1
|
Raschi E, Borghi MO, Tedesco F, Meroni PL. Antiphospholipid syndrome pathogenesis in 2023: an update of new mechanisms or just a reconsideration of the old ones? Rheumatology (Oxford) 2024; 63:SI4-SI13. [PMID: 38320591 DOI: 10.1093/rheumatology/kead603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/27/2023] [Indexed: 02/08/2024] Open
Abstract
Antibodies against phospholipid (aPL)-binding proteins, in particular, beta 2 glycoprotein I (β2GPI), are diagnostic/classification and pathogenic antibodies in antiphospholipid syndrome (APS). β2GPI-aPL recognize their target on endothelium and trigger a pro-thrombotic phenotype which is amplified by circulating monocytes, platelets and neutrophils. Complement activation is required as supported by the lack of aPL-mediated effects in animal models when the complement cascade is blocked. The final result is a localized clot. A strong generalized inflammatory response is associated with catastrophic APS, the clinical variant characterized by systemic thrombotic microangiopathy. A two-hit hypothesis was suggested to explain why persistent aPL are associated with acute events only when a second hit allows antibody/complement binding by modulating β2GPI tissue presentation. β2GPI/β2GPI-aPL are also responsible for obstetric APS, being the molecule physiologically present in placental/decidual tissues. Additional mechanisms mediated by aPL with different characteristics have been reported, but their diagnostic/prognostic value is still a matter of research.
Collapse
Affiliation(s)
- Elena Raschi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Maria Orietta Borghi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesco Tedesco
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| |
Collapse
|
2
|
de Laat B, Gehlen R, de Groot PG. Viewpoint: The value of non-criteria antiphospholipid antibodies. Rheumatology (Oxford) 2024; 63:SI64-SI71. [PMID: 38320588 DOI: 10.1093/rheumatology/kead632] [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: 07/13/2023] [Accepted: 09/29/2023] [Indexed: 02/08/2024] Open
Abstract
In 2006, at a meeting in Sydney, Australia, consensus was reached by an international group of specialists to establish a number of serological criteria that identify patients with a history of thrombosis or pregnancy complications as having antiphospholipid syndrome (APS). These criteria were originally formulated for research purposes and to compare clinical trials in different centres. However, these same criteria are now generally used and accepted for the diagnosis and treatment of patients. The practice of using these criteria for direct patient care requires that these criteria are based on sound scientific evidence. Indeed, for all the autoantibodies that are officially included in the serological criteria, it has been shown that they induce thrombosis and fetal loss when infused into mice. There are also a number of additional autoantibodies that have been identified in these patients but for these antibodies there was not enough evidence to meet the official APS criteria in 2006. Seventeen years have now passed since the consensus meeting, therefore, this review examines whether additional studies performed with these 'non-criteria' autoantibodies have provided sufficient results to suggest the inclusion of these autoantibodies in the official serological criteria of APS.
Collapse
Affiliation(s)
- Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Rachel Gehlen
- Synapse Research Institute, Maastricht, The Netherlands
| | | |
Collapse
|
3
|
Tufano A, Brenner B. Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years. Semin Thromb Hemost 2024; 50:96-103. [PMID: 37201536 DOI: 10.1055/s-0043-1769013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.
Collapse
Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Sergio Pansini, Naples, Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Haifa, Israel
| |
Collapse
|
4
|
Müller-Calleja N, Ruf W, Lackner KJ. Lipid-binding antiphospholipid antibodies: significance for pathophysiology and diagnosis of the antiphospholipid syndrome. Crit Rev Clin Lab Sci 2024:1-18. [PMID: 38293818 DOI: 10.1080/10408363.2024.2305121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of pathogenic antiphospholipid antibodies (aPL). Since approximately 30 years ago, lipid-binding aPL, which do not require a protein cofactor, have been regarded as irrelevant for APS pathogenesis even though anticardiolipin are a diagnostic criterion of APS. In this review, we will summarize the available evidence from in vitro studies, animal models, and epidemiologic studies, which suggest that this concept is no longer tenable. Accordingly, we will only briefly touch on the role of other aPL in APS. This topic has been amply reviewed in detail elsewhere. We will discuss the consequences for laboratory diagnostics and future research required to resolve open questions related to the pathogenic role of different aPL specificities.
Collapse
Affiliation(s)
- Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Wolfram Ruf
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Immunology and Microbiology, Scripps Research, La Jolla, CA, USA
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| |
Collapse
|
5
|
Tohidi-Esfahani I, Mittal P, Isenberg D, Cohen H, Efthymiou M. Platelets and Thrombotic Antiphospholipid Syndrome. J Clin Med 2024; 13:741. [PMID: 38337435 PMCID: PMC10856779 DOI: 10.3390/jcm13030741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Antiphospholipid antibody syndrome (APS) is an autoimmune disorder characterised by thrombosis and the presence of antiphospholipid antibodies (aPL): lupus anticoagulant and/or IgG/IgM anti-β2-glycoprotein I and anticardiolipin antibodies. APS carries significant morbidity for a relatively young patient population from recurrent thrombosis in any vascular bed (arterial, venous, or microvascular), often despite current standard of care, which is anticoagulation with vitamin K antagonists (VKA). Platelets have established roles in thrombosis at any site, and platelet hyperreactivity is clearly demonstrated in the pathophysiology of APS. Together with excess thrombin generation, platelet activation and aggregation are the common end result of all the pathophysiological pathways leading to thrombosis in APS. However, antiplatelet therapies play little role in APS, reserved as a possible option of low dose aspirin in addition to VKA in arterial or refractory thrombosis. This review outlines the current evidence and mechanisms for excessive platelet activation in APS, how it plays a central role in APS-related thrombosis, what evidence for antiplatelets is available in clinical outcomes studies, and potential future avenues to define how to target platelet hyperreactivity better with minimal impact on haemostasis.
Collapse
Affiliation(s)
- Ibrahim Tohidi-Esfahani
- Haematology Department, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Prabal Mittal
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London WC1E 6JF, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
| |
Collapse
|
6
|
Robert M, Scherlinger M. Platelets are a major player and represent a therapeutic opportunity in systemic lupus erythematosus. Joint Bone Spine 2024; 91:105622. [PMID: 37495075 DOI: 10.1016/j.jbspin.2023.105622] [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: 04/18/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by immune dysregulation and organ injury with a premature mortality due to cardiovascular diseases. Platelets, that are primarily known for their role in hemostasis, have been shown to play an active role in the pathogenesis and in the progression of immune-mediated inflammatory diseases. Here we summarize the evidence of their roles in SLE pathogenesis which supports the development of targeted treatments. Platelets and their precursors, the megakaryocytes, are intrinsically different in SLE patients compared with healthy controls. Different triggers related to innate and adaptive immunity activate platelets which release extracellular vesicles, soluble factors and interact with immune cells, thereby perpetuating inflammation. Platelets are involved in organ damage in SLE, especially in lupus nephritis and participate in the heightened cardiovascular mortality. They also play a clear role in antiphospholipid syndrome which can be associated with both thrombocytopenia and thrombosis. To tackle platelet activation and their interactions with immune cells now constitute promising therapeutic strategies in SLE.
Collapse
Affiliation(s)
- Marie Robert
- Service de médecine interne et immunologie clinique, centre hospitalier universitaire Édouard-Herriot, hospices civils de Lyon, Lyon, France
| | - Marc Scherlinger
- Service de rhumatologie, centre hospitalier universitaire de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France; Laboratoire d'immuno-rhumatologie moléculaire, Institut national de la santé et de la recherche médicale (Inserm) UMR S 1109, Strasbourg, France; Centre national de référence des maladies auto-immunes et systémiques rares, Est/Sud-Ouest (RESO), France.
| |
Collapse
|
7
|
Shi Y, Huang C, Zhou Y, Jiang H, Zhao Y, Li M, Zeng X, Zhao J. Tacrolimus shows adequate efficacy in patients with antiphospholipid antibodies associated thrombocytopenia: a retrospective cohort study. Clin Exp Med 2023; 23:5433-5443. [PMID: 37930607 DOI: 10.1007/s10238-023-01248-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Thrombocytopenia is a common manifestation associated with the presence of antiphospholipid antibodies (aPL). The aim of this study is to investigate the efficacy and safety of tacrolimus treatment in aPL associated thrombocytopenia. This is a single-center retrospective study. Patients who had persistent positive aPL and thrombocytopenia that was treated with tacrolimus were included. A total of 49 patients [38 females (77.6%)] were enrolled from Nov 2013 to Apr 2022 with a median treatment duration of 22 months. Seventeen fulfilled classification criteria of antiphospholipid syndrome (APS), 18 systemic lupus erythematosus (SLE). The median age of study patients was 37 years (IQR 31, 48). Forty-three (87.8%) patients were on concomitant use of glucocorticoids, 6 on tacrolimus monotherapy. The overall response rate in this cohort was 85.7% (n = 42), including 49% of complete responses (n = 24). The median time to achieve a response was 3 months. Nine (18.4%) patients with overall response experienced a loss of response. The response rate during follow-up in patients with monotherapy was noninferior. Patients with positive antinuclear antibody (ANA) showed the tendency of maintaining response (p = 0.028). The 19 patients who were on medium and high dosage of glucocorticoids (> 15 mg prednisone/d) managed to taper glucocorticoids rapidly. Side effects were reported in 12.2% (n = 6) of the patients (elevated creatinine, general malaise, elevated liver enzyme). Tacrolimus has adequate efficacy, steroid-sparing effect and is well tolerated for aPL associated thrombocytopenia. Patients with positive ANA might benefit the most from tacrolimus treatment.
Collapse
Affiliation(s)
- Yu Shi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Hui Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yongqiang Zhao
- Department of Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| |
Collapse
|
8
|
Endo M, Gotoh M, Nakashima M, Kawamoto Y, Sakai S, Murakami-Murofushi K, Hashimoto K, Miyamoto Y. 2-Carba cyclic phosphatidic acid regulates blood coagulation and fibrinolysis system for repair after brain injury. Brain Res 2023; 1818:148511. [PMID: 37506965 DOI: 10.1016/j.brainres.2023.148511] [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: 03/23/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
Effective blood coagulation prevents inflammation and neuronal loss after brain injury. 2-Carba-cyclic phosphatidic acid (2ccPA), a biotherapeutic for brain injury, inhibits blood extravasation resulting from blood-brain barrier breakdown. However, the hemostasis mechanism of 2ccPA remains unclear. We determined the effects of 2ccPA-injection on blood coagulation and fibrinolysis using a needle-induced brain injury model. 2ccPA suppressed the expression of platelet degranulation-related genes. Immediately after brain injury, 2ccPA increased CD41+ platelet aggregation around the lesions and promoted fibrin aggregation. Additionally, 2ccPA supported fibrinolysis by upregulating plasminogen activator expression. These results suggest the acute effects of 2ccPA on brain hemostasis.
