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Loiseau P, Foret T, DeFilippis EM, Risse J, Etienne AD, Dufrost V, Moulinet T, Erkan D, Devilliers H, Wahl D, Zuily S. Risk of livedo with antiphospholipid antibodies in patients with systemic lupus erythematosus: A systematic review and meta-analysis. Lupus 2022; 31:1595-1605. [DOI: 10.1177/09612033221126852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Livedo is a well-known skin condition in patients with systemic lupus erythematosus (SLE) which correspond to small vessels involvement. The influence of antiphospholipid antibodies (aPL) on the occurrence of livedo is controversial. The aim of our study was to estimate the risk of livedo associated with aPL in patients with SLE. Methods We conducted a systematic review and meta-analysis of the literature from 1977 to 2021 to estimate the risk of livedo in SLE patients according to different aPL profiles. Data sources were PubMed, Embase, Cochrane Library, hand search, and reference lists of studies. Studies were selected if they included SLE patients with descriptions of the exposure to aPL and the outcome ( livedo). Two independent investigators assessed study eligibility, quality, and extracted patient characteristics from each study as well as exposure (aPL) and outcome ( livedo). Risk estimates were pooled using random effects models and sensitivity analyses. For all stages of the meta-analysis, we followed the PRISMA guidelines. PROSPERO registration number: CRD42015027377. Results Of the 2,355 articles identified, 27 were included with a total of 4,810 SLE patients. The frequency of livedo was 25.5% in aPL-positive patients and 13.3% in aPL-negative patients. The overall Odds Ratio (OR) for livedo in aPL-positive patients compared to aPL-negative patients was 2.91 (95% CI; 2.17–3.90). The risk of livedo was significantly increased for most of aPL subtypes, including lupus anticoagulant (LA) (OR = 4.45 [95% CI; 2.21–8.94]), IgG anticardiolipin (OR = 3.95 [95% CI; 2.34–6.65]), and IgG anti-β2-glycoprotein 1 (OR = 3.49 [95% CI; 1.68–7.27]). Conclusions We demonstrated in this meta-analysis an excess risk of livedo in aPL-positive SLE patients compared to aPL-negative patients. For daily practice, in patients with SLE, livedo associated with aPL could correspond to a peculiar group of patients with small vessel disease. Livedo could be a good candidate for inclusion in future classification criteria for antiphospholipid syndrome.
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Affiliation(s)
- Pierre Loiseau
- CHU Amiens-Picardie, Department of Internal Medicine, Amiens, France
| | - Thomas Foret
- CHU de Besançon, Vascular Medicine Unit, Vascular Surgery Department, Besançon, France
| | | | | | - Anais D Etienne
- Department of Internal Medicine, CHRU de Nancy, Nancy, France
| | - Virginie Dufrost
- Université de Lorraine, Nancy, France
- Vascular Medicine Division And Regional Competence Centre For Rare Vascular And Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
| | - Thomas Moulinet
- Department of Internal Medicine, CHRU de Nancy, Nancy, France
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, NY, USA
| | - Hervé Devilliers
- CHRU de Dijon, Department of Internal Medicine, Regional Competence Centre For Systemic Autoimmune Diseases, Dijon, France
| | - Denis Wahl
- Université de Lorraine, Nancy, France
- Vascular Medicine Division And Regional Competence Centre For Rare Vascular And Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, Nancy, France
- Vascular Medicine Division And Regional Competence Centre For Rare Vascular And Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
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Depascale R, Del Frate G, Gasparotto M, Manfrè V, Gatto M, Iaccarino L, Quartuccio L, De Vita S, Doria A. Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review. Ther Adv Musculoskelet Dis 2021; 13:1759720X211040696. [PMID: 34616495 PMCID: PMC8488521 DOI: 10.1177/1759720x211040696] [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: 05/05/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022] Open
Abstract
Lung involvement in systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS) has extensively been outlined with a multiplicity of different manifestations. In SLE, the most frequent finding is pleural effusion, while in pSS, airway disease and parenchymal disorders prevail. In both cases, there is an increased risk of pre-capillary and post-capillary pulmonary arterial hypertension (PAH) and pulmonary venous thromboembolism (VTE). The risk of VTE is in part due to an increased thrombophilic status secondary to systemic inflammation or to the well-established association with antiphospholipid antibody syndrome (APS). The lung can also be the site of an organ-specific complication due to the aberrant pathologic immune-hyperactivation as occurs in the development of lymphoma or amyloidosis in pSS. Respiratory infections are a major issue to be addressed when approaching the differential diagnosis, and their exclusion is required to safely start an immunosuppressive therapy. Treatment strategy is mainly based on glucocorticoids (GCs) and immunosuppressants, with a variable response according to the primary pathologic process. Anticoagulation is recommended in case of VTE and multi-targeted treatment regimens including different drugs are the mainstay for PAH management. Antibiotics and respiratory physiotherapy can be considered relevant complement therapeutic measures. In this article, we reviewed lung manifestations in SLE and pSS with the aim to provide a comprehensive overview of their diagnosis and management to physicians taking care of patients with connective tissue diseases.
