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Knight JS, Erkan D. Rethinking antiphospholipid syndrome to guide future management and research. Nat Rev Rheumatol 2024; 20:377-388. [PMID: 38702511 DOI: 10.1038/s41584-024-01110-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 05/06/2024]
Abstract
Antiphospholipid syndrome (APS) consists of thrombotic, non-thrombotic and obstetric clinical manifestations developing in individuals with persistent antiphospholipid antibodies (aPL). Although researchers have made progress in characterizing different clinical phenotypes of aPL-positive people, the current approach to clinical management is still mostly based on a 'one size fits all' strategy, which is derived from the results of a limited number of prospective, controlled studies. With the 2023 publication of the ACR-EULAR APS classification criteria, it is now possible to rethink APS, to lay the groundwork for subphenotyping through novel pathophysiology-informed approaches, and to set a future APS research agenda guided by unmet needs in clinical management.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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Chighizola CB, Willis R, Maioli G, Sciascia S, Andreoli L, Amengual O, Radin M, Gerosa M, Atsumi T, de Jesus G, Trespidi L, Branch DW, Caporali R, Andrade D, Roubey R, Petri M, Bertolaccini ML. Deciphering the clinical significance of longitudinal antiphospholipid antibody titers. Autoimmun Rev 2024; 23:103510. [PMID: 38171447 DOI: 10.1016/j.autrev.2023.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
In antiphospholipid syndrome (APS), the risk of clinical manifestations increases with higher titers of antiphospholipid antibodies (aPL). Despite the adoption of aPL titers in the classification approach to aPL-positive subjects, the value of longitudinal monitoring of those titers in the follow-up is still debated, being well studied only in systemic lupus erythematosus (SLE). The literature suggests that the rate of aPL positivity decreases during follow-up in primary APS, estimating that seroconversion occurs in between 8.9 and 59% of patients over time. Negativisation of aPL occurs more frequently in asymptomatic aPL carriers than in patients with full-blown APS as well as in subjects with single aPL positivity or low aPL antibody titers. In patients with SLE, aPL typically behave fluctuating from positive to negative and back again in the course of follow-up. The few studies assessing the longitudinal course of aPL positivity with no associated systemic connective tissue disease reported a progressive decrement of aPL titers over time, in particular of antibodies against β2 glycoprotein I (antiβ2GPI) and cardiolipin (aCL) of IgG isotype. After a thrombotic event, aPL titers tend to decrease, as emerged from cohorts of both primary and secondary APS. Hydroxychloroquine has been identified as the most effective pharmacological agent to reduce aPL titers, with multiple studies demonstrating a parallel reduction in thrombosis rate. This review addresses available evidence on the significance of aPL titer fluctuation from clinical, therapeutic and pathogenic perspectives.
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Affiliation(s)
- Cecilia B Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy.
| | - Rohan Willis
- University of Texas Medical Branch, Internal Medicine, Galveston, USA
| | - Gabriella Maioli
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Savino Sciascia
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Olga Amengual
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Massimo Radin
- University of Turin, Department of Clinical and Biological Sciences, Turin, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | - Tatsuya Atsumi
- Hokkaido University, Department of Rheumatology, Endocrinology and Nephrology Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Guilherme de Jesus
- Universidade do Estado do Rio de Janeiro, Department of Obstetrics, Rio de Janeiro, Brazil
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Pediatric Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Clinical Rheumatology Unit, ASST G. Pini - CTO, Milan, Italy
| | | | - Robert Roubey
- Department of Rheumatology, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Rheumatology, Baltimore, MD, USA
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Daughety MM, Erkan D, Lockshin MD, Ortel TL. Antiphospholipid Syndrome. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00061-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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4
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Barilaro G, Coloma-Bazan E, Chacur A, Della Rocca C, Perez-Isidro A, Ruiz-Ortiz E, Viñas O, Tàssies Penella D, Reverter JC, Molina Andujar A, Cervera R, Espinosa G. Persistence of antiphospholipid antibodies over time and its association with recurrence of clinical manifestations: A longitudinal study from a single centre. Clin Exp Rheumatol 2022; 21:103208. [PMID: 36202304 DOI: 10.1016/j.autrev.2022.103208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To analyze the antiphospholipid antibody (aPL) persistence over time in patients with antiphospholipid syndrome (APS) and its association with clinical recurrence and to identify predictors of aPL persistence over time. PATIENTS AND METHODS 200 patients with a diagnosis of APS and at least three follow-up aPL determinations were included. Persistent aPL profile was defined as the presence of lupus anticoagulant (LAC) and/or IgG/IgM anticardiolipin (aCL) and/or IgG/IgM anti-β2 glycoprotein-I (aβ2GPI) (> 99th percentile) antibodies in at least 66% of follow-up measurements. Multilevel mixed-effect generalized linear models with logit link were used. RESULTS 112 (56%) patients maintained persistent aPL profiles over time, while 88 (44%) were transient. Median follow-up time was 172.5 months. Follow-up time did not affect the odds of aPL persistence in multivariate analysis (p = 1.00). Baseline triple aPL positivity [OR 78 (95%CI 16.9-359.7, p < 0.001)] and double aPL positivity [OR = 7.6 (95%CI 3.7-15.7, p < 0.001)] correlated with persistent aPLs over time, while isolated LAC [OR = 0.26 (95% CI 0.08-0.49, p = 0.002)] or isolated IgG/IgM aCL [OR = 0.20 (95% CI 0.11-0.59, p = 0.004)] positivity, were predictors of transient aPL profile. Patients with persistent aPLs had higher rate of clinical recurrence in comparison to patients with transient aPLs [OR = 2.48 (95%CI 1.34-4.58, p = 0.003)]. CONCLUSIONS More than half of patients with baseline medium-high titer aPL positivity had persistent positive aPLs over time. Patients with persistent aPLs were more prone to present recurrence of clinical manifestations. Multiple aPL positivity increased the odds of a persistent aPL profile over time, while isolated LAC and aCL positivity decreased it.
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Affiliation(s)
- Giuseppe Barilaro
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.
| | - Emmanuel Coloma-Bazan
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Alejandro Chacur
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Latina 04100, Italy
| | - Albert Perez-Isidro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Estibaliz Ruiz-Ortiz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Odette Viñas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Dolors Tàssies Penella
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Hemotherapy and Hemostasis, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Joan Carles Reverter
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Hemotherapy and Hemostasis, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Alicia Molina Andujar
- Department of Nephrology and Renal Transplantation, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (CSUR) of the Spanish Health System, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
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Lupus anticoagulant test persistence over time and its associations with future thrombotic events. Blood Adv 2022; 6:2957-2966. [PMID: 35042230 PMCID: PMC9131910 DOI: 10.1182/bloodadvances.2021006011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/07/2022] [Indexed: 11/20/2022] Open
Abstract
Data on lupus anticoagulant (LA) test stability in patients persistently positive for LA are limited and its implications on clinical outcomes are lacking. We investigated the rate and predictors of a negative LA test and whether experiencing a negative test affected a patient's risk of future thrombotic events or death in a prospective observational study of persistently LA positive patients. We followed 164 patients (84% women) for a median of 9.2 years and a total of 1,438 follow-up visits. During the observation period, 50 thrombotic events (23 arterial and 27 venous events) occurred and 24 patients died. Forty-six of the patients had at least one negative LA test during the observation period, corresponding to a 10-year cumulative incidence of a negative LA test of 28% (95%CI: 20-35). The majority of patients with available follow-up after a negative LA test (n=41) had at least one subsequent positive test for LA (n=28/41, 68%). Vitamin K antagonist (VKA) treatment at baseline was associated with a negative LA test during follow up. Using a multistate time-to-event model with multivariable adjustment, a negative LA test had no impact on a patient's prospective risk of thrombosis or mortality. We conclude that a negative LA test during observation cannot be used clinically to stratify a patient's risk for future events.
