies (hydroxychloroquine, statins and vitamin D), targeted treatment including rituximab, belimumab, and anti-TNF agents, complement inhibition and drugs based on peptides of beta-2-glycoprotein I. In addition, the report summarises potential new players, including coenzyme Q10, adenosine receptor agonists and adenosine potentiation. In each case, the report provides recommendations for clinicians, based on the current state of the art, and suggests a clinical research agenda. The initiation and development of appropriate clinical studies requires a focus on devising suitable outcome measures, including a disease activity index, an optimal damage index, and a specific quality of life index.
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Affiliation(s)
- Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University
College London, London, UK
- University College London Hospitals NHS Foundation Trust,
London, UK
| | - Maria J Cuadrado
- Rheumatology Department, Clinica Universidad de Navarra, Madrid,
Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital
for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ali Duarte-Garcia
- Division of Rheumatology, Department of Internal Medicine, Mayo
Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health
Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Isenberg
- University College London Hospitals NHS Foundation Trust,
London, UK
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor,
Michigan, USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, and Department
of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Anisur Rahman
- Centre for Rheumatology, Division of Medicine, University
College London, London, UK
| | - Jane E Salmon
- Division of Rheumatology, Hospital for Special surgery, Weill
Cornell Medicine, New York, NY, USA
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, National
and Kapodistrian University of Athens, Athens, Greece
| | - David J Williams
- University College London Hospitals NHS Foundation Trust,
London, UK
- UCL EGA Institute for Women’s Health, University College
London, London, UK
| | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of
Texas Medical Branch, Galveston, TX, USA
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray
UT; Division of General Internal Medicine, University of Utah School of
Medicine, Salt Lake City, UT, USA
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17
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de Jesús GR, Benson AE, Chighizola CB, Sciascia S, Branch DW. 16th International Congress on Antiphospholipid Antibodies Task Force Report on Obstetric Antiphospholipid Syndrome. Lupus 2020; 29:1601-1615. [PMID: 32883160 DOI: 10.1177/0961203320954520] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Obstetric antiphospholipid syndrome (APS) remains a clinical challenge for practitioners, with several controversial points that have not been answered so far. This Obstetric APS Task Force met on the 16th International Congress on Antiphospholipid Antibodies in Manchester, England, to discuss about treatment, diagnostic and clinical aspects of the disease. This report will address evidence-based medicine related to obstetric APS, including limitations on our current management, the relationship between antibodies against domain 1 of β2GPI and obstetric morbidity, hydroxychloroquine use in patients with obstetric APS and factors associated with thrombosis after obstetric APS. Finally, future directions for better understanding this complex condition are also reported by the Task Force coordinators.
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Affiliation(s)
- Guilherme R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ashley E Benson
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Cecilia B Chighizola
- Experimental Laboratory of Immunorheumatological Researches, Allergology, Clinical Immunology & Rheumatology Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - David W Branch
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
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18
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Udry S, Latino JO, Belizna C, Perés Wingeyer S, Fernández Romero DS, de Larrañaga G. A high-risk laboratory profile of antiphospholipid antibodies and thrombosis is associated with a large number of extra-criteria manifestations in obstetric antiphospholipid syndrome. Immunol Res 2020; 67:478-485. [PMID: 31873844 DOI: 10.1007/s12026-019-09110-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Extra-criteria manifestations such as thrombocytopenia and livedo are described associated with antiphospholipid syndrome (APS) but are not included in the current classification criteria. Their clinical expression might be important, as they may be associated with a high-risk profile of antiphospholipid antibodies (aPL) and thrombosis. We evaluated the association between the presence of extra-criteria manifestations in primary obstetric-APS (POAPS) and aPL profiles. We also evaluated whether the presence of extra-criteria manifestations in POAPS patients increases the risk of developing thrombosis during the follow-up period (median follow-up 5 years; range 3-9 years). We selected 79 women who were included in our study only if they were first diagnosed with POAPS (with no history of previous thrombosis) and reevaluated for the presence of thrombosis after the follow-up period. We evaluated the association between the aPL profile and extra-criteria manifestations. We also evaluated the relationship of thrombosis during the follow-up period with extra-criteria manifestations and other risk factors. Patients with three or more extra-criteria manifestations presented high rates of triple positivity for the aPL profile (75%) (p < 0.001). We also found a relationship between the presence of extra-criteria manifestations and the presence of high titers of aPL: 91.7% of patients with three or more extra-criteria manifestations had high titers of aPL (p < 0.01). We further evaluated the group of POAPS patients according to thrombotic events during the follow-up. Among these patients, 6 (7.6%) presented thrombosis. Notably, 100% of patients with a thrombotic event during the follow-up had more than three extra-criteria manifestations. POAPS patients with extra-criteria manifestations might have a high-risk aPL profile and a major risk of developing thrombosis.
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Affiliation(s)
- Sebastián Udry
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Acute Hospital "Dr. Carlos G. Durand", Av. Díaz Vélez 5044, C1405AEN, Buenos Aires, Argentina.,Hemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", Uspallata 2272, C1282AEN, Buenos Aires, Argentina
| | - José Omar Latino
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Acute Hospital "Dr. Carlos G. Durand", Av. Díaz Vélez 5044, C1405AEN, Buenos Aires, Argentina
| | - Cristina Belizna
- Vascular and Coagulation Department, University Hospital Angers, 4 Rue Larrey, 49000, Angers, France.,MITOVASC institute and CARFI facility, UMR CNRS 6015, INSERM U1083, University of Angers, Angers, France
| | - Silvia Perés Wingeyer
- Hemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", Uspallata 2272, C1282AEN, Buenos Aires, Argentina
| | - Diego Santiago Fernández Romero
- Autoimmune, Thrombophilic Diseases and Pregnancy Section, Acute Hospital "Dr. Carlos G. Durand", Av. Díaz Vélez 5044, C1405AEN, Buenos Aires, Argentina
| | - Gabriela de Larrañaga
- Hemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases "Dr. Francisco J. Muñiz", Uspallata 2272, C1282AEN, Buenos Aires, Argentina.
