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Melayah S, Omrani N, Alouini H, Ghozzi M, Mrad S, Boussarsar M, Chaouch H, Hachfi W, Letaief A, Mankaï A, Ghedira I. IgA is the predominant isotype of anti-β2 glycoprotein I in patients with COVID-19. Lab Med 2024; 55:373-379. [PMID: 38124622 DOI: 10.1093/labmed/lmad097] [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] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE The aim of this research was to determine the frequency of antiphospholipid antibodies (aPL) in patients with COVID-19. METHODS The frequency and titers of anticardiolipin antibodies (aCL) and anti-β2 glycoprotein I antibodies (aβ2GPI) were determined in sera of adult patients hospitalized with COVID-19. Immunoglobulin (Ig)G, IgA, IgM aCL, and aβ2GPI were measured using enzyme-linked immunosorbent assay. RESULTS Eighty-three patients were included in the study. The mean age of patients was 62 ± 13.9 years, ranging from 23 to 86 years. Stratification according to severity of infection divided patients in 2 groups: 45 patients with moderate infection and 38 patients with critical or severe infection. Out of the 83 patients suffering from COVID-19, aPL (aCL or aβ2GPI) were detected in 24 patients (28.9%). IgG, IgA and IgM aβ2GPI were positive in 2.4%, 16.9% and 8.4%, respectively. IgG, IgA and IgM aCL showed positivity in 7.2%, 0%, and 4.8%, respectively. The frequency of aPL was 36.8% in patients with critical/severe infection and 22.2% in patients with moderate infection. In critical/severe patients, the frequency of aβ2GPI was significantly higher than aCL (34.2% vs 13.2%, P = .03) and aβ2GPI-IgA were significantly more frequent than aβ2GPI-IgG (21.1% vs 2.6%, P = .028). CONCLUSION In this cross-sectional study, aPL and particularly aβ2GPI-IgA were common in patients with COVID-19.
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Affiliation(s)
- Sarra Melayah
- Laboratory of Immunology, Farhat Hached University Hospital, Sousse, Tunisia
- Department of Immunology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
- LR12SP11, Department of Biochemistry, Sahloul University Hospital, Sousse, Tunisia
| | - Nouha Omrani
- Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hela Alouini
- Department of Immunology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Mariam Ghozzi
- Laboratory of Immunology, Farhat Hached University Hospital, Sousse, Tunisia
- Department of Immunology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
- LR14SP02, Research Unit "Epidemiology and Immunogenetics of Viral Infections," Sahloul University Hospital, Sousse, Tunisia
| | - Sawssen Mrad
- Laboratory of Biochemistry, Farhat Hached University Hospital, Sousse, Tunisia
| | - Mohamed Boussarsar
- Departments of Departments of Medical Intensive Care, Farhat Hached University Hospital, Sousse, Tunisia
| | - Houda Chaouch
- Infectious Diseases, Farhat Hached University Hospital, Sousse, Tunisia
| | - Wissem Hachfi
- Infectious Diseases, Farhat Hached University Hospital, Sousse, Tunisia
| | - Amel Letaief
- Infectious Diseases, Farhat Hached University Hospital, Sousse, Tunisia
| | - Amani Mankaï
- Laboratory of Immunology, Farhat Hached University Hospital, Sousse, Tunisia
- High School of Sciences and Techniques of Health, University of Tunis El Manar, Tunis, Tunisia
- Research Unit "Obesity: Etiopathology and Treatment, UR18ES01," National Institute of Nutrition and Food Technology, Tunis, Tunisia
| | - Ibtissem Ghedira
- Laboratory of Immunology, Farhat Hached University Hospital, Sousse, Tunisia
- Department of Immunology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
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Bakow BR, Yanek L, Crowther MA, Chaturvedi S. Low recurrent thrombosis rates in single positive antiphospholipid syndrome regardless of type of anticoagulation. Thromb Res 2024; 237:88-93. [PMID: 38569453 PMCID: PMC11056290 DOI: 10.1016/j.thromres.2024.03.013] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 02/12/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024]
Abstract
Thrombotic antiphospholipid syndrome (TAPS) is characterized by thrombosis and persistently positive tests for antiphospholipid antibodies or lupus anticoagulant (LAC). Triple-positive APS has the highest risk of recurrent thrombosis, but no studies have focused on recurrent thrombosis in patients with single-positive TAPS. We conducted a retrospective cohort study of patients with single-positive TAPS diagnosed at Lifespan Health System, Rhode Island, to determine the rates and risk factors for recurrent thrombosis. Between January 2001 and April 2022, 128 patients were assessed who had single-positive APS (LAC = 98, aCL = 21, aβ2GPI = 9) and who had been followed for a total of 1453.8 patient-years (median follow-up 3.04 years). The initial antithrombotic regimen was warfarin in 44 %, a direct oral anticoagulant (DOAC) in 34 %, enoxaparin in 2 %, and no antithrombotic therapy or antiplatelet therapy only in 20 %. Recurrent thrombosis occurred in 16 (12.5 %) with a recurrent thrombosis rate of 3.08 per 100 patient-years. Systemic lupus erythematosus was the only variable significantly associated with recurrent thrombosis in a model adjusted for age, sex, body mass index, and type of positive APS test. All 16 patients with recurrent thrombosis were initially treated with warfarin, and, at the time of recurrent thrombosis, 13 patients remained on warfarin and three were off anticoagulation. In conclusion, the recurrent thrombosis rate in single-positive APS is low, and not all patients with a single-positive test may need indefinite anticoagulation with warfarin. Larger prospective studies are required to confirm this finding and establish optimal anticoagulation regimens for low-risk TAPS.
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Affiliation(s)
- Brianna R Bakow
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa Yanek
- Division of Internal Medicine, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Foret T, Dufrost V, Lagrange J, Costa P, Mourey G, Lecompte T, Magy-Bertrand N, Regnault V, Zuily S, Wahl D. Thrombin Generation Assay in Antiphospholipid Antibodies Positive Subjects as a Personalized Thrombotic Risk Assessment: State of the Art and Perspectives. Curr Rheumatol Rep 2024; 26:178-187. [PMID: 38372872 DOI: 10.1007/s11926-024-01140-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF THE REVIEW Thrombotic risk assessment in antiphospholipid positive (aPL +) subjects is a major challenge, and the study of in vitro thrombin generation (thrombin generation assays (TGA)) could provide useful information. Activated protein C (APC) sensitivity is involved in thrombotic events in antiphospholipid syndrome patients. We summarized methods used to assess APC sensitivity with TGA and evaluated the prognostic role of APC resistance through literature search. RECENT FINDINGS APC resistance induced by aPL is a complex pathway. Several cross-sectional studies assessed APC sensitivity to understand thrombotic event mechanisms in aPL + subjects. Only one prospective cohort had investigated the prognostic impact of APC resistance in aPL + subjects, with a positive and significant correlation between APC sensitivity and the risk of thrombosis during the follow up (hazard ratio, 6.07 [95% CI, 1.69-21.87]). APC resistance assessed with TGA could be associated with thrombotic events in aPL + subjects.
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Affiliation(s)
- Thomas Foret
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France.
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France.
| | - Virginie Dufrost
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Jeremy Lagrange
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Patricia Costa
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France
| | - Guillaume Mourey
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France
- Medical Biology Laboratory, Biological Haemostasis Department, CHU Besançon, F-25000, Besançon, France
| | - Thomas Lecompte
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
- Université de Lorraine, Nancy, France
| | | | - Veronique Regnault
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Denis Wahl
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
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Pandya J, Onel K, Erkan D. The clinical relevance of different antiphospholipid antibody profiles in pediatric rheumatology patients. Pediatr Rheumatol Online J 2024; 22:46. [PMID: 38671480 PMCID: PMC11046946 DOI: 10.1186/s12969-024-00954-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/29/2023] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The clinical relevance of different antiphospholipid antibody (aPL) profiles, including low level anticardiolipin (aCL) and anti-β2-glycoprotein-I (aβ2GPI) antibodies, is ill-defined in the pediatric population. Our purpose is to describe the demographic, clinical, and laboratory characteristics of aPL positive pediatric patients based on different aPL profiles. FINDINGS In this single center retrospective cohort study, based on the screening of our pediatric (age ≤ 18) rheumatology electronic medical records (2016-2022), we identified patients who had at least one "positive" aPL (lupus anticoagulant [LA], aCL IgG/M, or aβ2GPI IgG/M) result. Patients were grouped into high- (LA positive and/or aCL/aβ2GPI IgG/M > 40U [ELISA]) and low-risk (LA negative and aCL/aβ2GPI IgG/M 20-39U) aPL profiles; those with persistently positive aPL were descriptively analyzed for demographic and clinical characteristics. Of 57 included patients, 34 (59%) had initial high- and 23 (40%) had initial low-risk profiles. Based on subsequent aPL results available in 42/57 (74%) patients, 25/27 (93%) in the high-, and 7/15 (47%) in the low-risk groups remained still positive. Of these 32 patients with persistently positive aPL, moderate-to-large vessel or microvascular thrombosis occurred in nine (28%) patients with high-risk and in none with low-risk aPL profiles; non-thrombotic aPL-related manifestations were reported in 15 (47%) patients with persistent aPL positivity. CONCLUSION An initial high-risk aPL profile was persistent in approximately 90% of our cohort, a third of whom had thrombosis, and half had non-thrombotic aPL manifestations. Our results underscore the need for a large-scale effort to better characterize aPL-related manifestations in pediatric patients with persistent high-risk aPL-profiles.
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Affiliation(s)
- Jheel Pandya
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 E 70th Street, 10021, New York, NY, USA.
| | - Karen Onel
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 E 70th Street, 10021, New York, NY, USA
| | - Doruk Erkan
- Hospital for Special Surgery, Barbara Volcker Center for Women and Rheumatic Disease, Weill Cornell Medicine, 535 E70th Street, 10021, New York, NY, USA
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Affiliation(s)
- Shree K Kurup
- Department of Ophthalmology and Visual Sciences, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Alan H Markowitz
- Department of Surgery, Cardiac Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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6
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Benkirane A, Devalet B, Montigny P, London F. Late-onset of primary antiphospholipid syndrome: a case report. Acta Neurol Belg 2021; 121:1375-1376. [PMID: 33242192 DOI: 10.1007/s13760-020-01555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Adam Benkirane
- Department of Neurology, Université Catholique de Louvain (UCLouvain), CHU UCL Namur, 1 Avenue G. Thérasse, B-5530, Yvoir, Belgium
| | - Bérangère Devalet
- Department of Hematology, Université Catholique de Louvain (UCLouvain), CHU UCL Namur, Yvoir, Belgium
| | - Pauline Montigny
- Department of Rheumatology, Université Catholique de Louvain (UCLouvain), CHU UCL Namur, Yvoir, Belgium
| | - Frédéric London
- Department of Neurology, Université Catholique de Louvain (UCLouvain), CHU UCL Namur, 1 Avenue G. Thérasse, B-5530, Yvoir, Belgium.
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Khogeer H, Altahan S, Alrehaily A, Sheikh A, Awartani K, Al-Kaff M, Saleh S, Alzahrani H, Alfattani A, Owaidah T. The Diagnostic Value of New Additional Antiphospholipid Antibodies in Antiphospholipid Syndrome. Ann Clin Lab Sci 2021; 51:552-556. [PMID: 34452895] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The antiphospholipid syndrome (APS) is an autoimmune disease that is characterized by thrombosis and/or pregnancy failure and associated with the presence of all or at least one of three standard antibodies (anti-phospholipid (aPL) antibodies, including lupus anticoagulant (LA), anti-cardiolipin (aCL), and anti-β2-glycoprotein I (anti-β2GPI)). A growing body of evidence recommends adding additional aPL antibodies, such as anti-phosphatidylserine (aPS), anti-prothrombin (aPT), and anti-annexin A5 (aAA5), to conventional laboratory tests (revised Sapporo criteria), especially in seronegative APS cases. OBJECTIVES We aimed to compare the diagnostic value, utility, and performance of these three additional antibodies along with the standard aPL antibodies in cases with confirmed and non-criteria APS (seronegative). METHODS This was a prospective observational study on 59 patients who presented with clinical features of APS at the hematology, medical, rheumatology, and obstetric clinics. LA was detected by standard coagulation tests, while other aPL, IgG, and IgM antibodies (aCL, aβ2GPI, aPS, aPT, aAA5) were detected with enzyme-linked immunosorbent assay (ELISA). RESULTS Anti-PS antibody was more frequent compared to aPT and aAA5 in both confirmed cases (84.6%) and non-criteria (seronegative) (15.4%) APS. As a single test, the aPS antibody was significantly better (P<0.05) than the aPT and aAA5 antibodies in the detection of APS cases. Seven non-criteria patients were confirmed using additional aPL antibodies. Among these patients, four, two, and one patient was confirmed with aPS, aPT, and aAA5 antibodies, respectively. CONCLUSION Our data support the findings of previously published studies and attribute the clinical significance of additional aPL antibodies, particularly aPS, in identifying non-criteria APS cases. In the future, along with conventional aPL antibodies, these additional antibodies should be included as standard laboratory tests in the revised Sapporo criteria.