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Martins FF, Campos TML. Evaluation of Frequency, Clinical Correlation, and Antibodies Confirmation Profile in Patients with Suspected Antiphospholipid Syndrome. TH OPEN 2021; 5:e470-e478. [PMID: 34693196 PMCID: PMC8526142 DOI: 10.1055/s-0041-1736289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/11/2021] [Indexed: 12/22/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombotic manifestations and/or pregnancy-related complications in patients with persistent antiphospholipid (aPL) antibodies. The introduction of Sapporo's classification criteria allowed uniformity in the classification of this pathology, representing a considerable advance in its diagnosis. However, currently some doubts about the application of these criteria still persist. The aim of this study was to contribute to the better understanding of APS by the assessment of aPL prevalence, the association between clinical and laboratory tests, and evaluation of the aPL confirmatory profile. In this study, 1,179 samples from patients with suspected APS of both genders, without age restrictions, who were advised to test for complete aPL's profile were analyzed. The samples were tested for lupus anticoagulant (LAC), anticardiolipin immunoglobulin (Ig) G/IgM and anti-β-2-glycoprotein I IgG/IgM antibodies. Patient samples with isolated test requests for analysis and samples from patients under the influence of anticoagulants or in an infectious process were excluded. The overall positivity found was 17.9% and the most frequent aPL was LAC. The antibodies were determined in isolation and in association. The prevalence of triple positivity was 0.8% and double positivity was 1.8%. Positivity was higher in inpatient/emergency services compared with outpatient services. There was a higher positivity in individuals over 41 years, males, patients with systemic lupus erythematosus, kidney complications, and deep vein thrombosis/thrombophlebitis. The positivity confirmation with second sample was 39.5% and the confirmation profile shows that 50.6% of samples confirmed with same positivity profile; 17.3% with a different profile and regarding to these, 2.5% of the samples confirmed positivity with a different antibody from the previously detected. This study suggests that the aPL's positivity tends to increase with age, showing that the aPL's testing should be avoided during an acute event and reinforces the need for complete aPL laboratory profile in the second sample and subsequent determinations.
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Affiliation(s)
- Filipe F Martins
- Department of Immunohemotherapy, Tâmega e Sousa Hospital Center, Penafiel, Portugal
| | - Teresa M L Campos
- Department of Immunohemotherapy, Tâmega e Sousa Hospital Center, Penafiel, Portugal
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Khawaja M, Magder L, Goldman D, Petri MA. Loss of antiphospholipid antibody positivity post-thrombosis in SLE. Lupus Sci Med 2021; 7:7/1/e000423. [PMID: 33023978 PMCID: PMC7539588 DOI: 10.1136/lupus-2020-000423] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/13/2020] [Accepted: 09/08/2020] [Indexed: 11/13/2022]
Abstract
Background/Purpose Loss of positivity of antiphospholipid antibodies has been observed in clinical practice post-thrombosis in patients with SLE with secondary antiphospholipid syndrome (APS). Our study defined the frequency of this loss and the duration before positivity recurred. Methods In this prospective study, patients with SLE having at least two positive antiphospholipid markers prior to thrombosis and at least 1 year of follow-up after thrombosis were included. Antiphospholipid markers included lupus anticoagulant (dilute Russell viper venom test >45 s followed by mixing and confirmatory tests) and/or anticardiolipin titre (aCL IgG ≥20, aCL IgM ≥20 and/or aCL IgA ≥20). The percentage of visits with positive antiphospholipid markers after thrombosis was calculated. For patients with a negative antiphospholipid marker any time after thrombosis, survival estimates were performed to calculate the time to return of antiphospholipid positivity. Results In APS due to SLE, complete loss of antiphospholipid positivity post-thrombosis was up to 41% for aCL IgG, 51% for IgM and 50% for IgA, but only 20% for those with lupus anticoagulant. Of those who at some point lost aCL IgG or became negative for lupus anticoagulant, the majority (60% and 76%, respectively) reacquired the antibody within 5 years. In contrast, of those who lost aCL IgM or IgA, fewer reacquired it within 5 years (37% and 17%, respectively). Conclusion Intermittent positivity of antiphospholipid antibodies is present in APS due to SLE. These fluctuations make it difficult to decide on length of anticoagulation. Lupus anticoagulant is more likely to persist post-thrombosis.
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Affiliation(s)
- Muznay Khawaja
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence Magder
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Daniel Goldman
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michelle A Petri
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Petri MA, Avci M, Magder LS. Evaluation of different ways to identify persistent positivity of lupus anticoagulant in systemic lupus erythematosus. Lupus Sci Med 2021; 7:7/1/e000406. [PMID: 33139453 PMCID: PMC7607609 DOI: 10.1136/lupus-2020-000406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/04/2020] [Accepted: 10/03/2020] [Indexed: 11/28/2022]
Abstract
Objective Persistent positivity for lupus anticoagulant has been associated with an increased risk of thrombosis among patients with SLE. Persistent positivity is often defined as having two positive assessments separated by more than 90 days. Our objective was to determine whether frequent repeated lupus anticoagulant testing would identify more patients with persistent positivity, and whether the additional patients identified were still at increased risk of thrombosis. Methods Using a large longitudinal cohort with frequent lupus anticoagulant testing, we compared three different hypothetical clinical strategies for identifying persistent positivity: (1) assessment of lupus anticoagulant twice more than 90 days apart; (2) assessment of lupus anticoagulant annually, with repeat testing if an annual assessment was positive; and (3) assessment of lupus anticoagulant 16 times (approximately quarterly for 4 years). The prevalence of persistent positivity was compared between the approaches and by demographic subgroups. Subgroups based on these definitions were compared with respect to the risk of thrombosis in subsequent follow-up using discrete survival analysis. Results Among the 785 patients included in our analysis, the prevalence of persistent lupus anticoagulant as defined by the first two patient assessments was 4.3%. Annual assessment resulted in a prevalence of 6.6%, and using all 16 assessments resulted in a prevalence of 10.5%. The prevalence was substantially higher in men than in women, and in Caucasians than in African-Americans (p<0.01 for all comparisons). The rate of thrombosis was significantly elevated among those with persistently positive lupus anticoagulant by any definition (HR ranging from 2.75 to 3.42) relative to those without persistently positive lupus anticoagulant. Conclusion While there are other risk factors for thrombosis (including other antiphospholipid subtypes), more frequent testing (not limited to twice over 3 months) for lupus anticoagulant would be useful for identifying more patients with SLE at elevated risk for thrombosis.