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19
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Rodziewicz M, D'Cruz DP. An update on the management of antiphospholipid syndrome. Ther Adv Musculoskelet Dis 2020; 12:1759720X20910855. [PMID: 32523633 PMCID: PMC7236388 DOI: 10.1177/1759720x20910855] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/30/2020] [Indexed: 11/21/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by recurrent venous or arterial thrombosis with or without pregnancy morbidity in the presence of persistent antiphospholipid (aPL) autoantibodies. Anticoagulation has, until now, formed the cornerstone of treatment but a significant proportion of patients continue to experience thrombosis and pregnancy morbidity despite this treatment. Thrombosis is the most common cause of mortality and accounts for two fifths of deaths. Direct oral anticoagulant drugs represent an attractive alternative to conventional vitamin K antagonist drugs but emerging evidence suggests these may not be suitable for high-risk patients with thrombotic APS. Laboratory studies and case reports of the successful use of different classes of drugs in APS is increasing our understanding of the other pathophysiological mechanisms which may contribute to the high morbidity of APS. This review summarizes current accepted anticoagulant treatment for APS and examines other potential drugs such as immunomodulating agents, statins and novel agents such as sirolimus and defibrotide.
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Affiliation(s)
- Mia Rodziewicz
- Louise Coote Lupus Unit, Guy's Hospital, 4th Floor Tower Wing, Great Maze Pond, London SE1 9RT, UK
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20
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Schreiber K, Hunt BJ. Managing antiphospholipid syndrome in pregnancy. Thromb Res 2020; 181 Suppl 1:S41-S46. [PMID: 31477227 DOI: 10.1016/s0049-3848(19)30366-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterised by the presence of antiphospholipid antibodies (aPL). The antibodies currently included in the classification criteria include lupus anticoagulant (LA), anticardiolipin antibodies (aCL) and anti-^2-glycoprotein 1 antibodies (^2GPI). APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature and obstetrical complications. Pregnancy complications in obstetric APS (OAPS) include unexplained recurrent early pregnancy loss, fetal death, or premature birth due to severe preeclampsia, eclampsia, intrauterine growth restriction or other consequences of placental insufficiency. Careful, well monitored obstetric care with the use of aspirin and heparin has likely improved the pregnancy outcome in obstetric APS and currently approximately 70-80% of pregnant women with APS have a successful pregnancy outcome. However, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. Other treatments options are currently being explored and retrospective studies suggest that trials with hydroxychloroquine and possibly pravastatin are warranted in pregnant women with aPL. In this review will focus on the current treatment of OAPS.
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Affiliation(s)
- Karen Schreiber
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK; Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Beverley J Hunt
- The Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK.
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21
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaria Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Ortells LC, Pérez ECC, Rego GDC, Corral SG, Varela CF, López MM, Nishishinya B, Navarro MN, Testa CP, Pérez HS, Silva-Fernández L, Taboada VMM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations. REUMATOLOGIA CLINICA 2020; 16:133-148. [PMID: 30686569 DOI: 10.1016/j.reuma.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS Forty-six recommendations were drawn up, addressing 5main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clinic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaria Ortiz
- Unidad de Hemostasia y Trombosis, Servicio de Hematología. Hospital Vall d́Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología. Facultad de Medicina. Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología. Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte. Medicina del Deporte. Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología. Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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22
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Gris JC, Mousty É, Bouvier S, Ripart S, Cochery-Nouvellon É, Fabbro-Peray P, Broner J, Letouzey V, Pérez-Martin A. Increased incidence of cancer in the follow-up of obstetric antiphospholipid syndrome within the NOH-APS cohort. Haematologica 2020; 105:490-497. [PMID: 31101755 PMCID: PMC7012495 DOI: 10.3324/haematol.2018.213991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/16/2019] [Indexed: 12/16/2022] Open
Abstract
Malignancies can be associated with positive antiphospholipid antibodies but the incidence of cancer among women with the purely obstetric form of antiphospholipid syndrome (APS) is currently unknown. Our aim was to investigate the comparative incidence of cancers in women with a history of obstetric APS within a referral university hospital-based cohort (NOH-APS cohort). We performed a 17-year observational study of 1,592 non-thrombotic women with three consecutive spontaneous abortions before the 10th week of gestation or one fetal death at or beyond the 10th week of gestation. We compared the incidence of cancer diagnosis during follow-up among the cohort of women positive for antiphospholipid antibodies (n=517), the cohort of women carrying the F5 rs6025 or F2 rs1799963 polymorphism (n=279) and a cohort of women with negative thrombophilia screening results (n=796). The annualized rate of cancer was 0.300% (0.20%-0.44%) for women with obstetric APS and their cancer risk was substantially higher than that of women with negative thrombophilia screening [adjusted hazard ratio (aHR) 2.483; 95% confidence interval (CI) 1.27-4.85]. The computed standardized incidence ratio for women with obstetric APS was 2.89; 95% CI: 1.89-4.23. Among antiphospholipid antibodies, lupus anticoagulant was associated with incident cancers (aHR 2.608; 95% CI: 1.091-6.236). Our cohort study shows that the risk of cancer is substantially higher in women with a history of obstetric APS than in the general population, and in women with a similar initial clinical history but negative for antiphospholipid antibodies.
