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Zuo Y, Navaz S, Tsodikov A, Kmetova K, Kluge L, Ambati A, Hoy CK, Yalavarthi S, de Andrade D, Tektonidou MG, Sciascia S, Pengo V, Ruiz-Irastorza G, Michael Belmont H, Gerosa M, Fortin PR, de Jesus GR, Ware Branch D, Andreoli L, Rodriguez-Almaraz E, Petri M, Cervera R, Willis R, Karp DR, Li QZ, Cohen H, Bertolaccini ML, Erkan. D, Knight JS. Anti-Neutrophil Extracellular Trap Antibodies in Antiphospholipid Antibody-Positive Patients: Results From the Antiphospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking Clinical Database and Repository. Arthritis Rheumatol 2023; 75:1407-1414. [PMID: 36862141 PMCID: PMC10758259 DOI: 10.1002/art.42489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/18/2023] [Accepted: 02/28/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVE This study aimed to elucidate the presence, antigen specificities, and potential clinical associations of anti-neutrophil extracellular trap (anti-NET) antibodies in a multinational cohort of antiphospholipid (aPL) antibody-positive patients who did not have lupus. METHODS Anti-NET IgG/IgM levels were measured in serum samples from 389 aPL-positive patients; 308 patients met the classification criteria for antiphospholipid syndrome. Multivariate logistic regression with best variable model selection was used to determine clinical associations. For a subset of the patients (n = 214), we profiled autoantibodies using an autoantigen microarray platform. RESULTS We found elevated levels of anti-NET IgG and/or IgM in 45% of the aPL-positive patients. High anti-NET antibody levels are associated with more circulating myeloperoxidase (MPO)-DNA complexes, which are a biomarker of NETs. When considering clinical manifestations, positive anti-NET IgG was associated with lesions affecting the white matter of the brain, even after adjusting for demographic variables and aPL profiles. Anti-NET IgM tracked with complement consumption after controlling for aPL profiles; furthermore, patient serum samples containing high levels of anti-NET IgM efficiently deposited complement C3d on NETs. As determined by autoantigen microarray, positive testing for anti-NET IgG was significantly associated with several autoantibodies, including those recognizing citrullinated histones, heparan sulfate proteoglycan, laminin, MPO-DNA complexes, and nucleosomes. Anti-NET IgM positivity was associated with autoantibodies targeting single-stranded DNA, double-stranded DNA, and proliferating cell nuclear antigen. CONCLUSION These data reveal high levels of anti-NET antibodies in 45% of aPL-positive patients, where they potentially activate the complement cascade. While anti-NET IgM may especially recognize DNA in NETs, anti-NET IgG species appear to be more likely to target NET-associated protein antigens.
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Affiliation(s)
- Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sherwin Navaz
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alex Tsodikov
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Katarina Kmetova
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Lyndsay Kluge
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amala Ambati
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Claire K. Hoy
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | | | | | | | | | | | | | - D. Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | | | | | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ricard Cervera
- Hospital Clinic de Barcelona, Barcelona, Catalonia, Spain
| | - Rohan Willis
- University of Texas Medical Branch, Galveston, TX, USA
| | - David R. Karp
- Division of Rheumatic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Quan-Zhen Li
- Department of Immunology, Immune Phenotyping Core Facility, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - Doruk Erkan.
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Woodruff MC, Bonham KS, Anam FA, Walker TA, Faliti CE, Ishii Y, Kaminski CY, Ruunstrom MC, Cooper KR, Truong AD, Dixit AN, Han JE, Ramonell RP, Haddad NS, Rudolph ME, Yalavarthi S, Betin V, Natoli T, Navaz S, Jenks SA, Zuo Y, Knight JS, Khosroshahi A, Lee FEH, Sanz I. Chronic inflammation, neutrophil activity, and autoreactivity splits long COVID. Nat Commun 2023; 14:4201. [PMID: 37452024 PMCID: PMC10349085 DOI: 10.1038/s41467-023-40012-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023] Open
Abstract
While immunologic correlates of COVID-19 have been widely reported, their associations with post-acute sequelae of COVID-19 (PASC) remain less clear. Due to the wide array of PASC presentations, understanding if specific disease features associate with discrete immune processes and therapeutic opportunities is important. Here we profile patients in the recovery phase of COVID-19 via proteomics screening and machine learning to find signatures of ongoing antiviral B cell development, immune-mediated fibrosis, and markers of cell death in PASC patients but not in controls with uncomplicated recovery. Plasma and immune cell profiling further allow the stratification of PASC into inflammatory and non-inflammatory types. Inflammatory PASC, identifiable through a refined set of 12 blood markers, displays evidence of ongoing neutrophil activity, B cell memory alterations, and building autoreactivity more than a year post COVID-19. Our work thus helps refine PASC categorization to aid in both therapeutic targeting and epidemiological investigation of PASC.
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Affiliation(s)
- Matthew C Woodruff
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA.