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Affiliation(s)
- Michelle A Petri
- Division of Rheumatology, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA
| | - Mertcan Avci
- Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Laurence S Magder
- School of Medicine, Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, Maryland, USA
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Scaperotti MM, Kwon D, Kallakury BV, Steen V. Not all that is 'full house' is systemic lupus erythematosus: a case of membranous nephropathy due to syphilis infection. BMJ Case Rep 2021; 14:e244466. [PMID: 34413046 PMCID: PMC8378353 DOI: 10.1136/bcr-2021-244466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 11/03/2022] Open
Abstract
We describe an unusual case of membranous nephropathy precipitated by syphilis infection in a patient without systemic lupus erythematosus (SLE). A previously healthy 20-year-old man presented with leg and facial swelling. Laboratory investigation revealed nephrotic range proteinuria, acute kidney injury, hypocomplementaemia and a highly positive rapid plasma reagin. Kidney biopsy showed membranous nephropathy with 'full-house' immunofluorescence (IgG, IgA, IgM, C1q and C3), mimicking lupus nephritis class Vb. However, the patient had no features of SLE and had negative antinuclear and anti-double-stranded DNA antibodies. He was treated with high-dose methylprednisolone and mycophenolate mofetil for lupus nephritis and with penicillin for syphilis. After 2 months of therapy, his proteinuria resolved, and his renal function and C4 level normalised. This case illustrates that syphilis infection can be a mimicker of lupus nephritis. A literature review suggests that ful-house nephropathy may occur independently of lupus nephritis and may or may not develop into SLE.
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Affiliation(s)
| | - DongHyang Kwon
- Pathology, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Virginia Steen
- Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA
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Zemet R, Dulitzki M, Baum M, Ofer Friedman H, Morag I, Simchen MJ. Early-onset preeclampsia - The impact of antiphospholipid antibodies on disease severity. Eur J Obstet Gynecol Reprod Biol 2021; 263:79-84. [PMID: 34167038 DOI: 10.1016/j.ejogrb.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 06/05/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Antiphospholipid antibodies have been associated with various obstetric complications, including recurrent pregnancy loss, preeclampsia, intrauterine growth restriction, placental insufficiency, and late fetal loss. Despite the amassed body of evidence emphasizing the association between antiphospholipid antibodies and preeclampsia, the severity of preeclampsia with regard to antiphospholipid antibodies status has not been elucidated. This study aimed to evaluate whether early-onset preeclampsia with severe features before 34 weeks' gestation is clinically different when associated with antiphospholipid antibodies. STUDY DESIGN In this retrospective case-control study, we collected data on pregnancy outcomes of 101 women with singleton pregnancies who delivered prior to 34 weeks of gestation due to preeclampsia with severe features. The antiphospholipid antibodies status of 55 of these women was available for analysis. The study group comprised 20 women with positive antiphospholipid antibodies (positive-aPL group), while the control group comprised 35 women without antiphospholipid antibodies (negative-aPL group). Obstetric and neonatal outcomes, laboratory results and pregnancy complications were extracted from medical records. RESULTS In the clinical setting of early-onset preeclampsia with severe features necessitating delivery before 34 weeks gestation, positive-aPL women were hospitalized earlier (29, IQR 26.3-32, vs. 32, IQR 28-33 weeks gestation, P = 0.05), gave birth at a significantly earlier gestational age (30, IQR 28.3-32.8 vs. 33, IQR 30-34, P = 0.02) with a lower mean birth-weight (1266.7 ± 579.6 vs. 1567.3 ± 539.7 g, P = 0.058) compared with negative-aPL women. Furthermore, platelet nadir was significantly lower for positive-aPL compared with negative-aPL women (97 ± 49×103/µL vs. 141 ± 61×103/µL, P < 0.001) and maximal serum creatinine was higher (1.0 ± 0.3 mg/dL vs. 0.9 ± 0.1 mg/dL, P = 0.03). Rates of neonatal complications were low and comparable between groups, except for higher rates of retinopathy of prematurity requiring treatment in the study group (30.0% vs. 5.7%, p = 0.02), and there was a trend for higher perinatal mortality among study group infants. CONCLUSIONS The presence of antiphospholipid antibodies in women with early-onset preeclampsia with severe features is associated with earlier, more severe disease course. Expedited screening for antiphospholipid antibodies in cases of early-onset severe preeclampsia may be considered, along with close monitoring for pregnant women with positive antibodies.
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Affiliation(s)
- Roni Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Dulitzki
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Micha Baum
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Ofer Friedman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Morag
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Neonatology, The Edmond and Lili Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Michal J Simchen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Pires Da Rosa G, Rodríguez-Pintó I, Cervera R, Espinosa G. Management of patients with antiphospholipid antibodies: what to do in laboratory scenarios that do not fit the guidelines. Expert Rev Hematol 2021; 14:457-466. [PMID: 33909986 DOI: 10.1080/17474086.2021.1923474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Some patients with positive antiphospholipid antibodies (aPL) have not been included in randomized clinical trials or observational registries and, therefore, information on their risk of obstetric or thrombotic recurrence and optimal treatment is scarce.Areas covered: In the present review, the existing evidence regarding the management of two laboratory scenarios not covered by the guidelines is presented: (1) patients with antiphospholipid syndrome (APS) clinical manifestations and aPL positivity not fulfilling APS laboratory criteria, and (2) the possibility of discontinuing anticoagulation in APS patients whose aPL become persistently negative.Expert opinion: Growing evidence suggests a role for low titers and 'non-criteria' aPL, especially in obstetric APS. Treatment is not formally recommended but might be considered according to the individual's risk profile. Regarding the question of whether or not to discontinue anticoagulants after the 'spontaneous' disappearance of aPL, there is no definite answer. Retrospective studies seem to suggest that withdrawal of anticoagulation could be safe in certain patients with APS, especially in those with a first provoked venous thrombosis and whose aPL became persistently negative during follow-up. Still, before the withdrawal can be recommended in routine clinical practice, multicenter and prospective studies are required to validate this hypothesis.
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Affiliation(s)
- Gilberto Pires Da Rosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ignasi Rodríguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua De Terrassa, Terrassa, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
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Gkrouzman E, Sevim E, Finik J, Andrade D, Pengo V, Sciascia S, Tektonidou MG, Ugarte A, Chighizola CB, Belmont HM, Lopez-Pedrera C, Ji L, Fortin P, Efthymiou M, de Jesus GR, Branch DW, Nalli C, Petri M, Rodriguez E, Cervera R, Knight JS, Atsumi T, Willis R, Bertolaccini ML, Cohen H, Rand J, Erkan D. Antiphospholipid Antibody Profile Stability Over Time: Prospective Results From the APS ACTION Clinical Database and Repository. J Rheumatol 2021; 48:541-547. [PMID: 33259328 PMCID: PMC10727093 DOI: 10.3899/jrheum.200513] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The APS ACTION Registry studies long-term outcomes in persistently antiphospholipid antibody (aPL)-positive patients. Our primary objective was to determine whether clinically meaningful aPL profiles at baseline remain stable over time. Our secondary objectives were to determine (1) whether baseline characteristics differ between patients with stable and unstable aPL profiles, and (2) predictors of unstable aPL profiles over time. METHODS A clinically meaningful aPL profile was defined as positive lupus anticoagulant (LAC) test and/or anticardiolipin (aCL)/anti-β2 glycoprotein-I (anti-β2-GPI) IgG/M ≥ 40 U. Stable aPL profile was defined as a clinically meaningful aPL profile in at least two-thirds of follow-up measurements. Generalized linear mixed models with logit link were used for primary objective analysis. RESULTS Of 472 patients with clinically meaningful aPL profile at baseline (median follow-up 5.1 yrs), 366/472 (78%) patients had stable aPL profiles over time, 54 (11%) unstable, and 52 (11%) inconclusive. Time did not significantly affect odds of maintaining a clinically meaningful aPL profile at follow-up in univariate (P = 0.906) and multivariable analysis (P = 0.790). Baseline triple aPL positivity decreased (OR 0.25, 95% CI 0.10-0.64, P = 0.004) and isolated LAC test positivity increased (OR 3.3, 95% CI 1.53-7.13, P = 0.002) the odds of an unstable aPL profile over time. CONCLUSION Approximately 80% of our international cohort patients with clinically meaningful aPL profiles at baseline remain stable at a median follow-up of 5 years; triple aPL-positivity increase the odds of a stable aPL profile. These results will guide future validation studies of stored blood samples through APS ACTION Core Laboratories.