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Affiliation(s)
- Haitham Khogeer
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Shatha Altahan
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Ali Alrehaily
- Department of Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Aamir Sheikh
- Department of Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Khalid Awartani
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Murad Al-Kaff
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Saleh Saleh
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Hazzaa Alzahrani
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Areej Alfattani
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
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Shi T, Gu ZD, Diao QZ. Meta-analysis on aspirin combined with low-molecular-weight heparin for improving the live birth rate in patients with antiphospholipid syndrome and its correlation with d-dimer levels. Medicine (Baltimore) 2021; 100:e26264. [PMID: 34160390 PMCID: PMC8238312 DOI: 10.1097/md.0000000000026264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/22/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Antiphospholipid antibody syndrome (APS) is a systemic, autoimmune, prothrombotic disease characterized by persistent antiphospholipid antibodies, thrombosis, recurrent abortion, complications during pregnancy, and occasionally thrombocytopenia. At present, there is no consensus on the treatment of this disease. Long-term anticoagulation is recommended in most cases in patients with thrombotic APS. This study aimed to evaluate whether aspirin combined with low-molecular-weight heparin (LMWH) can improve the live birth rate in antiphospholipid syndrome and its correlation with D-dimer. METHODS The data were retrieved from the WanFang Data, CBM, VIP, CNKI, the Cochrane Library, PubMed, EMBASE, OVID, and Web of Science databases. We collected data on randomized controlled trials of aspirin combined with LMWH in the treatment of pregnant women with APS. The "Risk of Bias Assessment" tool and the "Jadad Scale" provided by the Cochrane Collaboration were used to evaluate the risk of bias and quality of the collected literature. The risk ratio (RR) and its 95% confidence interval (CI) were determined using Statase-64 software. RESULTS In this study, a total of 11 studies were included, comprising a total of 2101 patients. The live birth rate in pregnant women with APS was higher on administration of aspirin combined with LMWH than with aspirin alone (RR = 1.29, 95% CI = 1.22-1.35, P < .001). d-dimer concentration in plasma predicted the live birth rate, which was higher below the baseline than above it (RR = 1.16, 95% CI = 1.09-1.23, P < .001). The subgroup analysis of the live birth rate was carried out based on the course of treatment, and the results were consistent with the overall results. Begg funnel plot test revealed no publication bias. Sensitivity analysis showed that deleting any study did not affect the results. CONCLUSION Aspirin combined with LMWH for APS may improve live birth rate, and detection of d-dimer levels in APS pregnant women may predict pregnancy complications and guide the use of anticoagulants.
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MESH Headings
- Abortion, Habitual/blood
- Abortion, Habitual/immunology
- Abortion, Habitual/prevention & control
- Antibodies, Antiphospholipid/blood
- Antibodies, Antiphospholipid/immunology
- Anticoagulants/administration & dosage
- Antiphospholipid Syndrome/blood
- Antiphospholipid Syndrome/complications
- Antiphospholipid Syndrome/drug therapy
- Antiphospholipid Syndrome/immunology
- Aspirin/administration & dosage
- Biomarkers/blood
- Birth Rate
- Drug Therapy, Combination/methods
- Female
- Fibrin Fibrinogen Degradation Products/analysis
- Heparin, Low-Molecular-Weight/administration & dosage
- Humans
- Live Birth
- Pregnancy
- Pregnancy Complications, Hematologic/blood
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/drug therapy
- Pregnancy Complications, Hematologic/immunology
- Prognosis
- Randomized Controlled Trials as Topic
- Thrombosis/blood
- Thrombosis/complications
- Thrombosis/drug therapy
- Thrombosis/immunology
- Treatment Outcome
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Affiliation(s)
- Ting Shi
- The Department of Blood Transfusion
| | | | - Qi-Zhi Diao
- The Department of Clinical Laboratory Medicine, Yongchuan Hospital, Chongqing Medical University, Yongchuan, Chongqing, China
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Gelman R, Kharouf F, Ishay Y, Gural A. Cold Agglutinin-Mediated Autoimmune Hemolytic Anemia in Association with Antiphospholipid Syndrome. Acta Haematol 2021; 144:693-697. [PMID: 34000726 DOI: 10.1159/000516295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/09/2021] [Accepted: 03/29/2021] [Indexed: 01/15/2023]
Abstract
Antiphospholipid syndrome and cold agglutinin-mediated autoimmune hemolytic anemia are 2 distinct immune-mediated hematologic disorders. While no clear association exists between these 2 entities, complement activation is known to occur in both of them. Herein, we report a unique case of cold agglutinin hemolytic anemia in a patient with a known primary antiphospholipid syndrome.
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Affiliation(s)
- Ram Gelman
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Fadi Kharouf
- Rheumatology Unit, Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Yuval Ishay
- Department of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Alexander Gural
- Department of Hematology and Transfusion Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
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10
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Abstract
BACKGROUND Many studies reported high prevalence of antiphospholipid antibodies (aPL) in patients with COVID-19 raising questions about its true prevalence and its clinical impact on the disease course. METHODS We conducted a meta-analysis and a systematic review to examine the prevalence of aPL and its clinical impact in patients with COVID-19. RESULTS 21 studies with a total of 1159 patients were included in our meta-analysis. Among patients hospitalised with COVID-19, the pooled prevalence rate of one or more aPL (IgM or IgG or IgA of anticardiolipin (aCL) or anti-ß2 glycoprotein (anti-ß2 GPI) or antiphosphatidylserine/prothrombin, or lupus anticoagulant (LA)) was 46.8% (95% CI 36.1% to 57.8%). The most frequent type of aPL found was LA, with pooled prevalence rate of 50.7% (95% CI 34.8% to 66.5%). Critically ill patients with COVID-19 had significantly higher prevalence of aCL (IgM or IgG) (28.8% vs 7.10%, p<0.0001) and anti-ß2 GPI (IgM or IgG) (12.0% vs 5.8%, p<0.0001) as compared with non-critically ill patients. However, there was no association between aPL positivity and mean levels of C reactive protein (mean difference was 32 (95% CI -15 to 79), p=0.18), D-dimer (mean difference was 34 (95% CI -194 to 273), p=0.77), mortality (1.46 (95% CI 0.29 to 7.29), p=0.65), invasive ventilation (1.22 (95% CI 0.51 to 2.91), p=0.65) and venous thromboembolism (1.38 (95% CI 0.57 to 3.37), p=0.48). CONCLUSIONS aPLs were detected in nearly half of patients with COVID-19, and higher prevalence of aPL was found in severe disease. However, there was no association between aPL positivity and disease outcomes including thrombosis, invasive ventilation and mortality. However, further studies are required to identify the clinical and pathological role of aPL in COVID-19.
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Affiliation(s)
- Muhanad Taha
- Department of Pulmonary/Critical Care, Wayne State University, Detroit, Michigan, USA
| | - Lobelia Samavati
- Department of Pulmonary/Critical Care, Wayne State University, Detroit, Michigan, USA
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11
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Pleguezuelo DE, Díaz-Simón R, Cabrera-Marante O, Lalueza A, Paz-Artal E, Lumbreras C, Serrano Hernández A. Case Report: Resetting the Humoral Immune Response by Targeting Plasma Cells With Daratumumab in Anti-Phospholipid Syndrome. Front Immunol 2021; 12:667515. [PMID: 33912194 PMCID: PMC8072150 DOI: 10.3389/fimmu.2021.667515] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/22/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction Monoclonal antibodies (mAb) targeting plasma cells are malignant gammopathy designed and approved therapies. In recent years, these antibodies have also been increasingly introduced for non-malignant conditions such as autoimmune-mediated diseases. The Anti-Phospholipid Syndrome (APS) is an immune-mediated disorder in which autoantibodies against phospholipid associated proteins could elicit the activation of the coagulation cascade in specific situations. Therefore, the mainstream treatment for APS patients is the use of anticoagulant therapy. However, there are refractory patients who would benefit from targeting the antibodies rather than their effects. Rituximab, a B-cell depleting mAb, and intravenous immunoglobulins (IVIG) have been used in APS patients without showing a clear beneficial effect or a significant drop in anti-phospholipid antibody (aPL) levels. Clinical case We present our first APS case treated with daratumumab, an anti-CD38 mAb, in a 21-year-old patient with APS who presented with recurrent venous thromboembolic events despite adequate anticoagulant therapy. She tested positive for lupus anticoagulant, anti-cardiolipin IgG, anti-beta-2-glycoprotein-I IgG and anti-phosphatidylserine/prothrombin IgG and IgM. She was administered one dose weekly of daratumumab for 4 weeks. The treatment showed an adequate safety profile and was well tolerated. The patient was discharged after undergoing a clinically significant improvement. After the therapy, her levels of positive aPL declined significantly and most continued to decrease during the next three months. The patient experienced a new thrombotic episode two years after the therapy associated with poor adherence to antithrombotic therapy. Conclusions The treatment with daratumumab showed an adequate safety profile, was well tolerated and led to a significant clinical improvement. Levels of aPL lowered on therapy and the next three months and then rose again during follow-up. Further investigation is needed to better elucidate the role and optimal timing and doses of daratumumab in treatment of refractory APS.
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Affiliation(s)
| | - Raquel Díaz-Simón
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Antonio Lalueza
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Estela Paz-Artal
- Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Lumbreras
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
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12
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Yang J, Liang M. Risk factors for pregnancy morbidity in women with antiphospholipid syndrome. J Reprod Immunol 2021; 145:103315. [PMID: 33845396 DOI: 10.1016/j.jri.2021.103315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/25/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
Antiphospholipid syndrome (APS) increases the risk of obstetric complications, but risk factors for pregnancy morbidity in women with APS remain incompletely characterized. This retrospective study included pregnant women with APS and a control group without APS admitted to Peking University People's Hospital between January 2013 and September 2019. Clinical data were extracted from medical records. Univariate and multivariate logistic regression analyses were used to identify factors associated with adverse pregnancy outcomes (fetal loss, premature birth, fetal growth restriction [FGR], preeclampsia and neonatal death). We included 64 pregnancies in 59 patients with APS (age, 32.3 ± 4.3 years) and 256 pregnancies in 256 women without APS (age, 30.4 ± 3.3 years). Compared with the control group, the APS group had higher incidence rates of preeclampsia (10.9 % vs. 2.3 %, P = 0.002), premature rupture of membranes (17.2 % vs. 3.9 %, P < 0.001), postpartum hemorrhage (23.4 % vs. 4.3 %, P < 0.001), fetal loss (4.7 % vs. 0.8 %, P = 0.024) and premature delivery at ≤34 weeks (7.8 % vs. 2.3 %, P = 0.047). The incidence rates of hypertension during pregnancy, HELLP syndrome, gestational diabetes, oligohydramnios and FGR were similar in both groups. Multivariate logistic regression revealed that three or more prior spontaneous miscarriages (odds ratio [OR], 6.162; 95 % confidence interval [CI], 1.271-29.882; P = 0.024) and double-positivity for antiphospholipid antibodies (OR, 4.024; 95 %CI, 1.025-15.794; P = 0.046) were independently associated with adverse pregnancy outcomes. APS increases the risks of adverse maternal and fetal outcomes during pregnancy. Three or more spontaneous miscarriages and double-positivity for antiphospholipid antibodies are risk factors for adverse pregnancy outcomes in women with APS.
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Affiliation(s)
- Jingjing Yang
- Obstetrics and Gynecology Department, Peking University People's Hospital, Beijing, China
| | - Meiying Liang
- Obstetrics and Gynecology Department, Peking University People's Hospital, Beijing, China.
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Freeman-Beman L, Ratner S, Kabani N, Neculiseanu E, Ginzler E. COVID-19 Coagulopathy in a Patient With Systemic Lupus Erythematosus and Antiphospholipid Antibodies. J Clin Rheumatol 2021; 27:e60-e61. [PMID: 32947435 DOI: 10.1097/rhu.0000000000001599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Hamadé A, Woehl B, Harzallah I, Talbot M, Tousch J, Jambert L. Antiphospholipid antibodies in patients with coronavirus disease 2019 infection hospitalized in conventional unit. Blood Coagul Fibrinolysis 2021; 32:73-79. [PMID: 33273262 DOI: 10.1097/mbc.0000000000000963] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antiphospholipid (aPL) antibodies can arise transiently at times of viral diseases. The objective of this work was to evaluate the incidence of aPL antibodies in patients hospitalized in conventional unit for coronavirus disease 2019 (COVID-19) infection and confirmed venous thromboembolic events (VTE) associated with aPL antibodies. 41 patients infected with COVID-19 were tested for aPL antibodies. None had reported history of aPL syndrome. Arterial and venous duplex ultrasound of lower limbs was performed in all patients at Day 0 and Day 5. All patients had antithrombotic-prophylaxis upon admission using lower molecular weight heparin with Enoxaparin. Biological parameters were collected and analyzed. Nine patients (22%) developed VTE and seven (17%) were positive for aPL antibodies of which five had isolated positive lupus anticoagulant. The sixth patient was double aPL positive IgM anticardiolipin (147.8 U/ml) and anti-Beta2 Glyco protein 1 (97.3 U/ml) antibodies. The seventh was triple positive, IgM anticardiolipin 85.6 UI/ml, IgM anti-Beta2 Glyco protein 1 63.0 U/ml and positive lupus anticoagulant. Among the seven patients with aPL antibodies 2 (28.60%) had VTE. However, the incidence of VTE in patients negative for aPL antibodies was also significant as 20.6% (seven of 34). aPL antibodies were significantly associated with the transfer to ICUs of, P = 0.018. Not only the incidence of aPL antibodies was quite significant within our cohort, but also we observed 28.6% of VTE in aPL-positive patients. We strongly recommend routine testing for aPL antibodies in COVID-19 patients and systematic screening with duplex ultrasound search of vascular complications.
