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Noordermeer T, Chemlal S, Jansma JJ, van der Vegte V, Schutgens REG, Limper M, de Groot PG, Meijers JCM, Urbanus RT. Anti-β2-glycoprotein I and anti-phosphatidylserine/prothrombin antibodies interfere with cleavage of factor V(a) by activated protein C. J Thromb Haemost 2023; 21:2509-2518. [PMID: 37290588 DOI: 10.1016/j.jtha.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The acquired thrombotic risk factor known as lupus anticoagulant (LA) interferes with laboratory clotting assays and can be caused by autoantibodies against β2-glycoprotein I (β2GPI) and prothrombin. LA is associated with activated protein C (APC) resistance, which might contribute to thrombotic risk in patients with antiphospholipid syndrome. How antibodies against β2GPI and prothrombin cause APC resistance is currently unclear. OBJECTIVES To investigate how anti-β2GPI and antiphosphatidylserine/prothrombin (PS/PT) antibodies induce APC resistance. METHODS The effects of anti-β2GPI and anti-PS/PT antibodies on APC resistance were studied in plasma (of patients with antiphospholipid syndrome) and with purified coagulation factors and antibodies. RESULTS APC resistance was observed in LA-positive patients with anti-β2GPI or anti-PS/PT antibodies and in normal plasma spiked with monoclonal anti-β2GPI or anti-PS/PT antibodies with LA activity. Analysis of factor (F)V cleavage patterns after APC incubation indicated that anti-β2GPI antibodies attenuated APC-mediated FV cleavage at R506 and R306. APC-mediated cleavage at R506 is required for FV cofactor activity during inactivation of FVIIIa. Assays with purified coagulation factors confirmed that anti-β2GPI antibodies interfered with the cofactor function of FV during FVIIIa inactivation but not with FVa inactivation. Anti-PS/PT antibodies attenuated APC-mediated FVa and FVIIIa inactivation. Analysis of FV(a) cleavage patterns after APC incubation indicated that anti-PS/PT antibodies interfere with APC-mediated cleavage of FV at positions R506 and R306. CONCLUSION Anti-β2GPI antibodies with LA activity contribute to a procoagulant state by causing APC resistance via interference with the cofactor function of FV during FVIIIa inactivation. LA-causing anti-PS/PT antibodies interfere with the anticoagulant function of APC by preventing FV(a) cleavage.
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Affiliation(s)
- Tessa Noordermeer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Circulatory Health Research Center, University Medical Center Utrecht, Utrecht, the Netherlands. https://twitter.com/Tessa_Noorder
| | - Soumaya Chemlal
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Circulatory Health Research Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Janna J Jansma
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Circulatory Health Research Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vossa van der Vegte
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Circulatory Health Research Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, the Netherlands; Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rolf T Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Circulatory Health Research Center, University Medical Center Utrecht, Utrecht, the Netherlands.
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Noordermeer T, Schutgens REG, Visser C, Rademaker E, de Maat MPM, Jansen AJG, Limper M, Cremer OL, Kruip MJHA, Endeman H, Maas C, de Laat B, Urbanus RT. Lupus anticoagulant associates with thrombosis in patients with COVID-19 admitted to intensive care units: A retrospective cohort study. Res Pract Thromb Haemost 2022; 6:e12809. [PMID: 36178455 PMCID: PMC9481876 DOI: 10.1002/rth2.12809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/20/2022] Open
Abstract
Background Thrombosis is a frequent and severe complication in patients with coronavirus disease 2019 (COVID‐19) admitted to the intensive care unit (ICU). Lupus anticoagulant (LA) is a strong acquired risk factor for thrombosis in various diseases and is frequently observed in patients with COVID‐19. Whether LA is associated with thrombosis in patients with severe COVID‐19 is currently unclear. Objective To investigate if LA is associated with thrombosis in critically ill patients with COVID‐19. Patients/Methods The presence of LA and other antiphospholipid antibodies was assessed in patients with COVID‐19 admitted to the ICU. LA was determined with dilute Russell's viper venom time (dRVVT) and LA‐sensitive activated partial thromboplastin time (aPTT) reagents. Results Of 169 patients with COVID‐19, 116 (69%) tested positive for at least one antiphospholipid antibody upon admission to the ICU. Forty (24%) patients tested positive for LA; of whom 29 (17%) tested positive with a dRVVT, 19 (11%) tested positive with an LA‐sensitive aPTT, and 8 (5%) tested positive on both tests. Fifty‐eight (34%) patients developed thrombosis after ICU admission. The odds ratio (OR) for thrombosis in patients with LA based on a dRVVT was 2.5 (95% confidence interval [CI], 1.1–5.7), which increased to 4.5 (95% CI, 1.4–14.3) in patients at or below the median age in this study (64 years). LA positivity based on a dRVVT or LA‐sensitive aPTT was only associated with thrombosis in patients aged less than 65 years (OR, 3.8; 95% CI, 1.3–11.4) and disappeared after adjustment for C‐reactive protein. Conclusion Lupus anticoagulant on admission is strongly associated with thrombosis in critically ill patients with COVID‐19, especially in patients aged less than 65 years.