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Affiliation(s)
- Elena Gkrouzman
- E. Gkrouzman, MD, MS, Hospital for Special Surgery, New York, New York, USA;
| | - Ecem Sevim
- E. Sevim, MD, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, New York, USA
| | - Jackie Finik
- J. Finik, MPH, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Danieli Andrade
- D. Andrade, MD, PhD, University of São Paulo, São Paulo, Brazil
| | | | - Savino Sciascia
- S. Sciascia, MD, PhD, Center of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - Maria G Tektonidou
- M.G. Tektonidou, MD, PhD, National and Kapodistrian University of Athens, Athens, Greece
| | - Amaia Ugarte
- A. Ugarte, MD, Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | - Cecilia B Chighizola
- C.B. Chighizola, MD, PhD, Clinical Immunology & Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - H Michael Belmont
- H.M. Belmont, MD, Hospital for Joint Diseases, New York University, New York, New York, USA
| | - Chary Lopez-Pedrera
- C. Lopez-Pedrera, PhD, Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Lanlan Ji
- L. Ji, MD, Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Paul Fortin
- P. Fortin, MD, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Maria Efthymiou
- M. Efthymiou, PhD, H. Cohen, MD, Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - D Ware Branch
- D.W. Branch, MD, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Cecilia Nalli
- C. Nalli, MD, Rheumatology and Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Michelle Petri
- M. Petri, MD, MPH, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esther Rodriguez
- E. Rodriguez, MD, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ricard Cervera
- R. Cervera, MD, PhD, FRCP, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Jason S Knight
- J.S. Knight, MD, PhD, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Tatsuya Atsumi
- T. Atsumi, MD, PhD, Hokkaido University Hospital, Sapporo, Japan
| | - Rohan Willis
- R. Willis, MD, Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, Texas, USA
| | - Maria Laura Bertolaccini
- M.L. Bertolaccini, PhD, Academic Department of Vascular Surgery, King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine & Sciences, London, UK
| | - Hannah Cohen
- M. Efthymiou, PhD, H. Cohen, MD, Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Jacob Rand
- J. Rand, MD, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Doruk Erkan
- D. Erkan, MD, MPH, Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
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The effect of hydroxychloroquine on thrombosis prevention and antiphospholipid antibody levels in primary antiphospholipid syndrome: A pilot open label randomized prospective study. Autoimmun Rev 2020; 19:102491. [DOI: 10.1016/j.autrev.2020.102491] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 12/15/2022]
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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] [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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Marchetti T, Ribi C, Perneger T, Trendelenburg M, Huynh-Do U, de Moerloose P, Chizzolini C. Prevalence, persistence and clinical correlations of classic and novel antiphospholipid antibodies in systemic lupus erythematosus. Rheumatology (Oxford) 2018; 57:1350-1357. [PMID: 29672737 DOI: 10.1093/rheumatology/key095] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives aPL are frequently present in SLE. In a well characterized SLE cohort we aimed at investigating the prevalence of aPL and assessing their analytical performance and clinical association by testing criteria specificities including LA, aCL IgG and IgM, anti-β2-glycoprotein 1 (antiβ2GP1) IgG and IgM, as well as the non-criteria aPS-PT IgG and IgM and anti-β2GP1 domain 1 (aD1) IgG. Methods We included 178 patients satisfying the ACR SLE classification criteria, from whom 283 samples and thrombotic events were collected longitudinally. Each sample was tested for criteria and non-criteria aPL using validated techniques in a single centre. Results All assays provided highly reproducible results. Of the samples, 42.5% were positive for at least one criteria assay, 20.5% showed double positivity and 12.6% triple positivity. All criteria and non-criteria specificities persisted over time. Most antibody titres were only moderately correlated; however, strong correlation was observed on one hand between aD1 IgG, antiβ2GP1 IgG and aCL IgG, and on the other between aPS-PT IgG and LA. aD1 IgG titres were extremely elevated in triple-positive samples. aPS-PT IgG by itself, and jointly with LA, was associated with thrombosis, an association mostly driven by venous thrombotic events. Conclusions In this SLE cohort, the non-criteria aPL aD1 IgG and aPS-PT IgG performed differently. aD1 IgG was highly enriched in triple-positive samples, and aPS-PT IgG, jointly with LA, was associated with thrombotic events.
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Affiliation(s)
- Tess Marchetti
- Hemostasis Unit, Department of Internal Medicine Specialties, University Hospital and School of Medicine, Geneva, Switzerland
| | - Camillo Ribi
- Division of Clinical Immunology and Allergy, University Hospital Lausanne, Lausanne, Switzerland
| | - Thomas Perneger
- Clinical Epidemiology, Department of Community Health and Medicine, University Hospital and School of Medicine, Geneva, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine and Clinical Immunology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology, Hypertension and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philippe de Moerloose
- Hemostasis Unit, Department of Internal Medicine Specialties, University Hospital and School of Medicine, Geneva, Switzerland
| | - Carlo Chizzolini
- Clinical Immunology Unit, Department of Internal Medicine Specialties, University Hospital and School of Medicine, Geneva, Switzerland, Switzerland
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17
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Joste V, Dragon-Durey MA, Darnige L. Diagnostic biologique du syndrome des antiphospholipides : des critères à la pratique. Rev Med Interne 2018; 39:34-41. [DOI: 10.1016/j.revmed.2017.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/06/2017] [Indexed: 12/12/2022]
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18
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Riancho-Zarrabeitia L, Daroca G, Muñoz P, López-Hoyos M, Haya A, Martínez-Taboada VM. Serological evolution in women with positive antiphospholipid antibodies. Semin Arthritis Rheum 2017; 47:397-402. [DOI: 10.1016/j.semarthrit.2017.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/19/2017] [Accepted: 05/06/2017] [Indexed: 11/27/2022]
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19
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Length of exposure to antiphospholipid antibodies, rather than age, is a risk factor for thrombosis: a retrospective single-centre observational study. Rheumatol Int 2017; 38:229-238. [DOI: 10.1007/s00296-017-3878-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
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20
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Could Anticoagulation or Antiaggregation Treatment Be Ceased in Patients With Primary Antiphospholipid Syndrome When Antiphospholipid Antibodies Become Persistently Negative? J Clin Rheumatol 2017; 23:350-353. [DOI: 10.1097/rhu.0000000000000538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Hoi AY, Ross L, Day J, Buchanan RRC. Immunotherapeutic strategies in antiphospholipid syndrome. Intern Med J 2017; 47:250-256. [DOI: 10.1111/imj.13245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 08/14/2016] [Accepted: 08/20/2016] [Indexed: 11/29/2022]
Affiliation(s)
- A. Y. Hoi
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
- Department of Rheumatology; Monash Health; Melbourne Victoria Australia
- School of Clinical Sciences; Monash University; Melbourne Victoria Australia
| | - L. Ross
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
| | - J. Day
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
| | - R. R. C. Buchanan
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
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22
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Marchetti T, de Moerloose P, Gris JC. Antiphospholipid antibodies and the risk of severe and non-severe pre-eclampsia: the NOHA case-control study. J Thromb Haemost 2016; 14:675-84. [PMID: 26782635 DOI: 10.1111/jth.13257] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 11/25/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND pre-eclampsia (PEecl) can be defined as non-severe (NS-PEecl) or severe (S-PEecl). Our study aimed to determine the incidence of antiphospholipid antibodies (aPLs) in women with a past history of NS-PEecl or S-PEecl. PATIENTS AND METHODS This case-control study includes 195 control women, 199 NS-PEecl patients and 143 S-PEecl patients whose plasma samples were collected 6 months after their first delivery. Each plasma was tested for lupus anticoagulant (LA), anticardiolipin (aCL) and antiβ2GP1 antibodies, as well as antibodies against phosphatidylserine/prothrombin complex (aPS/PT) and domain I of the β2GP1. RESULTS When compared with the control group no significant associations were found for the NS-PEecl group after adjustment of confounding variables. For the S-PEecl group, there was an association with antiβ2GP1 immunoglobulin G (IgG) (OR 16.91, 95% CI 3.71-77.06), as well as age, obesity, smoking and multiparity. Antiβ2GP1-domain I IgG was associated with aCL, antiβ2GP1 and aPS/PT IgG in the three groups. aPS/PT IgG was associated with aCL IgG, and aPS/PT IgM was associated with aCL and antiβ2GP1 IgM in the three groups. CONCLUSION S-PEecl is a distinct entity from NS-PEecl and is mainly associated with the presence of antiβ2GP1 IgG. Antiβ2GP1 domain I correlates with other aPL IgG tests, and aPS/PT may be promising in patients for whom LA tests cannot be interpreted.