Collapse
Affiliation(s)
- Misaki Endo
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Mari Gotoh
- Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Mari Nakashima
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Yuka Kawamoto
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Shiho Sakai
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | | | - Kei Hashimoto
- Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Academic Production, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan.
| | - Yasunori Miyamoto
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan.
| |
Collapse
|
9
|
Feugray G, Miranda S, Le Cam Duchez V, Bellien J, Billoir P. Endothelial Progenitor Cells in Autoimmune Disorders. Stem Cell Rev Rep 2023; 19:2597-2611. [PMID: 37676423 DOI: 10.1007/s12015-023-10617-y] [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] [Accepted: 08/26/2023] [Indexed: 09/08/2023]
Abstract
Circulating endothelial progenitor cells (EPCs) were first described in 1997 by Asahara et al. as "putative endothelial cells" from human peripheral blood. The study of endothelial progenitors is also intensifying in several pathologies associated with endothelial damage, including diabetes, myocardial infarction, sepsis, pulmonary arterial hypertension, obstructive bronchopneumopathy and transplantation. EPCs have been studied in several autoimmune diseases with endothelial involvement such as systemic lupus erythematosus, thrombotic thrombocytopenic purpura, antineutrophil cytoplasmic antibodies, vasculitis, rheumatoid arthritis, Goujerot-Sjögren and antiphospholipid syndrome. Factors involved in endothelial damage are due to overexpression of pro-inflammatory cytokines and/or autoantibodies. Management of these pathologies, particularly the long-term use of glucocorticoids and methotrexate, promote atherosclerosis. A lack of standardized assessment of the number and function of EPCs represents a serious challenge for the use of EPCs as prognostic markers of cardiovascular diseases (CVD). The objective of this review was to describe EPCs, their properties and their involvement in several autoimmune diseases.
Collapse
Affiliation(s)
- Guillaume Feugray
- UNIROUEN, INSERM U1096 EnVI, CHU Rouen, Department of General Biochemistry, Normandie University, F-76000, Rouen, France
| | - Sébastien Miranda
- UNIROUEN, INSERM U1096, CHU Rouen. Department of Internal Medicine, Normandie University, Rouen, France
| | | | - Jérémy Bellien
- UNIROUEN, INSERM U1096 EnVI, CHU Rouen, Department of Pharmacology, Normandie University, F-76000, Rouen, France
| | - Paul Billoir
- UNIROUEN, INSERM U1096, CHU Rouen. Department of Internal Medicine, Normandie University, Rouen, France.
- Normandy Univ, U1096, Rouen University Hospital, Vascular Hemostasis Unit, Rouen, France.
| |
Collapse
|
10
|
Tang Z, Shi H, Chen C, Teng J, Dai J, Ouyang X, Liu H, Hu Q, Cheng X, Ye J, Su Y, Sun Y, Pan H, Wang X, Liu J, Su B, Yang C, Xu Y, Liu T. Activation of Platelet mTORC2/Akt Pathway by Anti-β2GP1 Antibody Promotes Thrombosis in Antiphospholipid Syndrome. Arterioscler Thromb Vasc Biol 2023; 43:1818-1832. [PMID: 37381985 DOI: 10.1161/atvbaha.123.318978] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Anti-β2GP1 (β2-glycoprotein 1) antibodies are the primary pathogenic antibody to promote thrombosis in antiphospholipid syndrome (APS), yet the underlying mechanism remains obscure. We aimed to explore the intracellular pathway that mediated platelet activation. METHODS Platelets were isolated from patients with APS and subjected to RNA sequencing. Platelet aggregation, the release of platelet granules, platelet spreading, and clot retraction were detected to evaluate platelet activation. We purified anti-β2GP1 antibodies from patients with APS and the total IgG from healthy donors to stimulate platelets with/without FcγRIIA (Fcγ receptor IIA) blocking antibody or Akt (protein kinase B) inhibitor. Platelet-specific Sin1 (stress-activated protein kinase-interacting protein) deficiency mice were established. The thrombus model of inferior vena cava flow restriction, ferric chloride-induced carotid injury model, and laser-induced vessel wall injury in cremaster arterioles model were constructed after administration of anti-β2GP1 antibodies. RESULTS Combined RNA sequencing and bioinformatics analysis suggested that APS platelets exhibited increased levels of mRNA associated with platelet activation, which was in line with the hyperactivation of APS platelets in response to stimuli. Platelet activation in APS platelets was accompanied by upregulation of the mTORC2 (mammalian target of the rapamycin complex 2)/Akt pathway and increased levels of SIN1 phosphorylation at threonine 86. Anti-β2GP1 antibody derived from patients with APS enhanced platelet activation and upregulated the mTORC2/Akt pathway. Moreover, the Akt inhibitor weakened the potentiating effect of the anti-β2GP1 antibody on platelet activation. Notably, Sin1 deficiency suppresses anti-β2GP1 antibody-enhanced platelet activation in vitro and thrombosis in all 3 models. CONCLUSIONS This study elucidated the novel mechanism involving the mTORC2/Akt pathway, which mediates the promotion of platelet activation and induction of thrombosis by the anti-β2GP1 antibody. The findings suggest that SIN1 may be a promising therapeutic target for the treatment of APS.
Collapse
Affiliation(s)
- Zihan Tang
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Changming Chen
- Department of Laboratory Medicine, Ruijin Hospital (C.C., J.D., X.W.), Shanghai Jiao Tong University School of Medicine, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Jing Dai
- Department of Laboratory Medicine, Ruijin Hospital (C.C., J.D., X.W.), Shanghai Jiao Tong University School of Medicine, China
| | - Xinxing Ouyang
- Department of Immunology and Microbiology, Shanghai Institute of Immunology, Ministry of Education Key Laboratory of Cell Death and Differentiation (X.O., B.S.), Shanghai Jiao Tong University School of Medicine, China
- Department of Tumor Biology, Shanghai Chest Hospital (X.O.), Shanghai Jiao Tong University School of Medicine, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Yue Sun
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Haoyu Pan
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Xuefeng Wang
- Department of Laboratory Medicine, Ruijin Hospital (C.C., J.D., X.W.), Shanghai Jiao Tong University School of Medicine, China
| | - Junling Liu
- Department of Biochemistry and Molecular Cell Biology (J.L., Y.X.), Shanghai Jiao Tong University School of Medicine, China
| | - Bing Su
- Department of Immunology and Microbiology, Shanghai Institute of Immunology, Ministry of Education Key Laboratory of Cell Death and Differentiation (X.O., B.S.), Shanghai Jiao Tong University School of Medicine, China
- Center for Human Translational Immunology at Shanghai Institute of Immunology, Ruijin Hospital (B.S.), Shanghai Jiao Tong University School of Medicine, China
- Shanghai Jiao Tong University School of Medicine-Yale Institute for Immune Metabolism (B.S.), Shanghai Jiao Tong University School of Medicine, China
- Key Laboratory of Molecular Radiation Oncology of Hunan Province, Xiangya Hospital, Central South University, Changsha, China (B.S.)
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| | - Yanyan Xu
- Department of Biochemistry and Molecular Cell Biology (J.L., Y.X.), Shanghai Jiao Tong University School of Medicine, China
| | - Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital (Z.T., H.S., J.T., H.L., Q.H., X.C., J.Y., Y. Su, Y. Sun, H.P., C.Y., T.L.), Shanghai Jiao Tong University School of Medicine, China
| |
Collapse
|
11
|
Yun Z, Duan L, Liu X, Cai Q, Li C. An update on the biologics for the treatment of antiphospholipid syndrome. Front Immunol 2023; 14:1145145. [PMID: 37275894 PMCID: PMC10237350 DOI: 10.3389/fimmu.2023.1145145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/04/2023] [Indexed: 06/07/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombosis and pregnancy morbidity with the persistent presence of antiphospholipid antibodies (aPLs). Although anticoagulation is the primary treatment for APS, it fails in approximately 20-30% of obstetric APS cases and more than 30% of thrombotic APS cases. Therefore, there is a need for new, targeted treatments beyond anticoagulants. Biologics, such as rituximab and eculizumab, have been recommended for refractory catastrophic APS. This review focuses on the recent advancements in the pathogenesis of APS and explores the potential of targeted treatments, including eculizumab, rituximab, belimumab, daratumumab, obinutuzumab, and anti-TNF-α antibodies, for APS management.
Collapse
Affiliation(s)
- Zelin Yun
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
| | - Lizhi Duan
- Department of Rheumatology and Immunology, Gangkou Hospital of Hebei Port Group Company Limited, Qinhuangdao, Hebei, China
| | - Xiangjun Liu
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
| | - Qingmeng Cai
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism and Immune Diagnosis (BZ0135), Peking University People’s Hospital, Beijing, China
| |
Collapse
|
12
|
Girón-Ortega JA, Girón-González JA. Direct-acting oral anticoagulants in antiphospholipid syndrome: A systematic review. Med Clin (Barc) 2023:S0025-7753(23)00157-4. [PMID: 37105842 DOI: 10.1016/j.medcli.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
The objective of the systematic review is to analyze the efficacy of direct-acting oral anticoagulants (DOAC) in the prophylaxis of thrombosis in antiphospholipid syndrome (APS). We searched for clinical trials, cohort studies and meta-analyses published from January 1, 2012 to September 30, 2022. Articles that analyzed the efficacy of DOAC in the prevention of thrombosis recurrence, with or without comparison with antivitamin K (VKA) drugs, were selected. DOACs, specifically rivaroxaban and apixaban, were significantly less effective than VKAs in preventing recurrence of thrombosis in patients with APS and prior arterial thrombosis or the concomitant presence of two or three different antiphospholipid antibodies. The proportion of patients with severe bleeding as side effect are similar in those treated with DOAC and with VKA. The results argue against the use of DOAC in the treatment of patients with thrombotic APS.
Collapse
Affiliation(s)
| | - José Antonio Girón-González
- Servicio de Medicina Interna, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, España
| |
Collapse
|
13
|
El Hasbani G, Saliba AN, Uthman I, Taher AT. Hematological manifestations of antiphospholipid syndrome: Going beyond thrombosis. Blood Rev 2023; 58:101015. [PMID: 36175215 DOI: 10.1016/j.blre.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Thrombotic complications are a hallmark of antiphospholipid syndrome (APS). These vascular - arterial, venous, and/or small vessel - complications are well described and known to hematologists and healthcare providers caring for patients with this disease. In this review, we shed light on other hematological manifestations of the disease, including bleeding, thrombocytopenia, autoimmune hemolytic anemia, and thrombotic microangiopathy syndromes. While these manifestations are not bona fide clinical criteria for the diagnosis of APS, they frequently interact and contribute to the complexity of clinical management of APS.