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Affiliation(s)
| | | | - Ines Harzallah
- Service d'Hémétologie, GHR Mulhouse Sud-Alsace, Hôpital Emile Muller, Mulhouse, France
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15
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Wang Y, Xiao Y, Deng X, Xu N, Chen Z. Cardiac thrombus and stroke in a child with Mycoplasma pneumoniae pneumonia: A case report. Medicine (Baltimore) 2021; 100:e24297. [PMID: 33592875 PMCID: PMC7870197 DOI: 10.1097/md.0000000000024297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cardiac thrombus and stroke are rare complications in Mycoplasma pneumoniae infection, which is a common cause of community-acquired pneumonia in children. Early detection and prevention of thrombus in children with M pneumoniae pneumonia is relatively difficult. PATIENT CONCERNS A 5-year-old boy with severe M pneumoniae pneumonia was referred to our center. During the treatment with sufficient antibiotics, an echocardiography surprisingly revealed a thrombus in the left atrium, with significant changes in D-dimer level and anti-phospholipid antibodies. At day 12 after admission, the patient showed impaired consciousness, aphasia, and reduced limb muscle power. Magnetic resonance angiography (MRA) showed right middle cerebral artery infarction. DIAGNOSES Cardiac thrombus and stroke associated with M pneumoniae pneumonia. INTERVENTIONS He was started on aggressive antibiotic therapy and urokinase thrombolytic therapy for 24 hours, continued with low molecular heparin calcium and aspirin along with rehabilitation training. OUTCOMES On follow up, the D-dimer decreased slowly and echocardiograms showed a steadily decreasing size of thrombus with eventual disappearance at day 22 after admission. His left limb muscle power was improved after rehabilitation for 2 months. LESSONS Early diagnosis and treatment with multiple modalities maybe useful for improving prognosis of cardiac thrombus and stroke in M pneumoniae pneumonia. Changes in D-dimer level and anti-phospholipid antibodies should be routinely monitored in severe M pneumoniae pneumonia.
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Affiliation(s)
- Yefeng Wang
- Department of Cardiology, Hunan Children's Hospital
| | - Yunbin Xiao
- Department of Cardiology, Hunan Children's Hospital
| | - Xicheng Deng
- Department of Cardiothoracic Surgery, Hunan Children's Hospital
| | - Ningan Xu
- Department of Health Care Center, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhi Chen
- Department of Cardiology, Hunan Children's Hospital
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16
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Devaux CA, Camoin-Jau L, Mege JL, Raoult D. Can hydroxychloroquine be protective against COVID-19-associated thrombotic events ? J Microbiol Immunol Infect 2021; 54:37-45. [PMID: 33500211 PMCID: PMC7783458 DOI: 10.1016/j.jmii.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/15/2020] [Accepted: 12/24/2020] [Indexed: 02/06/2023]
Abstract
Although SARS-CoV-2 is considered a lung-tropic virus, severe COVID-19 is not just a viral pulmonary infection, clinically it is a multi-organ pathology with major coagulation abnormalities and thromboembolism events. Recently, antiphospholipid (aPL) antibodies were found increased in a large number of COVID-19 patients. Elevated aPL have been well documented in antiphospholipid syndrome (APS), a systemic autoimmune disorder characterized by recurrent venous or arterial thrombosis and/or obstetrical morbidity. Among treatment regimen of APS, hydroxychloroquine (HCQ) is one of the molecules proposed in the primary prevention of thrombosis and obstetrical morbidity in those patients. Due to its antithrombotic properties documented in APS therapy, HCQ could be considered a good candidate for the prevention of thrombotic events in COVID-19 patients in association with anticoagulant and its repurposing deserves further evaluation.
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Affiliation(s)
- Christian A Devaux
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; CNRS, Marseille, France.
| | - Laurence Camoin-Jau
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France; Laboratoire D'Hématologie, Hôpital de La Timone, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
| | - Jean-Louis Mege
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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Patel S, Sanborn D, Issa M. 57-Year-Old Woman With Weakness and Word-Finding Difficulties. Mayo Clin Proc 2021; 96:473-477. [PMID: 33549264 DOI: 10.1016/j.mayocp.2020.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Shruti Patel
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David Sanborn
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Meltiady Issa
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN.
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Abstract
Antiphospholipid syndrome (APS), which is characterized by the presence of antiphospholipid antibodies (aPL), is associated with increased risk of thrombosis and obstetric complications, including preterm delivery and recurrent pregnancy losses. APS shows diverse clinical manifestations and the risk of complications varies among clinical subtypes. Although these patients are usually treated with aspirin and anticoagulants, the optimal treatment in various clinical settings is unclear, as the risk of complications vary among clinical subtypes and the management strategy depends on whether the patient is pregnant or not. Also, there are unmet needs for the evidence-based, pregnancy-related treatment of asymptomatic women positive for aPL. This review focuses on the management of positive aPL or APS in pregnant and postpartum women, and in women attempting to become pregnant. For asymptomatic aPL positive women, no treatment, low dose aspirin (LDA) or LDA plus anticoagulants can be considered during antepartum and postpartum. In obstetric APS patients, preconceptional LDA is recommended. LDA plus low molecular weight heparin is administered after confirmation of pregnancy. Vascular APS patients should take frequent pregnancy test and receive heparin instead of warfarin after confirmation of pregnancy. During pregnancy, heparin plus LDA is recommended. Warfarin can be restarted 4 to 6 hours after vaginal delivery and 6 to 12 hours after cesarean delivery. Most importantly, a tailored approach and patient-oriented treatment are mandatory.
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Affiliation(s)
- Eunyoung Emily Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea.
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Gasparini G, Canepa P, Verdiani S, Carmisciano L, Cozzani E, De Grazia D, Andrea O, Icardi G, Parodi A. A retrospective study on the prevalence of anti-phospholipid antibodies, thrombotic events and cutaneous signs of vasculopathy in 173 hospitalized COVID-19 patients. Int J Immunopathol Pharmacol 2021; 35:20587384211042115. [PMID: 34541915 PMCID: PMC8460963 DOI: 10.1177/20587384211042115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hypercoagulability is a risk factor of thromboembolic events in COVID-19. Anti-phospholipid (aPL) antibodies have been hypothesized to be involved. Typical COVID-19 dermatological manifestations of livedo reticularis and digital ischemia may resemble cutaneous manifestations of anti-phospholipid syndrome (APS). OBJECTIVES To investigate the association between aPL antibodies and thromboembolic events, COVID-19 severity, mortality, and cutaneous manifestations in patients with COVID-19. METHODS aPL antibodies [anti-beta2-glycoprotein-1 (B2GP1) and anti-cardiolipin (aCL) antibodies] were titered in frozen serum samples from hospitalized COVID-19 patients and the patients' clinical records were retrospectively analyzed. RESULTS 173 patients were enrolled. aPL antibodies were detected in 34.7% of patients, anti-B2GP1 antibodies in 30.1%, and aCL antibodies in 10.4%. Double positivity was observed in 5.2% of patients. Thromboembolic events occurred in 9.8% of patients, including 11 pulmonary embolisms, 1 case of celiac tripod thrombosis, and six arterial ischemic events affecting the cerebral, celiac, splenic, or femoral-popliteal arteries or the aorta. aPL antibodies were found in 52.9% of patients with vascular events, but thromboembolic events were not correlated to aPL antibodies (adjusted OR = 1.69, p = 0.502). Ten patients (5.8%) had cutaneous signs of vasculopathy: nine livedo reticularis and one acrocyanosis. No significant association was observed between the presence of cutaneous vasculopathy and aPL antibodies (p = 0.692). CONCLUSIONS Anti-phospholipid antibodies cannot be considered responsible for hypercoagulability and thrombotic events in COVID-19 patients. In COVID-19 patients, livedo reticularis and acrocyanosis do not appear to be cutaneous manifestations of APS.
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Affiliation(s)
- Giulia Gasparini
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San MartinoIRCCS, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Paola Canepa
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Simonetta Verdiani
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Luca Carmisciano
- Section of Statistics, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San MartinoIRCCS, Genoa, Italy
| | - Denise De Grazia
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Orsi Andrea
- Hygiene and Preventive medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Hygiene and Preventive medicine Unit, Ospedale Policlinico San MartinoIRCCS, Genoa, Italy
| | - Giancarlo Icardi
- Hygiene and Preventive medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Hygiene and Preventive medicine Unit, Ospedale Policlinico San MartinoIRCCS, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Dermatology Unit, Ospedale Policlinico San MartinoIRCCS, Genoa, Italy
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20
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Bao SH, Frempong ST, Ruan JL. D-Dimer Assay May Guide LMWH Treatment in Repeated Biochemical Pregnancy Losses in Women with Positive Antiphospholipid Antibody. Clin Lab 2020; 66. [PMID: 32162875 DOI: 10.7754/clin.lab.2019.190637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Do D-dimer levels influence the pregnancy outcomes after treatment with low molecular weight heparin (LMWH) in women of recurrent miscarriage (RM), repeated biochemical pregnancy losses (BPL), and a positive test for antiphospholipid antibodies (aPLs)? METHODS This study was a retrospective chart review of 569 RM patients who were identified as having a history of BPL and a positive aPL. These patients were grouped into three groups according to their treatment plan including those who received low dose aspirin (LDA) alone (group A), LDA plus LMWH after ovulation therapy (group B), and LDA plus LMWH after pregnancy confirmation (group C). We hypothesized that the administration of LMWH after ovulation increased the rates of live birth. D-dimer may predict the pregnancy outcome after treatment. RESULTS The live birth rate of group B and group C is significantly higher than group A (86.96% and 66.80% vs. 52.89%, p < 0.0001, respectively). The live birth rate in group A, B, and C with elevated D-dimer is 36.92%, 90.52%, and 61.60% respectively. However, there is no significant difference in live birth rate among those who had normal baseline D-dimer. CONCLUSIONS These results suggest that LMWH therapy is more effective in improving the live birth rate when given after ovulation than after pregnancy confirmation. The plasma D-dimer assay can possibly guide LMWH treatment appropriately.
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21
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Tu TM, Goh C, Tan YK, Leow AS, Pang YZ, Chien J, Shafi H, Chan BP, Hui A, Koh J, Tan BY, Umapathi NT, Yeo LL. Cerebral Venous Thrombosis in Patients with COVID-19 Infection: a Case Series and Systematic Review. J Stroke Cerebrovasc Dis 2020; 29:105379. [PMID: 33254369 PMCID: PMC7538072 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105379] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/08/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There has been increasing reports associating the coronavirus disease 2019 (COVID-19) with thromboembolic phenomenon including ischemic strokes and venous thromboembolism. Cerebral venous thrombosis (CVT) is a rare neurovascular emergency that has been observed in some COVID-19 patients, yet much remains to be learnt of its underlying pathophysiology. OBJECTIVE We present a case series of local patients with concomitant COVID-19 infection and CVT; and aim to perform a systematic review of known cases in the current literature. METHODS We describe two patients with concomitant COVID-19 infection and CVT from a nationwide registry in Singapore. We then conducted a literature search in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 11th June 2020. All studies reporting CVT in COVID-19 patients were included. RESULTS Nine studies and 14 COVID-19 patients with CVT were studied. The median age was 43 years (IQR=36-58) and majority had no significant past medical conditions (60.0%). The time taken from onset of COVID-19 symptoms to CVT diagnosis was a median of 7 days (IQR=6-14). CVT was commonly seen in the transverse (75.0%) and sigmoid sinus (50.0%); 33.3% had involvement of the deep venous sinus system. A significant proportion of patients had raised D-dimer (75.0%) and CRP levels (50.0%). Two patients reported presence of antiphospholipid antibodies. Most patients received anticoagulation (91.7%) while overall mortality rate was 45.5%. CONCLUSIONS The high mortality rate of CVT in COVID-19 infection warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated.
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Affiliation(s)
- Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Kiat Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Aloysius St Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Yu Zhi Pang
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Jaime Chien
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Humaira Shafi
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Andrew Hui
- Division of Neurology, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Jasmine Koh
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore.
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22
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Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, Sule G, Gockman K, Madison JA, Zuo M, Yadav V, Wang J, Woodard W, Lezak SP, Lugogo NL, Smith SA, Morrissey JH, Kanthi Y, Knight JS. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci Transl Med 2020; 12:eabd3876. [PMID: 33139519 PMCID: PMC7724273 DOI: 10.1126/scitranslmed.abd3876] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/14/2020] [Accepted: 10/30/2020] [Indexed: 01/08/2023]
Abstract
Patients with COVID-19 are at high risk for thrombotic arterial and venous occlusions. Lung histopathology often reveals fibrin-based blockages in the small blood vessels of patients who succumb to the disease. Antiphospholipid syndrome is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies targeting phospholipids and phospholipid-binding proteins (aPL antibodies). Case series have recently detected aPL antibodies in patients with COVID-19. Here, we measured eight types of aPL antibodies in serum samples from 172 patients hospitalized with COVID-19. These aPL antibodies included anticardiolipin IgG, IgM, and IgA; anti-β2 glycoprotein I IgG, IgM, and IgA; and anti-phosphatidylserine/prothrombin (aPS/PT) IgG and IgM. We detected aPS/PT IgG in 24% of serum samples, anticardiolipin IgM in 23% of samples, and aPS/PT IgM in 18% of samples. Antiphospholipid autoantibodies were present in 52% of serum samples using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 ELISA-specific units). Higher titers of aPL antibodies were associated with neutrophil hyperactivity, including the release of neutrophil extracellular traps (NETs), higher platelet counts, more severe respiratory disease, and lower clinical estimated glomerular filtration rate. Similar to IgG from patients with antiphospholipid syndrome, IgG fractions isolated from patients with COVID-19 promoted NET release from neutrophils isolated from healthy individuals. Furthermore, injection of IgG purified from COVID-19 patient serum into mice accelerated venous thrombosis in two mouse models. These findings suggest that half of patients hospitalized with COVID-19 become at least transiently positive for aPL antibodies and that these autoantibodies are potentially pathogenic.