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Affiliation(s)
- Jean-Christophe Gris
- Department of Hematology, University Hospital of Nîmes, Nîmes, France .,Faculty of Pharmaceutical and Biological Sciences, University of Montpellier, Montpellier, France.,UPRES EA2992 "Caractéristiques Féminines des Dysfonctions des Interfaces Vasculaires", University of Montpellier, Montpellier, France.,I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Éve Mousty
- Department of Gynecology and Obstetrics, University Hospital of Nîmes, Nîmes, France
| | - Sylvie Bouvier
- Department of Hematology, University Hospital of Nîmes, Nîmes, France.,Faculty of Pharmaceutical and Biological Sciences, University of Montpellier, Montpellier, France.,UPRES EA2992 "Caractéristiques Féminines des Dysfonctions des Interfaces Vasculaires", University of Montpellier, Montpellier, France
| | - Sylvie Ripart
- Department of Gynecology and Obstetrics, University Hospital of Nîmes, Nîmes, France
| | - Éva Cochery-Nouvellon
- Department of Hematology, University Hospital of Nîmes, Nîmes, France.,UPRES EA2992 "Caractéristiques Féminines des Dysfonctions des Interfaces Vasculaires", University of Montpellier, Montpellier, France
| | - Pascale Fabbro-Peray
- Department of Biostatistics, Epidemiology, Public Health, Innovation and Methodology, University Hospital of Nîmes, Nîmes, France
| | - Jonathan Broner
- Department of Internal Medicine, University Hospital of Nîmes, Nîmes, France
| | - Vincent Letouzey
- Department of Gynecology and Obstetrics, University Hospital of Nîmes, Nîmes, France
| | - Antonia Pérez-Martin
- UPRES EA2992 "Caractéristiques Féminines des Dysfonctions des Interfaces Vasculaires", University of Montpellier, Montpellier, France.,Department of Vascular Medicine, University Hospital of Nîmes, Nîmes, France
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23
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Chayoua W, Kelchtermans H, Gris JC, Moore GW, Musiał J, Wahl D, de Groot PG, de Laat B, Devreese KMJ. The (non-)sense of detecting anti-cardiolipin and anti-β2glycoprotein I IgM antibodies in the antiphospholipid syndrome. J Thromb Haemost 2020; 18:169-179. [PMID: 31519058 DOI: 10.1111/jth.14633] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/15/2019] [Accepted: 09/09/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with the persistent presence of lupus anticoagulant (LAC), anti-cardiolipin (aCL) and/or anti-β2glycoprotein I (aβ2GPI) antibodies of the immunoglobulin G/immunoglobulin M (IgG/IgM) isotype. However, the role of aCL and aβ2GPI IgM as a serologic marker in APS is debated. OBJECTIVES We aimed to assess the diagnostic and clinical value of IgM antiphospholipid antibodies (aPL) in APS within the classification criteria. PATIENTS/METHODS Our multicenter study comprised 1008 patients, including APS patients and controls. Anti-CL and aβ2GPI IgG and IgM antibodies were detected with four commercially available solid phase assays. RESULTS Positivity for aCL and/or aβ2GPI antibodies was significantly correlated with thrombosis and pregnancy morbidity, independent of the isotype and solid phase assay. Higher odds ratios were obtained for IgG compared to IgM positivity. Isolated IgM was rare in thrombotic APS, but more frequent in obstetric APS, ranging from 3.5% to 5.4% and 5.7% to 12.3%, respectively, dependent on the solid phase assay. In a multivariate logistic regression analysis of aPL, IgM positivity was found to be associated with pregnancy morbidity. However, detection of IgM was not independently associated with thrombosis. Combined positivity for LAC, IgG, and IgM was highly associated with thrombosis and pregnancy morbidity. CONCLUSIONS Our data support testing for aCL and aβ2GPI IgM in women suspected of obstetric APS. However, no added value was found for testing IgM in patients suspected of thrombotic APS. Still, IgM aPL might be useful as a second-line test to improve thrombotic risk stratification.
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Affiliation(s)
- Walid Chayoua
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - Hilde Kelchtermans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - Jean-Christophe Gris
- Centre Hospitalier Universitaire de Nîmes et Université de Montpellier, Montpellier, France
- Ivan Sechenov First Moscow State Medical University, Moscow, Russia
| | - Gary W Moore
- Department of Haemostasis & Thrombosis, Guy's & St. Thomas' Hospitals, London, UK
| | - Jacek Musiał
- Jagiellonian University Medical College, Krakow, Poland
| | - Denis Wahl
- DCAC, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Inserm, Centre Hospitalier Regional Universitaire de Nancy, Université de Lorraine, Nancy, France
| | | | - Bas de Laat
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - Katrien M J Devreese
- Department of Diagnostic Sciences, Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium
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24
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Sobhani NC, Shulman R, Tran EE, Gonzalez JM. Early Onset Severe Hypertensive Disease in Pregnancy and Screening for Antiphospholipid Syndrome. AJP Rep 2020; 10:e32-e36. [PMID: 32140289 PMCID: PMC7056392 DOI: 10.1055/s-0040-1702926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022] Open
Abstract
Objective Although preterm delivery (PTD) before 34 weeks for severe hypertensive disease is a diagnostic criterion for antiphospholipid syndrome (APS), there is no consensus regarding testing for antiphospholipid antibodies (aPL) in this setting. We aim to describe the frequency of and the characteristics associated with inpatient aPL testing in this population. Study Design In this retrospective study of PTD before 34 weeks for severe hypertensive disease, charts were reviewed for aPL testing, gestational age at delivery, fetal complications, and severity of maternal disease. Wilcoxon rank-sum test, Fisher's exact, and chi-squared tests were used for analyses of continuous and categorical variables, and multivariate logistic regression for adjusted odds ratios. Results Among 133 cases, 14.3% had APS screening via aPL testing. Screened patients delivered earlier than unscreened patients (28.9 vs. 31.7 weeks, p <0.001). Each additional week of gestation was associated with a 39% decrease in the odds of screening (95% confidence interval: 0.43-0.85). There were no other differences between the groups. Conclusion APS screening after PTD for severe hypertensive disease is uncommon but more likely with earlier PTD. Despite conflicting recommendations from professional organizations, prior studies demonstrate contraceptive, obstetrical, and long-term risks associated with APS, suggesting that we should increase our screening efforts.