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Affiliation(s)
- Roberto Depascale
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Giulia Del Frate
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Michela Gasparotto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valeria Manfrè
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Quartuccio
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Antiphospholipid antibodies and the risk of thrombocytopenia in patients with systemic lupus erythematosus: A systematic review and meta-analysis. Autoimmun Rev 2019; 18:102395. [DOI: 10.1016/j.autrev.2019.102395] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/12/2019] [Indexed: 01/30/2023]
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4
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Prevalence of Pulmonary Embolism Among Systemic Lupus Erythematosus Discharges. J Clin Rheumatol 2017; 23:200-206. [DOI: 10.1097/rhu.0000000000000521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Mahajan A, Herrmann M, Muñoz LE. Clearance Deficiency and Cell Death Pathways: A Model for the Pathogenesis of SLE. Front Immunol 2016; 7:35. [PMID: 26904025 PMCID: PMC4745266 DOI: 10.3389/fimmu.2016.00035] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/24/2016] [Indexed: 12/21/2022] Open
Abstract
Alterations of cell death pathways, including apoptosis and the neutrophil specific kind of death called NETosis, can represent a potential source of autoantigens. Defects in the clearance of apoptotic cells may be responsible for the initiation of systemic autoimmunity in several chronic inflammatory diseases, including systemic lupus erythematosus (SLE). Autoantigens are released mainly from secondary necrotic cells because of a defective clearance of apoptotic cells or an inefficient degradation of DNA-containing neutrophil extracellular traps (NETs). These modified autoantigens are presented by follicular dendritic cells to autoreactive B cells in germinal centers of secondary lymphoid organs. This results in the loss of self-tolerance and production of autoantibodies, a unifying feature of SLE. Immune complexes (IC) are formed from autoantibodies bound to uncleared cellular debris in blood or tissues. Clearance of IC by blood phagocytes, macrophages, and dendritic cells leads to proinflammatory cytokine secretion. In particular, plasmacytoid dendritic cells produce high amounts of interferon-α upon IC uptake, thereby contributing to the interferon signature of patients with SLE. The clearance of antinuclear IC via Fc-gamma receptors is considered a central event in amplifying inflammatory immune responses in SLE. Along with this, the accumulation of cell remnants represents an initiating event of the etiology, while the subsequent generation of autoantibodies against nuclear antigens (including NETs) results in the perpetuation of inflammation and tissue damage in patients with SLE. Here, we discuss the implications of defective clearance of apoptotic cells and NETs in the development of clinical manifestations in SLE.
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Affiliation(s)
- Aparna Mahajan
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3, Rheumatology and Immunology , Erlangen , Germany
| | - Martin Herrmann
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3, Rheumatology and Immunology , Erlangen , Germany
| | - Luis E Muñoz
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3, Rheumatology and Immunology , Erlangen , Germany
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Doria A, Zen M, Bettio S, Gatto M, Bassi N, Nalotto L, Ghirardello A, Iaccarino L, Punzi L. Autoinflammation and autoimmunity: Bridging the divide. Autoimmun Rev 2012; 12:22-30. [DOI: 10.1016/j.autrev.2012.07.018] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Overlap connective tissue disease syndromes. Autoimmun Rev 2012; 12:363-73. [PMID: 22743033 DOI: 10.1016/j.autrev.2012.06.004] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/12/2012] [Indexed: 02/06/2023]
Abstract
Overlap Syndromes (OSs) have been defined as entities satisfying classification criteria of at least two connective tissue diseases (CTDs) occurring at the same or at different times in the same patient. CTDs include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), polymyositis/dermatomyositis (PDM), and Sjögren syndrome (SS). Every combination between these disorders has been reported. In some OS a specific autoantibody has been indentified, supporting the hypothesis that these syndromes are not a mere association of two or more CTD in the same patient, but a well defined clinical entity with specific clinical characteristics. As an example, anti-t-RNA synthetase syndrome is characterized by the presence of anti-t-RNA synthetase antibodies. Notably, clinical manifestations observed in OS may be different from those observed in the single CTD. The treatment of OS is mainly based on the use of corticosteroids and immunosuppressants. Biologic drugs, i.e. anti-TNFα or anti-CD20 monoclonal antibodies, have been recently introduced as alternative treatments in refractory cases. Moreover, there are some concerns with the use of anti-TNF agents in patients with systemic autoimmune diseases due to the risk of triggering disease exacerbations. In this paper the most frequent OS are described with a special focus on the specific immunologic and clinical aspects. Furthermore, some personal data on anti-t-RNA synthetase syndrome and rhupus syndrome are reported.
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Dahle C, Vrethem M, Olsson JE, Ernerudh J. High level of anticardiolipin antibodies is an unusual finding in an unselected stroke population. Eur J Neurol 2011; 2:331-6. [DOI: 10.1111/j.1468-1331.1995.tb00135.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Woo KS, Kim KE, Kim JM, Han JY, Chung WT, Kim KH. Prevalence and clinical associations of lupus anticoagulant, anticardiolipin antibodies, and anti-beta2-glycoprotein I antibodies in patients with systemic lupus erythematosus. Korean J Lab Med 2010; 30:38-44. [PMID: 20197721 DOI: 10.3343/kjlm.2010.30.1.38] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The presence of antiphospholipid antibodies (aPLs) is associated with the clinical features of antiphospholipid syndrome (APS), which comprises venous and arterial thrombosis and pregnancy loss, and systemic lupus erythematosus (SLE). The prevalence of aPLs has been reported to be different in patient populations affected by either of these conditions. We performed a retrospective study to evaluate the prevalence and clinical associations of aPLs, including lupus anticoagulant (LAC), anticardiolipin (aCL), and anti-beta2-glycoprotein I antibodies (anti-beta2-GPI) in a cohort of Korean patients with SLE. METHODS This study included samples from 88 SLE patients for whom aPL testing had been advised between June 2006 and July 2009 at the Dong-A University Hospital. Serum and plasma samples were tested for LAC, aCL (IgG, IgM), and anti-beta2-GPI (IgG, IgM) antibodies. Clinical data from patients were obtained from a review of medical records. RESULTS LAC was the most common (34.1% of total patients, 30/88) antibody, followed by IgM aCL (31.8%, 28/88), IgG aCL (18.2%, 16/88), and IgM and IgG anti-beta2-GPI (both 5.7%, 5/88 each). Positivity for LAC was strongly associated with venous/arterial thrombosis (P=0.002). CONCLUSIONS LAC was the most common antibody detected in Korean SLE patients and is shown to have a significant association with the presence of venous/arterial thrombosis. The measurement of LAC may be clinically useful in identifying patients with SLE who are at a high risk for venous/arterial thrombosis.