Collapse
Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, CT 06606, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon..
| |
Collapse
|
14
|
Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
Collapse
Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
| |
Collapse
|
15
|
Harsini S, Rezaei N. Autoimmune diseases. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
16
|
Capozzi A, Riitano G, Recalchi S, Manganelli V, Longo A, Falcou A, De Michele M, Garofalo T, Pulcinelli FM, Sorice M, Misasi R. Antiphospholipid antibodies in patients with stroke during COVID-19: A role in the signaling pathway leading to platelet activation. Front Immunol 2023; 14:1129201. [PMID: 36936925 PMCID: PMC10017527 DOI: 10.3389/fimmu.2023.1129201] [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: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Background Several viral and bacterial infections, including COVID-19, may lead to both thrombotic and hemorrhagic complications. Previously, it has been demonstrated an "in vitro" pathogenic effect of "antiphospholipid" antibodies (aPLs), which are able to activate a proinflammatory and procoagulant phenotype in monocytes, endothelial cells and platelets. This study analyzed the occurrence of aPL IgG in patients with acute ischemic stroke (AIS) during COVID-19, evaluating the effect of Ig fractions from these patients on signaling and functional activation of platelets. Materials and methods Sera from 10 patients with AIS during COVID-19, 10 non-COVID-19 stroke patients, 20 COVID-19 and 30 healthy donors (HD) were analyzed for anti-cardiolipin, anti-β2-GPI, anti-phosphatidylserine/prothrombin and anti-vimentin/CL antibodies by ELISA. Platelets from healthy donors were incubated with Ig fractions from these patients or with polyclonal anti-β2-GPI IgG and analyzed for phospho-ERK and phospho-p38 by western blot. Platelet secretion by ATP release dosage was also evaluated. Results We demonstrated the presence of aPLs IgG in sera of patients with AIS during COVID-19. Treatment with the Ig fractions from these patients or with polyclonal anti-β2-GPI IgG induced a significant increase of phospho-ERK and phospho-p38 expression. In the same vein, platelet activation was supported by the increase of adenyl nucleotides release induced by Ig fractions. Conclusions This study demonstrates the presence of aPLs in a subgroup of COVID-19 patients who presented AIS, suggesting a role in the mechanisms contributing to hypercoagulable state in these patients. Detecting these antibodies as a serological marker to check and monitor COVID-19 may contribute to improve the risk stratification of thromboembolic manifestations in these patients.
Collapse
Affiliation(s)
- Antonella Capozzi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Gloria Riitano
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Serena Recalchi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Valeria Manganelli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Agostina Longo
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Anne Falcou
- Emergency Department, “Sapienza” University of Rome, Rome, Italy
| | | | - Tina Garofalo
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Fabio M. Pulcinelli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Maurizio Sorice
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
- *Correspondence: Maurizio Sorice,
| | - Roberta Misasi
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome, Italy
| |
Collapse
|
17
|
Shi Y, Zhao J, Jiang H, Huang C, Qi W, Song Y, Wang Q, Li M, Tian X, Zhao Y, Zeng X. Thrombocytopenia in primary antiphospholipid syndrome: association with prognosis and clinical implications. Rheumatology (Oxford) 2022; 62:256-263. [PMID: 35536236 DOI: 10.1093/rheumatology/keac264] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/22/2022] [Accepted: 04/19/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Thrombocytopenia, a frequent clinical manifestation in patients with APS, could be an independent predictor of recurrent thrombotic, obstetric and severe extracriteria events. METHODS This single-centre prospective study enrolled 218 consecutive patients diagnosed with primary APS between 2010 and 2021. Thrombocytopenia was defined as a platelet count less than 100 × 109/L. RESULTS Our cohort included 74 (33.94%) patients with thrombocytopenia and 144 patients with a continuous normal platelet count. Comparison of baseline characteristics indicated that patients with thrombocytopenia had more visceral venous thromboses [10 (13.51%) vs 5(3.47%); P = 0.009] and extracriteria manifestations [mainly haemolytic anaemia; 20 (27.03%) vs 17 (11.81%); P = 0.007]. Hypocomplementemia was more likely among patients with thrombocytopenia [19 (25.68%) vs 16 (11.11%); P = 0.01]. The presence of aCL-IgG/IgM, anti-β2-glycoprotein I and lupus anticoagulant were more frequently detected in patients with thrombocytopenia. In survival analysis, thrombotic, obstetric and severe extracriteria survival rates were significantly worse in patients with thrombocytopenia. In multivariate Cox regression, thrombocytopenia was an independent risk factor for all endpoint events, including thrombotic events [hazard ratio (HR) 2.93 (95% CI 1.31, 6.56), P = 0.009], pregnancy morbidity [HR 8.00 (95% CI 2.43, 26.37), P = 0.0006] and severe extracriteria events [HR 15.27 (95% CI 1.85, 125.98), P = 0.01]. CONCLUSION Thrombocytopenia could identify primary APS patients at high risk of developing thrombotic events, pregnancy morbidity and severe extracriteria events.
Collapse
Affiliation(s)
- Yu Shi
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
| | - Jiuliang Zhao
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| | - Hui Jiang
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
| | - Can Huang
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| | - Wanting Qi
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
| | | | - Qian Wang
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| | - Mengtao Li
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| | - Xinping Tian
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| | - Yongqiang Zhao
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital.,National Clinical Research Center for Dermatologic and Immunologic Diseases
| |
Collapse
|
18
|
Targeting thromboinflammation in antiphospholipid syndrome. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2022; 21:744-757. [PMID: 36696191 DOI: 10.1016/j.jtha.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 01/26/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease, where persistent presence of antiphospholipid antibodies (aPL) leads to thrombotic and obstetric complications. APS is a paradigmatic thromboinflammatory disease. Thromboinflammation is a pathophysiological mechanism coupling inflammation and thrombosis, which contributes to the pathophysiology of cardiovascular disease. APS can serve as a model to unravel mechanisms of thromboinflammation and the relationship between innate immune cells and thrombosis. Monocytes are activated by aPL into a proinflammatory and procoagulant phenotype, producing proinflammatory cytokines such as tumor necrosis factor α, interleukin 6, as well as tissue factor. Important cellular signaling pathways involved are the NF-κB-pathway, mammalian target of rapamycin (mTOR) signaling, and the NOD-, LRR-, and pyrin domain-containing protein 3 inflammasome. All of these may serve as future therapeutic targets. Neutrophils produce neutrophil extracellular traps in response to aPL, and this leads to thrombosis. Thrombosis in APS also stems from increased interaction of neutrophils with endothelial cells through P-selectin glycoprotein ligand-1. NETosis can be targeted not only with several experimental therapeutics, such as DNase, but also through the redirection of current therapies such as defibrotide and the antiplatelet agent dipyridamole. Activation of platelets by aPL leads to a procoagulant phenotype. Platelet-leukocyte interactions are increased, possibly mediated by increased levels of soluble P-selectin and soluble CD40-ligand. Platelet-directed future treatment options involve the inhibition of several platelet receptors activated by aPL, as well as mTOR inhibition. This review discusses mechanisms underlying thromboinflammation in APS that present targetable therapeutic options, some of which may be generalizable to other thromboinflammatory diseases.
Collapse
|
19
|
Capecchi M, Abbattista M, Ciavarella A, Uhr M, Novembrino C, Martinelli I. Anticoagulant Therapy in Patients with Antiphospholipid Syndrome. J Clin Med 2022; 11:jcm11236984. [PMID: 36498557 PMCID: PMC9741036 DOI: 10.3390/jcm11236984] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the persistent positivity of antiphospholipid antibodies (aPLA) together with thrombosis or obstetrical complications. Despite their recognized predominant role, aPLA are not sufficient to induce the development of thrombosis and a second hit has been proposed to be necessary. The mainstay of treatment of APS is anticoagulant therapy. However, its optimal intensity in different presentations of the disease remains undefined. Moreover, decision on which patients with aPLA would benefit from an antithrombotic prophylaxis and its optimal intensity are challenging because of the lack of stratification tools for the risk of thrombosis. Finally, decision on the optimal type of anticoagulant drug is also complex because the central pathway responsible for the development of thrombosis is so far unknown and should be carried out on an individual basis after a careful evaluation of the clinical and laboratory features of the patient. This review addresses the epidemiology, physiopathology, diagnosis and management of thrombosis and obstetrical complications in APS, with a special focus on the role of direct oral anticoagulants.
Collapse
Affiliation(s)
- Marco Capecchi
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Maria Abbattista
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mario Uhr
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Department of Hematology, Synlab-Suisse, 6900 Lugano, Switzerland
| | - Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Ida Martinelli
- Division of Hematology, Clinica Moncucco, 6900 Lugano, Switzerland
- Correspondence: ; Tel.: +41-91-960-80-81
| |
Collapse
|
20
|
Gullapalli K, Prasad RM, Al-abcha A, Hussain Z, Alsouqi A, Mosalem O, Hrinczenko B. Efficacy and Safety of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e29449. [PMID: 36299971 PMCID: PMC9587712 DOI: 10.7759/cureus.29449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Due to a high risk of recurrent thromboembolism in patients with antiphospholipid syndrome (APS), long-term anticoagulation is recommended. For decades, vitamin K antagonists (VKAs) have been the gold standard for thromboprophylaxis in these patients. Due to the widespread use of direct oral anticoagulants (DOACs) in various thromboembolic conditions and their potential advantages compared to VKAs, several studies have been conducted to evaluate their safety and efficacy in APS. We performed a literature search using PubMed, Embase, and Cochrane databases for studies comparing DOACs to VKAs in patients with APS. Relative risk (RR) and the corresponding 95% confidence intervals (95% CI) were estimated for recurrent thromboembolic events, bleeding, and mortality. A total of 1437 patients pooled from 12 studies were analyzed. The risk of recurrent thrombosis, especially arterial thrombosis, doubled with DOACs compared to VKAs (RR 2.61, 95% CI 1.44-4.71; p=0.001). The risk further increased in patients with a triple-positive antiphospholipid antibody profile (RR 4.50, 95% CI 1.91-10.63; p=0.0006) and with the use of rivaroxaban (RR 1.95, 95% CI 1.10-3.45; p=0.02). The risk of major bleeding and mortality were not significantly different between the two arms. A trend favoring DOACs compared to VKAs was observed for all bleeding events. This meta-analysis comes in agreement with previous studies and supports the use of VKAs in APS. Our study revealed that VKAs remain the gold standard for the management of APS, especially triple-positive APS. DOACs, particularly rivaroxaban, are not as effective in preventing recurrent thromboembolism in high-risk APS patients. Further studies are needed to evaluate the role of DOACs apart from rivaroxaban with a focus on their efficacy in the management of isolated or double-positive APS.