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Affiliation(s)
- Nasim C. Sobhani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | | | - Erin E. Tran
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois
| | - Juan M. Gonzalez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
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25
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Abstract
Antiphospholipid syndrome is an autoimmune systemic disorder characterized by arterial, venous, or small vessel thrombosis and/or recurrent early pregnancy loss, fetal loss, or pregnancy morbidity in the setting of documented persistent antiphospholipid antibodies that include the lupus anticoagulant, or moderate-high titer anticardiolipin, or anti-β2Glycoprotein I antibodies. Associated clinical manifestations include livedo reticularis, cutaneous ulcerations, thrombocytopenia, hemolytic anemia, valvular heart disease, and nephropathy. The degree of risk associated with antiphospholipid antibody depends on the characteristics of the antiphospholipid antibody profile and on the presence of additional thrombotic risk factors. Current standard treatment for unprovoked thrombosis is long-term warfarin or other vitamin K antagonist therapy. Treatment to prevent recurrent obstetric complications is low-dose aspirin and prophylactic heparin, usually low-molecular-weight heparin. Optimal treatment for standard therapy failures or for certain nonthrombotic manifestations is uncertain, although nonanticoagulation therapies that address multiple demonstrated mechanisms of disease are being explored.
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Affiliation(s)
- Lisa R Sammaritano
- Associate Professor of Clinical Medicine, Weill Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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26
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Tektonidou MG, Andreoli L, Limper M, Tincani A, Ward MM. Management of thrombotic and obstetric antiphospholipid syndrome: a systematic literature review informing the EULAR recommendations for the management of antiphospholipid syndrome in adults. RMD Open 2019; 5:e000924. [PMID: 31168416 PMCID: PMC6525610 DOI: 10.1136/rmdopen-2019-000924] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/31/2023] Open
Abstract
Objective To perform a systematic literature review (SLR) informing the European Lmmendations for the management of antiphospholipid syndrome (APS) in adults. Methods A SLR through January 2018 was performed. Research questions were constructed using the Patient, Intervention, Comparator, Outcome (PICO) format. We included data from articles that reported on each relevant intervention. Summary effect estimates were calculated for direct comparison studies that matched the PICO question exactly, and for studies with the relevant intervention and comparator. When meta-analyses were available, we used these estimates. Results From 7534 retrieved articles (+15 from hand searches), 188 articles were included in the review. In individuals with high-risk antiphospholipid antibody (aPL) profile without prior thrombotic or obstetric APS, two meta-analyses showed a protective effect of low-dose aspirin (LDA) against thrombosis. Two randomised controlled trials (RCTs) and three cohort studies showed no additional benefit of treatment with vitamin K antagonists at target international normalised ratio (INR) 3–4 versus INR 2–3 in patients with venous thrombosis. In patients with arterial thrombosis, two RCTs and two cohort studies showed no difference in risk of recurrent thrombosis between the two target INR groups. One open-label trial showed higher rates of thrombosis recurrences in triple aPL-positive patients treated with rivaroxaban than those treated with warfarin. RCTs and cohort studies showed that combination treatment with LDA and heparin was more effective than LDA alone in several types of obstetric APS. SLR results were limited by the indirect evidence and the heterogeneity of patient groups for some treatments, and only a few high-quality RCTs. Conclusion Well-designed studies of homogeneous APS patient populations are needed.
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Affiliation(s)
- Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - Laura Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marteen Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, NIAMS/NIH, Bethesda, Maryland, USA
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Ruffatti A, Favaro M, Calligaro A, Zambon A, Del Ross T. Management of pregnant women with antiphospholipid antibodies. Expert Rev Clin Immunol 2019; 15:347-358. [DOI: 10.1080/1744666x.2019.1565995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Alessandra Zambon
- Obstetrics and Gynecology Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
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Gris JC, Cyprien F, Bouvier S, Cochery-Nouvellon E, Lavigne-Lissalde G, Mercier E, Balducchi JP. Antiphospholipid antibodies are associated with positive screening for common mental disorders in women with previous pregnancy loss. The NOHA-PSY observational study. World J Biol Psychiatry 2019; 20:51-63. [PMID: 28532221 DOI: 10.1080/15622975.2017.1333146] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Case reports describe neuropsychiatric manifestations associated with antiphospholipid antibodies (aPlAbs). In patients sharing the same symptoms fulfilling the antiphospholipid syndrome (APS) clinical criteria, the prevalence of common mental disorders has, however, never been studied. METHODS We observed women with three consecutive abortions before the 10th week of gestation or one foetal loss at or beyond the 10th week. We compared the prevalence of common psychiatric disorders detected through screening using the Mini International Neuropsychiatric Interview, 10 years after inclusion, in women with APS (n = 506), women negative for aPlAbs but carrying the F5rs6025 or F2rs1799963 thrombogenic polymorphism (n = 269), and women with negative thrombophilia screening results as controls (n = 764). RESULTS Similar prevalence values were obtained for controls and women bearing one of the two thrombogenic polymorphisms. Women with APS more frequently had mood disorders (relative risk (RR) 1.57 (1.262-1.953), P = .0001) and anxiety (RR 1.645 (1.366-1.979), P < .0001). Within the APS group, lupus anticoagulant (LA) and anti-β2GP1 IgG, or triple positivity, were strong risk factors for mood disorders. CONCLUSIONS Women with obstetric APS have a higher risk of positive screening for common mental disorders than women without APS.