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Affiliation(s)
- Kwang-Sook Woo
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
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Baharfard N, Shiroodi MK, Fotoohi F, Samangooie S, Asli IN, Eghtesadi-Araghi P, Javadi H, Semnani S, Amini A, Assadi M. Myocardial perfusion imaging using a technetium-99m sestamibi in asymptomatic and low risk for coronary artery disease patients with diagnosed systemic lupus erythematosus. Perfusion 2010; 26:151-7. [PMID: 21078771 DOI: 10.1177/0267659110389844] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The aim of the present study was to evaluate technetium-99m sestamibi single photon emission tomography (SPECT) myocardial perfusion imaging (MPI) and its association with some clinical and laboratory parameters in an asymptomatic systemic lupus erythematosus (SLE) population. MATERIALS AND METHODS Twenty-one subjects with SLE and no suspected or documented coronary artery disease (CAD) accomplished myocardial perfusion imaging. Some SLE and CAD parameters were also evaluated in association with myocardial SPECT. RESULTS Twenty-one women with a diagnosis of SLE (mean age 36.9 ± 12.8) entered the study. All patients were in the low-risk category for CAD pretest; however, abnormal myocardial perfusion results were found in eight (38%) patients. Amongst the traditional CAD risk factors, there was a significant association between the presence of dyslipidemia and myocardial perfusion abnormalities (P= 0.047). However, we found no significant association between other traditional and SLE-specific risk factors. CONCLUSION This study's significant finding was that asymptomatic CAD is common in SLE patients, even in those thought to be low risk for CAD and in the absence of cardiac symptoms.
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Affiliation(s)
- Nastaran Baharfard
- Department of Nuclear Medicine, Taleghani Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
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11
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Wesemann DR, Costenbader KH, Coblyn JS. Co-existing sarcoidosis, systemic lupus erythematosus and the antiphospholipid antibody syndrome: case reports and discussion from the Brigham and Women's Hospital Lupus Center. Lupus 2009; 18:202-5. [PMID: 19213857 DOI: 10.1177/0961203308100483] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sarcoidosis, systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS) are chronic conditions of immune dysregulation whose aetiologies remain mysterious. Expression of sarcoidosis and SLE within individuals has been reported in a handful of cases in the last 60 years. In this study, we report two cases of sarcoidosis and SLE occurring together, and each case demonstrated complications associated with the presence of anticardiolipin antibodies. Clinical, serological and pathological findings confirmed the diagnoses in each case and both patients improved with therapy. The association of sarcoidosis, SLE and APS is unique and may present difficult therapeutic options, as well as to shed light on their immunopathogenesis.
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Affiliation(s)
- D R Wesemann
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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12
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Horstman LL, Jy W, Bidot CJ, Ahn YS, Kelley RE, Zivadinov R, Maghzi AH, Etemadifar M, Mousavi SA, Minagar A. Antiphospholipid antibodies: paradigm in transition. J Neuroinflammation 2009; 6:3. [PMID: 19154576 PMCID: PMC2640381 DOI: 10.1186/1742-2094-6-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 01/20/2009] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES This is a critical review of anti-phospholipid antibodies (aPL). Most prior reviews focus on the aPL syndrome (APS), a thrombotic condition often marked by neurological disturbance. We bring to attention recent evidence that aPL may be equally relevant to non-thrombotic autoimmune conditions, notably, multiple sclerosis and ITP. ORGANIZATION After a brief history, the recent proliferation of aPL target antigens is reviewed. The implication is that many more exist. Theories of aPL in thrombosis are then reviewed, concluding that all have merit but that aPL may have more diverse pathological consequences than now recognized. Next, conflicting results are explained by methodological differences. The lupus anticoagulant (LA) is then discussed. LA is the best predictor of thrombosis, but why this is true is not settled. Finally, aPL in non-thrombotic disorders is reviewed. CONCLUSION The current paradigm of aPL holds that they are important in thrombosis, but they may have much wider clinical significance, possibly of special interest in neurology.
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Affiliation(s)
- Lawrence L Horstman
- Wallace Coulter Platelet Laboratory, Division of Hematology and Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Wenche Jy
- Wallace Coulter Platelet Laboratory, Division of Hematology and Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Carlos J Bidot
- Wallace Coulter Platelet Laboratory, Division of Hematology and Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Yeon S Ahn
- Wallace Coulter Platelet Laboratory, Division of Hematology and Oncology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Roger E Kelley
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, The Jacobs Neurological Institute, Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo NY, USA
| | - Amir H Maghzi
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Etemadifar
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Ali Mousavi
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Minagar
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
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Abstract
Over recent decades short- and medium-term survival has greatly improved in patients affected with systemic lupus erythematosus, but long-term prognosis still remains poor mainly due to complications of the disease and/or its treatment. To improve long-term prognosis in systemic lupus erythematosus, we should try to adopt, early in the disease course, strategies that can contribute to reducing long-term complications, including screening for and prophylaxis against infections, control of risk factors for atherosclerosis, and cancer surveillance. However, in patients with systemic lupus erythematosus all these preventive strategies are often not sufficient. Indeed, two important systemic lupus erythematosus-related factors play a relevant role in all these complications: severe disease manifestations, such as glomerulonephritis and central nervous system involvement, and corticosteroid and cyclophosphamide use. Therefore, to prevent long-term complications, we should try to control disease activity and severity using the lowest effective dosage of these drugs. Moreover, strategies directed at preventing clinical manifestations in asymptomatic antinuclear antibody-positive individuals or in antiphospholipid antibody-positive systemic lupus erythematosus patients, as well as at preventing severe manifestations in patients with mild systemic lupus erythematosus at the time of the diagnosis should be considered.
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Affiliation(s)
- A Doria
- Division of Rheumatology, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
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Kashef S, Karimi M, Amirghofran Z, Ayatollahi M, Pasalar M, Ghaedian MM, Kashef MA. Antiphospholipid antibodies and hepatitis C virus infection in Iranian thalassemia major patients. Int J Lab Hematol 2008; 30:11-6. [PMID: 18190462 DOI: 10.1111/j.1751-553x.2007.00916.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although the precise nature of Antiphospholipid antibodies is still not clearly defined, they are known to have association with thromboembolic events and have been found in hepatitis C virus (HCV) infection. Moreover, high prevalence of HCV infection and thrombotic risk is described in thalassemia. We aimed at investigating the prevalence of anticardiolipin antibodies (aCLAbs), lupus anticoagulant (LA), and their relation with HCV infection in Iranian thalassemic patients. Presence of anti-HCV antibody, serum HCV-RNA, aCLAbs, and LA activity was determined in 131 patients with thalassemia major (male/female: 63/68 aged 3-29 years) registered at thalassemia unit, Dastgheib Hospital, Shiraz, Iran. Sixty-one healthy controls were also included. Anti-HCV antibody was positive in 24 (18.3%), IgG aCLAbs in 56 (42.7%), and LA activity in 9 (6.9%) patients. 87.5% of patients positive for aCLAbs had a low titer of aCLAbs. Although none of the participants had a previous history of thrombosis, higher prevalence of aCLAbs was detected in thalassemic patients compared with controls. No significant difference in the prevalence of aCLAbs was found between HCV-infected and noninfected patients. A high prevalence of aCLAbs, the majority in low titers, was detected in Iranian thalassemic patients irrespective of previous history of thrombosis and presence of HCV infection.