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Affiliation(s)
- Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Shanea K Estes
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ramadan A Ali
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alex A Gandhi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hui Shi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Division of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gautam Sule
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kelsey Gockman
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jacqueline A Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Melanie Zuo
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vinita Yadav
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jintao Wang
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Wrenn Woodard
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sean P Lezak
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Tan X, Ding J, Pu D, Wu J. Anti-phospholipid antibody may reduce endometrial receptivity during the window of embryo implantation. J Gynecol Obstet Hum Reprod 2020; 50:101912. [PMID: 32950746 DOI: 10.1016/j.jogoh.2020.101912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 04/07/2020] [Revised: 06/28/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anti-phospholipid antibodies (aPL) have been reported to be associated with repeated implantation failure (RIF), but the mechanism remains controversial. Endometrial receptivity is well known to be crucial for embryo implantation. This study aims to investigate the effect of aPL on endometrial receptivity in RIF women with positive aPL. METHODS Sixty-four infertile women with normal menstrual cycles were enrolled. The control group comprised 32 pregnant women with negative aPL who conceived successfully after their first in vitro fertilization-embryo transfer (IVF-ET) cycle, and the RIF group comprised 32 women with positive aPL. Endometrial biopsy samples were collected seven days after the luteinizing hormone surge (LH + 7). The expression of LIF and HOXA10 was evaluated by immunohistochemistry, qRT-PCR and Western blot. Endometrial pinopode development was examined by scanning electron microscopy. RESULTS The mRNA expression of LIF and HOXA10 in the RIF group was significantly decreased compared with that in the control group during the implantation window. The immunohistochemistry and Western blot results confirmed these findings. Then, ultrastructural analyses of endometrial cells showed fewer pinopode processes, a more atypical morphology and increased atrophy in the RIF group compared with the control group, and these results were statistically significant. CONCLUSION aPL positivity may inhibit the expression of LIF and HOXA10 in the endometrium and influence pinopode development. Our findings suggest that positivity for aPL is associated with impaired endometrial receptivity, which results in the development of RIF.
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Affiliation(s)
- Xiaofang Tan
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210029, China; Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, 226006, China
| | - Jiayi Ding
- Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, 226006, China
| | - Danhua Pu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210029, China.
| | - Jie Wu
- State Key Laboratory of Reproductive Medicine, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210029, China.
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Devreese KMJ, Linskens EA, Benoit D, Peperstraete H. Antiphospholipid antibodies in patients with COVID-19: A relevant observation? J Thromb Haemost 2020; 18:2191-2201. [PMID: 32619328 PMCID: PMC7361253 DOI: 10.1111/jth.14994] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND High incidence of thrombosis in COVID-19 patients indicates a hypercoagulable state. Hence, exploring the involvement of antiphospholipid antibodies (aPL) in these patients is of interest. OBJECTIVES To illustrate the incidence of criteria (lupus anticoagulant [LAC], anticardiolipin [aCL] immunoglobulin G [IgG]/IgM, antibeta2-glycoprotein I antibodies [aβ2GPI] IgG/IgM) and noncriteria (anti-phosphatidyl serine/prothrombin [aPS/PT], aCL, and aβ2GPI IgA) aPL in a consecutive cohort of critically ill SARS-CoV-2 patients, their association with thrombosis, antibody profile and titers of aPL. PATIENTS/METHODS Thirty-one consecutive confirmed COVID-19 patients admitted to the intensive care unit were included. aPL were measured at one time point, with part of the aPL-positive patients retested after 1 month. RESULTS Sixteen patients were single LAC-positive, two triple-positive, one double-positive, one single aCL, and three aCL IgG and LAC positive. Seven of nine thrombotic patients had at least one aPL. Sixteen of 22 patients without thrombosis were aPL positive, amongst them two triple positives. Nine of 10 retested LAC-positive patients were negative on a second occasion, as well as the double-positive patient. Seven patients were aPS/PT-positive associated to LAC. Three patients were aCL and aβ2GPI IgA-positive. CONCLUSION Our observations support the frequent single LAC positivity during (acute phase) observed in COVID-19 infection; however, not clearly related to thrombotic complications. Triple aPL positivity and high aCL/aβ2GPI titers are rare. Repeat testing suggests aPL to be mostly transient. Further studies and international registration of aPL should improve understanding the role of aPL in thrombotic COVID-19 patients.
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Affiliation(s)
- Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Eleni A Linskens
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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25
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Gatto M, Perricone C, Tonello M, Bistoni O, Cattelan AM, Bursi R, Cafaro G, De Robertis E, Mencacci A, Bozza S, Vianello A, Iaccarino L, Gerli R, Doria A, Bartoloni E. Frequency and clinical correlates of antiphospholipid antibodies arising in patients with SARS-CoV-2 infection: findings from a multicentre study on 122 cases. Clin Exp Rheumatol 2020; 38:754-759. [PMID: 32723434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES COVID-19 features include disseminated intravascular coagulation and thrombotic microangiopathy indicating a hypercoagulable state. We aimed to investigate antiphospholipid antibodies (aPL) prevalence and clinical relationships in a large cohort of COVID-19 patients. METHODS We analysed the prevalence and titres of serum aPL in 122 patients with COVID-19 and 157 with primary antiphospholipid syndrome (PAPS) and 91 with other autoimmune rheumatic diseases (oARD) for comparison. IgG/IgM anticardiolipin (aCL) and IgG/IgM anti-beta2glycoprotein I (β2GPI) were assayed using homemade ELISA, IgA aCL and anti-β2GPI by commercial ELISA kits and lupus anticoagulant (LAC) by multiple coagulation tests following updated international guidelines. RESULTS Prevalence of IgG and IgM aCL and of IgG and IgM anti-β2GPI across COVID-19 patients were 13.4%, 2.7%, 6.3% and 7.1%, being significantly lower than in PAPS (p<0.0001 for all). Frequency of IgG aCL and IgM anti-β2GPI was comparable to oARD (13.4% vs. 13.2% and 7.1% vs. 11%, respectively), while IgG anti-β2GPI and IgM aCL were lower (p<0.01). IgA aCL and IgA anti-β2GPI were retrieved in 1.7% and 3.3% of COVID-19 patients, respectively. Positive LAC was observed in 22.2% COVID-19 vs. 54.1% of PAPS (p<0.0001) and 14.6% of oARD (p=0.21). Venous or arterial thromboses occurred in 18/46 (39.1%) COVID-19 patients and were not associated with positive aPL (p=0.09). CONCLUSIONS Thrombosis is a frequent manifestation during COVID-19 infection. However, prevalence and titres of aPL antibodies or LAC were neither consistently increased nor associated with thrombosis when measured at a single timepoint, therefore not representing a suitable screening tool in the acute stage of disease.
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Affiliation(s)
- Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padova, Italy
| | - Carlo Perricone
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padova, Italy
| | - Onelia Bistoni
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
| | | | - Roberto Bursi
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
| | - Edoardo De Robertis
- Section of Anesthesia, Intensive Care and Pain, Department of Surgical and Biomedical Sciences, University of Perugia, Italy
| | - Antonella Mencacci
- Medical Microbiology Unit, Department of Medicine, University of Perugia, Italy
| | - Silvia Bozza
- Medical Microbiology Unit, Department of Medicine, University of Perugia, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, Department of Cardio-Thoracic and Vascular Sciences, University of Padova, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Italy
| | - Roberto Gerli
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Italy.
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine, University of Perugia, Italy
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26
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Yonezawa M, Kuwabara Y, Ono S, Ouchi N, Ichikawa T, Takeshita T. Significance of Anti-Phosphatidylethanolamine Antibodies in the Pathogenesis of Recurrent Pregnancy Loss. Reprod Sci 2020; 27:1888-1893. [PMID: 32548803 DOI: 10.1007/s43032-020-00208-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Anti-phosphatidylethanolamine antibody (aPE), an anti-phospholipid autoantibody (aPL), has been proposed as a factor in recurrent pregnancy loss (RPL). However, conflicting views exist on the pathogenicity of RPL, and aPE has not yet been included in the classification criteria for antiphospholipid syndrome (APS). Here, we aimed to determine the clinical importance of examining aPE. aPE (IgG, IgM) was measured in 1705 patients with a history of RPL and re-examined after a 12-week interval in patients who tested positive. Persistent positive patients were administered low-dose aspirin during the subsequent pregnancy and clinical outcomes depending on the presence, type, and persistence of aPE were evaluated. Among the patients positive for aPE IgG and aPE IgM in the first examination (n = 117; 6.87%, and n = 235; 13.6%, respectively), 31.5% and 37.6% were negative upon re-examination, respectively. Moreover, among the cases with known pregnancy outcome, the miscarriage rate in the cumulative positive aPE group was 32.6% (29/89), which did not differ significantly from that of the aPE negative group (27.7%; 80/209; P = 0.178). Alternatively, the miscarriage rate in the persistently positive group was 40.7% (22/54), which was significantly higher than that in the transient positive group, 20.0% (7/35) (P = 0.041). Particularly, this difference become more significant when focusing on aPE IgM, 46.9% (15/32) in the persistent, compared with 16.7% (4/24) in the transient positive group (P = 0.024). aPE IgM is suggested to serve as a pathogenic aPL together with anti-cardiolipin antibodies and lupus anticoagulants, particularly if these factors persist over an extended period of time.
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Affiliation(s)
- Mirei Yonezawa
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yoshimitsu Kuwabara
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Shuichi Ono
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Nozomi Ouchi
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Tomoko Ichikawa
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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27
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Hamulyák EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev 2020; 5:CD012852. [PMID: 32358837 PMCID: PMC7195627 DOI: 10.1002/14651858.cd012852.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Aspirin and heparin are widely used as preventive strategy to reduce the high risk of recurrent pregnancy loss in women with antiphospholipid antibodies (aPL). This review supersedes a previous, out-of-date review that evaluated all potential therapies for preventing recurrent pregnancy loss in women with aPL. The current review focusses on a narrower scope because current clinical practice is restricted to using aspirin or heparins, or both for women with aPL in an attempt to reduce pregnancy complications. OBJECTIVES To assess the effects of aspirin or heparin, or both for improving pregnancy outcomes in women with persistent (on two separate occasions) aPL, either lupus anticoagulant (LAC), anticardiolipin (aCL) or aβ2-glycoprotein-I antibodies (aβ2GPI) or a combination, and recurrent pregnancy loss (two or more, which do not have to be consecutive). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 June 2019), and reference lists of retrieved studies. Where necessary, we attempted to contact trial authors. SELECTION CRITERIA Randomised, cluster-randomised and quasi-randomised controlled trials that assess the effects of aspirin, heparin (either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH]), or a combination of aspirin and heparin compared with no treatment, placebo or another, on pregnancy outcomes in women with persistent aPL and recurrent pregnancy loss were eligible. All treatment regimens were considered. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion criteria and risk of bias. Two review authors independently extracted data and checked them for accuracy and the certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Eleven studies (1672 women) met the inclusion criteria; nine randomised controlled trials and two quasi-RCTs. The studies were conducted in the USA, Canada, UK, China, New Zealand, Iraq and Egypt. One included trial involved 1015 women, all other included trials had considerably lower numbers of participants (i.e. 141 women or fewer). Some studies had high risk of selection and attrition bias, and many did not include sufficient information to judge the risk of reporting bias. Overall, the certainty of evidence is low to very low due to the small numbers of women in the studies and to the risk of bias. The dose and type of heparin and aspirin varied among studies. One study compared aspirin alone with placebo; no studies compared heparin alone with placebo and there were no trials that had a no treatment comparator arm during pregnancy; five studies explored the efficacy of heparin (either UFH or LMWH) combined with aspirin compared with aspirin alone; one trial compared LMWH with aspirin; two trials compared the combination of LMWH plus aspirin with the combination of UFH plus aspirin; two studies evaluated the combination of different doses of heparin combined with aspirin. All trials used aspirin at a low dose. Aspirin versus placebo We are very uncertain if aspirin has any effect on live birth compared to placebo (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71 to 1.25, 1 trial, 40 women, very low-certainty evidence). We are very uncertain if aspirin has any effect on the risk of pre-eclampsia, pregnancy loss, preterm delivery of a live infant, intrauterine growth restriction or adverse events in the child, compared to placebo. We are very uncertain if aspirin has any effect on adverse events (bleeding) in the mother compared with placebo (RR 1.29, 95% CI 0.60 to 2.77, 1 study, 40 women). The certainty of evidence for these outcomes is very low because of imprecision, due to the low numbers of women involved and the wide 95% CIs, and also because of risk of bias. Venous thromboembolism and arterial thromboembolism were not reported in the included studies. Heparin plus aspirin versus aspirin alone Heparin plus aspirin may increase the number of live births (RR 1.27, 95% CI 1.09 to 1.49, 5 studies, 1295 women, low-certainty evidence). We are uncertain if heparin plus aspirin has any effect on the risk of pre-eclampsia, preterm delivery of a live infant, or intrauterine growth restriction, compared with aspirin alone because of risk of bias and imprecision due to the low numbers of women involved and the wide 95% CIs. We are very uncertain if heparin plus aspirin has any effect on adverse events (bleeding) in the mother compared with aspirin alone (RR 1.65, 95% CI 0.19 to 14.03, 1 study, 31 women). No women in either the heparin plus aspirin group or the aspirin alone group had heparin-induced thrombocytopenia, allergic reactions, or venous or arterial thromboembolism. Similarly, no infants had congenital malformations. Heparin plus aspirin may reduce the risk of pregnancy loss (RR 0.48, 95% CI 0.32 to 0.71, 5 studies, 1295 women, low-certainty evidence). When comparing LMWH plus aspirin versus aspirin alone the pooled RR for live birth was 1.20 (95% CI 1.04 to 1.38, 3 trials, 1155 women). In the comparison of UFH plus aspirin versus aspirin alone, the RR for live birth was 1.74 (95% CI 1.28 to 2.35, 2 trials, 140 women). AUTHORS' CONCLUSIONS The combination of heparin (UFH or LMWH) plus aspirin during the course of pregnancy may increase live birth rate in women with persistent aPL when compared with aspirin treatment alone. The observed beneficial effect of heparin was driven by one large study in which LMWH plus aspirin was compared with aspirin alone. Adverse events were frequently not, or not uniformly, reported in the included studies. More research is needed in this area in order to further evaluate potential risks and benefits of this treatment strategy, especially among women with aPL and recurrent pregnancy loss, to gain consensus on the ideal prevention for recurrent pregnancy loss, based on a risk profile.