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Affiliation(s)
- Jean-Christophe Gris
- a Department of Hematology , University Hospital , Nîmes , France.,b Research team UPRES EA2992 , 'Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa', University of Montpellier , Montpellier , France.,c Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences , University of Montpellier , Montpellier , France
| | - Fabienne Cyprien
- d Department of Neurosurgery , University Hospital , Montpellier , France.,e Inserm U1061 , "Neuropsychiatrie: recherche épidémiologique et clinique" , Montpellier , France
| | - Sylvie Bouvier
- a Department of Hematology , University Hospital , Nîmes , France.,b Research team UPRES EA2992 , 'Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa', University of Montpellier , Montpellier , France.,c Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences , University of Montpellier , Montpellier , France
| | - Eva Cochery-Nouvellon
- a Department of Hematology , University Hospital , Nîmes , France.,b Research team UPRES EA2992 , 'Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa', University of Montpellier , Montpellier , France
| | - Géraldine Lavigne-Lissalde
- a Department of Hematology , University Hospital , Nîmes , France.,b Research team UPRES EA2992 , 'Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa', University of Montpellier , Montpellier , France
| | - Erick Mercier
- a Department of Hematology , University Hospital , Nîmes , France.,b Research team UPRES EA2992 , 'Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa', University of Montpellier , Montpellier , France.,c Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences , University of Montpellier , Montpellier , France
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29
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de Jesús GR, Sciascia S, Andrade D, Barbhaiya M, Tektonidou M, Banzato A, Pengo V, Ji L, Meroni PL, Ugarte A, Cohen H, Branch DW, Andreoli L, Belmont HM, Fortin PR, Petri M, Rodriguez E, Cervera R, Knight JS, Atsumi T, Willis R, Nascimento IS, Rosa R, Erkan D, Levy RA. Factors associated with first thrombosis in patients presenting with obstetric antiphospholipid syndrome (APS) in the APS Alliance for Clinical Trials and International Networking Clinical Database and Repository: a retrospective study. BJOG 2018; 126:656-661. [PMID: 30222236 DOI: 10.1111/1471-0528.15469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients. DESIGN Retrospective study. SETTING The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository. POPULATION Women with Ob-APS. METHODS Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM). MAIN OUTCOME MEASURES Risk factors for thrombosis and aGAPSS. RESULTS Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089]. CONCLUSION Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women. TWEETABLE ABSTRACT More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity.
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Affiliation(s)
- G R de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - S Sciascia
- Department of Clinical and Biological Sciences, Centre of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - D Andrade
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - M Barbhaiya
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - M Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, University of Athens, Athens, Greece
| | - A Banzato
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - V Pengo
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - L Ji
- Rheumatology and Immunology Department, Peking University, First Hospital, Beijing, China
| | - P L Meroni
- Department of Rheumatology, University of Milan, Milan, Italy
| | - A Ugarte
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital Universitario Cruces, Barakaldo, Spain
| | - H Cohen
- Department of Haematology, University College London, London, UK
| | - D W Branch
- Department of Obstetrics and Gynecology, University of Utah Health Sciences and Intermountain Healthcare, Salt Lake City, UT, USA
| | - L Andreoli
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - H M Belmont
- Division of Rheumatology, NYU School of Medicine, New York, NY, USA
| | - P R Fortin
- Division of Rheumatology, Centre Hospitalier de l'Université Laval, Québec, QC, Canada
| | - M Petri
- Division of Rheumatology, John Hopkins University, Baltimore, MD, USA
| | - E Rodriguez
- Rheumatology Department, Hospital 12 de Octubre, Madrid, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - J S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - T Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - R Willis
- Antiphospholipid Standardization Laboratory, Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - I S Nascimento
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - R Rosa
- Departament of Rheumatology, Universidade de São Paulo, São Paulo, Brazil
| | - D Erkan
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - R A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,GlaxoSmithKline Immunology and Inflammation, Upper Providence, PA, USA
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Chayoua W, Kelchtermans H, Moore GW, Musiał J, Wahl D, de Laat B, Devreese KMJ. Identification of high thrombotic risk triple-positive antiphospholipid syndrome patients is dependent on anti-cardiolipin and anti-β2glycoprotein I antibody detection assays. J Thromb Haemost 2018; 16:2016-2023. [PMID: 30079628 DOI: 10.1111/jth.14261] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 12/31/2022]
Abstract
Essentials Triple-positivity is associated with a high risk for a first thrombotic event and recurrence. Identification of triple-positives is dependent on the solid phase assay used. In triple-positivity, IgM only adds value in thrombotic risk stratification together with IgG. Thrombotic risk in triple-positive patients with IgM only, depends on the platform. ABSTRACT Background The antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with the persistent presence of antiphospholipid antibodies (aPL). Triple-positivity (i.e. positivity for lupus anticoagulant [LAC], anti-cardiolipin [aCL] and anti-β2glycoprotein I [aβ2GPI] antibodies) is associated with a high thrombotic risk. Objectives We investigated the variability in triple-positivity detection by measuring the same samples with four commercially available solid phase assays. In addition, the added clinical value of aPL in LAC-positive patients was investigated, as well as the association of IgM triple-positivity and thrombosis. Patients/Methods We included 851 patients from seven European medical centers. Anti-CL and aβ2GPI IgG/IgM antibodies were determined by four platforms: BioPlex® 2200, ImmunoCap® EliA, ACL AcuStar® and QUANTA Lite ELISA® . Results Triple-positivity detection by solid phase assays varied, ranging from 89 up to 118 in thrombotic APS patients (n = 258), of which 86 were detected independent of the platform. Lupus anticoagulant positivity resulted in an odds ratio (OR) for thrombosis of 3.4; triple-positivity (irrespective of the isotype) increased the OR from 4.3 up to 5.2, dependent on the platform. Triple-positivity solely for the IgM isotype did not increase the OR for thrombosis compared with LAC positivity. The highest OR for thrombosis was reached for positivity for IgG and IgM aβ2GPI and aCL (8.6 up to 28.9). Conclusions Triple-positivity proved to be highly associated with thrombosis, but identification is assay dependent. Within triple-positivity, IgM antibodies only have an added clinical value in patients positive for IgG antibodies.