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Affiliation(s)
- S Kashef
- Allergy Research Center, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran.
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Doria A, Arienti S, Rampudda M, Canova M, Tonon M, Sarzi-Puttini P. Preventive strategies in systemic lupus erythematosus. Autoimmun Rev 2008; 7:192-7. [DOI: 10.1016/j.autrev.2007.11.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Swadźba J, Iwaniec T, Szczeklik A, Musiał J. Revised classification criteria for antiphospholipid syndrome and the thrombotic risk in patients with autoimmune diseases. J Thromb Haemost 2007; 5:1883-9. [PMID: 17596131 DOI: 10.1111/j.1538-7836.2007.02669.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The classification criteria for antiphospholipid syndrome (APS) were updated in 2006. OBJECTIVE The aim of the study was to analyze associations between clinical complications and laboratory test abnormalities typical for APS in a group of patients with autoimmune diseases, based on the recently updated criteria. PATIENTS/METHODS Three hundred and thirty-six patients were enrolled into the study, with the majority (n = 235) suffering from systemic lupus erythematosus. Laboratory determinations included: lupus anticoagulant (LA), anticardiolipin (aCL) and anti-beta(2)-glycoprotein I (anti-beta(2)GPI) antibodies (ABs) [of both immunoglobulin G (IgG) and IgM class]. RESULTS A significant association was found between laboratory and clinical features of APS; odds ratios (ORs) for thrombosis associated with the presence of LA, aCL, and anti-beta(2)GPI Abs were 4.04 [95% CI: 2.44-6.68], 3.71 (95% CI 2.32-5.92) and 2.57 (95% CI 1.60-4.1), respectively. Detailed analysis showed marked differences between the risk of clinical complications associated with the presence of an antibody in the IgG class (OR 4.15, 95% CI 2.42-7.12, and OR 4.77, 95% CI 2.37-9.61 for aCL and anti-beta(2)GPI, respectively) and in the IgM class (OR 2.2, 95% CI 1.31-3.70, and OR 1.9, 95% CI 1.15-3.14 for aCL and anti-beta(2)GPI, respectively). The postulated inclusion of anti-beta(2)GPI antibody positivity into the previous laboratory criteria changed only slightly the number of patients diagnosed with APS (from 112 to 117). CONCLUSIONS The updated APS classification criteria clearly represent a step forward. However, our results argue against the use of overall positivity for aCL or anti-beta(2)GPI, and favor a clear distinction between the IgG and IgM classes of antiphospholipid ABs. Patients with both LA and anti-beta(2)GPI IgG or LA and aCL IgG positivity may represent the subgroups at the highest risk of thrombotic complications.
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Affiliation(s)
- J Swadźba
- Department of Medicine, Jagiellonian University School of Medicine, Kraków, Poland
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Toubi E, Shoenfeld Y. Livedo Reticularis as a Criterion for Antiphospholipid Syndrome. Clin Rev Allergy Immunol 2007; 32:138-44. [DOI: 10.1007/s12016-007-0004-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 01/13/2023]
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Kobayashi T, Wada H, Kamikura Y, Matsumoto T, Mori Y, Kaneko T, Nobori T, Matsumoto M, Fujimura Y, Shiku H. Decreased ADAMTS13 activity in plasma from patients with thrombotic thrombocytopenic purpura. Thromb Res 2007; 119:447-52. [PMID: 16797677 DOI: 10.1016/j.thromres.2006.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 04/21/2006] [Accepted: 04/21/2006] [Indexed: 10/24/2022]
Abstract
The ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type I domain 13) activity was measured by a fluorescence resonance energy transfer (FRET) assay in the plasma of healthy volunteers and thrombotic thrombocytopenic purpura (TTP) patients to examine its usefulness in the diagnosis of TTP. The plasma levels of the ADAMTS13 activity did not show a normal distribution. Its median value was 107% (range: 55-170%) in healthy volunteers, but was significantly lower in patients with TTP (acquired or familial) and in patients with hematopoietic stem cell transplantation. However, it was not significantly lower in patients with antiphospholipid syndrome (APS). The ADAMTS13 activity by a FRET assay was closely correlated with that by the ADAMTS13 multimer method (r=0.816; p<0.001). In 18 patients with less than 10% of ADAMTS13 activity by FRET assay, less than 10% of that by multimer assay was 16, thus suggesting a good correlation for a low level of ADAMTS13. These findings suggest that the ADAMTS13 FRET assay correlates well with the ADAMTS13 multimer method and it is therefore useful for making a diagnosis of TTP.
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Affiliation(s)
- Toshihiko Kobayashi
- Second Department of Internal Medicine, Mie University Graduate School of Medicine, Tsu, Japan
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19
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that usually develops in young women aged 18-50 years and is characterized by the presence of autoantibodies. Diagnosis is difficult as SLE is a great imitator of other diseases. When SLE is suspected clinically in a patient (involvement of two or more organ systems), an initial laboratory evaluation would be antinuclear antibody (ANA) testing. If ANA is negative, SLE is unlikely and results positive at less than 1:40 strongly argue against SLE. Other explanations for organ system involvement should be pursued. Results positive at greater than 1:40 may merit further evaluation for SLE and at times referral to a rheumatologist for a full SLE evaluation. While the American College of Rheumatology classification criteria for SLE are primarily a tool for research, they may be useful clinically, in that those patients fulfilling four or more criteria are highly likely to have SLE.
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Affiliation(s)
- B T Kurien
- Arthritis and Immunology Program, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK 73104, USA.