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Affiliation(s)
- Eva N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Luuk Jj Scheres
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mauritia C Marijnen
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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28
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Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, Chen H, Ding X, Zhao H, Zhang H, Wang C, Zhao J, Sun X, Tian R, Wu W, Wu D, Ma J, Chen Y, Zhang D, Xie J, Yan X, Zhou X, Liu Z, Wang J, Du B, Qin Y, Gao P, Qin X, Xu Y, Zhang W, Li T, Zhang F, Zhao Y, Li Y, Zhang S. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med 2020; 382:e38. [PMID: 32268022 PMCID: PMC7161262 DOI: 10.1056/nejmc2007575] [Citation(s) in RCA: 1549] [Impact Index Per Article: 387.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The authors describe a 69-year-old man with Covid-19 diagnosed in January 2020 in Wuhan, China, along with two other critically ill patients with Covid-19 who were also seen in the same intensive care unit. Coagulopathy and antiphospholipid antibodies were seen in all three patients.
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Affiliation(s)
- Yan Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Meng Xiao
- Peking Union Medical College Hospital, Beijing, China
| | - Shulan Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Peng Xia
- Peking Union Medical College Hospital, Beijing, China
| | - Wei Cao
- Peking Union Medical College Hospital, Beijing, China
| | - Wei Jiang
- Peking Union Medical College Hospital, Beijing, China
| | - Huan Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Xin Ding
- Peking Union Medical College Hospital, Beijing, China
| | - Hua Zhao
- Peking Union Medical College Hospital, Beijing, China
| | - Hongmin Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Chunyao Wang
- Peking Union Medical College Hospital, Beijing, China
| | - Jing Zhao
- Peking Union Medical College Hospital, Beijing, China
| | - Xuefeng Sun
- Peking Union Medical College Hospital, Beijing, China
| | - Ran Tian
- Peking Union Medical College Hospital, Beijing, China
| | - Wei Wu
- Peking Union Medical College Hospital, Beijing, China
| | - Dong Wu
- Peking Union Medical College Hospital, Beijing, China
| | - Jie Ma
- Peking Union Medical College Hospital, Beijing, China
| | - Yu Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Dong Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Jing Xie
- Peking Union Medical College Hospital, Beijing, China
| | - Xiaowei Yan
- Peking Union Medical College Hospital, Beijing, China
| | - Xiang Zhou
- Peking Union Medical College Hospital, Beijing, China
| | - Zhengyin Liu
- Peking Union Medical College Hospital, Beijing, China
| | - Jinglan Wang
- Peking Union Medical College Hospital, Beijing, China
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, China
| | - Yan Qin
- Peking Union Medical College Hospital, Beijing, China
| | - Peng Gao
- Peking Union Medical College Hospital, Beijing, China
| | - Xuzhen Qin
- Peking Union Medical College Hospital, Beijing, China
| | - Yingchun Xu
- Peking Union Medical College Hospital, Beijing, China
| | - Wen Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Taisheng Li
- Peking Union Medical College Hospital, Beijing, China
| | | | | | - Yongzhe Li
- Peking Union Medical College Hospital, Beijing, China
| | - Shuyang Zhang
- Peking Union Medical College Hospital, Beijing, China
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29
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Doms J, Horisberger A, Ribi C. [Management of the antiphospholipid syndrome in adults]. Rev Med Suisse 2020; 16:670-674. [PMID: 32270932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The antiphospholipid syndrome (APS) is a complex autoimmune -disease characterized by the expression of antiphospholipid -antibodies (APL) and a variety of clinical presentation. The latest classification defines APS by the occurrence of vascular thrombosis and/or typical obstetrical morbidity together with persistently -detectable APL at least 12 weeks apart. The latest recommendation proposes a risk profile based on the type and titer of APL detected, in order to guide the intensity of prophylactic measures. Based on current knowledge, novel oral anticoagulants should not be used in APS, particularly in patients with a high-risk APL profile or arterial thrombosis. Beyond the mere aspect of anticoagulant treatment, immunomodulatory approaches to the APS such as hydroxychloroquine are under investigation.
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Affiliation(s)
- Jacqueline Doms
- Service d'immunologie et allergologie, Département de médecine interne, CHUV, 1011 Lausanne
| | - Alice Horisberger
- Service d'immunologie et allergologie, Département de médecine interne, CHUV, 1011 Lausanne
| | - Camillo Ribi
- Service d'immunologie et allergologie, Département de médecine interne, CHUV, 1011 Lausanne
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30
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Ferrannini G, Svenungsson E, Kjellström B, Elvin K, Grosso G, Näsman P, Rydén L, Norhammar A. Antiphospholipid antibodies in patients with dysglycaemia: A neglected cardiovascular risk factor? Diab Vasc Dis Res 2020; 17:1479164120922123. [PMID: 32506943 PMCID: PMC7607409 DOI: 10.1177/1479164120922123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiovascular disease is a serious complication in patients with dysglycaemia, defined as either type 2 diabetes or impaired glucose tolerance. Research focusing on the identification of potential markers for atherothrombotic disease in these subjects is warranted. The antiphospholipid syndrome is a common acquired prothrombotic condition, defined by a combination of thrombotic events and/or obstetric morbidity and positivity of specific antiphospholipid antibodies. Available information on antiphospholipid antibodies in dysglycaemia is scarce. OBJECTIVE This study investigates the association between antiphospholipid antibodies and dysglycaemia. PATIENTS/METHODS The PAROKRANK (periodontitis and its relation to coronary artery disease) study included 805 patients, investigated 6-10 weeks after a first myocardial infarction, and 805 matched controls. Participants without known diabetes (91%) underwent an oral glucose tolerance test. Associations between antiphospholipid antibodies (anti-cardiolipin and anti-β2 glycoprotein-I IgG, IgM and IgA) and dysglycaemia were analysed. RESULTS In total, 137 (9%) subjects had previously known type 2 diabetes and 371 (23%) newly diagnosed dysglycaemia. Compared with the normoglycaemic participants, those with dysglycaemia had a higher proportion with first myocardial infarction (61% vs 45%, p < 0.0001) and were more often antiphospholipid antibody IgG positive (8% vs 5%; p = 0.013). HbA1c, fasting glucose and 2-h glucose were significantly associated to antiphospholipid antibody IgG. Odds ratios (ORs) were 1.04 (95% confidence interval [CI] 1.02-1.06), 1.14 (95% CI 1.00 - 1.27) and 1.12 (95% CI 1.04 - 1.21), respectively, after adjustments for age, gender and smoking. CONCLUSIONS This study reports an association between antiphospholipid antibody IgG positivity and dysglycaemia. Further studies are needed to verify these findings and to investigate if antithrombotic therapy reduces vascular complications in antiphospholipid antibody positive subjects with dysglycaemia.
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Affiliation(s)
- Giulia Ferrannini
- Cardiology Unit, Department of Medicine
Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Giulia Ferrannini, Department of Medicine,
Heart & Vascular Theme, Karolinska Institutet, Karolinska University
Hospital, Solnavägen 1, Stockholm, 171 77, Sweden.
| | - Elisabet Svenungsson
- Rheumatology Unit, Department of
Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
| | - Barbro Kjellström
- Cardiology Unit, Department of Medicine
Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
| | - Kerstin Elvin
- Division of Immunology and Allergy,
Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital,
Stockholm, Sweden
| | - Giorgia Grosso
- Rheumatology Unit, Department of
Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
| | - Per Näsman
- Centre for Safety Research, KTH Royal
Institute of Technology, Stockholm, Sweden
| | - Lars Rydén
- Cardiology Unit, Department of Medicine
Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
| | - Anna Norhammar
- Cardiology Unit, Department of Medicine
Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Capio Saint Görans Hospital, Stockholm,
Sweden
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Zhou Z, Ye J, Teng J, Liu H, Cheng X, Sun Y, Su Y, Chi H, Wang F, Yang C, Jin W. Clinical characteristics of infective endocarditis in patients with antineutrophil cytoplasmic antibody or antiphospholipid antibody: a retrospective study in Shanghai. BMJ Open 2020; 10:e031512. [PMID: 32051300 PMCID: PMC7044959 DOI: 10.1136/bmjopen-2019-031512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This study aimed to characterise rheumatic manifestations and autoantibodies in 432 patients diagnosed with infective endocarditis (IE) in Shanghai. DESIGN, SETTING AND PARTICIPANTS A retrospective study was conducted in Ruijin Hospital from 1997 to 2017. The clinical and laboratory characteristics of a total of 432 patients were analysed. In addition, the differences between patients with positive and negative antineutrophil cytoplasmic antibodies (ANCA) and antiphospholipid (aPL) antibodies as well as the survival rates of these patients were compared. RESULTS A total of 432 patients, including 278 male patients and 154 female patients, were included. The mean age of the patients was 46±16 years. A total of 346 patients (80%) had cardiac surgery, and 55 patients (13%) died in the hospital. Among the IE patients, 104 were tested for either ANCA or aPL and were analysed in different groups. Twenty-one (24%) positive ANCA patients were proteinase 3-ANCA positive. Compared with the ANCA-negative group, patients with positive ANCA had higher IgM (p=0.048), lower haemoglobin (p=0.001) and a higher likelihood of arthritis (p=0.003). Twenty-one (40%) aPL-positive patients had a higher erythrocyte sedimentation rate than was found in the aPL-negative group (p=0.003). In addition, the survival rate of the ANCA-positive IE patients was lower (p=0.032) than that of the ANCA-negative group, while there was no difference between patients with or without aPL antibodies (p=0.728). CONCLUSION This study supports the claim that rheumatic manifestations and autoantibodies are frequently present in patients with IE and might lead to early misdiagnosis. Physicians should pay more attention to the measurement of autoantibodies in these patients.
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Affiliation(s)
- Zhuochao Zhou
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huihui Chi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Jin
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Shima N, Akiyama Y, Yamamoto S, Kokuzawa A, Nagatani K, Iwamoto M, Matsubara D, Kawai S, Sato K, Minota S. A Non-smoking Woman with Anti-phospholipid Antibodies Proved to Have Thromboangiitis Obliterans. Intern Med 2020; 59:439-443. [PMID: 31588083 PMCID: PMC7028403 DOI: 10.2169/internalmedicine.3372-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 48-year-old woman with severe pain and numbness of her right leg and foot was admitted to our hospital. She had never smoked and had little exposure to passive smoking. Initially, polyarteritis nodosa with anti-phospholipid antibodies was considered. Combination therapy with methylprednisolone pulse therapy, intravenous cyclophosphamide pulse therapy, vasodilators, antiplatelet agents, and anticoagulants was not effective. Vasculopathy was progressive, and she presented with gangrene of the toes. She required amputation of her right leg. The pathological findings of the amputated leg revealed thromboangiitis obliterans (TAO). TAO should be considered even in non-smoking women. Non-response to immunosuppressant and anticoagulant therapies may be a clue to the diagnosis of TAO.
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Affiliation(s)
- Natsuki Shima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Yoichiro Akiyama
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Shotaro Yamamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Ayako Kokuzawa
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
- Department of Rheumatology, Tochigi Medical Center Shimotsuga, Japan
| | | | - Shigeo Kawai
- Department of Diagnostic Pathology, Tochigi Medical Center Shimotsuga, Japan
| | - Kojiro Sato
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
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Linge P, Arve S, Olsson LM, Leonard D, Sjöwall C, Frodlund M, Gunnarsson I, Svenungsson E, Tydén H, Jönsen A, Kahn R, Johansson Å, Rönnblom L, Holmdahl R, Bengtsson A. NCF1-339 polymorphism is associated with altered formation of neutrophil extracellular traps, high serum interferon activity and antiphospholipid syndrome in systemic lupus erythematosus. Ann Rheum Dis 2020; 79:254-261. [PMID: 31704719 DOI: 10.1136/annrheumdis-2019-215820] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 06/01/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES: A single nucleotide polymorphism in the NCF1 gene (NCF1-339, rs201802880), encoding NADPH oxidase type II subunit NCF1/p47phox, reducing production of reactive oxygen species (ROS) is strongly associated with the development of systemic lupus erythematosus (SLE). This study aimed at characterising NCF1-339 effects on neutrophil extracellular trap (NET) formation, type I interferon activity and antibody profile in patients with SLE. METHODS: Neutrophil NET-release pathways (n=31), serum interferon (n=141) and finally antibody profiles (n=305) were investigated in SLE subjects from Lund, genotyped for NCF1-339. Then, 1087 SLE subjects from the rheumatology departments of four Swedish SLE centres, genotyped for NCF1-339, were clinically characterised to validate these findings. RESULTS: Compared with patients with normal-ROS NCF1-339 genotypes, neutrophils from patients with SLE with low-ROS NCF1-339 genotypes displayed impaired NET formation (p<0.01) and increased dependence on mitochondrial ROS (p<0.05). Low-ROS patients also had increased frequency of high serum interferon activity (80% vs 21.4%, p<0.05) and positivity for anti-β2 glycoprotein I (p<0.01) and anticardiolipin antibodies (p<0.05) but were not associated with other antibodies. We confirmed an over-representation of having any antiphospholipid antibody, OR 1.40 (95% CI 1.01 to 1.95), anti-β2 glycoprotein I, OR 1.82 (95% CI 1.02 to 3.24) and the antiphospholipid syndrome (APS), OR 1.74 (95% CI 1.19 to 2.55) in all four cohorts (n=1087). CONCLUSIONS: The NCF1-339 SNP mediated decreased NADPH oxidase function, is associated with high interferon activity and impaired formation of NETs in SLE, allowing dependence on mitochondrial ROS. Unexpectedly, we revealed a striking connection between the ROS deficient NCF1-339 genotypes and the presence of phospholipid antibodies and APS.