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Affiliation(s)
- T Marchetti
- Haemostasis Unit, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - P de Moerloose
- Haemostasis Unit, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - J C Gris
- Laboratoire et Consultations d'Hématologie, CHU Nîmes, Nîmes, France
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23
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Ruff WE, Vieira SM, Kriegel MA. The role of the gut microbiota in the pathogenesis of antiphospholipid syndrome. Curr Rheumatol Rep 2015; 17:472. [PMID: 25475595 DOI: 10.1007/s11926-014-0472-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Infectious triggers are associated with the induction of transient antiphospholipid antibodies. One therefore wonders if microbes that permanently colonize us play a role in the pathogenesis of antiphospholipid syndrome (APS). The microbiota represents the collection of all microorganisms colonizing humans and is necessary for normal host physiology. The microbiota, however, is a constant stress on the immune system, which is tasked with recognizing and eliminating pathogenic microbes while tolerating commensal populations. A growing body of literature supports a critical role for the commensal-immune axis in the development of autoimmunity against colonized barriers (e.g., gut or skin) and sterile organs (e.g., pancreas or joints). Whether these interactions affect the development and sustainment of autoreactive CD4(+) T cells and pathogenic autoantibodies in APS is unknown. This review provides an overview of the current understanding of the commensal-immune axis in autoimmunity with a focus on the potential relevance to APS. Additionally, we discuss emerging findings supporting the involvement of the gut microbiota in a spontaneous model of APS, the (NZW × BXSB)F1 hybrid, and formalize hypotheses to explain how interactions between the immune system and the microbiota may influence human APS etiopathogenesis.
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Affiliation(s)
- William E Ruff
- Department of Immunobiology, Yale University School of Medicine, 300 George St, Suite 353G, New Haven, CT, 06511, USA,
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24
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Abstract
For patients with antiphospholipid syndrome (APS), the consensus is to treat those who develop thrombosis with long-term oral anticoagulation therapy and to prevent obstetric manifestations by use of aspirin and heparin. These recommendations are based on data from randomized controlled trials and observational studies. Despite this body of knowledge, areas of uncertainty regarding the management of APS exist where evidence is scarce or nonexistent. In other words, for a subset of patients the course of management is unclear. Some examples are patients with 'seronegative' APS, those who do not fulfil the formal (clinical or serological) classification criteria for definite APS, and those with recurrent thrombotic events despite optimal anticoagulation. Other challenges include the treatment of clinical manifestations not included in the classification criteria, such as haematologic manifestations (thrombocytopenia and haemolytic anaemia), neurologic manifestations (chorea, myelitis and multiple sclerosis-like lesions), and nephropathy and heart valve disease associated with antiphospholipid antibodies (aPL), as well as the possible withdrawal of anticoagulation treatment in selected cases of thrombotic APS in which assays for aPL become persistently negative. This Review focuses on the current recommendations for thrombotic and obstetric manifestations of APS, as well as the management of difficult cases. Some aspects of treatment, such as secondary prophylaxis of venous thrombosis, are based on strong evidence--the 'lights' of APS treatment. Conversely, other areas, such as the treatment of non-criteria manifestations of APS, are based only on expert consensus or common sense and remain the 'shadows' of APS therapy.
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Erkan D, Aguiar CL, Andrade D, Cohen H, Cuadrado MJ, Danowski A, Levy RA, Ortel TL, Rahman A, Salmon JE, Tektonidou MG, Willis R, Lockshin MD. 14th International Congress on Antiphospholipid Antibodies: task force report on antiphospholipid syndrome treatment trends. Autoimmun Rev 2014; 13:685-96. [PMID: 24468415 DOI: 10.1016/j.autrev.2014.01.053] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 01/09/2014] [Indexed: 12/30/2022]
Abstract
Antiphospholipid Syndrome (APS) is characterized by vascular thrombosis and/or pregnancy morbidity occurring in patients with persistent antiphospholipid antibodies (aPL). The primary objective of the APS Treatment Trends Task Force, created as part of the 14th International Congress on aPL, was to systematically review the potential future treatment strategies for aPL-positive patients. The task force chose as future clinical research directions: a) determining the necessity for controlled clinical trials in venous thromboembolism with the new oral direct thrombin or anti-factor Xa inhibitors pending the results of the ongoing rivaroxaban in APS (RAPS) trial, and designing controlled clinical trials in other forms of thrombotic APS; b) systematically analyzing the literature as well as aPL/APS registries, and creating specific registries for non-warfarin/heparin anticoagulants; c) increasing recruitment for an ongoing primary thrombosis prevention trial, and designing secondary thrombosis and pregnancy morbidity prevention trials with hydroxychloroquine; d) determining surrogate markers to select patients for statin trials; e) designing controlled studies with rituximab and other anti-B-cell agents; f) designing mechanistic and clinical studies with eculizumab and other complement inhibitors; and g) chemically modifying peptide therapy to improve the half-life and minimize immunogenicity. The report also includes recommendations for clinicians who consider using these agents in difficult-to-manage aPL-positive patients.