Collapse
|
21
|
Naranjo L, Stojanovich L, Djokovic A, Andreoli L, Tincani A, Maślińska M, Sciascia S, Infantino M, Garcinuño S, Kostyra-Grabczak K, Manfredi M, Regola F, Stanisavljevic N, Milanovic M, Saponjski J, Roccatello D, Cecchi I, Radin M, Benucci M, Pleguezuelo D, Serrano M, Shoenfeld Y, Serrano A. Circulating immune-complexes of IgG/IgM bound to B2-glycoprotein-I associated with complement consumption and thrombocytopenia in antiphospholipid syndrome. Front Immunol 2022; 13:957201. [PMID: 36172349 PMCID: PMC9511106 DOI: 10.3389/fimmu.2022.957201] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is a multisystemic autoimmune disorder characterized by thrombotic events and/or gestational morbidity in patients with antiphospholipid antibodies (aPL). In a previous single center study, APS-related clinical manifestations that were not included in the classification criteria (livedo reticularis, thrombocytopenia, leukopenia) were associated with the presence of circulating immune-complexes (CIC) formed by beta-2-glycoprotein-I (B2GP1) and anti-B2GP1 antibodies (B2-CIC). We have performed a multicenter study on APS features associated with the presence of B2-CIC. Methods A multicenter, cross-sectional and observational study was conducted on 303 patients recruited from six European hospitals who fulfilled APS classification criteria: 165 patients had primary APS and 138 APS associated with other systemic autoimmune diseases (mainly systemic lupus erythematosus, N=112). Prevalence of B2-CIC (IgG/IgM isotypes) and its association with clinical manifestations and biomarkers related to the disease activity were evaluated. Results B2-CIC prevalence in APS patients was 39.3%. B2-CIC-positive patients with thrombotic APS presented a higher incidence of thrombocytopenia (OR: 2.32, p=0.007), heart valve thickening and dysfunction (OR: 9.06, p=0.015) and triple aPL positivity (OR: 1.83, p=0.027), as well as lower levels of C3, C4 and platelets (p-values: <0.001, <0.001 and 0.001) compared to B2-CIC-negative patients. B2-CIC of IgM isotype were significantly more prevalent in gestational than thrombotic APS. Conclusions Patients with thrombotic events and positive for B2-CIC had lower platelet count and complement levels than those who were negative, suggesting a greater degree of platelet activation.
Collapse
Affiliation(s)
- Laura Naranjo
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Aleksandra Djokovic
- Cardiology Department, University Hospital Center Bezanijska Kosa, Belgrade, Serbia
- School of Medicine , University of Belgrade, Belgrade, Serbia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Maślińska
- Early Arthritis Clinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Savino Sciascia
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Maria Infantino
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Florence, Italy
| | - Sara Garcinuño
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Kinga Kostyra-Grabczak
- Early Arthritis Clinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Mariangela Manfredi
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Florence, Italy
| | - Francesca Regola
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Natasa Stanisavljevic
- Internal Medicine, University Hospital Center Bezanijska Kosa, Belgrade, Serbia
- School of Medicine , University of Belgrade, Belgrade, Serbia
| | - Milomir Milanovic
- Internal Medicine Department, Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia
| | - Jovica Saponjski
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dario Roccatello
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Irene Cecchi
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Massimo Radin
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Maurizio Benucci
- Rheumatology Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Daniel Pleguezuelo
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Serrano
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- *Correspondence: Manuel Serrano,
| | - Yehuda Shoenfeld
- Ariel University, Ariel, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Antonio Serrano
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| |
Collapse
|
22
|
Butt A, Erkan D, Lee AI. COVID-19 and antiphospholipid antibodies. Best Pract Res Clin Haematol 2022; 35:101402. [PMID: 36494152 PMCID: PMC9568270 DOI: 10.1016/j.beha.2022.101402] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome and the coagulopathy of COVID-19 share many pathophysiologic features, including endotheliopathy, hypercoagulability, and activation of platelets, complement pathways, and neutrophil extracellular traps, all acting in concert via a model of immunothrombosis. Antiphospholipid antibody production in COVID-19 is common, with 50% of COVID-19 patients being positive for lupus anticoagulant in some studies, and with non-Sapporo criteria antiphospholipid antibodies being prevalent as well. The biological significance of antiphospholipid antibodies in COVID-19 is uncertain, as such antibodies are usually transient, and studies examining clinical outcomes in COVID-19 patients with and without antiphospholipid antibodies have yielded conflicting results. In this review, we explore the biology of antiphospholipid antibodies in COVID-19 and other infections and discuss mechanisms of thrombogenesis in antiphospholipid syndrome and parallels with COVID-19 coagulopathy. In addition, we review the existing literature on safety of COVID-19 vaccination in patients with antiphospholipid antibodies and antiphospholipid syndrome.
Collapse
Affiliation(s)
- Ayesha Butt
- Section of Hematology, Department of Medicine, Yale School of Medicine, 333 Cedar St., New Haven, CT, 06520, USA.
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, 535 E. 70th St., 6th floor, New York, NY, 10021, USA.
| | - Alfred Ian Lee
- Section of Hematology, Department of Medicine, Yale School of Medicine, 333 Cedar St., New Haven, CT, 06520, USA.
| |
Collapse
|
23
|
Cheng C, Bison E, Pontara E, Cattini MG, Tonello M, Denas G, Pengo V. Platelet- and endothelial-derived microparticles in the context of different antiphospholipid antibody profiles. Lupus 2022; 31:1328-1334. [DOI: 10.1177/09612033221118465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Studies on microparticles (MPs) in patients with antiphospholipid antibodies (aPL) are sparse and inconclusive. The relation between MPs and different aPL antibody profiles has never been tested. We evaluated the presence of platelet and endothelial microparticles in patients positive for IgG anti-β2-glycoprotein I (aβ2GPI) antibodies according to triple, double and single positive aPL profiles. Methods Megamix (Biocytex) was used to set up the MPs gating according to the datasheet. Markers of Platelet Microparticles (PMPs) were CD41a-PE and annexin-V-FITC that was used to determine phosphatidylserine (PS) exposure. CD144-FITC was used as a marker of Endothelial Microparticles (EMPs). Results The number of total MPs and EMPs was significantly higher in triple positive groups with respect to single positive group and showed a significant correlation with IgG aβ2GPI titers. The number PMPs was the lowest in triple positive group and inversely correlated with IgG aβ2GPI titers. Conclusions Elevated levels of total MPs and EMPs suggest a state of vascular activation in IgG aβ2GPI positive individuals according to the number of positive tests. PMPs may be fast cleared from circulation in high risk triple positive patients.
Collapse
Affiliation(s)
- Chunyan Cheng
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Elisa Bison
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Elena Pontara
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Maria Grazia Cattini
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Marta Tonello
- Department of Medicine, Rheumatology Section, University of Padua, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| |
Collapse
|
24
|
Shi M, Gao W, Jin Y, Zhu J, Liu Y, Wang T, Li C. Antiphospholipid Syndrome-Related Pulmonary Embolism: Clinical Characteristics and Early Recognition. Front Cardiovasc Med 2022; 9:872523. [PMID: 35898271 PMCID: PMC9309373 DOI: 10.3389/fcvm.2022.872523] [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: 02/09/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pulmonary thromboembolism is a common disease frequently encountered in the emergency room and has a high mortality rate. Antiphospholipid syndrome (APS) is a high-risk factor for recurrent pulmonary embolism (PE). It is critical to effectively administer anticoagulants to avoid the recurrence of thrombotic events. This study aims to identify the clinical characteristics of APS patients with PE (APS-PE) and to develop a risk score for determining the presence of APS in PE patients in the emergency situations. Methods We retrospectively enrolled 76 PE patients in this study, with 46 patients in the APS-PE group and 30 patients in the non-APS-PE group. We compared differences in demographics, laboratory parameters, and early mortality risk between the two groups. Risk factors for APS-PE were screened using logistic regression analysis. We also developed an early risk score using multivariate analysis weighted points proportional to the β- regression coefficient values and calculated the sensitivity and specificity for APS in PE patients. Results In the APS-PE group, we observed a higher proportion of males (43.6 vs. 20%), a higher proportion of low-risk patients (58.7 vs. 10%), lower levels of white blood cells and platelets (PLT), longer activated partial thromboplastin time (APTT), and a slight increase in D-dimer levels. Patients who were triple positive for antiphospholipid antibodies (aPLs) were younger. The APTT gradually increased as the number of positive aPLs increased. The risk factors for APS included male (OR = 5.565, 95% CI 1.176–26.341), decreased PLT (OR = 0.029, 95% CI 0.003–0.330), slightly increased D-dimer (OR = 0.089, 95% CI 0.019–0.426), and prolonged APTT (OR = 4.870, 95% CI 1.189–19.951). The risk score was named MPDA and included male, PLT, D-dimer and APTT, which can predict APS in PE patients with the AUC at 0.888 (95% CI 0.811–0.965). Conclusion The risk factors for APS in PE patients are male, low PLT, prolonged APTT and slightly increased D-dimer. The MPDA is a quantitative scoring system which is highly suggestive of APS in PE patients.
Collapse
Affiliation(s)
- Maojing Shi
- Trauma Center, Peking University People's Hospital, Beijing, China
| | - Weibo Gao
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuebo Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuansheng Liu
- Department of Emergency, Peking University People's Hospital, Beijing, China
- Yuansheng Liu
| | - Tianbing Wang
- Trauma Center, Peking University People's Hospital, Beijing, China
- Tianbing Wang
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- *Correspondence: Chun Li
| |
Collapse
|
25
|
Ruiz-Irastorza G, Khamashta MA. What are the prospects for antiplatelet agents for thromboprophylaxis in antiphospholipid syndrome? Expert Rev Clin Immunol 2022; 18:779-781. [PMID: 35703006 DOI: 10.1080/1744666x.2022.2090338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, University of the Basque Country, Bizkaia, Spain
| | - Munther A Khamashta
- Women & Children's Health, King's College London, UK.,GSK, Dubai, United Arab Emirates
| |
Collapse
|
26
|
Knight JS, Kanthi Y. Mechanisms of immunothrombosis and vasculopathy in antiphospholipid syndrome. Semin Immunopathol 2022; 44:347-362. [PMID: 35122116 PMCID: PMC8816310 DOI: 10.1007/s00281-022-00916-w] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune thrombophilia propelled by circulating antiphospholipid antibodies that herald vascular thrombosis and obstetrical complications. Antiphospholipid antibodies recognize phospholipids and phospholipid-binding proteins and are not only markers of disease but also key drivers of APS pathophysiology. Thrombotic events in APS can be attributed to various conspirators including activated endothelial cells, platelets, and myeloid-lineage cells, as well as derangements in coagulation and fibrinolytic systems. Furthermore, recent work has especially highlighted the role of neutrophil extracellular traps (NETs) and the complement system in APS thrombosis. Beyond acute thrombosis, patients with APS can also develop an occlusive vasculopathy, a long-term consequence of APS characterized by cell proliferation and infiltration that progressively expands the intima and leads to organ damage. This review will highlight known pathogenic factors in APS and will also briefly discuss similarities between APS and the thrombophilic coagulopathy of COVID-19.