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Affiliation(s)
- Petrus Linge
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Sabine Arve
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Lina M Olsson
- Department of Medical Biochemistry and Biophysics, Division of Medical Inflammation Research, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Dag Leonard
- Department of Medical Sciences, Science for Life Laboratories, Rheumatology Unit, Uppsala University, Uppsala, Uppland, Sweden
| | - Christopher Sjöwall
- Department of Clinical and Experimental Medicine, Rheumatology/AIR, Linköping University, Linkoping, Ostergotland, Sweden
| | - Martina Frodlund
- Department of Clinical and Experimental Medicine, Rheumatology/AIR, Linköping University, Linkoping, Ostergotland, Sweden
| | - Iva Gunnarsson
- Department of Medicine Solna, Unit of Rheumatology, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Elisabet Svenungsson
- Department of Medicine Solna, Unit of Rheumatology, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Helena Tydén
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
| | - Robin Kahn
- Department of Clinical Sciences Lund, Section of Pediatrics, Lund University, Lund, Skane, Sweden
- Wallenberg Center for Molecular Medicin, Lund University, Lund, Skane, Sweden
| | - Åsa Johansson
- Division for Hematology and Transfusion Medicine, Department of laboratory medicine, Lund University, Lund, Skane, Sweden
- Regional Laboratories Region Skane, Department of Clinical Immunology and Transfusion Medicine, Skanes universitetssjukhus Lund Labmedicin Skane, Lund, Skane, Sweden
| | - Lars Rönnblom
- Department of Medical Sciences, Science for Life Laboratories, Rheumatology Unit, Uppsala University, Uppsala, Uppland, Sweden
| | - Rikard Holmdahl
- Department of Medical Biochemistry and Biophysics, Division of Medical Inflammation Research, Karolinska Institute, Stockholm, Stockholm County, Sweden
| | - Anders Bengtsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lunds University Faculty of Medicine, Lund, Skane, Sweden
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Islam MA, Alam SS, Kundu S, Prodhan AHMSU, Khandker SS, Reshetnyak T, Kotyla PJ, Hassan R, Hossan T. Prevalence of antiphospholipid antibodies in Behçet's disease: A systematic review and meta-analysis. PLoS One 2020; 15:e0227836. [PMID: 31929597 PMCID: PMC6957187 DOI: 10.1371/journal.pone.0227836] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/30/2019] [Indexed: 01/31/2023] Open
Abstract
Behçet's disease (BD) is a multifactorial systemic inflammatory disease of unknown aetiology characterised by several clinical manifestations including vascular involvements (i.e., both arterial and venous thrombosis). Antiphospholipid antibodies (aPLs)-including anticardiolipin (aCL), anti-β2-glycoprotein I (β2-GPI) antibodies and lupus anticoagulant (LA) are detected in systemic autoimmune diseases which contribute to thrombosis. The aim of this systematic review and meta-analysis was to evaluate the prevalence of aPLs in patients with BD as compared to controls. A protocol was registered in PROSPERO (Registration No. CRD42018088125) and a systematic literature search was conducted through PubMed, Web of Science, Embase, Scopus and ScienceDirect databases. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects model. Quality assessment was carried out by using the modified 9-star Newcastle-Ottawa Scale (NOS). Publication bias was evaluated via visualisation of contour- enhanced and trim and fill funnel plots along with Begg's and Egger's tests. We included ten case-control studies (a total of 999 participants from 380 BD patients and 619 controls) based on the inclusion criteria. The prevalence of aCL (OR: 12.10, 95% CI: 5.15-28.41, p<0.00001) and anti-β2-GPI antibodies (OR: 23.57, 95% CI: 1.31-423.63, p = 0.03) were statistically significant, however, the prevalence of LA was not significant (OR: 13.77, 95% CI: 0.65-293.59, p = 0.09). The results remained statistically significant from different sensitivity analyses which represented the robustness of this meta-analysis. According to the NOS, 50.0% of the studies were considered as of high methodological quality (low risk of bias). No significant publication bias was detected from contour-enhanced and trim and fill funnel plots or Begg's and Egger's tests. This meta-analysis established that there is a significantly high prevalence of aPLs (i.e., aCL and anti-β2-GPI antibodies) in patients with BD when compared to controls.
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Affiliation(s)
- Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Sayeda Sadia Alam
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka , Bangladesh
| | - Shoumik Kundu
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka , Bangladesh
| | | | - Shahad Saif Khandker
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka , Bangladesh
| | - Tatiana Reshetnyak
- Department of Systemic Rheumatic Disease, V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - Przemysław J. Kotyla
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Faculty in Katowice, Medical University of Silesia, Katowice, Poland
| | - Rosline Hassan
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Tareq Hossan
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka , Bangladesh
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Vinholt PJ, Just SA. Escaping the catch 22 of lupus anticoagulant testing. RMD Open 2020; 6:rmdopen-2019-001156. [PMID: 32144138 PMCID: PMC7059445 DOI: 10.1136/rmdopen-2019-001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/23/2020] [Accepted: 02/13/2020] [Indexed: 11/03/2022] Open
Abstract
High-risk patients with antiphospholipid syndrome (APS) experience increased risk of thrombosis when treated with direct oral anticoagulant (DOAC) therapy compared with warfarin. It is essential to establish the APS diagnosis to choose therapy and determine treatment duration. It requires testing for antiphospholipid antibodies, including lupus anticoagulant (LAC). In this viewpoint, we discuss the options for timing of LAC testing, which includes testing before starting anticoagulant treatment (DOAC or warfarin), after switching to heparin or after withdrawal of anticoagulant treatment. DOACs interfere with LAC testing and recommendations emerge stating not to conduct on-therapy LAC testing. All approaches are to some extent currently practised, but have limitations and the area is therefore seemingly a catch 22. We put forward that the anticoagulant effect of DOAC can be eliminated in the laboratory and therefore patients can be tested on-therapy. While it may not eliminate all cases of interference, it could aid the interpretation in these situations and this approach is attractive from the patient and clinician’s perspective. Nevertheless, to prevent misdiagnosis the diagnostic workup for APS requires collaboration between the clinician and the laboratory. We advocate for standardisation in laboratory and clinical practice when diagnosing APS.
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Affiliation(s)
| | - Søren Andreas Just
- Section of Rheumatology, Department of Medicine, Svendborg Hospital - Odense University Hospital, Svendborg, Denmark
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Abstract
Antiphospholipid syndrome (APS) is a rare systemic autoimmune disease, the obstetric features of which include recurrent early miscarriage, fetal death at or beyond 10 weeks of gestation, and early delivery for severe preeclampsia or placental insufficiency. Controversies regarding the specificity of these obstetric clinical features, as well as the laboratory diagnostic criteria, are the subject of current debate and reanalysis. Clinical and laboratory features can be used to stratify women with APS in terms of risk of adverse second and third trimester pregnancy outcomes. Numerous "treatments" have been used in high-risk and refractory patients, but rigorously designed clinical trials are needed. APS is a rare disease that requires innovative investigative approaches to provide credible results.
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Affiliation(s)
- D Ware Branch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT
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37
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Radin M, Sciascia S, Erkan D, Pengo V, Tektonidou MG, Ugarte A, Meroni P, Ji L, Belmont HM, Cohen H, Ramires de Jesús G, Branch DW, Fortin PR, Andreoli L, Petri M, Rodriguez E, Rodriguez-Pinto I, Knight JS, Atsumi T, Willis R, Gonzalez E, Lopez-Pedrera R, Rossi Gandara AP, Borges Gualhardo Vendramini M, Banzato A, Sevim E, Barbhaiya M, Efthymiou M, Mackie I, Bertolaccini ML, Andrade D. The adjusted global antiphospholipid syndrome score (aGAPSS) and the risk of recurrent thrombosis: Results from the APS ACTION cohort. Semin Arthritis Rheum 2019; 49:464-468. [PMID: 31153708 PMCID: PMC7402528 DOI: 10.1016/j.semarthrit.2019.04.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/01/2019] [Accepted: 04/29/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess whether patients with antiphospholipid syndrome (APS) and history of recurrent thrombosis have higher levels of adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) when compared to patients without recurrent thrombosis. METHODS In this cross-sectional study of antiphospholipid antibody (aPL)-positive patients, we identified APS patients with a history of documented thrombosis from the AntiPhospholipid Syndrome Alliance For Clinical Trials and InternatiOnal Networking (APS ACTION) Clinical Database and Repository ("Registry"). Data on aPL-related medical history and cardiovascular risk factors were retrospectively collected. The aGAPSS was calculated at Registry entry by adding the points corresponding to the risk factors: three for hyperlipidemia, one for arterial hypertension, five for positive anticardiolipin antibodies, four for positive anti-β2 glycoprotein-I antibodies and four for positive lupus anticoagulant test. RESULTS The analysis included 379 APS patients who presented with arterial and/or venous thrombosis. Overall, significantly higher aGAPSS were seen in patients with recurrent thrombosis (arterial or venous) compared to those without recurrence (7.8 ± 3.3 vs. 6 ± 3.9, p<0.05). When analyzed based on the site of the recurrence, patients with recurrent arterial, but not venous, thrombosis had higher aGAPSS (8.1 ± SD 2.9 vs. 6 ± 3.9; p<0.05). CONCLUSIONS Based on analysis of our international large-scale Registry of aPL-positive patients, the aGAPSS might help risk stratifying patients based on the likelihood of developing recurrent thrombosis in APS.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, Turin 10124, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Piazza del Donatore di Sangue 3, Turin 10124, Italy.
| | - Doruk Erkan
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Amaia Ugarte
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Bizkaia, The Basque Country, Spain
| | - Pierluigi Meroni
- Laboratory of Immuno-Rheumatology Research, Istituto Auxologico Italiano, Milan, Italy
| | - Lanlan Ji
- Peking University First Hospital, Beijing, China
| | - H Michael Belmont
- NYU School of Medicine Langone Medical Center, New York, NY, United States
| | - Hannah Cohen
- University College London, London, United Kingdom
| | | | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, United States
| | | | - Laura Andreoli
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Ignasi Rodriguez-Pinto
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | | | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, TX,United States
| | - Emilio Gonzalez
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, TX,United States
| | | | | | | | | | - Ecem Sevim
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Medha Barbhaiya
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, United States
| | | | - Ian Mackie
- University College London, London, United Kingdom
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom
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Khizroeva J, Nalli C, Bitsadze V, Lojacono A, Zatti S, Andreoli L, Tincani A, Shoenfeld Y, Makatsariya A. Infertility in women with systemic autoimmune diseases. Best Pract Res Clin Endocrinol Metab 2019; 33:101369. [PMID: 31837981 DOI: 10.1016/j.beem.2019.101369] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Infertility consists by definition in" failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse" while the term subfertility means a delay to achieve pregnancy. Several factors can contribute to infertility or subfertility in patients with systemic autoimmune diseases. The association of systemic autoimmune conditions with endometriosis, celiac disease and thyroid autoimmunity that are well known causes of infertility and/or subfertility need to be taken in consideration when difficulties in the onset of pregnancy is reported. The majority of the used antirheumatic drugs do not interfere with fertility. However, the use of cyclophosphamide, limited to severe disease, can provoke premature ovarian failure; to preserve fertility a preventive treatment is available. Nonsteroidal anti-inflammatory drugs can cause temporary infertility and corticosteroids are associated to a prolonged time to pregnancy in some rheumatic diseases. Data on the association of antiphospholipid antibodies (aPL) with infertility are still debated but in general an increased rate of aPL is described patients undergoing medically assisted reproductive techniques. In systemic lupus erythematosus aPL and other autoantibodies (i.e. anti-oocytes) can contribute to the infertility of some patients. Subfertility, rather than infertility, is observed in patients with rheumatoid arthritis; the particular physical conditions of these women can also account for this. Physicians should not forget the patients' age, that is mandatory in order to preserve their chance to have children.
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Affiliation(s)
- Jamilya Khizroeva
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Cecilia Nalli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili Brescia, Italy
| | - Victoria Bitsadze
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Andrea Lojacono
- Obstetric and Gynecology Unit, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili Brescia, Italy
| | - Sonia Zatti
- Obstetric and Gynecology Unit, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili Brescia, Italy
| | - Angela Tincani
- Rheumatology and Immunology Unit, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili Brescia, Italy; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
| | - Yehuda Shoenfeld
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia; Department of Medicine 'B', The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Alexander Makatsariya
- Department of Obstetrics and Gynecology of I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Cruz ACL, Colella MP, De Paula EV, Annichinno-Bizzachi J, Orsi FA. Clinical course of primary immune thrombocytopenia with positive antiphospholipid antibodies. Eur J Intern Med 2019; 69:e6-e7. [PMID: 31447273 DOI: 10.1016/j.ejim.2019.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/14/2019] [Accepted: 08/17/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Ana Clara Ladeira Cruz
- School of Medical Sciences, University of Campinas, Brazil RuaTessália Vieira de Camargo, 126. Cidade Universitária "Zeferino Vaz", CEP: 13083-887 Campinas, SP, Brazil.
| | - Marina Pereira Colella
- Thrombosis and Haemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, Rua Carlos Chagas, 480. Cidade Universitária "ZeferinoVaz", CEP: 13083-970 Campinas, SP, Brazil.
| | - Erich Vinícius De Paula
- Thrombosis and Haemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, Rua Carlos Chagas, 480. Cidade Universitária "ZeferinoVaz", CEP: 13083-970 Campinas, SP, Brazil; Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Brazil RuaTessália Vieira de Camargo, 126. Cidade Universitária "Zeferino Vaz", CEP: 13083-887 Campinas, SP, Brazil.
| | - Joyce Annichinno-Bizzachi
- Thrombosis and Haemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, Rua Carlos Chagas, 480. Cidade Universitária "ZeferinoVaz", CEP: 13083-970 Campinas, SP, Brazil; Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Brazil RuaTessália Vieira de Camargo, 126. Cidade Universitária "Zeferino Vaz", CEP: 13083-887 Campinas, SP, Brazil.
| | - Fernanda Andrade Orsi
- School of Medical Sciences, University of Campinas, Brazil RuaTessália Vieira de Camargo, 126. Cidade Universitária "Zeferino Vaz", CEP: 13083-887 Campinas, SP, Brazil; Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Brazil Rua Tessália Vieira de Camargo, 126. Cidade Universitária "ZeferinoVaz", CEP: 13083-887 Campinas, SP, Brazil.