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Affiliation(s)
- Doruk Erkan
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA.
| | - Cassyanne L Aguiar
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Danieli Andrade
- Department of Rheumatology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Hannah Cohen
- Department of Hematology, University College London Hospitals NHS Foundation Trust and University College London, London UK
| | | | - Adriana Danowski
- Department of Rheumatology, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thomas L Ortel
- Hemostasis and Thrombosis Center, Duke University Medical Center, Durham, NC, USA
| | - Anisur Rahman
- Department of Hematology, University College London Hospitals NHS Foundation Trust and University College London, London UK
| | - Jane E Salmon
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Maria G Tektonidou
- First Department of Medicine, University of Athens School of Medicine, Athens, Greece
| | - Rohan Willis
- Division of Rheumatology,University of Texas Medical Branch, Galveston, TX, USA
| | - Michael D Lockshin
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
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Broder A, Putterman C. Commentary on "The risky business of studying prognosis". J Rheumatol 2013; 40:1771. [PMID: 24085758 PMCID: PMC3904680 DOI: 10.3899/jrheum.130393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Anna Broder
- Division of Rheumatology, Albert Einstein College of Medicine, Forchheimer 701N, 1300 Morris Park Ave., Bronx, New York 10461, USA
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Maher J. Role of the clinical immunology laboratory in disease monitoring. World J Immunol 2013; 3:18-30. [DOI: 10.5411/wji.v3.i2.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/17/2013] [Indexed: 02/05/2023] Open
Abstract
Immunological investigations provide useful information to guide diagnosis of several disorders. Many such tests are also commonly repeated at intervals, in an effort to facilitate disease monitoring. In general however, immunology test results are often slow to alter. Furthermore, audit activity has indicated that repeated testing accounts for a substantial workload in many immunology services, which may waste resources and compromise the efficient completion of necessary tests. Consequently, the need and appropriate minimum interval between repeated testing requires critical evaluation. In this review, the clinical utility of repeated performance of several common immunology investigations has been evaluated, based upon published evidence. In some cases (e.g., paraprotein quantification, or measurement of anti-glomerular basement membrane antibodies), repeated testing provides vital clinical information and can be justified on a frequent and individualized basis. However, many other investigations provided by immunology services provide less valuable information when used to aid disease monitoring rather than diagnosis. It is hoped that the data summarized here will facilitate a more evidence-based approach to repeated testing. Such information may also assist with the local implementation of demand management strategies based upon setting of minimum retesting intervals for these investigations.
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28
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Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res 2013; 56:358-61. [DOI: 10.1007/s12026-013-8407-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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29
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Erkan D, Lockshin MD. Antiphospholipid syndrome. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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30
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Broder A, Putterman C. Hydroxychloroquine use is associated with lower odds of persistently positive antiphospholipid antibodies and/or lupus anticoagulant in systemic lupus erythematosus. J Rheumatol 2013; 40:30-3. [PMID: 22859353 PMCID: PMC3768146 DOI: 10.3899/jrheum.120157] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Antiphospholipid antibodies (aPL) play an active role in the pathogenesis of the antiphospholipid syndrome (APS). Primary prevention in APS may be aimed at decreasing existing elevated aPL levels, or preventing high aPL titers and/or lupus anticoagulant (LAC) from developing in the first place. Hydroxychloroquine (HCQ) has been shown in retrospective studies to decrease aPL titers in laboratory studies, and to decrease thrombosis risk in patients with systemic lupus erythematosus (SLE). We investigated an association between HCQ use and persistent aPL and/or LAC in SLE. METHODS We identified all patients over 21 years old with SLE from an urban tertiary care center who had aPL and LAC measured on at least 2 occasions at least 12 weeks apart. We defined the presence of persistent LAC+ and/or at least 1 aPL ≥ 40 U [immunoglobulin A (IgA), IgG, or IgM] as the main outcome variable. RESULTS Among 90 patients included in the study, 17 (19%) had persistent LAC+ and/or at least 1 aPL ≥ 40 U. HCQ use was associated with significantly lower odds of having persistent LAC+ and/or aPL ≥ 40 U (OR 0.21, 95% CI 0.05, 0.79, p = 0.02), adjusted for age, ethnicity, and sex. CONCLUSION This is the first study to show that HCQ use is associated with lower odds of having persistently positive LAC and/or aPL. Data from this study provide a basis for the design of future prospective studies investigating the role of HCQ in primary and secondary prevention of APS.
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Affiliation(s)
- Anna Broder
- Division of Rheumatology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York 10461, USA.
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Lockshin MD. Pregnancy and antiphospholipid syndrome. Am J Reprod Immunol 2012; 69:585-7. [PMID: 23279134 DOI: 10.1111/aji.12071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022] Open
Abstract
APS causes adverse pregnancy outcome, especially in younger patients with SLE or prior thromboses. LAC is the best predictor of adverse outcome. Prior conclusions on the efficacy of heparin for prevention of poor outcome may be suspect. New therapies are under evaluation in animal models but how to introduce them into the clinic is unclear.
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Affiliation(s)
- Michael D Lockshin
- Department of Medicine and Obstetrics-Gynecology, Weill-Cornell Medical College, Hospital for Special Surgery New York, NY, USA.
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Lockshin MD, Kim M, Laskin CA, Guerra M, Branch DW, Merrill J, Petri M, Porter TF, Sammaritano L, Stephenson MD, Buyon J, Salmon JE. Prediction of adverse pregnancy outcome by the presence of lupus anticoagulant, but not anticardiolipin antibody, in patients with antiphospholipid antibodies. ACTA ACUST UNITED AC 2012; 64:2311-8. [PMID: 22275304 DOI: 10.1002/art.34402] [Citation(s) in RCA: 243] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate which serologic and clinical findings predict adverse pregnancy outcome in patients with antiphospholipid antibody (aPL) and to test the hypothesis that a pattern of clinical and serologic variables can identify women at highest risk of adverse pregnancy outcome. METHODS Women enrolled in a multicenter prospective observational study of risk factors for adverse pregnancy outcome in patients with aPL (lupus anticoagulant [LAC], anticardiolipin antibody [aCL], and/or antibody to β2-glycoprotein I [anti-β2 GPI]) and/or systemic lupus erythematosus (SLE) were recruited for the present prospective study. Demographic, clinical, serologic, and treatment data were recorded at the time of the first study visit. The relationship between individual and combined variables and adverse pregnancy outcome was assessed by bivariate and multivariate analysis. RESULTS Between 2003 and 2011 we enrolled 144 pregnant patients, of whom 28 had adverse pregnancy outcome. Thirty-nine percent of the patients with LAC had adverse pregnancy outcome, compared to 3% of those who did not have LAC (P<0.0001). Among women with IgG aCL at a level of ≥40 units/ml, only 8% of those who were LAC negative had adverse pregnancy outcome, compared to 43% of those who were LAC positive (P=0.002). IgM aCL, IgG anti-β2 GPI, and IgM anti-β2 GPI did not predict adverse pregnancy outcome. In bivariate analysis, adverse pregnancy outcome occurred in 52% of patients with and 13% of patients without prior thrombosis (P=0.00005), and in 23% with SLE versus 17% without SLE (not significant); SLE was a predictor in multivariate analysis. Prior pregnancy loss did not predict adverse pregnancy outcome. Simultaneous positivity for aCL, anti-β2 GPI, and LAC did not predict adverse pregnancy outcome better than did positivity for LAC alone. CONCLUSION LAC is the primary predictor of adverse pregnancy outcome after 12 weeks' gestation in aPL-associated pregnancies. Anticardiolipin antibody and anti-β2 GPI, if LAC is not also present, do not predict adverse pregnancy outcome.