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Affiliation(s)
- W Chayoua
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - H Kelchtermans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - G W Moore
- Viapath Analytics, Department of Haemostasis and Thrombosis, Guy's and St Thomas' Hospitals, London, UK
| | - J Musiał
- Department of Internal Medicine, Allergy and Immunology, Jagiellonian University Medical College, Kraków, Poland
| | - D Wahl
- Inserm, DCAC, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Regional Universitaire de Nancy, Université de Lorraine, Nancy, France
| | - B de Laat
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - K M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Gent, Belgium
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Abstract
Abstract. Antiphospholipid syndrome (APS) is an autoantibody-mediated acquired thrombophilia. It is characterized by the presence of antiphospholipid antibodies (APL) that are directed against phospholipid-binding plasma proteins, such as beta-2-glycoprotein I (b2GPI). Its main manifestations are recurrent vascular thromboses (so-called “thrombotic APS”) and pregnancy complications (“obstetric APS”). According to the current consensus criteria, a persistently positive functional lupus anticoagulant (LA) assay and/or the presence of anti-b2GPI and/or anti-cardiolipin antibodies, together with clinical symptoms, is mandatory for the diagnosis of APS. Other clinical features, such as thrombocytopenia, Coombs-positive haemolytic anaemia, heart valve disease, renal microangiopathy and neurologic disorders are also common in APL-positive patients. APS can be associated with other autoimmune disorders, such as systemic lupus erythematosus. In rare cases, catastrophic APS (CAPS) occurs, with the development of excessive thrombosis at multiple sites, usually affecting small vessels and leading to multi-organ dysfunction and organ failure. Treatment usually comprises antithrombotic therapy using antiplatelet and anticoagulant agents. However, there is no consensus concerning the intensity or duration of therapy. Despite apparently adequate anticoagulation, the risk of recurrent thrombosis remains high. For patients with CAPS, a combined therapeutic approach that includes anticoagulation, glucocorticoids, plasma exchange and/or intravenous immunoglobulin seems to be the best treatment option. Keywords: Antiphospholipid syndrome, lupus anticoagulants, anti-cardiolipin, anti-beta-2-glycoprotein I, vascular thrombosis, pregnancy complication
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Affiliation(s)
- Birgit Linnemann
- Division of Angiology, East Bavarian Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
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Antovic A, Sennström M, Bremme K, Svenungsson E. Obstetric antiphospholipid syndrome. Lupus Sci Med 2018; 5:e000197. [PMID: 30364418 PMCID: PMC6195166 DOI: 10.1136/lupus-2016-000197] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Abstract
The present clinical and laboratory classification criteria for antiphospholipid syndrome (APS) were established in Sydney, Australia, in 2006. In this review, we focus on the obstetric subset of APS (OAPS), defined by persistent positivity for antiphospholipid antibodies together with either early recurrent pregnancy loss, early fetal death, stillbirth or premature birth <34 gestational weeks due to pre-eclampsia, eclampsia and placental insufficiency. It is important to diagnose these cases since most women suffering from OAPS can, when given appropriate treatment, have successful pregnancies. Furthermore, patients with OAPS may, depending on the antibody profile, be at enhanced risk of thrombotic events later in life. We present an update on the present knowledge of possible underlying pathogenesis, risk factors and risk estimations for adverse pregnancy outcomes before and during pregnancy, current treatment concepts, and long-term outcomes for women with OAPS and their children.
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Affiliation(s)
- Aleksandra Antovic
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Maria Sennström
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Bremme
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Unit of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Zuo Y, Barbhaiya M, Erkan D. Primary Thrombosis Prophylaxis in Persistently Antiphospholipid Antibody-Positive Individuals: Where Do We Stand in 2018? Curr Rheumatol Rep 2018; 20:66. [DOI: 10.1007/s11926-018-0775-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is defined as the association of thrombotic events and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies (aPL). In this review, we will highlight the most important clinical presentations of APS with a focus on the obstetric morbidity, the current management strategies and the outlook for the future. RECENT FINDINGS The use of aspirin and heparin has improved the pregnancy outcome in obstetric APS and approximately 70% of pregnant women with APS have a successful pregnancy outcome. Unfortunately, the current standard of care does not prevent all pregnancy complications as the current treatment fails in 20-30% of APS pregnancies. This therefore highlights the need for alternative treatments to improve obstetrical outcome. Other treatment options are currently explored and retrospective studies show that pravastatin for example is beneficial in women with aPL-related early preeclampsia. Moreover, the immunmodulator hydroxychloroquine may play a beneficial role in the prevention of aPL-related pregnancy complications. SUMMARY APS is among the most frequent acquired risk factors for a treatable cause of recurrent pregnancy loss and increases the risk of conditions associated with ischaemic placental dysfunction, such as fetal growth restriction, preeclampsia, premature birth and intrauterine death. Current treatment is mainly based on aspirin and heparin. Studies to inform on alternative treatment options are urgently needed.
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Affiliation(s)
- David Garcia
- From the University of Washington School of Medicine, Seattle (D.G.); and the Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York (D.E.)
| | - Doruk Erkan
- From the University of Washington School of Medicine, Seattle (D.G.); and the Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York (D.E.)
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Antiphospholipid antibody profile-based outcome of purely vascular and purely obstetric antiphospholipid syndrome. J Thromb Thrombolysis 2018; 46:166-173. [DOI: 10.1007/s11239-018-1672-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Ruffatti A, Hoxha A, Favaro M, Tonello M, Colpo A, Cucchini U, Banzato A, Pengo V. Additional Treatments for High-Risk Obstetric Antiphospholipid Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:28-39. [PMID: 27342460 DOI: 10.1007/s12016-016-8571-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Most investigators currently advocate prophylactic-dose heparin plus low-dose aspirin as the preferred treatment of otherwise healthy women with obstetric antiphospholipid syndrome, whilst women with a history of vascular thrombosis alone or associated with pregnancy morbidity are usually treated with therapeutic heparin doses in association with low-dose aspirin in an attempt to prevent both thrombosis and pregnancy morbidity. However, the protocols outlined above fail in about 20 % of pregnant women with antiphospholipid syndrome. Identifying risk factors associated with pregnancy failure when conventional therapies are utilized is an important step in establishing guidelines to manage these high-risk patients. Some clinical and laboratory risk factors have been found to be related to maternal-foetal complications in pregnant women on conventional therapy. However, the most efficacious treatments to administer to high-risk antiphospholipid syndrome women in addition to conventional therapy in order to avoid pregnancy complications are as yet unestablished. This is a comprehensive review on this topic and an invitation to participate in a multicentre study in order to identify the best additional treatments to be used in this subset of antiphospholipid syndrome patients.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
- Reumatologia, Policlinico Universitario, Via Giustiniani, 2-35128, Padova, Italy.