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20
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Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4:295-306. [PMID: 16420554 DOI: 10.1111/j.1538-7836.2006.01753.x] [Citation(s) in RCA: 4394] [Impact Index Per Article: 244.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
New clinical, laboratory and experimental insights, since the 1999 publication of the Sapporo preliminary classification criteria for antiphospholipid syndrome (APS), had been addressed at a workshop in Sydney, Australia, before the Eleventh International Congress on antiphospholipid antibodies. In this document, we appraise the existing evidence on clinical and laboratory features of APS addressed during the forum. Based on this, we propose amendments to the Sapporo criteria. We also provide definitions on features of APS that were not included in the updated criteria.
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Affiliation(s)
- S Miyakis
- St George Hospital, University of New South Wales, Sydney, Australia
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21
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Finis A, Ssenyonjo H, Knopp U, Koch C, Seidel G, Arnold H, Giese A. Infarction of the right hemisphere in a patient with antiphospholipid antibody syndrome. Acta Neurochir (Wien) 2005; 147:997-1002; discussion 1002. [PMID: 16041471 DOI: 10.1007/s00701-005-0574-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
Hemicraniectomy as a surgical treatment for intracranial pressure following large ischemic lesions is widely practiced in selected patients. The antiphospholipid antibody syndrome (APS), a disorder characterized by recurrent arterial and venous thrombosis, is a very rare cause of space occupying ischemic lesions. We present a case of a 35 year old female diagnosed with APS who initially presented with small ischemic lesions and within days developed a massive near-total infarction of the right hemisphere. Because of central nervous system, skin and systemic manifestations Sneddon's syndrome and catastrophic antiphospholipid antibody syndrome (CAPS) remained a possible diagnoses. Sneddon's syndrome is a non-inflammatory occlusive arteriopathy of small and medium size arteries predominantly of the skin and brain, whereas the catastrophic antiphospholipid antibody syndrome is characterized by acute multi-organ system thrombosis of small and large vessels. In addition to the diagnostic criteria for APS a heterozygous factor V Leiden mutation was found in this patient, which may be a contributing risk factor for cerebral ischemia. When considering invasive decompressive procedures the neurosurgeon has to be aware of the poor prognosis of some forms of APS with systemic manifestations.
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Affiliation(s)
- A Finis
- Department of Neurosurgery, University of Schleswig-Holstein, Campus Lübeck, Germany
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22
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Zampieri S, Iaccarino L, Ghirardello A, Tarricone E, Arienti S, Sarzi-Puttini P, Gambari P, Doria A. Systemic Lupus Erythematosus, Atherosclerosis, and Autoantibodies. Ann N Y Acad Sci 2005; 1051:351-61. [PMID: 16126977 DOI: 10.1196/annals.1361.077] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Over the past number of years numerous data have been published regarding increased atherosclerosis in patients with systemic lupus erythematosus (SLE), and it has been shown that premature or accelerated atherosclerosis is an important cause of morbidity and mortality in these patients. Besides the traditional risk factors for cardiovascular disease, the association between SLE and atherosclerosis can be attributed to additional risk factors closely related to inflammation and autoimmunity. In particular, several autoantibodies and their respective autoantigens have been identified as possible factors in the development and progression of the atherosclerotic process in SLE. The understanding of SLE-related risk factors for enhanced atherosclerosis could shed more light on disease mechanisms, leading to new therapeutic strategies for the treatment of cardiovascular diseases in SLE patients. In the present paper, the biological characteristics and possible pathogenetic role of the oxidized low-density lipoprotein (oxLDL) and anti-oxLDL, beta(2)-glycoprotein I (beta(2)GPI) and anti-beta(2)GPI, and heat-shock protein 60/65 (HSP60/65) and anti-HSP60/65 autoantibody systems are summarized.
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Affiliation(s)
- Sandra Zampieri
- Division of Rheumatology, University of Padova, Via Giustiniani 2, I-35128 Padua, Italy
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23
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Levy Y, Shenkman B, Tamarin I, Pauzner R, Shoenfeld Y, Langevitz P, Savion N, Varon D. Increased platelet deposition on extracellular matrix under flow conditions in patients with antiphospholipid syndrome who experience thrombotic events. ACTA ACUST UNITED AC 2005; 52:4011-7. [PMID: 16320349 DOI: 10.1002/art.21437] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess platelet function under defined flow conditions in patients with antiphospholipid syndrome (APS) and to correlate the results with thrombotic complications and the presence of subsets of antiphospholipid antibodies (aPL), lupus anticoagulant (LAC), and/or anticardiolipin antibodies (aCL). METHODS We studied 88 randomized APS patients with or without a history of thrombosis. Seventeen patients with other thrombosis (no APS) and 26 healthy subjects served as controls. Platelet adhesion and aggregation on the extracellular matrix were measured with a cone-and-plate(let) analyzer (CPA) by examining the percentage of total area covered with platelets (surface coverage [SC]) and the mean size of surface-bound objects (average size [AS]) and were compared with platelet responses to different ADP concentrations by conventional aggregometry. RESULTS Under defined flow conditions, SC and AS were significantly higher for venous thrombosis and arterial thrombosis in APS patients compared with no thrombosis, other thrombosis, and healthy control groups. The increased platelet adhesion and aggregation in APS patients with thrombotic events was associated with higher levels of von Willebrand factor (vWF) antigen (mean +/- SD 230.6 +/- 51.2%) and ristocetin cofactor activity (181.0 +/- 36.0%). No change in CPA and vWF parameters was found in APS patients with positive results for aPL who did not undergo thrombotic events or in patients with other thrombosis. The CPA parameters were neither associated with the high response of platelets to ADP nor associated with the presence of LAC, aCL, or both. The CPA parameters were similarly increased irrespective of aspirin use. The results suggest that the increased adhesion properties of platelets in APS patients could be mediated by high levels and activity of vWF. This complements the known ability of APS antibodies to enhance platelet response to agonists in conventional aggregometry. CONCLUSION The CPA test was found to be valuable in differentiating APS patients with and without thrombotic complications.
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Affiliation(s)
- Yair Levy
- Meir Medical Center, Kfar Saba, Israel.