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Affiliation(s)
- Michael D Lockshin
- Hospital for Special Surgery and Weill Cornell Medical College, New York, New York.
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Lockshin MD. Antiphospholipid: to test, or not to test, that is the question. Int J Clin Pract 2012; 66:620-1. [PMID: 22698413 DOI: 10.1111/j.1742-1241.2012.02892.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- M D Lockshin
- Department of Medicine and Obstetrics-Gynecology, Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery and Weill Cornell Medical College, New York, NY, USA.
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The association of antiphospholipid antibodies with intrauterine fetal death: A case–control study. Thromb Res 2012; 130:32-7. [DOI: 10.1016/j.thromres.2011.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/04/2011] [Accepted: 11/16/2011] [Indexed: 11/20/2022]
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Willis R, Seif AM, McGwin G, Martinez-Martinez LA, González EB, Dang N, Papalardo E, Liu J, Vilá LM, Reveille JD, Alarcón GS, Pierangeli SS. Effect of hydroxychloroquine treatment on pro-inflammatory cytokines and disease activity in SLE patients: data from LUMINA (LXXV), a multiethnic US cohort. Lupus 2012; 21:830-5. [PMID: 22343096 DOI: 10.1177/0961203312437270] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE We sought to determine the effect of hydroxychloroquine therapy on the levels proinflammatory/prothrombotic markers and disease activity scores in patients with systemic lupus erythematosus (SLE) in a multiethnic, multi-center cohort (LUMINA). METHODS Plasma/serum samples from SLE patients (n = 35) were evaluated at baseline and after hydroxychloroquine treatment. Disease activity was assessed using SLAM-R scores. Interferon (IFN)-α2, interleukin (IL)-1β, IL-6, IL-8, inducible protein (IP)-10, monocyte chemotactic protein-1, tumor necrosis factor (TNF)-α and soluble CD40 ligand (sCD40L) levels were determined by a multiplex immunoassay. Anticardiolipin antibodies were evaluated using ELISA assays. Thirty-two frequency-matched plasma/serum samples from healthy donors were used as controls. RESULTS Levels of IL-6, IP-10, sCD40L, IFN-α and TNF-α were significantly elevated in SLE patients versus controls. There was a positive but moderate correlation between SLAM-R scores at baseline and levels of IFN-α (p = 0.0546). Hydroxychloroquine therapy resulted in a significant decrease in SLAM-R scores (p = 0.0157), and the decrease in SLAM-R after hydroxychloroquine therapy strongly correlated with decreases in IFN-α (p = 0.0087). CONCLUSIONS Hydroxychloroquine therapy resulted in significant clinical improvement in SLE patients, which strongly correlated with reductions in IFN-α levels. This indicates an important role for the inhibition of endogenous TLR activation in the action of hydroxychloroquine in SLE and provides additional evidence for the importance of type I interferons in the pathogenesis of SLE. This study underscores the use of hydroxychloroquine in the treatment of SLE.
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Affiliation(s)
- R Willis
- University of Texas Medical Branch, Galveston, USA
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Alpert DR, Salmon JE. False-positive tests for heparin-induced thrombocytopenia in patients with antiphospholipid syndrome and systemic lupus erythematosus: a rebuttal. J Thromb Haemost 2010; 8:1439-41. [PMID: 20345710 DOI: 10.1111/j.1538-7836.2010.03866.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Espinosa G, Cervera R. Management of the antiphospholipid syndrome. AUTO- IMMUNITY HIGHLIGHTS 2010; 1:15-22. [PMID: 26000103 PMCID: PMC4389060 DOI: 10.1007/s13317-010-0004-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 03/04/2010] [Indexed: 01/08/2023]
Abstract
Antiphospholipid syndrome (APS) is characterized by recurrent venous or arterial thromboses, fetal losses and thrombocytopenia in the presence of antiphospholipid antibodies, namely lupus anticoagulant, anticardiolipin antibodies or antibodies directed to various proteins, mainly β2 glycoprotein I, or all three. There is consensus in treating patients with APS and first venous thrombosis with oral anticoagulation to a target international normalized ratio (INR) of 2.0-3.0. A recent systematic review recommended a target INR of >3.0 in those patients with APS and arterial thrombosis. The approach in women with obstetric manifestations of APS is based on the use of aspirin plus heparin. The best treatment for patients with the catastrophic variant of the APS is a combination of anticoagulation, corticosteroids, and plasma exchange or intravenous immunoglobulins.
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Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Catalonia, Spain
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Pierangeli SS, Erkan D. Antiphospholipid syndrome treatment beyond anticoagulation: are we there yet? Lupus 2010; 19:475-85. [DOI: 10.1177/0961203310361489] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Persistently positive antiphospholipid antibodies in association with thromboses and/or pregnancy morbidity is the hallmark of the antiphospholipid syndrome. The management of antiphospholipid antibody-positive patients has been focused on utilizing anti-thrombotic medications such as heparin or warfarin. Given that our understanding of the molecular mechanisms of antiphospholipid antibody-mediated thrombosis has been growing, it is highly likely that the current ‘anti-thrombotic’ approach to these patients will be replaced by an ‘immunomodulatory’ approach in the near future. This review article will address the experimental and/or clinical evidence behind some of these potential ‘immunomodulatory’ approaches (tissue factor inhibition, P38 mitogen-activated protein kinase inhibition, nuclear factor-κB inhibition, platelet glycoprotein receptor inhibition, hydroxychloroquine, statins, inhibition of β2GPI and/or anti-β2GPI binding to target cells, complement inhibition, and B cell inhibition) in antiphospholipid syndrome.
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Affiliation(s)
- SS Pierangeli
- Division of Rheumatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA,
| | - D. Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
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The association of antiphospholipid antibodies with pregnancy-related first time venous thrombosis--a population-based case-control study. Thromb Res 2010; 125:e222-7. [PMID: 20051285 DOI: 10.1016/j.thromres.2009.12.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 12/02/2009] [Accepted: 12/03/2009] [Indexed: 11/20/2022]
Abstract
In this population-based case-control study we explored the association of antiphospholipid antibodies with pregnancy-related venous thrombosis. From 1990 through 2003 615 pregnant women were identified at 18 hospitals in Norway with a diagnosis of first time VT. In 2006, 531 of 559 eligible cases and 1092 of 1229 eligible controls were invited for further investigations. The final study population comprised 313 cases and 353 controls, who completed a comprehensive questionnaire and donated a single blood sample, 3-16 years after index pregnancy. We report the results on lupus anticoagulant, anticardiolipin antibodies, and anti-ss(2) glycoprotein-1 antibodies alone, in combination, and with the contribution of the factor V Leiden and the prothrombin gene G20210A polymorphisms. Cut-off values for APAs were chosen according to current international consensus. 29 (9.3%) of the cases and 24 (6.8%) of the controls had at least one positive test for APAs (OR 1.4; 95% CI 0.8-2.5). Nine cases (2.8%) and no controls had more than one positive test (multi-positivity) for APAs. After excluding women with factor V Leiden or prothrombin polymorphisms, still 6 cases were multi-positive for APAs. We conclude that multi-positivity, but not single-positivity, for APAs was weakly associated with a history of ante- and postnatal VT.