Collapse
Affiliation(s)
- Jason S Knight
- Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| |
Collapse
|
27
|
Gamal S, Mohamed S, Moghazy A. Thrombocytopenia in a cohort of primary and secondary antiphospholipid syndrome patients: Relation to clinical, laboratory manifestations and damage index. Arch Rheumatol 2022; 37:252-260. [PMID: 36017208 PMCID: PMC9377168 DOI: 10.46497/archrheumatol.2022.9088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives
This study aims to evaluate the prevalence of thrombocytopenia in a cohort of patients with primary and secondary antiphospholipid syndrome (APS) and to examine the relation of thrombocytopenia to the clinical, laboratory findings, and damage index for antiphospholipid syndrome (DIAPS). Patients and methods
Between August 2018 and February 2019, a total of 168 patients (16 males, 152 females; mean age: 32.5±8.4 years; range, 18 to 59 years) who were followed in our clinic for APS were retrospectively analyzed. Medical records of the patients were screened and clinical data, laboratory investigations, and treatments applied were recorded. The DIAPS was calculated for all patients. The patients were divided into two groups according to the presence or absence of thrombocytopenia and both groups were compared regarding clinical, laboratory findings and DIAPS. Further subgroup analysis was done for patients with primary APS. Results
The most common clinical manifestations in our patients were obstetric manifestations (77.4% in pregnant women), musculoskeletal manifestations (69%) and peripheral vascular thrombosis (54.8%). The prevalence of thrombocytopenia in our study was 42.3%, and it was significantly associated with musculoskeletal manifestations (p=0.043), vascular thrombosis (p=0.043), neurological manifestations (p=0.030), cutaneous manifestations (p=0.006), and use of immunosuppressives (p=0.047). The DIAPS was significantly higher in the thrombocytopenia group (p=0.034). Further subgroup analysis of patients with primary APS revealed that neurological manifestations (p=0.010) were significantly higher in the thrombocytopenia group, while the DIAPS was higher in the thrombocytopenia group, but it did not reach statistical significance (p=0.082). Conclusion
Thrombocytopenia may be associated with a higher incidence of vascular thrombosis, neurological manifestations, musculoskeletal manifestations, use of immunosuppressive treatment, and DIAPS. In primary APS patients, thrombocytopenia may be a risk for neurological manifestations.
Collapse
Affiliation(s)
- Sherif Gamal
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Samar Mohamed
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abdelkawy Moghazy
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
28
|
Neuropsychiatric Manifestations of Antiphospholipid Syndrome—A Narrative Review. Brain Sci 2022; 12:brainsci12010091. [PMID: 35053834 PMCID: PMC8773877 DOI: 10.3390/brainsci12010091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a common autoimmune pro-thrombotic condition characterised by thrombosis and pregnancy morbidity. There are a broad range of neuropsychiatric manifestations associated with APS, from focal symptoms to more global dysfunction. Patients commonly present with transient ischaemic attacks and ischaemic strokes, with identifiable lesions on brain imaging. However, the underlying pathogenesis remains uncertain in other manifestations, such as cognitive dysfunction, seizures, headache and chorea. The aim is to provide a comprehensive review of the various neuropsychiatric manifestations associated with APS. A detailed literature search was applied to PubMed, including citations from 1983 to December 2021.
Collapse
|
29
|
Arreola-Diaz R, Majluf-Cruz A, Sanchez-Torres LE, Hernandez-Juarez J. The Pathophysiology of The Antiphospholipid Syndrome: A Perspective From The Blood Coagulation System. Clin Appl Thromb Hemost 2022; 28:10760296221088576. [PMID: 35317658 PMCID: PMC8950029 DOI: 10.1177/10760296221088576] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The antiphospholipid syndrome (APS), a systemic autoimmune disease characterized by a hypercoagulability associated to vascular thrombosis and/or obstetric morbidity, is caused by the presence of antiphospholipid antibodies such as lupus anticoagulant, anti-β-2-glycoprotein 1, and/or anticardiolipin antibodies. In the obstetrical APS, antiphospholipid antibodies induce the production of proinflammatory cytokines and tissue factor by placental tissues and recruited neutrophils. Moreover, antiphospholipid antibodies activate the complement system which, in turn, induces a positive feedback leading to recruitment of neutrophils as well as activation of the placenta. Activation of these cells triggers myometrial contractions and cervical ripening provoking the induction of labor. In thrombotic and obstetrical APS, antiphospholipid antibodies activate endothelial cells, platelets, and neutrophils and they may alter the multimeric pattern and concentration of von Willebrand factor, increase the concentration of thrombospondin 1, reduce the inactivation of factor XI by antithrombin, increase the activation of factor XII, and reduce the activity of tissue plasminogen activator with the subsequent production of plasmin. All these effects result in less permeable clots, denser, thinner, and with more branched fibrin fibers which are more difficult to lysate. As a consequence, thrombosis, the defining clinical criterion of APS, complicates the clinical course of the patient.
Collapse
Affiliation(s)
- R Arreola-Diaz
- Departamento de Inmunologia, Escuela Nacional de Ciencias Biologicas, Instituto Politecnico Nacional, Ciudad de Mexico, Mexico
| | - A Majluf-Cruz
- Unidad de Investigacion Medica en Trombosis, Hemostasia y Aterogenesis, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - L E Sanchez-Torres
- Departamento de Inmunologia, Escuela Nacional de Ciencias Biologicas, Instituto Politecnico Nacional, Ciudad de Mexico, Mexico
| | - J Hernandez-Juarez
- CONACyT-Facultad de Odontologia, Universidad Autonoma Benito Juarez de Oaxaca, Oaxaca de Juarez, Mexico
| |
Collapse
|
30
|
Green D. Pathophysiology of the Antiphospholipid Antibody Syndrome. Thromb Haemost 2021; 122:1085-1095. [PMID: 34794200 PMCID: PMC9391091 DOI: 10.1055/a-1701-2809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The antiphospholipid syndrome is characterized by antibodies directed against phospholipid-binding proteins and phospholipids attached to cell membrane receptors, mitochondria, oxidized lipoproteins, and activated complement components. When antibodies bind to these complex antigens, cells are activated and the coagulation and complement cascades are triggered, culminating in thrombotic events and pregnancy morbidity that further define the syndrome. The phospholipid-binding proteins most often involved are annexins II and V, β2-glycoprotein I, prothrombin, and cardiolipin. A distinguishing feature of the antiphospholipid syndrome is the "lupus anticoagulant". This is not a single entity but rather a family of antibodies directed against complex antigens consisting of β2-glycoprotein I and/or prothrombin bound to an anionic phospholipid. Although these antibodies prolong in vitro clotting times by competing with clotting factors for phospholipid binding sites, they are not associated with clinical bleeding. Rather, they are thrombogenic because they augment thrombin production in vivo by concentrating prothrombin on phospholipid surfaces. Other antiphospholipid antibodies decrease the clot-inhibitory properties of the endothelium and enhance platelet adherence and aggregation. Some are atherogenic because they increase lipid peroxidation by reducing paraoxonase activity, and others impair fetal nutrition by diminishing placental antithrombotic and fibrinolytic activity. This plethora of destructive autoantibodies is currently managed with immunomodulatory agents, but new approaches to treatment might include vaccines against specific autoantigens, blocking the antibodies generated by exposure to cytoplasmic DNA, and selective targeting of aberrant B-cells to reduce or eliminate autoantibody production.
Collapse
Affiliation(s)
- David Green
- Medicine/Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, United States
| |
Collapse
|
31
|
Passam FH, Chen G, Chen VM, Qi M, Krilis SA, Giannakopoulos B. Βeta-2-glycoprotein I exerts antithrombotic function through its domain V in mice. J Autoimmun 2021; 126:102747. [PMID: 34794103 DOI: 10.1016/j.jaut.2021.102747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 11/26/2022]
Abstract
Little is known about the physiological role of beta-2-glycoprotein I (β2GPI) despite it being the major auto-antigen in the antiphospholipid syndrome. A systematic study of the role of β2GPI in thrombus formation in vivo has not been performed to date. Herein, we report that β2GPI deficient (-/-) mice have enhanced thrombus formation compared to wild type (WT) mice in a laser-induced arteriole and venule model of thrombosis. Furthermore, neutrophil accumulation and elastase activity was enhanced in thrombi of β2GPI -/- compared with WT mice. The antithrombotic function of β2GPI is dependent on its fifth domain (domain V); intravenous administration of the β2GPI domain deletion mutant lacking domain V (human recombinant domain I-IV) had no effect on platelet and fibrin thrombus size in β2GPI -/- or WT mice. On the contrary, intravenous administration of human recombinant domain V significantly inhibited platelet and fibrin thrombus size in both β2GPI -/- mice and WT mice. These findings reveal a major role for β2GPI as a natural anticoagulant and implicate domain V of β2GPI as a potential antithrombotic therapy.
Collapse
Affiliation(s)
- Freda H Passam
- Faculty Medicine Health, University of Sydney, Sydney, Australia; Heart Research Institute, Sydney, Australia
| | - Gang Chen
- Department of Infectious Disease, Immunology and Sexual Health, St George Hospital, University of New South Wales, Sydney, Australia
| | - Vivien M Chen
- Department of Haematology, Concord Hospital, Sydney, NSW, Australia; ANZAC Research Institute, University of Sydney, NSW, Australia
| | - Miao Qi
- Department of Infectious Disease, Immunology and Sexual Health, St George Hospital, University of New South Wales, Sydney, Australia
| | - Steven A Krilis
- Department of Infectious Disease, Immunology and Sexual Health, St George Hospital, University of New South Wales, Sydney, Australia; Department of Medicine, St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia.
| | - Bill Giannakopoulos
- Department of Infectious Disease, Immunology and Sexual Health, St George Hospital, University of New South Wales, Sydney, Australia; Department of Medicine, St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia.
| |
Collapse
|
32
|
A systematic review of the association between anti-β-2 glycoprotein I antibodies and APS manifestations. Blood Adv 2021; 5:3931-3936. [PMID: 34547773 PMCID: PMC8945648 DOI: 10.1182/bloodadvances.2021005205] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022] Open
Abstract
Anti-β-2 glycoprotein I antibodies (anti-B2GPI) are often cited as the major pathogenically relevant antibody in antiphospholipid syndrome (APS), but it is unclear if there is clinical evidence to support this theory. We performed a systematic review to determine if immunoglobulin G anti-B2GPI positivity was independently associated with thrombotic and/or obstetric manifestations of APS. We searched MEDLINE, EMBASE, The Cochrane Library, and clinicaltrials.gov electronic databases through April 2020 for prospective studies that met prespecified design criteria. Of 4758 articles identified through computer-assisted search, 4 studies examining obstetric outcomes and 2 studies examining thrombotic outcomes were included for qualitative assessment. The presence of anti-B2GPI had only a weak independent association with thrombosis and was, at best, inconsistently associated with obstetric complications. A quantitative assessment could not be performed because of study heterogeneity. The overall quality of the evidence was very low. Although anti-B2GPI are commonly thought to mediate APS manifestations, clinical evidence is lacking with very low-quality data to support a weak association with thrombosis.