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Ishikura K, Wada H, Kamikura Y, Hattori K, Fukuzawa T, Yamada N, Nakamura M, Nobori T, Nakano T. High prevalence of anti-prothrombin antibody in patients with deep vein thrombosis. Am J Hematol 2004; 76:338-42. [PMID: 15282665 DOI: 10.1002/ajh.20124] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The present study was designed to determine the prevalence of lupus anticoagulant (LA) antibody and several antibodies for antiphospholipid syndrome (APS) in patients with deep vein thrombosis (DVT)/pulmonary embolism (PE) (n = 48), cerebral thrombosis (CT, n = 30), systemic lupus erythematosus (SLE, n = 22), and idiopathic thrombocytopenic purpura (ITP, n = 30). The presence of antibodies was examined by using the respective ELISA kits. LA was positive in 38.6% of patients with DVT/PE, suggesting that LA is one of the most important risk factors in DVT/PE. The highest prevalence of anti-beta(2) glycoprotein I (beta(2)GPI) IgG was in CT and SLE, followed by DVT, and none in ITP and healthy volunteers (control, n = 40), suggesting that it is related to thrombosis, particularly arterial thrombosis. The highest prevalence of anti-prothrombin (aPT) IgG antibody was in DVT, followed by CT and SLE, and none in ITP and the control, suggesting that it is related to thrombosis, especially venous thrombosis. The highest prevalence of antiphospholipid (aPL) IgG was in DVT, CT, and SLE, but 0% in ITP and control. On the other hand, aPL IgM, anti-annexin V IgG, and anti-annexin V IgM were positive in patients both with and without thrombosis, suggesting that they are not related to thrombosis. Our results indicated that among the anti-phospholipid antibodies, LA is the most sensitive marker for APS while anti-beta(2)GPI IgG, aPT IgG, and aPL IgG are risk factors for thrombosis. In particular, aPT IgG is a significant marker for DVT/PE.
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Affiliation(s)
- Ken Ishikura
- First Department of Internal Medicine, Mie University School of Medicine, Tsu, Mie, Japan
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25
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Doria A, Shoenfeld Y, Wu R, Gambari PF, Puato M, Ghirardello A, Gilburd B, Corbanese S, Patnaik M, Zampieri S, Peter JB, Favaretto E, Iaccarino L, Sherer Y, Todesco S, Pauletto P. Risk factors for subclinical atherosclerosis in a prospective cohort of patients with systemic lupus erythematosus. Ann Rheum Dis 2003; 62:1071-7. [PMID: 14583570 PMCID: PMC1754370 DOI: 10.1136/ard.62.11.1071] [Citation(s) in RCA: 285] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate traditional and non-traditional risk factors for subclinical atherosclerosis in systemic lupus erythematosus (SLE). METHODS A prospective cohort of 78 patients with SLE without overt atherosclerotic disease was studied. SLE clinical and laboratory parameters, disease activity and damage, treatment and traditional risk factors for atherosclerosis were evaluated. At baseline (T1) and after five years' follow up (T2), the serum levels of anti-oxidised palmitoyl arachidonoyl phosphocholine (oxPAPC), anti-heat shock protein 65, and anti-beta(2)-glycoprotein I antibodies and C reactive protein were tested. At T2, intima-media thickness (IMT) was measured using duplex carotid sonography. Thickened intima, plaque, mean IMT (m-IMT), and maximum IMT (M-IMT) were assessed. RESULTS A thickened intima was seen in 22/78 (28%) patients and plaque in 13/78 (17%). M-IMT and m-IMT were (mean (SD)) 0.77 (0.34) mm and 0.55 (0.15) mm, respectively. Patients with carotid abnormalities were significantly older, had higher blood pressure and total serum cholesterol levels, and had taken a higher prednisone cumulative dosage than those without any lesions. The carotid abnormalities were associated with renal disease and ECLAM >2 at T1, and with azathioprine treatment. In multivariate analysis, age and cumulative prednisone dose were associated with carotid abnormalities; age, hypertension, and anti-oxPAPC at T2 were correlated with higher M-IMT and m-IMT. CONCLUSIONS In patients with SLE some non-traditional risk factors for atherosclerosis were identified, the most important of which was the cumulative prednisone dose. The role of some traditional risk factors, such as age and hypertension, was also confirmed. The predictive value of the new immunological and inflammatory markers of atherosclerosis seems to be masked by some disease related features.
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Affiliation(s)
- A Doria
- Division of Rheumatology, Department of Medical and Surgical Science, University of Padova, Italy.
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26
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Ghirardello A, Doria A, Zampieri S, Gerli R, Rapizzi E, Gambari PF. Anti-ribosomal P protein antibodies detected by immunoblotting in patients with connective tissue diseases: their specificity for SLE and association with IgG anticardiolipin antibodies. Ann Rheum Dis 2000; 59:975-81. [PMID: 11087701 PMCID: PMC1753043 DOI: 10.1136/ard.59.12.975] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the prevalence and clinical and serological associations of anti-ribosomal P protein antibodies (anti-P antibodies) in patients with connective tissue diseases (CTDs) and investigate the immunobiological nature of autoantibody clustering in which anti-P antibodies play a part. METHODS IgG anti-P antibodies in the sera of 267 patients with CTDs and 31 healthy subjects were analysed by immunoblotting performed on cytoplasmic extract of Raji cells. 60 patients with systemic lupus erythematosus (SLE), 32 systemic sclerosis, 46 primary Sjögren's syndrome, 16 poly/dermatomyositis, 11 rheumatoid arthritis, 8 undifferentiated CTD, 72 overlap CTD, and 22 primary antiphospholipid syndrome were studied. Anti-P antibodies were affinity purified by elution from nitrocellulose bound antigen and tested by ELISA for their binding activity to cardiolipin. RESULTS Anti-P antibodies were detected in 16 (6%) patients and in none of the controls: 12/60 SLE (20%) and 4/80 undifferentiated/overlap patients with CTD (5%). A close association of IgG antibodies with P proteins and with cardiolipin was seen in lupus sera (p=0.0009, odds ratio 18.33). Anti-P antibodies from 9 of 12 anti-P lupus serum samples could be affinity purified and none of the affinity purified fractions cross reacted with ELISA plate coated cardiolipin. CONCLUSIONS Anti-P immunoreactivity is a specific marker of SLE and lupus-like disease and its detection is recommended as a powerful diagnostic tool. Anti-P antibodies are strongly clustered with IgG anticardiolipin antibodies in lupus sera, even if they are independently elicited. This suggests that their cognate autoantigens play a part in a common pathogenetic pathway in SLE.