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Affiliation(s)
- Tessa Noordermeer
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Emma Rademaker
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht The Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Olaf L Cremer
- Intensive Care Center University Medical Center Utrecht Utrecht The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands
| | - Coen Maas
- Central Diagnostic Laboratory University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Bas de Laat
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM) Maastricht University, Maastricht, the Netherlands Synapse Research Institute Maastricht The Netherlands
| | - Rolf T Urbanus
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
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Noordermeer T, Molhoek JE, Schutgens REG, Sebastian SAE, Drost‐Verhoef S, van Wesel ACW, de Groot PG, Meijers JCM, Urbanus RT. Anti-β2-glycoprotein I and anti-prothrombin antibodies cause lupus anticoagulant through different mechanisms of action. J Thromb Haemost 2021; 19:1018-1028. [PMID: 33421291 PMCID: PMC8048633 DOI: 10.1111/jth.15241] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/11/2020] [Accepted: 12/29/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The presence of lupus anticoagulant (LA) is an independent risk factor for thrombosis. This laboratory phenomenon is detected as a phospholipid-dependent prolongation of the clotting time and is caused by autoantibodies against beta2-glycoprotein I (β2GPI) or prothrombin. How these autoantibodies cause LA is unclear. OBJECTIVE To elucidate how anti-β2GPI and anti-prothrombin antibodies cause the LA phenomenon. METHODS The effects of monoclonal anti-β2GPI and anti-prothrombin antibodies on coagulation were analyzed in plasma and with purified coagulation factors. RESULTS Detection of LA caused by anti-β2GPI or anti-prothrombin antibodies required the presence of the procofactor factor V (FV) in plasma. LA effect disappeared when FV was replaced by activated FV (FVa), both in a model system and in patient plasma, although differences between anti-β2GPI and anti-prothrombin antibodies were observed. Further exploration of the effects of the antibodies on coagulation showed that the anti-β2GPI antibody attenuated FV activation by activated faxtor X (FXa), whereas the anti-prothrombin antibody did not. Binding studies showed that β2GPI--antibody complexes directly interacted with FV with high affinity. Anti-prothrombin complexes caused the LA phenomenon through competition for phospholipid binding sites with coagulation factors as reduced FXa binding to lipospheres was observed with flow cytometry in the presence of these antibodies. CONCLUSION Anti-β2GPI and anti-prothrombin antibodies cause LA through different mechanisms of action: While anti-β2GPI antibodies interfere with FV activation by FXa through a direct interaction with FV, anti-prothrombin antibodies compete with FXa for phospholipid binding sites. These data provide leads for understanding the paradoxical association between thrombosis and a prolonged clotting time in the antiphospholipid syndrome.
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Affiliation(s)
- Tessa Noordermeer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Jessica E. Molhoek
- Central Diagnostic LaboratoryUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Roger E. G. Schutgens
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Silvie A. E. Sebastian
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Central Diagnostic LaboratoryUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Sandra Drost‐Verhoef
- Central Diagnostic LaboratoryUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Annet C. W. van Wesel
- Central Diagnostic LaboratoryUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | | | - Joost C. M. Meijers
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamthe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Rolf T. Urbanus
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
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