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Anna Colpo
- Blood Transfusion Unit, University-Hospital of Padua, Padua, Italy
| | - Umberto Cucchini
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandra Banzato
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Vittorio Pengo
- Cardiology Unit, Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
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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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Machin SJ, Mackie IJ, Cohen H, Jayakody Arachchillage DR. Diagnosis and management of non-criteria obstetric antiphospholipid syndrome. Thromb Haemost 2017; 113:13-9. [DOI: 10.1160/th14-05-0416] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/05/2014] [Indexed: 01/03/2023]
Abstract
SummaryAccurate diagnosis of obstetric antiphospholipid syndrome (APS) is a prerequisite for optimal clinical management. The international consensus (revised Sapporo) criteria for obstetric APS do not include low positive anticardiolipin (aCL) and anti β2 glycoprotein I (aβ2GPI) antibodies (> 99th centile) and/or certain clinical criteria such as two unexplained miscarriages, three non-consecutive miscarriages, late preeclampsia, placental abruption, late premature birth, or two or more unexplained in vitro fertilisation failures. In this review we examine the available evidence to address the question of whether patients who exhibit non-criteria clinical and/or laboratory manifestations should be included within the spectrum of obstetric APS. Prospective and retrospective cohort studies of women with pregnancy morbidity, particularly recurrent pregnancy loss, suggest that elimination of aCL and/or IgM aβ2GPI, or low positive positive aCL or aβ2GPI from APS laboratory diagnostic criteria may result in missing the diagnosis in a sizeable number of women who could be regarded to have obstetric APS. Such prospective and retrospective studies also suggest that women with non-criteria obstetric APS may benefit from standard treatment for obstetric APS with low-molecular-weight heparin plus low-dose aspirin, with good pregnancy outcomes. Thus, non-criteria manifestations of obstetric APS may be clinically relevant, and merit investigation of therapeutic approaches. Women with obstetric APS appear to be at a higher risk than other women of pre-eclampsia, placenta- mediated complications and neonatal mortality, and also at increased long-term risk of thrombotic events. The applicability of these observations to outcomes in women with non-criteria obstetric APS remains to be determined.
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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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Drozdinsky G, Hadar E, Shmueli A, Gabbay-Benziv R, Shiber S. Obstetric antiphospholipid syndrome and long term arterial thrombosis risk. J Thromb Thrombolysis 2017; 44:371-375. [DOI: 10.1007/s11239-017-1526-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Arachchillage DRJ, Laffan M. Pathogenesis and management of antiphospholipid syndrome. Br J Haematol 2017; 178:181-195. [PMID: 28339096 DOI: 10.1111/bjh.14632] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antiphospholipid antibodies are a heterogeneous group of autoantibodies that have clear associations with thrombosis and pregnancy morbidity, and which together constitute the 'antiphospholipid syndrome' (APS). However, the pathophysiology of these complications is not well understood and their heterogeneity suggests that more than one pathogenic process may be involved. Diagnosis remains a combination of laboratory analysis and clinical observation but there have been significant advances in identifying specific pathogenic features, such as domain I-specific anti-β2-glycoprotein-I antibodies. This in turn has pointed to endothelial and complement activation as important factors in the pathogenesis of APS. Consequently, although anticoagulation remains the standard treatment for thrombotic APS and during pregnancy, the realisation that these additional pathways are involved in the pathogenesis of APS has significant implications for treatment: agents acting outside the coagulation system, such as hydroxychloroquine for pregnancy complications and sirolimus as an inhibitor of the mammalian target of rapamycin (mTOR) pathway, are now under evaluation and represent a radical change in thinking for haematologists. Conventional anticoagulation is also under challenge from new, direct acting anticoagulants. This review will provide a comprehensive overview of the evolving understanding of APS pathogenesis and how this and novel therapeutics will alter diagnosis and management.
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Affiliation(s)
- Deepa R J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
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Cochery-Nouvellon É, Mercier É, Bouvier S, Balducchi JP, Quéré I, Perez-Martin A, Mousty E, Letouzey V, Gris JC. Obstetric antiphospholipid syndrome: early variations of angiogenic factors are associated with adverse outcomes. Haematologica 2017; 102:835-842. [PMID: 28126966 PMCID: PMC5477602 DOI: 10.3324/haematol.2016.155184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 01/20/2017] [Indexed: 11/17/2022] Open
Abstract
The prognostic value of angiogenic factors in newly pregnant women with obstetric antiphospholipid syndrome (oAPS) has not been documented. We observed 513 oAPS who experienced three consecutive spontaneous abortions before the 10th week of gestation or one fetal loss at or beyond the 10th week. We assessed the plasma concentrations of the proangiogenic factor placenta growth factor (PIGF) and of the antiangiogenic factor soluble fms-like tyrosine kinase-1 on the eve and on the 4th day of the low-molecular weight heparin-low-dose aspirin treatment. Placenta growth factor and fms-like tyrosine kinase-1 plasma concentrations showed marked increases. Treatment-associated variations of PIGF and of soluble fms-like tyrosine kinase-1 were antagonist risk factors for placenta-mediated complications (PMC) and for severe PMC, for fetal death, stillbirth and neonatal death. The ratio between PIGF increase and soluble fms-like tyrosine kinase-1 was a summary variable whose best cut-off values (1.944.10−2) had high negative predictive values for PMC (0.918) and may be used to help rule out the development of PMC in evolutive pregnancies after 19 completed weeks. The early variations of PIGF and soluble fms-like tyrosine kinase-1 concentrations in newly pregnant oAPS may help to detect patients at low risk of PMC. (clinicaltrials.gov identifier: 02855047)
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Affiliation(s)
- Éva Cochery-Nouvellon
- Department of Hematology, University Hospital, Nîmes, France.,Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France
| | - Érick Mercier
- Department of Hematology, University Hospital, Nîmes, France.,Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France.,Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences, University of Montpellier, France