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Ząbczyk M, Celińska-Löwenhoff M, Plens K, Iwaniec T, Musiał J, Undas A. Antiphosphatidylserine/prothrombin complex antibodies as a determinant of prothrombotic plasma fibrin clot properties in patients with antiphospholipid syndrome. J Thromb Haemost 2019; 17:1746-1755. [PMID: 31220407 DOI: 10.1111/jth.14551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 04/02/2019] [Revised: 05/30/2019] [Accepted: 06/14/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiphosphatidylserine/prothrombin complex (aPS/PT) antibodies are recognized as a marker for antiphospholipid syndrome (APS). Dense and poorly lysable fibrin clots occur in thrombotic APS. Compact clots predict thromboembolism, but determinants of the unfavorable clot phenotype remain unknown in APS. We hypothesized that elevated aPS/PT antibodies determine unfavorable clot features. METHODS In a cohort study involving 124 consecutive patients with thrombotic APS, we measured at baseline plasma fibrin clot permeability (Ks ), efficiency of fibrinolysis (clot lysis time, CLT), and turbidity (off anticoagulation) along with immunoglobulin (Ig)G/IgM aPS/PT. During follow-up, symptomatic thromboembolic events were recorded. RESULTS Elevated IgG and IgM aPS/PT antibodies >30 international enzyme units (UI) were detected in 54.8% and 42.7% of APS patients, including 76.2% and 54% of lupus anticoagulant- (LA, n = 63) positive patients, respectively. Elevated IgG and IgM aPS/PT antibodies predicted low Ks (lower quartile, <6 × 10-9 cm2 ; odds ratio [OR] = 5.93, 95% confidence interval [CI] 2.09-16.82 and OR = 11.79, 95% CI 4.10-33.92) and prolonged CLT (top quartile, ≥116 min; OR = 4.85, 95% CI 2.42-25.07 and OR = 6.04, 95% CI 2.42-15.07). No such associations were observed for anticardiolipin or β2-glycoprotein I antibodies or LA presence. During follow-up (median 72.5, range 66-83 months), thromboembolic events observed in 32 (26.7%, 4.6%/year) patients were independently predicted by IgG aPS/PT antibodies >30 UI (hazard ratio [HR] = 3.04, 95% CI 1.20-8.88) and low Ks (HR = 3.00, 95% CI 1.41-6.50). CONCLUSIONS We identified aPS/PT antibodies as a determinant of denser and poorly lysable plasma fibrin clot formation in APS patients. The association of elevated aPS/PT antibodies with thromboembolism in APS could be at least in part mediated by prothrombotic clot properties.
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Affiliation(s)
- Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Krakow, Poland
| | | | | | - Teresa Iwaniec
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Musiał
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Krakow, Poland
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
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Tektonidou MG, Andreoli L, Limper M, Amoura Z, Cervera R, Costedoat-Chalumeau N, Cuadrado MJ, Dörner T, Ferrer-Oliveras R, Hambly K, Khamashta MA, King J, Marchiori F, Meroni PL, Mosca M, Pengo V, Raio L, Ruiz-Irastorza G, Shoenfeld Y, Stojanovich L, Svenungsson E, Wahl D, Tincani A, Ward MM. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019; 78:1296-1304. [PMID: 31092409 PMCID: PMC11034817 DOI: 10.1136/annrheumdis-2019-215213] [Citation(s) in RCA: 532] [Impact Index Per Article: 106.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 01/04/2023]
Abstract
The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. Based on evidence from a systematic literature review and expert opinion, overarching principles and recommendations were formulated and voted. High-risk antiphospholipid antibody (aPL) profile is associated with greater risk for thrombotic and obstetric APS. Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. Patients with APS and first unprovoked venous thrombosis should receive long-term treatment with vitamin K antagonists (VKA) with a target international normalised ratio (INR) of 2-3. In patients with APS with first arterial thrombosis, treatment with VKA with INR 2-3 or INR 3-4 is recommended, considering the individual's bleeding/thrombosis risk. Rivaroxaban should not be used in patients with APS with triple aPL positivity. For patients with recurrent arterial or venous thrombosis despite adequate treatment, addition of LDA, increase of INR target to 3-4 or switch to low molecular weight heparin may be considered. In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. In patients with recurrent pregnancy complications, increase of heparin to therapeutic dose, addition of hydroxychloroquine or addition of low-dose prednisolone in the first trimester may be considered. These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.
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Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology program, National and Kapodistrian 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, The Netherlands
| | - Zahir Amoura
- Sorbonne University, French National Center for SLE and Aps, Service de Medecine Interne 2, InstitutE3M, Pitié Salpétrière, Paris, France
| | - Ricard Cervera
- Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares de l'île deFrance, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité;INSERM U 1153, CRESS, Paris, France
| | | | - Thomas Dörner
- Department of Med/Rheumatology and Clinical Immunology, Charite University Hospital, Berlin, Germany
| | - Raquel Ferrer-Oliveras
- Obstetrics and Gynecology Department and Systemic Diseases Research Unit, Vall ďHebron Research Institute-VHIR, Barcelona, Spain
| | - Karen Hambly
- School of Sport and Exercise Sciences, University of Kent, Chatham, UK
| | | | - Judith King
- EULAR PARE Patient Research Partner, London, UK
| | | | - Pier Luigi Meroni
- MaACR, Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Vittorio Pengo
- Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Bern, Switzerland
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, Israel
| | | | - Elisabet Svenungsson
- Department of Medicine, Solna, Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases and Vascular Medicine Division, Nancy University Hospital, INSERM UMR-S 1116 University of Lorraine, Nancy, France
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Leon J, Pérez-Sáez MJ, Batal I, Beck LH, Rennke HG, Canaud G, Legendre C, Pascual J, Riella LV. Membranous Nephropathy Posttransplantation: An Update of the Pathophysiology and Management. Transplantation 2019; 103:1990-2002. [PMID: 31568231 DOI: 10.1097/tp.0000000000002758] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Membranous nephropathy (MN) is a common cause of nephrotic syndrome after transplantation and is associated with an increased risk of allograft loss. MN may occur either as a recurrent or as a de novo disease. As in native kidneys, the pathophysiology of the MN recurrence is in most cases associated with antiphospholipid A2 receptor antibodies. However, the posttransplant course has some distinct features when compared with primary MN, including a lower chance of spontaneous remission and a greater requirement for adjuvant immunosuppressive therapy to induce complete remission. Although the efficacy of rituximab in primary MN is now well established, no randomized studies have assessed its effectiveness in MN after transplant, and there are no specific recommendations for the management of these patients. This review aims to synthesize and update the pathophysiology of posttransplant MN, as well as to address unsolved issues specific to transplantation, including the prognostic value of antiphospholipid A2 receptor, the risk of living-related donation, the link between de novo MN and rejection, and different therapeutic strategies so far deployed in posttransplant MN. Lastly, we propose a management algorithm for patients with MN who are planning to receive a kidney transplant, including pretransplant considerations, posttransplant monitoring, and the clinical approach after the diagnosis of recurrence.
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Affiliation(s)
- Juliette Leon
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - María José Pérez-Sáez
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Ibrahim Batal
- Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Laurence H Beck
- Division of Nephrology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Guillaume Canaud
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - Christophe Legendre
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Leonardo V Riella
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder associated with arterial/venous thrombosis and pregnancy loss; thrombocytopenia is another common manifestation of APS. In the present study, we discovered a transient ethylenediaminetetraacetic acid-dependent pseudothrombocytopenia (EDTA-PTCP) phenomenon in APS, which has not yet been reported in the literature.
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Pineton de Chambrun M, Larcher R, Pène F, Argaud L, Demoule A, Jamme M, Coudroy R, Mathian A, Gibelin A, Azoulay E, Tandjaoui-Lambiotte Y, Dargent A, Beloncle FM, Raphalen JH, Couteau-Chardon A, de Prost N, Devaquet J, Contou D, Gaugain S, Trouiller P, Grangé S, Ledochowski S, Lemarie J, Faguer S, Degos V, Combes A, Luyt CE, Amoura Z. CAPS criteria fail to identify most severely-ill thrombotic antiphospholipid syndrome patients requiring intensive care unit admission. J Autoimmun 2019; 103:102292. [PMID: 31253464 DOI: 10.1016/j.jaut.2019.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 05/07/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Catastrophic antiphospholipid syndrome (CAPS), the most severe manifestation of antiphospholipid syndrome (APS), is characterised by simultaneous thromboses in multiple organs. Diagnosing CAPS can be challenging but its early recognition and management is crucial for a favourable outcome. This study was undertaken to evaluate the frequencies, distributions and ability to predict mortality of "definite/probable" or "no-CAPS" categories of thrombotic APS patients requiring admission to the intensive care unit (ICU). METHODS This French national multicentre retrospective study, conducted from January 2000 to September 2018, included all APS patients with any new thrombotic manifestation(s) admitted to 24 ICUs. RESULTS One hundred and thirty-four patients (male/female ratio: 0.4; mean age at admission: 45.4 ± 15.0 years), who experienced 152 CAPS episodes, required ICU admission. The numbers of definite, probable or no-CAPS episodes, respectively, were: 11 (7.2%), 60 (39.5%) and 81 (53.3%). No histopathological proof of microvascular thrombosis was the most frequent reason for not being classified as definite CAPS. Overall, 35/152 (23.0%) episodes were fatal, with comparable rates for definite/probable CAPS and no CAPS (23% vs. 28.8% respectively, p = 0.4). The Kaplan-Meier curve of estimated probability of survival showed no between-group survival difference (log-rank test p = 0.5). CONCLUSIONS In this study, CAPS criteria were not associated with mortality of thrombotic APS patients requiring ICU admission. Further studies are need evaluate the adequacy of CAPS criteria for critically-ill APS patients.
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Affiliation(s)
- Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et autres maladies auto-immunes systémiques rares, Paris, France; Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, Paris, France.
| | - Romaric Larcher
- Service de Médecine Intensive-Réanimation, Hôpital Lapeyronie, Centre Hospitalier Universitaire (CHU) de Montpellier; PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, APHP & Université Paris Descartes, Paris, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Alexandre Demoule
- APHP, Hôpital La Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation Médicale, Département R3S, Sorbonne Université, INSERM UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Matthieu Jamme
- Sorbonne Université, APHP, Hôpital Tenon, Service d'Urgences Néphrologiques et de Transplantation Rénale, Paris, France
| | - Remi Coudroy
- Service de Médecine Intensive-Réanimation, INSERM CIC1402, Groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Alexis Mathian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et autres maladies auto-immunes systémiques rares, Paris, France
| | - Aude Gibelin
- Sorbonne Université, APHP, Hôpital Tenon, Service de Réanimation Médico-Chirurgicale, Pôle Thorax Voies Aériennes, Paris, France
| | - Elie Azoulay
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Louis, APHP, Paris, France
| | | | - Auguste Dargent
- Service de Médecine Intensive-Réanimation, CHU Dijon; INSERM UMR 1231 LabEx Lipstic, Dijon, France
| | - François-Michel Beloncle
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, CHU d'Angers, Université d'Angers, Angers, France
| | - Jean-Herlé Raphalen
- Service d'Anesthésie et de Réanimation, Hôpital Necker, Université Paris Descartes, APHP, Paris, France
| | - Amélie Couteau-Chardon
- Service de Médecine Intensive-Réanimation, Hôpital Européen George-Pompidou, Université Paris Descartes, APHP, Paris, France
| | - Nicolas de Prost
- Service de Médecine Intensive-Réanimation, CHU Henri-Mondor, APHP, Créteil, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Samuel Gaugain
- Département d'Anesthésie et Réanimation, Hôpital Saint Louis-Lariboisière, Université Paris Diderot, APHP, Paris, France
| | - Pierre Trouiller
- Service de Réanimation Polyvalente et Unité de surveillance continue, Hôpital Antoine-Béclère, Hôpitaux Universitaires Paris-Sud, APHP, Clamart, France
| | - Steven Grangé
- Service de Médecine Intensive-Réanimation, Hôpital Charles-Nicolle, CHU de Rouen, Rouen, France
| | | | - Jérémie Lemarie
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, Nancy, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'organes - Unité de Réanimation, Centre de Référence des Maladies Rénales Rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Vincent Degos
- Service de Réanimation Neurochirurgicale, Sorbonne Université, Hôpital La Pitié-Salpêtrière, APHP, Paris, France
| | - Alain Combes
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, Paris, France
| | - Zahir Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et autres maladies auto-immunes systémiques rares, Paris, France
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Thaler MA, Bietenbeck A, Steigerwald U, Büttner T, Schierack P, Lindhoff-Last E, Roggenbuck D, Luppa PB. Evaluation of the sensitivity and specificity of a novel line immunoassay for the detection of criteria and non-criteria antiphospholipid antibodies in comparison to established ELISAs. PLoS One 2019; 14:e0220033. [PMID: 31339913 PMCID: PMC6655644 DOI: 10.1371/journal.pone.0220033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 07/07/2019] [Indexed: 12/14/2022] Open
Abstract
Background Persistent antiphospholipid antibodies (aPL) constitute the serological hallmark of the antiphospholipid syndrome (APS). Recently, various new assay technologies for the detection of aPL better suited to multiplex reaction environments than ELISAs emerged. We evaluated the diagnostic performance of such a novel line immunoassay (LIA) for the simultaneous detection of 10 different aPL. Methods Fifty-three APS patients and 34 healthy controls were investigated for criteria (antibodies against cardiolipin [aCL], β2-glycoprotein I [aβ2-GPI]) and non-criteria aPL (antibodies against phosphatidic acid [aPA], phosphatidyl-choline [aPC], -ethanolamine [aPE], -glycerol [aPG], -inositol [aPI], -serine [aPS], annexin V [aAnnV], prothrombin [aPT]) IgG and IgM by LIA. Criteria aPL were additionally determined with the established Alegria (ALE), AcuStar (ACU), UniCap (UNI), and AESKULISA (AES) systems and non-criteria aPL with the AES system. Diagnostic performance was evaluated with a gold standard for criteria aPL derived from the results of the four established assays via latent class analysis and with the clinical diagnosis as gold standard for non-criteria aPL. Results Assay performance of the LIA for criteria aPL was comparable to that of ALE, ACU, UNI, and AES. For non-criteria aPL, sensitivities of the LIA for aPA-, aPI-, aPS-IgG and aPA-IgM were significantly higher and for aPC-, aPE-, aAnnV-IgG and aPC- and aPE-IgM significantly lower than AES. Specificities did not differ significantly. Conclusions The LIA constitutes a valuable diagnostic tool for aPL profiling. It offers increased sensitivity for the detection of aPL against anionic phospholipids. In contrast, ELISAs exhibit strengths for the sensitive detection of aPL against neutral phospholipids.