Collapse
|
33
|
Capozzi A, Riitano G, Recalchi S, Manganelli V, Costi R, Saccoliti F, Pulcinelli F, Garofalo T, Misasi R, Longo A, Di Santo R, Sorice M. Effect of heparanase inhibitor on tissue factor overexpression in platelets and endothelial cells induced by anti-β2-GPI antibodies. J Thromb Haemost 2021; 19:2302-2313. [PMID: 34107171 PMCID: PMC8456873 DOI: 10.1111/jth.15417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/23/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anti-phospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis and pregnancy morbidity associated with the presence of "anti-phospholipid antibodies." Thrombosis may be the result of a hypercoagulable state related to activation of endothelial cells and platelets by anti-β2-glycoprotein I (β2-GPI) antibodies. Anti-β2-GPI antibodies induce a proinflammatory and procoagulant phenotype in these cells that, after activation, express tissue factor (TF), the major initiator of the clotting cascade, playing a role in thrombotic manifestations. Moreover, TF expression may also be induced by heparanase, an endo-β-D-glucuronidase, that generates heparan sulfate fragments, regulating inflammatory responses. OBJECTIVES In this study we analyzed, in human platelets and endothelial cells, the effect of a new symmetrical 2-aminophenyl-benzazolyl-5-acetate derivative (RDS3337), able to inhibit heparanase activity, on signal transduction pathways leading to TF expression triggered by anti-β2-GPI. METHODS Platelets and endothelial cells were incubated with affinity purified anti-β2-GPI after pretreatment with RDS3337. Cell lysates were analyzed for phospho-interleukin-1 receptor-associated kinase 1 (IRAK1), phospho-p65 nuclear factor kappa B (NF-κB) and TF by western blot. In addition, platelet activation and secretion by ATP release dosage were evaluated. RESULTS IRAK phosphorylation and consequent NF-κB activation, as well as TF expression triggered by anti-β2-GPI treatment were significantly prevented by previous pretreatment with RDS3337. In the same vein, pretreatment with RDS3337 prevented platelet aggregation and ATP release triggered by anti-β2-GPI antibodies. CONCLUSION These findings support the view of heparanase involvement in a prothrombotic state related to APS syndrome, suggesting a novel target to regulate overexpression of procoagulant protein(s).
Collapse
Affiliation(s)
- Antonella Capozzi
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Gloria Riitano
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Serena Recalchi
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Valeria Manganelli
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Roberta Costi
- Dipartimento di Chimica e Tecnologie del FarmacoIstituto Pasteur‐Fondazione Cenci Bolognetti“Sapienza” University of RomeRomeItaly
| | - Francesco Saccoliti
- Dipartimento di Chimica e Tecnologie del FarmacoIstituto Pasteur‐Fondazione Cenci Bolognetti“Sapienza” University of RomeRomeItaly
| | - Fabio Pulcinelli
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Tina Garofalo
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Roberta Misasi
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Agostina Longo
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| | - Roberto Di Santo
- Dipartimento di Chimica e Tecnologie del FarmacoIstituto Pasteur‐Fondazione Cenci Bolognetti“Sapienza” University of RomeRomeItaly
| | - Maurizio Sorice
- Department of Experimental Medicine“Sapienza” University of RomeRomeItaly
| |
Collapse
|
34
|
Platelet distribution width is highly associated with thrombotic events in primary antiphospholipid syndrome. Clin Rheumatol 2021; 40:4581-4588. [PMID: 34213673 DOI: 10.1007/s10067-021-05843-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Platelet activation is a possible pathogenic process contributing to thromboembolism in antiphospholipid syndrome (APS), and platelet distribution width (PDW) is associated with platelet activation. The objective of this study was to evaluate the association between platelet indices and thrombotic events in patients with primary APS. METHODS This single-center cross-sectional study included 207 consecutive patients with APS treated at our institution between 2010 and 2019. Results of blood tests were recorded retrospectively from medical records. RESULTS Of the included patients, 135 (65.2%) were female and 72 (34.8%) were male. They were classified into thrombotic (n = 150) or non-thrombotic (n = 57) groups. PDW, mean platelet volume, and large platelet ratio were significantly higher in the thrombotic group. In univariate logistic analysis, PDW was significantly associated with an increased odds of thrombosis [odds ratio (OR) 1.554, 95% confidence interval (CI) 1.289-1.873, p<0.001]. In multivariate logistic analysis, PDW and positive lupus anticoagulant (LA) were risk factors for thrombosis. Receiver operating characteristic analysis showed that PDW, combined with a positive LA, was a reliable indicator of thrombosis, with an area under the curve of 0.796 (95% CI 0.728-0.864). The optimal cutoff value for PDW was 12.4 fl, with a sensitivity of 72.0% and specificity of 77.2%. Multivariate logistic regression of PDW tertiles showed that the odds of thrombosis increased abruptly in the highest tertile. CONCLUSION This study confirmed the association between PDW and thrombotic events in APS patients, supporting the theory that platelet activation is a crucial mechanism of thrombosis in APS. Key Points • This study is the first to discuss the correlation between PDW and thromboses in patients with APS. • This study provides evidence of the important role of platelet activation in the pathogenesis of APS.
Collapse
|
35
|
Kumar S, Chinnaraj M, Planer W, Zuo X, Macor P, Tedesco F, Pozzi N. An allosteric redox switch in domain V of β 2-glycoprotein I controls membrane binding and anti-domain I autoantibody recognition. J Biol Chem 2021; 297:100890. [PMID: 34197876 PMCID: PMC8326733 DOI: 10.1016/j.jbc.2021.100890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 01/27/2023] Open
Abstract
β2-glycoprotein I (β2GPI) is an abundant multidomain plasma protein that plays various roles in the clotting and complement cascades. It is also the main target of antiphospholipid antibodies (aPL) in the acquired coagulopathy known as antiphospholipid syndrome (APS). Previous studies have shown that β2GPI adopts two interconvertible biochemical conformations, oxidized and reduced, depending on the integrity of the disulfide bonds. However, the precise contribution of the disulfide bonds to β2GPI structure and function is unknown. Here, we substituted cysteine residues with serine to investigate how the disulfide bonds C32-C60 in domain I (DI) and C288-C326 in domain V (DV) regulate β2GPI's structure and function. Results of our biophysical and biochemical studies support the hypothesis that the C32-C60 disulfide bond plays a structural role, whereas the disulfide bond C288-C326 is allosteric. We demonstrate that absence of the C288-C326 bond, unlike absence of the C32-C60 bond, diminishes membrane binding without affecting the thermodynamic stability and overall structure of the protein, which remains elongated in solution. We also document that, while absence of the C32-C60 bond directly impairs recognition of β2GPI by pathogenic anti-DI antibodies, absence of the C288-C326 disulfide bond is sufficient to abolish complex formation in the presence of anionic phospholipids. We conclude that the disulfide bond C288-C326 operates as a molecular switch capable of regulating β2GPI's physiological functions in a redox-dependent manner. We propose that in APS patients with anti-DI antibodies, selective rupture of the C288-C326 disulfide bond may be a valid strategy to lower the pathogenic potential of aPL.
Collapse
Affiliation(s)
- Suresh Kumar
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Mathivanan Chinnaraj
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - William Planer
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Xiaobing Zuo
- X-Ray Science Division, Argonne National Laboratory, Lemont, Illinois, USA
| | - Paolo Macor
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Francesco Tedesco
- Istituto Auxologico Italiano, IRCCS, Laboratory of Immuno-Rheumatology, Milan, Italy
| | - Nicola Pozzi
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St Louis, Missouri, USA.
| |
Collapse
|
36
|
Pardos-Gea J, Marques-Soares JR, Buján S, Ordi-Ros J, Alijotas-Reig J. Persistent thrombocytopenia predicts poor long-term survival in patients with antiphospholipid syndrome: a 38-year follow-up study. Rheumatology (Oxford) 2021; 61:1053-1061. [PMID: 34115832 DOI: 10.1093/rheumatology/keab475] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/25/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To investigate the impact of thrombocytopenia on survival in patients with antiphospholipid syndrome (APS). METHODS Thrombocytopenia and other predictors of outcome were retrospectively evaluated in an antiphospholipid-antibody (aPL)-positive and APS cohort with 38-year follow-up (1980-2018). Thrombocytopenia was defined as < 150 × 109 platelets/l. Hazard ratios (HR) of mortality were calculated using Cox-regression models. RESULTS Among 114 patients, 64% had primary APS, 25% secondary APS, and 10% asymptomatic aPL. Mean follow-up was 19 (5-38) years. ANA (HR 1.8, p= 0.10, 95%CI 0.8-3.6), arterial thrombotic events (HR 7.0, p= 0.016, 95%CI 1.4-3.5), myocardial infarction (HR 8.3, p= 0.03, 95%CI 1.1-59), intracardiac thrombosis (HR 17, p= 0.04, 95%CI 1-279), and thrombocytopenia (HR 2.9, p= 0.004, 95%CI 1.4-6.1) were risk factors for all-cause mortality but in multivariate analysis only thrombocytopenia (HR 2.7, p= 0.01, 95%CI 1.3-6.0) remained significant. Persistent (HR 4.4, p= 0.001, 95%CI 2.1-9.2) and low-moderate thrombocytopenia (HR 2.8, p= 0.01, 95%CI 1.2-6.4) were associated with a significant increase in mortality compared with acute (HR 1.6, p= 0.40, 95%CI 0.5-5.3) and severe forms (HR 2.1, p= 0.30, 95%CI 0.5-9.2). APS patients with vs without thrombocytopenia were more frequently male (58% vs 24%, p= 0.001) with arterial thrombosis (55% vs 32%, p= 0.04), LA positivity (100% vs 87%, p= 0.04), type I aPL profile (89% vs 71%, p= 0.05), and anticoagulant treatment (89% vs 63%, p= 0.01). Thrombosis caused 13% of deaths in thrombocytopenic patients and 1% in those without (p= 0.01). CONCLUSION Thrombocytopenia is an aPL-related manifestation that identifies patients with severe disease phenotype and high thrombotic risk. Persistent low-moderate thrombocytopenia is associated with a reduced long-term survival.