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Affiliation(s)
- A Ghirardello
- Division of Rheumatology, Department of Medical and Surgical Sciences, University of Padova, Padova, Italy
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27
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Abstract
ANA IIF is an effective screening assay in patients with clinical features of SLE and will detect most anti-ssDNA, anti-dsDNA, ENAs, and other autoantibodies. False positives are common. The clinical importance cannot be extrapolated from the ANA titre or pattern, although higher titres (> 1/160) are more likely to be important. HEp-2 cells are the most sensitive substrate for ANA detection, but this must be balanced against an increased incidence of insignificant positivity. ANA positive samples should be subjected to more specific assays for the diagnosis of SLE. A combination of ENA (Ro/La/Sm/RNP) and dsDNA assays will detect most patients with SLE as long as the characteristics of the assays used are well understood. ESR and CRP measurements provide useful additional information. Sjogren's syndrome and MCTD will produce overlapping serology with SLE, and anti-dsDNA titres are sometimes seen in autoimmune hepatitis and rheumatoid arthritis. All results should be reported in the light of the clinical details, by an experienced immunologist. A suggested diagnostic protocol is outlined in fig 1. The type of assay used crucially influences the predictive value of the tests. ELISA technology dominates routine laboratory practice, but tends to produce more false positive and true weak positive results, which may reduce the PPV of the test. This can be minimised by using IgG specific conjugates and careful assay validation. The NPV for SLE [figure: see text] is high for most assays but the PPV varies. Where necessary, laboratories should use crithidia or Farr dsDNA assays to confirm dubious ELISA dsDNA results, and ID/IB to confirm dubious ENA results. For monitoring, a precise, quantitative assay is required. It is unclear whether the detection of IgM or low affinity antibodies has a role here. A combination of anti-dsDNA, C3, C4, CRP, and ESR assays provides the most useful clinical information. Anti-ssDNA assays are likely to be useful, and are potentially more robust than anti-dsDNA assays, but require more validation. Local validation of individual assays and EQA participation is essential. Not all assays that apparently measure the same antibody specificities have equal clinical relevance, even within a single technology. Insufficient international or national reference preparations are currently available for many antibody specificities to enable effective standardisation. Quality assurance schemes reveal large differences in units reported by different assays for some analytes, even when calibrated against an IRP or equivalent reference preparation. Serial results can therefore only be compared from the same laboratory at present. Most autoantibodies increase during active disease, but few prospective data are currently available to justify treatment on the basis of rising titres. Further randomised prospective studies are required to examine the importance of antibody isotype and affinity in the monitoring of SLE by individual assay methods. The most important aspect of the appropriate use of laboratory assays is to become familiar with the limitations of the technology currently in use in your local laboratory, and to consult with your clinical immunologist in cases of doubt, preferably before commencing serological screening.
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Affiliation(s)
- W Egner
- Department of Immunology and Protein Reference Unit, Northern General Hospital, Sheffield, UK.
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28
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Affiliation(s)
- M Gantcheva
- Department of Dermatology, Medical Faculty of Sofia, Bulgaria
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29
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Abstract
Antiphospholipid antibody syndrome (APS) is one of the most important causes of thrombophilia, presenting most often as venous or arterial thrombosis, recurrent pregnancy loss, or thrombocytopenia. Both the lupus anticoagulant and anticardiolipin antibody are associated with APS. The mechanism of the prothrombotic state is not understood, but may involve beta-2 glycoprotein 1 (a naturally occurring anticoagulant), platelet aggregation, the protein C pathway, or endothelial cell function. The current treatment recommendation, after a venous or arterial thrombosis, is high-intensity, long-term warfarin therapy.
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Affiliation(s)
- M Petri
- Division of Molecular and Clinical Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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30
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Wahl DG, Guillemin F, de Maistre E, Perret C, Lecompte T, Thibaut G. Risk for venous thrombosis related to antiphospholipid antibodies in systemic lupus erythematosus--a meta-analysis. Lupus 1997; 6:467-73. [PMID: 9229367 DOI: 10.1177/096120339700600510] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the relative risk for venous thrombosis (VT) associated with antiphospholipid antibodies (aPL) in systemic lupus erythematosus (SLE). DESIGN Systematic review and meta-analysis of 26 articles that examined the association between aPL and VT in SLE. SETTING Mostly secondary and tertiary referral centres. PATIENTS 2249 patients with SLE, 1120 tested for LA (lupus anticoagulant) and 1563 tested for aCL (anticardiolipin antibodies). MAIN OUTCOME MEASURES A summary of study characteristics and a critical appraisal of study quality were done. Two statistical combinations of 18 primary studies that examined the association of VT and LA and of 14 studies that examined the association of VT and aCL were performed to estimate the risk for VT associated with aPL. RESULTS The odds ratios of the risk of VT related to the LA summarized from 18 studies were 5.61 [95% CI; 3.80-8.27] overall, 6.32 [CI; 3.71-10.78] for deep venous thrombosis and pulmonary embolism, 11.6 [3.65-36.91] for recurrent venous thrombosis after the first event. The odds ratios of the risk of VT related to aCL summarized from 14 studies were 2.17 [95% CI; 1.51-3.11] overall, 2.50 [CI; 1.51-4.14] for deep venous thrombosis and pulmonary embolism, 3.91 [1.14-13.38] for recurrent venous thrombosis after the first event. CONCLUSIONS Patients with SLE and LA are at approximately six times greater risk for VT than patients without LA, whereas patients with SLE and aCL are approximately two times greater risk for VT than patients without aCL. We have identified important methodologic limitations and differences in study characteristics. Other risk factors for VT have not been thoroughly evaluated in these studies. Further studies are needed that provide an accurate estimate of the absolute risk for aPL related VT.