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Affiliation(s)
- Markus A. Thaler
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
- * E-mail:
| | - Andreas Bietenbeck
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Udo Steigerwald
- Zentrallabor, Zentrum Innere Medizin—A4, Universitätsklinikum Würzburg, Würzburg, Germany
| | | | - Peter Schierack
- Institut für Biotechnologie, Fakultät Umwelt und Naturwissenschaften, Brandenburgische Technische Universität Cottbus-Senftenberg, Senftenberg, Germany
| | - Edelgard Lindhoff-Last
- Coagulation Research Center CCB (Cardioangiologisches Centrum Bethanien), Frankfurt am Main, Germany
| | - Dirk Roggenbuck
- Medipan / GA Generic Assays GmbH, Dahlewitz, Germany
- Institut für Biotechnologie, Fakultät Umwelt und Naturwissenschaften, Brandenburgische Technische Universität Cottbus-Senftenberg, Senftenberg, Germany
| | - Peter B. Luppa
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Hisada R, Kato M, Sugawara E, Kanda M, Fujieda Y, Oku K, Bohgaki T, Amengual O, Horita T, Yasuda S, Atsumi T. Circulating plasmablasts contribute to antiphospholipid antibody production, associated with type I interferon upregulation. J Thromb Haemost 2019; 17:1134-1143. [PMID: 30864219 DOI: 10.1111/jth.14427] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 09/22/2018] [Indexed: 08/30/2023]
Abstract
Essentials The mechanism of antiphospholipid antibodies (aPL) production remains unclear. We investigated lymphocyte subset, single nucleotide polymorphisms (SNP), and aPL-producing cells. The increase of circulating plasmablasts was associated with type I interferon upregulation. Our novel ex vivo assay revealed circulating plasmablasts as a major source of aPL. SUMMARY: Background/objective Antiphospholipid antibodies (aPL) are pathogenic autoantibodies in antiphospholipid syndrome (APS). This study aimed to clarify the mechanism of aPL production. Methods T cell and B cell subsets were evaluated in peripheral blood mononuclear cells (PBMCs) of 26 primary APS (PAPS), 19 systemic lupus erythematosus-associated APS (SLE/APS) patients and 10 healthy controls. The SLE-related or APS-related single nucleotide polymorphisms (SNP) were analyzed in those patients. Interferon (IFN) score was calculated based on the mRNA expression of Ly6e, Mx1, IFIT1, and IFIT3 in PBMCs. The PBMCs obtained from APS patients were cultured ex vivo following depletion of CD20 positive or negative B cells and the culture supernatants were applied to aPL measurements. Results In PAPS and SLE/APS patients, Th2, Th17, and plasmablasts were increased while regulatory T, memory B, and regulatory B cells were decreased compared to healthy controls. Genetic analysis revealed that the increase of plasmablasts was more pronounced in patients carrying a risk allele of toll like receptor (TLR) 7 SNP rs3853839. The IFN score was significantly higher in the risk allele carriers. Ex vivo experiments showed that aPL were present in the culture supernatant of PBMCs lacking CD20+CD19+ subset, but not in that of cells lacking CD20-CD19+ subset. Conclusions Our data indicate an important role of plasmablasts in the production of aPL. Furthermore, the increase of plasmablasts was associated with TLR 7 and type I IFN, suggesting a common pathophysiology in SLE and APS. Targeting plasmablasts might be a novel immunological therapeutic approach in the treatment of APS.
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Affiliation(s)
- Ryo Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Eri Sugawara
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masatoshi Kanda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Bohgaki
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Olga Amengual
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tetsuya Horita
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinsuke Yasuda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Cheng CY, Zhang YX, Denas G, Du Y, Jing ZC, Pengo V. Prevalence of antiphospholipid (aPL) antibodies among patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Intern Emerg Med 2019; 14:521-527. [PMID: 30603858 DOI: 10.1007/s11739-018-02021-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
How thrombophilia may contribute to the development of chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. We searched on PubMed and EMBASE (until 15 April 2018), studies on CTEPH reporting data on inherited or acquired thrombophilia. Starting from 367 articles mentioning the search terms, 347 were excluded mainly as duplicate articles or articles not in English. After reading the full text of remaining articles, ten were excluded for being reviews, editorials, letters or case reports, and two were further removed from the analysis because of the potential selection bias. All the eight considered studies provided the proportion of patients positive for antiphospholipid (aPL) antibodies. The crude rate of aPL in CTPEH patients is 11.8% (95% CI 10.09-13.8%). The meta-analysis considering the weighted mean proportion and 95% confidence intervals (CIs) yields a rate of aPL antibody-positive profile of 12.06% (95% CI 8.12-16.65%) among the patients with CTEPH in the random effects model (I2 76.33%; 95% CI 52.75-88.14%, p = 0.0001). The sensibility analysis confirms the result. No predictors of heterogeneity are found in a meta-regression analysis. Our results suggest that aPL antibodies are frequently associated with CTEPH underlining the need to test for aPL antibodies in young patients with "idiopathic" and "provoked" PE caused by mild provoking risk factors.
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Affiliation(s)
- Chun-Yan Cheng
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yi-Xin Zhang
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yao Du
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Zhi-Cheng Jing
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Guo H, Zhang Y, Li A, Wang C, Yang S, Zhang Y, Zhang J, Qiao R. Anti-domain 1 of beta2-glycoprotein I aids risk stratification in lupus anticoagulant-positive patients. Clin Exp Med 2019; 19:339-345. [PMID: 31093818 DOI: 10.1007/s10238-019-00555-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 03/02/2019] [Accepted: 04/15/2019] [Indexed: 01/14/2023]
Abstract
Lupus anticoagulant (LA) is considered a risk factor for thromboembolism (TE) and adverse pregnancy outcomes (APOs). However, quite a few patients diagnosed with LA positivity do not suffer these adverse events. Further testing of anticardiolipin (aCL), anti-beta2-glycoprotein I (anti-β2GPI) or anti-domain 1 of β2GPI (anti-D1) may help to assess the occurrence risk of TE and APOs. Therefore, we aimed to study how to stratify LA-positive patients. In our study, 167 LA-positive patients were consecutively enrolled from January 2015 to December 2016. Serum aCL and anti-β2GPI (IgG, IgM and IgA) and anti-D1 IgG were simultaneously measured. Among these patients, 114 (68.3%) were followed for an average of 36.5 months for TE and APOs. The outcomes showed that 105 patients experienced TE and/or APOs, and 62 patients were LA carriers. Anti-D1 had good consistency with triple positivity (LA+, aCL+, anti-β2GPI+) (kappa = 0.742). Elevated anti-D1 was related to increased risks for TE [odds ratio (OR) 29.87, 95% confidence interval (CI) 8.05-110.74] and APOs (OR 8.73, 95% CI 3.41-22.31). Area under curve showed that the diagnostic power of anti-D1 for TE and APOs was 0.856 (95% CI 0.743-0.970) and 0.682 (95% CI 0.599-0.765), respectively. Survival analysis revealed that patients with high anti-D1 titres had a high cumulative incidence of APOs (hazard ratio 4.66, 95% CI 1.46-14.87). In conclusion, anti-D1, based on good consistency with triple positivity in LA-positive patients, has a stronger association with TE and APOs and, to some degree, could predict pregnancy outcomes. Therefore, anti-D1 may aid risk stratification in LA-positive patients.
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Affiliation(s)
- Han Guo
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Yuncong Zhang
- Department of Clinical Laboratory, Peking University International Hospital, Beijing, China
| | - Aiwei Li
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Chanjuan Wang
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Shuo Yang
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Yinmei Zhang
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Jie Zhang
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China
| | - Rui Qiao
- Laboratory Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, China.
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Choi H, Ahn SS, Song JJ, Park YB, Song J, Lee SW. Anti-phospholipid antibody syndrome occurrence in patients with persistent anti-phospholipid antibodies. Rheumatol Int 2019; 39:1359-1367. [PMID: 31076830 DOI: 10.1007/s00296-019-04318-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 03/25/2019] [Accepted: 05/02/2019] [Indexed: 11/26/2022]
Abstract
We investigated the overall frequency of anti-phospholipid syndrome (APS) occurrence in Korean patients with consecutively detected anti-phospholipid antibodies with an interval of 12 weeks (persistent aPLs). We retrospectively reviewed the results of blood tests of aPLs in 14,889 patients in whom aPL tests were performed at Yonsei University College of Medicine, Severance Hospital, from January 2012 to August 2018, and included 833 patients with persistent aPLs. We obtained clinical and laboratory data including anti-cardiolipin antibodies IgM and IgG, anti-beta2 glycoprotein1 IgM and IgG, and lupus anticoagulant (LAC). Of 833 patients with persistent aPLs, 96 patients (11.5%) had APS (84 patients had thrombotic events and 12 had pregnancy morbidity). Among aPLs, LAC was detected in patients with APS more frequently than asymptomatic carriers of aPLs (46.9% vs. 25.9%, p < 0.001). Patients with LAC (relative risk (RR) 2.558, p < 0.001) and aPLs ≥ 2 (RR 1.731, p = 0.014) exhibited the higher rate of APS occurrence than those without. Moreover, patients with aPLs ≥ 3 and aPLs ≥ 4 exhibited the higher rates of APS occurrence than those without (RR 2.753, p < 0.001 and RR 3.209, p = 0.013). Meanwhile, patients with ANA, anti-dsDNA, anti-SSA/Ro, and SLE exhibited the increased frequency of LAC positivity, compared to those without (RR 3.304, p = 0.005, RR 4.269, p = 0.032, RR 3.750, p = 0.041 and RR 8.828, p < 0.001, respectively). APS occurs in 11.5% of Korean patients with persistent aPLs. LAC positivity and aPLs ≥ 2 were significantly associated with APS occurrence. SLE and SLE-related autoantibodies were associated with LAC positivity.
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Affiliation(s)
- Hyeok Choi
- Department of Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Serrano M, Martinez-Flores JA, Norman GL, Naranjo L, Morales JM, Serrano A. The IgA Isotype of Anti-β2 Glycoprotein I Antibodies Recognizes Epitopes in Domains 3, 4, and 5 That Are Located in a Lateral Zone of the Molecule (L-Shaped). Front Immunol 2019; 10:1031. [PMID: 31134087 PMCID: PMC6515947 DOI: 10.3389/fimmu.2019.01031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with presence of anti-phospholipid antibodies (aPL). The APS classification criteria only consider the aPL of IgG/IgM isotype, however testing of aPL of IgA isotype is recommended when APS is suspected and consensus aPL are negative. IgA anti-βeta-2 glycoprotein-I (B2GP1) has been clearly related with occurrence of thrombotic events. Antibodies anti-B2GP1 of IgG/M isotypes recognize an epitope in Domain 1 (R39-G43), the epitopes that recognize IgA anti-B2GP1 antibodies are not well-identified. Aim: To determine the zones of B2GP1 recognized by antibodies of IgA isotype from patients with APS symptomatology and positive for IgA anti-B2GP1. Methods: IgA antibodies to Domain-1(D1) and Domain-4/5(D4/5) of B2GP1 (ELISA) and epitope mapping on oligopeptide arrays of B2GP1 were evaluated in sera from a group of 93 patients with at least one thrombotic and with isolated positivity for IgA anti-B2GP1 antibodies (negative for other aPL). Results: A total of 47 patients (50.5%) were positive for anti-D4/5 and 23(25%) were positive for anti-D1. When peptide arrays were analyzed, three zones of B2GP1 reactivity were identified for more than 50% of patients. The center of these zones corresponds to amino acids 140(D3), 204(D4), and 264(D5). The peptides recognized on D3 and D4 contain amino acid sequences sharing high homology with proteins of microorganism that were previously related with a possible APS infectious etiology. In the three-dimensional structure of B2GP1, the three peptides, as the R39-G43 epitope, are located on the right side of the molecule (L-shape). The left side (J-shape) does not bind the antibodies. Conclusions: Patients with thrombotic APS clinical-criteria, and isolated IgA anti-B2GP1 positivity appear to preferentially bind, not to the D1 or D4/5 domains of B2GP1, but rather to three sites in D3, D4, and D5. The sites on D3 and D4 were previously described as the target identified by human monoclonal antibodies derived from patients that were capable of inducing APS in animal models. The localization of these epitopes opens a new route to explore to increase understanding of the patholophysiology of the APS and to propose new alternatives and therapeutic targets.
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Affiliation(s)
- Manuel Serrano
- Healthcare Research Institute of Hospital 12 de Octubre, Madrid, Spain
| | | | | | - Laura Naranjo
- Healthcare Research Institute of Hospital 12 de Octubre, Madrid, Spain
| | | | - Antonio Serrano
- Healthcare Research Institute of Hospital 12 de Octubre, Madrid, Spain
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