Collapse
Affiliation(s)
- José Pardos-Gea
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Segundo Buján
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | - José Ordi-Ros
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | - Jaume Alijotas-Reig
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| |
Collapse
|
37
|
Incidental diagnosis of antiphospholipid antibody syndrome (APS) in a trauma patient with thrombocytopenia & its anesthetic management. Trauma Case Rep 2021; 33:100488. [PMID: 33997231 PMCID: PMC8100616 DOI: 10.1016/j.tcr.2021.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2021] [Indexed: 11/21/2022] Open
|
38
|
Possible effects of chemokine-like factor-like MARVEL transmembrane domain-containing family on antiphospholipid syndrome. Chin Med J (Engl) 2021; 134:1661-1668. [PMID: 33813507 PMCID: PMC8318642 DOI: 10.1097/cm9.0000000000001449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease defined by thrombotic or obstetrical events and persistent antiphospholipid antibodies (aPLs). Chemokine-like factor-like MARVEL transmembrane domain-containing family (CMTM) is widely expressed in the immune system and may closely related to APS. This review aimed to systematically summarize the possible effects of CMTM on APS. Publications were collected from PubMed and Web of Science databases up to August 2020. CKLF, CKLFSF, CMTM, antiphospholipid syndrome, immune cells, and immune molecules were used as search criteria. Immune cells, including neutrophil, dendritic cells (DCs), T-cells, B-cells, and inflammatory cytokines, play an important role in the development of APS. Chemokine-like factor 1 (CKLF1) has a chemotactic effect on many cells and can affect the expression of inflammatory cytokines and adhesion molecules through the nuclear factor-kB (NF-kB) pathway or mitogen-activated protein kinase (MARK) pathway. CKLF1 can participate in the maturation of DCs, T lymphocyte activation, and the activation of neutrophils through the MAPK pathway. CMTM1 may act on Annexin A2 by regulating Ca2+ signaling. CMTM2 and CMTM6 are up-regulated in neutrophils of APS patients. Some CMTM family members influence the activation and accumulation of platelets. CMTM3 and CMTM7 are binding partners of B-cell linker protein (BLNK), thereby linking B cell receptor (BCR) and activating BLNK-mediated signal transduction in B cells. Moreover, CMTM3 and CMTM7 can act on DCs and B-1a cell development, respectively. CMTM may have potential effects on the development of APS by acting on immune cells and immune molecules. Thus, CMTM may act as a novel prognostic factor or immunomodulatory treatment option of APS.
Collapse
|
39
|
Understanding the Pathophysiology of Thrombotic APS through Animal Models. Int J Mol Sci 2021; 22:ijms22052588. [PMID: 33806694 PMCID: PMC7961365 DOI: 10.3390/ijms22052588] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a leading acquired cause of thrombotic events, with a notable tendency to promote thrombosis in vascular beds of all sizes, including both arterial and venous circuits. While pathogenic antiphospholipid antibodies circulate at relatively stable levels in blood, thrombosis tends to manifest as discrete and acute events, suggesting the requirement for a “second hit.” While this two-hit model is generally accepted, much remains to be learned about exactly how antiphospholipid antibodies predispose to thrombosis in vivo and exactly how this predisposition interacts with the second hit. To this end, investigators have turned to animal models. Numerous approaches for modeling APS in animals have been described to date, each with potential advantages and disadvantages. This review will attempt to describe the most common APS models employed so far while discussing some pros and cons of each. Mechanisms of thrombotic APS that have thus far been explored in animal models will also be briefly addressed.
Collapse
|
40
|
Gu SX, Tyagi T, Jain K, Gu VW, Lee SH, Hwa JM, Kwan JM, Krause DS, Lee AI, Halene S, Martin KA, Chun HJ, Hwa J. Thrombocytopathy and endotheliopathy: crucial contributors to COVID-19 thromboinflammation. Nat Rev Cardiol 2021; 18:194-209. [PMID: 33214651 PMCID: PMC7675396 DOI: 10.1038/s41569-020-00469-1] [Citation(s) in RCA: 251] [Impact Index Per Article: 83.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 02/06/2023]
Abstract
The core pathology of coronavirus disease 2019 (COVID-19) is infection of airway cells by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that results in excessive inflammation and respiratory disease, with cytokine storm and acute respiratory distress syndrome implicated in the most severe cases. Thrombotic complications are a major cause of morbidity and mortality in patients with COVID-19. Patients with pre-existing cardiovascular disease and/or traditional cardiovascular risk factors, including obesity, diabetes mellitus, hypertension and advanced age, are at the highest risk of death from COVID-19. In this Review, we summarize new lines of evidence that point to both platelet and endothelial dysfunction as essential components of COVID-19 pathology and describe the mechanisms that might account for the contribution of cardiovascular risk factors to the most severe outcomes in COVID-19. We highlight the distinct contributions of coagulopathy, thrombocytopathy and endotheliopathy to the pathogenesis of COVID-19 and discuss potential therapeutic strategies in the management of patients with COVD-19. Harnessing the expertise of the biomedical and clinical communities is imperative to expand the available therapeutics beyond anticoagulants and to target both thrombocytopathy and endotheliopathy. Only with such collaborative efforts can we better prepare for further waves and for future coronavirus-related pandemics.
Collapse
Affiliation(s)
- Sean X Gu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tarun Tyagi
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kanika Jain
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Vivian W Gu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Seung Hee Lee
- Division of Cardiovascular Diseases, Center for Biomedical Sciences, National Institute of Health, Cheongju, Chungbuk, Korea
| | - Jonathan M Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kwan
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Diane S Krause
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine and Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine and Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Kathleen A Martin
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Hyung J Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John Hwa
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
41
|
Moulinet T, Dufrost V, Clerc-Urmès I, Wahl D, Zuily S. Risk of thrombosis, pregnancy morbidity or death in antiphospholipid antibodies positive patients with or without thrombocytopenia. Eur J Intern Med 2021; 84:101-103. [PMID: 33082035 DOI: 10.1016/j.ejim.2020.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/30/2020] [Accepted: 10/14/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Autoimmune Disease, Nancy University Hospital, Vandœuvre-lès-Nancy, France; Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Virginie Dufrost
- Université de Lorraine, Vandœuvre-lès-Nancy, France; Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Vandœuvre-lès-Nancy, France
| | - Isabelle Clerc-Urmès
- Methodology, data management and statistics Unit, MPI department, Nancy University Hospital, Vandœuvre-lès-Nancy, France
| | - Denis Wahl
- Université de Lorraine, Vandœuvre-lès-Nancy, France; Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Vandœuvre-lès-Nancy, France; INSERM, UMR_S 1116, Vandœuvre-lès-Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, Vandœuvre-lès-Nancy, France; Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Vandœuvre-lès-Nancy, France; INSERM, UMR_S 1116, Vandœuvre-lès-Nancy, France.
| |
Collapse
|
42
|
Schell B, Desconclois C, Mariette X, Goujard C, Lenting PJ, Denis CV, Proulle V. Monoclonal gammopathy of clinical significance: in vivo demonstration of the anti-thrombotic effect of an acquired anti-thrombin antibody. Haematologica 2021; 106:316-319. [PMID: 32817284 PMCID: PMC7776332 DOI: 10.3324/haematol.2019.242370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Berenice Schell
- Service Hematologie Biologique, Hopital Bicetre, AP-HP, Le Kremlin-Bicetre
| | - Celine Desconclois
- Service Hematologie Biologique, Hopital Bicetre, AP-HP, Le Kremlin-Bicetre
| | - Xavier Mariette
- Service Rhumatologie, Hopital Bicetre, AP-HP, INSERM UMR_S 1184, Université Paris-Saclay
| | - Cecile Goujard
- Service Medecine Interne, Hopital Bicetre, AP-HP, Universite Paris-Saclay
| | | | | | - Valerie Proulle
- Service Hematologie Biologique, Hopital Bicetre, AP-HP, INSERM UMR_S 1176, Universite Paris-Saclay
| |
Collapse
|
43
|
Cheng C, Cheng GY, Denas G, Pengo V. Arterial thrombosis in antiphospholipid syndrome (APS): Clinical approach and treatment. A systematic review. Blood Rev 2020; 48:100788. [PMID: 33341301 DOI: 10.1016/j.blre.2020.100788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
Thrombotic Antiphospholipid Syndrome (APS) is a condition affecting young individuals in whom a thromboembolic event occurs in the presence of circulating antiphospholipid antibodies (aPL). An extensive body of literature has covered the most common clinical presentation of the syndrome, venous thromboembolism. Arterial thrombosis in APS, a lesser clinical expression, is less studied. This review will concentrate on the body of literature concerning pathogenesis, clinical presentation and management of arterial thrombosis in APS.
Collapse
Affiliation(s)
- Chunyan Cheng
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Gang-Yi Cheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
| |
Collapse
|
44
|
Janjetovic S, Beckmann L, Holstein K, Rolling C, Thiele B, Schafhausen P, Schön G, Bokemeyer C, Langer F, Voigtlaender M. Prevalence of definite antiphospholipid syndrome in carriers of the JAK2 V617F mutation. Thromb Res 2020; 198:55-61. [PMID: 33290883 DOI: 10.1016/j.thromres.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Patients with Philadelphia-negative myeloproliferative neoplasms (MPNs), particularly those carrying the JAK2V617F mutation, are at increased risk of thrombosis. While an association of MPNs with autoimmune disorders has been established, the prevalence of inherited or acquired thrombophilias in JAK2V617F-positive patients remains obscure. We therefore investigated the coincidence of the JAK2V617F mutation with additional thrombogenic risk factors. METHODS In a retrospective study, we analyzed all patients referred for thrombophilia work-up between 01/2011 and 08/2019, in whom additional JAK2V617F mutation analysis was performed because of thromboembolic events that were recurrent, atypically located and/or associated with abnormal blood counts. RESULTS Of 472 tested patients, 49 (10.4%) were JAK2V617F-positive. While the frequency of inherited thrombophilias (factor V Leiden and prothrombin G20210A mutation, deficiency of antithrombin, protein C, protein S) was not different between the two groups, the prevalence of definite antiphospholipid syndrome (APS), mostly associated with a moderate- or high-risk antibody profile, was significantly higher in patients with (22.4%) than in those without (8.4%) JAK2V617F mutation (p < 0.01). All evaluable JAK2V617F-positive patients with APS were subsequently diagnosed with MPN. In patients with JAK2V617F mutation, presence of concomitant APS was associated with a significantly younger age (49 ± 14 vs. 60 ± 15 years) at the time of thrombophilia work-up (p < 0.05). CONCLUSION We found a significant association between JAK2V617F-positive MPN and definite APS. The presence of concomitant APS in patients carrying the JAK2V617F mutation may lead to earlier manifestation of thromboembolic events and may warrant more aggressive antithrombotic treatment strategies to prevent recurrence.
