The effects of a human IgM monoclonal anticardiolipin antibody on pregnancy in a transgenic mouse model

Viewpoint: The value of non-criteria antiphospholipid antibodies

In 2006, at a meeting in Sydney, Australia, consensus was reached by an international group of specialists to establish a number of serological criteria that identify patients with a history of thrombosis or pregnancy complications as having antiphospholipid syndrome (APS). These criteria were originally formulated for research purposes and to compare clinical trials in different centres. However, these same criteria are now generally used and accepted for the diagnosis and treatment of patients. The practice of using these criteria for direct patient care requires that these criteria are based on sound scientific evidence. Indeed, for all the autoantibodies that are officially included in the serological criteria, it has been shown that they induce thrombosis and fetal loss when infused into mice. There are also a number of additional autoantibodies that have been identified in these patients but for these antibodies there was not enough evidence to meet the official APS criteria in 2006. Seventeen years have now passed since the consensus meeting, therefore, this review examines whether additional studies performed with these 'non-criteria' autoantibodies have provided sufficient results to suggest the inclusion of these autoantibodies in the official serological criteria of APS.

B cell biology, apoptosis, and autoantibodies to phospholipids

Systemic autoimmune diseases are characterised by the development of a relatively narrow spectrum of autoantibodies. These are of considerable diagnostic value. In addition, in some diseases, including anti-phospholipid syndrome, these autoantibodies can be directly pathogenic. Understanding how these autoantibodies are formed represents an important avenue towards understanding the pathogenesis of systemic autoimmune disease itself. The minimum requirements for production of autoantibodies are self-reactive B cells and the availability of autoantigen. In other words, their formation is determined by factors that shape the B cell repertoire and the distribution and immunogenicity of the relevant autoantigens. On the B cell side, the propensity to produce autoantibodies depends on the fidelity of B cell self-tolerance mechanisms, B cell differentiation and selection into different peripheral compartments. These processes are interdependent, because both selection into different peripheral and mechanisms of B cell self-tolerance are influenced by signalling through the B cell receptor (BCR). On the antigen supply side, apoptotic cells appear to be a crucial source of antigenic targets of systemic autoimmunity, and elaborate mechanisms exist to ensure that apoptotic corpses undergo efficient disposal and do not become immunogenic. Several defects have been described where the disposal of apoptotic cells is compromised leading to their accumulation in parenchymal organs. These may become immunogenic resulting in autoantibody formation. The mechanisms that lead to progression from accumulation of autoantigen, in the form of apoptotic corpses, to the production of autoantibodies by self-reactive B cells within different parts of the peripheral repertoire are discussed.