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Affiliation(s)
- D G Wahl
- Service de Medicine H., Nancy University Hospital, France
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31
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Doria A, Biasinutto C, Ghirardello A, Sartori E, Rondinone R, Piccoli A, Veller Fornasa C, Gambari PF. Photosensitivity in systemic lupus erythematosus: laboratory testing of ARA/ACR definition. Lupus 1996; 5:263-8. [PMID: 8869896 DOI: 10.1177/096120339600500404] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the prevalence of photosensitivity in SLE as defined by either clinical or laboratory assessment, the concordance of findings obtained by two methods, and the relationship between photosensitivity and clinical and immunological parameters. METHODS Forty-four SLE patients and 31 healthy subjects were included. Patients and controls underwent a standard questionnaire testing and the minimal erythemal dose (MED) measurement performed by Dermalight-Blue Point. The standard questionnaire was designed in order to meet, as near as possible, the definition of photosensitivity included in the ARA/ACR criteria for classification of SLE. RESULTS The prevalence of photosensitivity was (patients vs controls): 57% vs 45% according to questionnaire; 79.5% vs 51.6% (P = 0.02) according to MED. The agreement between questionnaire and phototest was absent in SLE (kappa 0.01) and poor in controls (kappa 0.36). Discoid rash was significantly associated with questionnaire positive (P = 0.01) and renal involvement with questionnaire negative results (P = 0.02), serositis with MED abnormality (P = 0.03), malar rash and anti-Sm antibody with MED normal values (P = 0.03 and P = 0.01), respectively). Moreover, by multivariate analysis, malar rash and anti-Sm antibody significantly predicted MED-defined photosensitivity, with probability ranging from 42% (presence of both) to 92% (lack of both). CONCLUSIONS Photosensitivity is frequently observed in SLE patients as well as in healthy subjects. Its prevalence is significantly higher in SLE than in controls only when it is detected using the laboratory method. However, due to the difficulty in objectively defining such manifestation, the disagreement between questionnaire and MED results was high and its clinical meaning appears ambiguous. Thus, the use of photosensitivity as a classification criterion for SLE remains questionable, at least when it is assessed according to the ARA/ACR definition.
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Affiliation(s)
- A Doria
- Division of Rheumatology, University of Padova, Italy
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32
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Abstract
The pathogenesis of the antiphospholipid syndrome remains uncertain. Antibodies that react with phospholipids may not be directly responsible for cellular injury, but may be part of the immune network through which autoantibodies with pathogenic potential are generated. The latter may recognize proteins such as beta 2-glycoprotein I that form complexes with phospholipids, proteins whose functions depend upon interaction with phospholipids such as protein C and its cofactors, altered lipoproteins such as oxidized low-density lipoproteins, or other molecules that share only antigenic similarity. Thus, a spectrum of autoantibodies that recognize different lipid-protein complexes may develop in these patients and contribute to the observed clinical heterogeneity of the syndrome. Current techniques do not permit identification of the subset of patients with antiphospholipid antibodies at risk for thrombosis or abortion and there are no prospective, controlled trials addressing the prophylaxis or treatment of affected individuals. Identification of the cellular targets of antibodies to lipid-protein moieties is needed to identify patients at risk for these complications and as a means to monitor therapy.
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Affiliation(s)
- D B Cines
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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33
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Barton LL. Povidone-iodine to prevent ophthalmia neonatorum. N Engl J Med 1995; 333:127. [PMID: 7632274 DOI: 10.1056/nejm199507133330213] [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: 01/26/2023]
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34
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Kennedy M, Jackson J, Khan I, Keeling PW, Gaffney E. Catastrophic anti-phospholipid syndrome in the absence of IgG anti-cardiolipin antibodies. Scand J Rheumatol 1995; 24:389-91. [PMID: 8610226 DOI: 10.3109/03009749509095187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The Catastrophic Anti-phospholipid Syndrome (CAPS) is a rare acute clinical syndrome associated with serum anti-phospholipid antibodies (aPL). It is rarely preceded by a precipitating event. It may occur as a primary event or be associated with auto-immune diseases. We report a fatal case occurring post-endoscopic retrograde cholangio-pancreatography (ERCP) in a patient with Systemic Lupus Erythematosus (SLE), positive lupus anticoagulant and negative IgG with positive IgM anti-cardiolipin titres. The diagnostic and therapeutic difficulties of such cases is addressed.
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Affiliation(s)
- M Kennedy
- Department of Histopathology, St. James's Hospital, Dublin, Ireland
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35
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Doria A, Ghirardello A, Boscaro M, Viero ML, Vaccaro E, Patrassi GM, Gambari PF. Fibrinolysis and coagulation abnormalities in systemic lupus erythematosus. Relationship with Raynaud's phenomenon, disease activity, inflammatory indices, anticardiolipin antibodies and corticosteroid therapy. Rheumatol Int 1995; 14:207-11. [PMID: 7724997 DOI: 10.1007/bf00262299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Endothelial cell damage in systemic lupus erythematosus (SLE) was evaluated by measuring fibrinolytic activity and von Willebrand factor levels. Tissue-type plasminogen activator (t-PA) antigen, plasminogen activator inhibitor (PAI) activity, and von Willebrand factor antigen (vWF:Ag) and activity (vWF:RCof) were measured in 21 SLE patients (12 of whom were therapy free) and 22 controls. In addition, the relationship between such parameters and Raynaud's phenomenon, disease activity [according to personal criteria, Systemic Lupus Activity Measure (SLAM) and European Consensus Lupus Activity Measurement (ECLAM) scores] inflammatory indices [ESR, C-reactive protein (CRP), alpha 2-globulin], anticardiolipin antibodies and corticosteroid therapy was investigated. Lower levels of t-PA antigen (P = 0.003) and higher levels of vWF:Ag (P = 0.001) were found in SLE patients in comparison with controls. Moreover, t-PA antigen was lower (P = 0.02) in steroid-free patients in comparison with those taking steroids. No relationship was found between fibrinolysis and coagulation abnormalities and Raynaud's phenomenon, disease activity, inflammatory indices and anticardiolipin antibodies. Endothelial cell damage is probably a common feature in SLE patients; nevertheless, we were unable to clarify the nature of such abnormality. It is worth noting that low doses of steroids seem to be effective in improving endothelial cell function in SLE patients.
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Affiliation(s)
- A Doria
- Division of Rheumatology, University of Padova, Italy
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Hopkinson NP, Lim K, Gardner-Medwin J. Antiphospholipid antibodies (aPL) in systemic lupus erythematosus. Are they specific tools for the diagnosis of aPL syndrome? Ann Rheum Dis 1994; 53:619-20. [PMID: 7979605 PMCID: PMC1005420 DOI: 10.1136/ard.53.9.619-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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