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Erkan D, Barbhaiya M, George D, Sammaritano L, Lockshin M. Moderate versus high-titer persistently anticardiolipin antibody positive patients: are they clinically different and does high-titer anti-beta 2-glycoprotein-I antibody positivity offer additional predictive information? Lupus 2009; 19:613-9. [PMID: 19934177 DOI: 10.1177/0961203309355300] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The association between antiphospholipid antibodies (aPL) and clinical events is stronger with a positive lupus anticoagulant (LA) test, higher anticardiolipin antibody (aCL) titers, and/or higher anti-beta(2)-glycoprotein-I antibody (abeta( 2)GPI) titers. The objective of this study was to determine the clinical characteristics of persistently high-titer (> or =80 U) aCL-positive patients compared with those with persistent moderate aCL titers (40-79 U). Second, we analyzed whether high-titer abeta(2)GPI test adds predictive information in persistently moderate-to-high titer aCL-positive patients. In this cross-sectional study, the primary analysis compared the clinical and aPL characteristics of 58 patients with at least two moderate-titer aCL results to another 85 patients with at least two high-titer aCL results. In the secondary analysis of patients with at least two abeta(2)GPI test results, we compared 29 patients with 'aCL 40-79 U and abeta( 2)GPI < 80 U' profiles with 8 patients with 'aCL 40-79U and abeta(2)GPI > or = 80 U', and also compared 27 patients with 'aCL > 80 U and abeta(2)GPI < 80 U' with 32 patients with 'aCL > 80 U and abeta(2)GPI > or = 80 U'. Although aPL-related vascular and pregnancy events were similar between the moderate- and high-titer aCL groups, the number of patients with positive LA tests (RR 2.06, CI 1.38-3.08, p < 0.01) and with at least one non-criteria aPL manifestation (RR 1.66, CI 1.20-2.30, p = 0.0005) were significantly higher in the high-titer aCL group. While magnetic resonance imaging (MRI) white matter changes were statistically more common in the high-titer aCL group (RR 2.03, CI 1.04-3.94, p = 0.02), there was a trend towards increased prevalence of livedo reticularis, cardiac valve disease, and cognitive dysfunction occurring in the high-titer aCL group. The secondary analysis showed that MRI white matter changes, cardiac valve disease, and cognitive dysfunction were proportionally more common in the high-titer abeta( 2)GPI groups, suggesting a linear relationship between non-criteria aPL manifestations and aPL titers. Our results suggest that patients with high aCL titers, compared with those with moderate titers, are more likely to have a positive LA test and a higher prevalence of non-criteria aPL manifestations. Furthermore, high-titer abeta(2)GPI positivity may further increase the prevalence of non-criteria aPL manifestations in moderate- or high-titer aCL-positive patients.
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Affiliation(s)
- D Erkan
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA.
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Espinosa G, Cervera R. Thromboprophylaxis and obstetric management of the antiphospholipid syndrome. Expert Opin Pharmacother 2009; 10:601-14. [DOI: 10.1517/14656560902772302] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Erkan D, Lockshin MD. New approaches for managing antiphospholipid syndrome. Nat Rev Rheumatol 2009; 5:160-70. [DOI: 10.1038/ncprheum1017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 12/17/2008] [Indexed: 11/09/2022]
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Pasquali JL, Poindron V, Korganow AS, Martin T. The antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2008; 22:831-45. [DOI: 10.1016/j.berh.2008.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hydroxychloroquine directly reduces the binding of antiphospholipid antibody-beta2-glycoprotein I complexes to phospholipid bilayers. Blood 2008; 112:1687-95. [PMID: 18577708 DOI: 10.1182/blood-2008-03-144204] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Treatment with the antimalarial drug hydroxychloroquine (HCQ) has been associated with reduced risk of thrombosis in the antiphospholipid (aPL) syndrome (APS) and, in an animal model of APS, with reduction of experimentally induced thrombosis. Recognition of beta2-glycoprotein I (beta2GPI) by aPL antibodies appears to play a major role in the disease process. We therefore used the techniques of ellipsometry and atomic force microscopy (AFM) to investigate whether HCQ directly affects the formation of aPL IgG-beta2GPI complexes on phospholipid bilayers. HCQ, at concentrations of 1 mug/mL and greater, significantly reduced the binding of aPL-beta2GPI complexes to phospholipid surfaces and THP-1 (human acute monocytic leukemia cell line) monocytes. The drug also reduced the binding of the individual proteins to bilayers. This HCQ-mediated reduction of binding was completely reversed when the HCQ-protein solutions were dialyzed against buffer. HCQ also caused modest, but statistically significant, reductions of clinical antiphospholipid assays. In conclusion, HCQ reduces the formation of aPL-beta2GPI complexes to phospholipid bilayers and cells. This effect appears to be due to reversible interactions between HCQ and the proteins and may contribute to the observed reduction of thrombosis in human and experimental APS. These results support the possibility that HCQ, or analogous molecules, may offer novel nonanticoagulant therapeutic strategies for treating APS.
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Erkan D, Lockshin MD. Antiphospholipid syndrome. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW To review the recently published studies that can guide physicians in the management of persistently antiphospholipid antibody (aPL)-positive patients. RECENT FINDINGS Two recent prospective randomized controlled trials of two intensities of warfarin concluded that both moderate and high-intensity anticoagulation are similarly protective in antiphospholipid syndrome patients after the first thrombosis. Despite lack of controlled studies, there is experimental evidence that hydroxychloroquine and statins may play a role in the management of aPL-positive patients. In the mouse model of antiphospholipid syndrome that involves the injection of high-titer antiphospholipid syndrome human serum, complement activation is essential in aPL-mediated fetal loss and heparin prevents aPL-induced complement activation. SUMMARY Primary thrombosis prevention in persistently aPL-positive individuals lacks an evidence-based approach; elimination of reversible thrombosis risk factors and prophylaxis during high-risk periods is crucial. Secondary thrombosis prevention in persistently aPL-positive individuals lacks a risk-stratified approach; although the current recommendation is life-long warfarin, the necessity, duration, and the intensity of warfarin are still debated. Catastrophic antiphospholipid syndrome patients usually receive a combination of anticoagulation, corticosteroids, intravenous immunoglobulin, and plasma exchange; there is a clear need to test new agents. A common strategy to prevent fetal loss in aPL-positive patients with history of pregnancy morbidities is low-dose aspirin and heparin; if patients fail this regimen, the next step is the addition of intravenous immunoglobulin although this is not supported by controlled studies. Currently, there is no evidence that anticoagulation is effective for nonthrombotic manifestations of antiphospholipid antibodies.
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Affiliation(s)
- Doruk Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, and Weill Medical College of Cornell University, New York, USA.
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Abstract
Challenges in new drug development for APS include the controversy about the strength of association between aPL and thrombotic events, and unknown mechanism of aPL-induced thrombosis. In the long-term management of patients who have APS, controlled studies with warfarin alternatives (such as antiplatelet agents), the new anticoagulant agents (such as direct and indirect thrombin inhibitors), and newer therapeutic agents are vital. It is highly possible that the current "antithrombotic" approach to patients who are aPL-positive will be replaced by a "more specifically targeted, anti-inflammatory or immunomodulatory" approach in the future.
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Affiliation(s)
- Doruk Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, NY 10021, USA.
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