Collapse
Affiliation(s)
- Snjezana Janjetovic
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Lennart Beckmann
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Katharina Holstein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christina Rolling
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Benjamin Thiele
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Philippe Schafhausen
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Florian Langer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Minna Voigtlaender
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| |
Collapse
|
45
|
GPR56/ADGRG1 is a platelet collagen-responsive GPCR and hemostatic sensor of shear force. Proc Natl Acad Sci U S A 2020; 117:28275-28286. [PMID: 33097663 PMCID: PMC7668045 DOI: 10.1073/pnas.2008921117] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
We identified the known collagen receptor GPR56/ADGRG1 on platelets. GPR56 is an adhesion G protein-coupled receptor that becomes activated following forced dissociation of its N-terminal fragment and C-terminal fragment or seven-transmembrane spanning domain (7TM). Fragment dissociation reveals the cryptic stalk of the 7TM, which acts as a tethered peptide agonist, and for GPR56, this activates platelet G13 signaling. GPR56 pharmacological probes activated platelets to undergo shape change and aggregation, which are critical for the formation of hemostatic plugs. Gpr56−/− mice exhibit prolonged bleeding, defective platelet plug formation in vessel injury assays, and delayed thrombotic vessel occlusion. Shear-force dependency of platelet adhesion to immobilized collagen was found to be GPR56 dependent. Circulating platelets roll along exposed collagen at vessel injury sites and respond with filipodia protrusion, shape change, and surface area expansion to facilitate platelet adhesion and plug formation. Various glycoproteins were considered to be both collagen responders and mediators of platelet adhesion, yet the signaling kinetics emanating from these receptors do not fully account for the rapid platelet cytoskeletal changes that occur in blood flow. We found the free N-terminal fragment of the adhesion G protein-coupled receptor (GPCR) GPR56 in human plasma and report that GPR56 is the platelet receptor that transduces signals from collagen and blood flow-induced shear force to activate G protein 13 signaling for platelet shape change. Gpr56−/− mice have prolonged bleeding, defective platelet plug formation, and delayed thrombotic occlusion. Human and mouse blood perfusion studies demonstrated GPR56 and shear-force dependence of platelet adhesion to immobilized collagen. Our work places GPR56 as an initial collagen responder and shear-force transducer that is essential for platelet shape change during hemostasis.
Collapse
|
46
|
Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
Collapse
|
47
|
Pontara E, Cheng C, Cattini MG, Bison E, Pelloso M, Denas G, Pengo V. An in vitro model to mimic the thrombotic occlusion of small vessels in catastrophic antiphospholipid syndrome (CAPS). Lupus 2019; 28:1663-1668. [PMID: 31701800 DOI: 10.1177/0961203319886915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Platelet activation and decrease in platelet count characterize the development of the most feared form of antiphospholipid syndrome (APS), i.e. catastrophic APS (CAPS). We aimed to assess if immuno-affinity purified anti-β2-glycoprotein I (aβ2GPI) antibodies enhance platelet activation inducing a significant flow obstruction in a platelet function analyzer (PFA). Affinity purified aβ2GPI antibodies were obtained from 13 triple positive patients with a strong lupus anticoagulant (LA) and high titers of IgG anticardiolipin antibodies (aCL) and IgG aβ2GPI. Platelet activation stimulated by adenosine diphosphate (ADP) in the presence or absence of aβ2GPI was measured by the expression of P-selectin on platelet surface using flow cytometry. P-selectin expression remained close to baseline when normal whole blood was incubated with aβ2GPI alone. When stimulated using aβ2GPI combined with ADP, P-selectin expression (28.42 ± 5.15% vs. 20.98 ± 3.94%, p = 0.0076) was significantly higher than ADP alone. Closure time of normal whole blood passed through the PFA was significantly shorter using affinity purified aβ2GPI than control IgG both in Col/ADP (160.1 ± 62.1 s vs. 218.6 ± 43.8 s; p = 0.021) and Col/EPI cartridges (149.5 ± 26.7 s vs. 186.9 ± 45.5 s; p = 0.030). Thus, platelet activation is enhanced by aβ2GPI antibodies with a consequent premature closure in a PFA, possibly resembling that in microcirculation in patients with CAPS.
Collapse
Affiliation(s)
- E Pontara
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - C Cheng
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - M G Cattini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - E Bison
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - M Pelloso
- Department of Medicine, Padova University Hospital, Padova, Italy
| | - G Denas
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - V Pengo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| |
Collapse
|
48
|
Crawley JTB, Zalli A, Monkman JH, Petri A, Lane DA, Ahnstrӧm J, Salles‐Crawley II. Defective fibrin deposition and thrombus stability in Bambi -/- mice are mediated by elevated anticoagulant function. J Thromb Haemost 2019; 17:1935-1949. [PMID: 31351019 PMCID: PMC6899896 DOI: 10.1111/jth.14593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/22/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Bone morphogenetic and activin membrane-bound inhibitor (BAMBI) is a transmembrane protein related to the type I transforming growth factor- β (TGF-β) receptor family that is present on both platelets and endothelial cells (ECs). Bambi-deficient mice exhibit reduced hemostatic function and thrombus stability characterized by an increased embolization. OBJECTIVE We aimed to delineate how BAMBI influences endothelial function and thrombus stability. METHODS Bambi-deficient mice were subjected to the laser-induced thrombosis model where platelet and fibrin accumulation was evaluated. Expression of thrombomodulin and tissue factor pathway inhibitor (TFPI) was also assessed in these mice. RESULTS Thrombus instability in Bambi-/- mice was associated with a profound defect in fibrin deposition. Injection of hirudin into Bambi+/+ mice prior to thrombus formation recapitulated the Bambi-/- thrombus instability phenotype. In contrast, hirudin had no additional effect upon thrombus formation in Bambi-/- mice. Deletion of Bambi in ECs resulted in mice with defective thrombus stability caused by decreased fibrin accumulation. Increased levels of the anticoagulant proteins TFPI and thrombomodulin were detected in Bambi-/- mouse lung homogenates. Endothelial cells isolated from Bambi-/- mouse lungs exhibited enhanced ability to activate protein C due to elevated thrombomodulin levels. Blocking thrombomodulin and TFPI in vivo fully restored fibrin accumulation and thrombus stability in Bambi-/- mice. CONCLUSIONS We demonstrate that endothelial BAMBI influences fibrin generation and thrombus stability by modulating thrombomodulin and TFPI anticoagulant function of the endothelium; we also highlight the importance of these anticoagulant proteins in the laser-induced thrombosis model.
Collapse
Affiliation(s)
- James T. B. Crawley
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | - Argita Zalli
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | - James H. Monkman
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | - Anastasis Petri
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | - David A. Lane
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | - Josefin Ahnstrӧm
- Centre for HaematologyHammersmith Hospital CampusImperial College LondonLondonUK
| | | |
Collapse
|
49
|
Ząbczyk M, Celińska-Löwenhoff M, Plens K, Iwaniec T, Musiał J, Undas A. Antiphosphatidylserine/prothrombin complex antibodies as a determinant of prothrombotic plasma fibrin clot properties in patients with antiphospholipid syndrome. J Thromb Haemost 2019; 17:1746-1755. [PMID: 31220407 DOI: 10.1111/jth.14551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/30/2019] [Accepted: 06/14/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiphosphatidylserine/prothrombin complex (aPS/PT) antibodies are recognized as a marker for antiphospholipid syndrome (APS). Dense and poorly lysable fibrin clots occur in thrombotic APS. Compact clots predict thromboembolism, but determinants of the unfavorable clot phenotype remain unknown in APS. We hypothesized that elevated aPS/PT antibodies determine unfavorable clot features. METHODS In a cohort study involving 124 consecutive patients with thrombotic APS, we measured at baseline plasma fibrin clot permeability (Ks ), efficiency of fibrinolysis (clot lysis time, CLT), and turbidity (off anticoagulation) along with immunoglobulin (Ig)G/IgM aPS/PT. During follow-up, symptomatic thromboembolic events were recorded. RESULTS Elevated IgG and IgM aPS/PT antibodies >30 international enzyme units (UI) were detected in 54.8% and 42.7% of APS patients, including 76.2% and 54% of lupus anticoagulant- (LA, n = 63) positive patients, respectively. Elevated IgG and IgM aPS/PT antibodies predicted low Ks (lower quartile, <6 × 10-9 cm2 ; odds ratio [OR] = 5.93, 95% confidence interval [CI] 2.09-16.82 and OR = 11.79, 95% CI 4.10-33.92) and prolonged CLT (top quartile, ≥116 min; OR = 4.85, 95% CI 2.42-25.07 and OR = 6.04, 95% CI 2.42-15.07). No such associations were observed for anticardiolipin or β2-glycoprotein I antibodies or LA presence. During follow-up (median 72.5, range 66-83 months), thromboembolic events observed in 32 (26.7%, 4.6%/year) patients were independently predicted by IgG aPS/PT antibodies >30 UI (hazard ratio [HR] = 3.04, 95% CI 1.20-8.88) and low Ks (HR = 3.00, 95% CI 1.41-6.50). CONCLUSIONS We identified aPS/PT antibodies as a determinant of denser and poorly lysable plasma fibrin clot formation in APS patients. The association of elevated aPS/PT antibodies with thromboembolism in APS could be at least in part mediated by prothrombotic clot properties.
Collapse
Affiliation(s)
- Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Krakow, Poland
| | | | | | - Teresa Iwaniec
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Musiał
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Krakow, Poland
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
| |
Collapse
|
50
|
Zhang Y, Jin S. Mitigating placental injuries through up-regulating DAF in experimental APS mice: new mechanism of progesterone. Clin Exp Immunol 2019; 197:376-386. [PMID: 31091357 PMCID: PMC6693963 DOI: 10.1111/cei.13313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 01/06/2023] Open
Abstract
Anti-phospholipid syndrome (APS) is characterized by recurrent pathological pregnancy, arterial or venous thrombosis in the presence of anti-phospholipid antibody (aPL). Complement activation is recognized as an intermediate link leading to placental thrombosis and placental inflammation in APS model mice. Decay accelerating factor (DAF, CD55), MAC-inhibitory protein (MAC-IP, CD59) and membrane co-factor protein (MCP, CD46) are important complement inhibitory proteins (CIPs) highly expressed in normal placenta to curb excessive complement activation and its mediated injuries. Anti-β2 glycoprotein I (anti-β2GPI) antibody is an important aPL. We found that placental DAF and CD46 decreased in β2GPI passively immunized APS model mice, accompanied by C3 deposition, neutrophil infiltration and increased proinflammatory cytokine levels detected in its placenta. Progesterone supplement can up-regulate DAF but not CD46 expression, curb C3 activation and decrease proinflammatory cytokines levels to reduce fetal loss frequency. Progesterone receptor antagonist (mifepristone) or knock-down DAF with specific siRNA, above the protective effects of progesterone, were significantly weakened. Another sex hormone, oestrogen, has no significant effect on placental DAF and C3 contents and fetal loss frequency in the APS mice model. This may be an important mechanism by which progesterone induces maternal-fetal immune tolerance. At the same time, it may provide evidence for the use of progesterone in APS abortion patients.
Collapse
Affiliation(s)
- Y. Zhang
- Department of Traditional Chinese MedicineMaternal and Child Health Hospital of Hubei ProvinceHubeiChina
| | - S. Jin
- Department of Traditional Chinese MedicineMaternal and Child Health Hospital of Hubei ProvinceHubeiChina
- First Clinical Medical CollegeHubei University of Chinese MedicineHubeiChina
| |
Collapse
|