| | - Sylvie Bouvier
- Department of Hematology, University Hospital, Nîmes, France.,Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France.,Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences, University of Montpellier, France
| | | | - Isabelle Quéré
- Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France.,Department of Vascular Medicine and Internal Medicine, University Hospital, Montpellier, France
| | - Antonia Perez-Martin
- Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France.,Department of Vascular Medicine, University Hospital, Nîmes, France
| | - Eve Mousty
- Department of Gynecology and Obstetrics, University Hospital, Nîmes, France
| | - Vincent Letouzey
- Department of Gynecology and Obstetrics, University Hospital, Nîmes, France
| | - Jean-Christophe Gris
- Department of Hematology, University Hospital, Nîmes, France .,Research team UPRES EA2992 "Caractéristiques féminines des dysfonctions des interfaces vasculaires CaFe-DIVa", University of Montpellier, France.,Laboratory of Hematology, Faculty of Pharmacy and Biological Sciences, University of Montpellier, France
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Ohhashi M, Takahashi H, Baba Y, Suzuki H, Horie K, Usui R, Ohkuchi A, Watanabe T, Matsubara S. Pregnancy-related thromboembolism and contributing risk factors: From 10 years of experience at a Japanese tertiary obstetrics institute. HYPERTENSION RESEARCH IN PREGNANCY 2017. [DOI: 10.14390/jsshp.hrp2017-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mai Ohhashi
- Department of Obstetrics and Gynecology, Jichi Medical University
- Equally contributed to this study
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University
- Equally contributed to this study
| | - Yosuke Baba
- Department of Obstetrics and Gynecology, Jichi Medical University
| | - Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University
| | - Kenji Horie
- Department of Obstetrics and Gynecology, Jichi Medical University
| | - Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University
| | - Takashi Watanabe
- Department of Obstetrics and Gynecology, Jichi Medical University
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Kwak-Kim J, Skariah A, Wu L, Salazar D, Sung N, Ota K. Humoral and cellular autoimmunity in women with recurrent pregnancy losses and repeated implantation failures: A possible role of vitamin D. Autoimmun Rev 2016; 15:943-7. [DOI: 10.1016/j.autrev.2016.07.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/06/2016] [Indexed: 11/16/2022]
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Abstract
Reproductive issues including contraception, fertility, and pregnancy are important components of the comprehensive care of women with systemic lupus erythematosus (SLE). SLE pregnancies are complicated due to risk for maternal disease exacerbation and potential for fetal and neonatal complications. Pre-pregnancy assessment is important to identify patients with severe disease-related damage who should avoid pregnancy, counsel patients to conceive when disease has been stable and inactive on appropriate medications, and assess relevant risk factors including renal disease, antiphospholipid antibody, and anti-Ro/SS-A and anti-La/SS-B antibodies. With careful planning, monitoring, and care, most women with SLE can anticipate a successful pregnancy.
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Affiliation(s)
- Lisa R Sammaritano
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY 10021;
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Kelchtermans H, Pelkmans L, de Laat B, Devreese KM. IgG/IgM antiphospholipid antibodies present in the classification criteria for the antiphospholipid syndrome: a critical review of their association with thrombosis. J Thromb Haemost 2016; 14:1530-48. [PMID: 27279342 DOI: 10.1111/jth.13379] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Indexed: 01/08/2023]
Abstract
UNLABELLED Essentials The clinical value of IgM antibodies in thrombotic antiphospholipid syndrome (APS) is debated. By review of literature, we reconsidered the clinical value of IgM antibodies in thrombotic APS. More significant correlations with thrombosis were found for the IgG compared to IgM isotype. Unavailability of paired IgG/IgM results hampers evaluating the added value of IgM positivity. Click to hear Dr de Groot's perspective on antiphospholipid syndrome SUMMARY Background Despite the update of the classification criteria for the antiphospholipid syndrome (APS), difficulties persist in the identification of patients at risk for thrombosis. Current guidelines include assays detecting IgG/IgM anti-β2 -glycoprotein I and anti-cardiolipin antibodies, although the relevance of IgM antibodies has been debated. Objectives Through a review of the literature from 2001 to 2014, we aimed to formally establish the thrombotic risk stratification potential of IgM as compared with IgG anti-phospholipid antibodies (aPLs). Patients/methods One thousand two hundred and twenty-eight articles were selected by a computer-assisted search of the literature. Of the 177 studies that met our inclusion criteria, the clinical value of IgG/IgM aPLs was established through analysis of odds ratios for thrombosis or percentage of positives in the thrombotic population. Results/conclusions We clearly found more significant correlations with thrombosis for the IgG than for the IgM isotype. Nonetheless, in a minority of studies, significant associations with thrombosis were found for IgM but not IgG antibodies. The unavailability of paired results of IgG and IgM for each separate patient hampers evaluation of the added value of isolated IgM positivity. To fully take advantage of results obtained by future studies, we strongly encourage scientists to provide all studied information per patient. We planned a large multicenter study to investigate clinical associations of isolated/combined positivity for criteria/non-criteria aPLs. Importantly, because of the presence of non-pathogenic aPLs, quantitative assays are characterized by a high false-positivity rate. Optimization of functional assays, such as thrombin generation measuring the whole scheme of coagulation, may help to reduce APS-related morbidity and mortality.
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Affiliation(s)
- H Kelchtermans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - L Pelkmans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - B de Laat
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - K M Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Khamashta M, Taraborelli M, Sciascia S, Tincani A. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2016; 30:133-48. [DOI: 10.1016/j.berh.2016.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pereira FR, Macri F, Jackowski MP, Kostis WJ, Gris JC, Beregi JP, Mekkaoui C. Diffusion tensor imaging in patients with obstetric antiphospholipid syndrome without neuropsychiatric symptoms. Eur Radiol 2015. [DOI: 10.1007/s00330-015-3922-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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