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA.
| | - Kevin S Bonham
- Department of Biological Sciences, Wellesley College, Wellesley, MA, USA
| | - Fabliha A Anam
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | - Tiffany A Walker
- Department of Medicine, Division of General Internal Medicine, Emory University, Atlanta, GA, USA
| | - Caterina E Faliti
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | - Yusho Ishii
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | | | - Martin C Ruunstrom
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Kelly Rose Cooper
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | - Alexander D Truong
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Adviteeya N Dixit
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Jenny E Han
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Richard P Ramonell
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | - Sherwin Navaz
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Scott A Jenks
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | - Yu Zuo
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Arezou Khosroshahi
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA
| | - F Eun-Hyung Lee
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA.
| | - Ignacio Sanz
- Department of Medicine, Division of Rheumatology, Lowance Center for Human Immunology, Emory University, Atlanta, GA, USA.
- Emory Autoimmunity Center of Excellence, Emory University, Atlanta, GA, USA.
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3
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Zuo Y, Navaz S, Liang W, Li C, Ayers CR, Rysenga CE, Harbaugh A, Norman GL, Solow EB, Bermas B, Akinmolayemi O, Rohatgi A, Karp DR, Knight JS, de Lemos JA. Prevalence of Antiphospholipid Antibodies and Association With Incident Cardiovascular Events. JAMA Netw Open 2023; 6:e236530. [PMID: 37014642 PMCID: PMC10074226 DOI: 10.1001/jamanetworkopen.2023.6530] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Importance The prevalence of antiphospholipid antibodies (aPL) and their association with future atherosclerotic cardiovascular disease (ASCVD) risk has yet to be thoroughly investigated. Objective To determine the association between measurements of aPL at a single time point and ASCVD risk in a diverse population. Design, Setting, and Participants This cohort study measured 8 aPL (anticardiolipin [aCL] IgG/IgM/IgA, anti-beta-2 glycoprotein I [aβ2GPI] IgG/IgM/IgA, and antiphosphatidylserine/prothrombin [aPS/PT] IgG/IgM) by solid-phase assays in plasma from participants of the Dallas Heart Study (DHS) phase 2, a multiethnic, population-based cohort study. Blood samples were collected between 2007 and 2009. The median follow-up was 8 years. Statistical analysis was performed from April 2022 to January 2023. Main Outcomes and Measures Associations of aPL with future ASCVD events (defined as first nonfatal myocardial infarction, first nonfatal stroke, coronary revascularization, or death from cardiovascular cause) were assessed by Cox proportional hazards models, adjusting for known risk factors, medications, and multiple comparisons. Results Among the 2427 participants (mean [SD] age, 50.6 [10.3] years; 1399 [57.6%] female; 1244 [51.3%] Black, 339 [14.0%] Hispanic, and 796 [32.8%] White), the prevalence of any positive aPL tested at a single time point was 14.5% (353 of 2427), with approximately one-third of those detected at a moderate or high titer; aCL IgM had the highest prevalence (156 individuals [6.4%]), followed by aPS/PT IgM (88 [3.4%]), aβ2GPI IgM (63 [2.6%]), and aβ2GPI IgA (62 [2.5%]). The IgA of aCL (adjusted hazard ratio [HR], 4.92; 95% CI, 1.52-15.98) and aβ2GPI (HR, 2.91; 95% CI, 1.32-6.41) were independently associated with future ASCVD events. The risk further increased when applying a positivity threshold of at least 40 units (aCL IgA: HR, 9.01 [95% CI, 2.73-29.72]; aβ2GPI IgA: HR, 4.09 [95% CI, 1.45-11.54]). Levels of aβ2GPI IgA negatively correlated with cholesterol efflux capacity (r = -0.055; P = .009) and positively correlated with circulating oxidized LDL (r = 0.055; P = .007). aβ2GPI IgA-positive plasma was associated with an activated endothelial cell phenotype as evidenced by increased surface expression of surface E-selectin, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1. Conclusions and Relevance In this population-based cohort study, aPL detectable by solid-phase assays were present in a substantial proportion of adults; positive aCL IgA and aβ2GPI IgA at a single time point were independently associated with future ASCVD events. Longitudinal studies with serial aPL measurements are needed to further explore these findings.
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Affiliation(s)
- Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sherwin Navaz
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Wenying Liang
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Colby R Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Christine E Rysenga
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Alyssa Harbaugh
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Gary L Norman
- Headquarters & Technology Center Autoimmunity, Werfen, San Diego, California
| | - E Blair Solow
- Division of Rheumatic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Bonnie Bermas
- Division of Rheumatic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Oludamilola Akinmolayemi
- Department of Internal Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York
| | - Anand Rohatgi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - David R Karp
- Division of Rheumatic Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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4
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Shi H, Zuo Y, Navaz S, Harbaugh A, Hoy CK, Gandhi AA, Sule G, Yalavarthi S, Gockman K, Madison JA, Wang J, Zuo M, Shi Y, Maile MD, Knight JS, Kanthi Y. Endothelial cell-activating antibodies in COVID-19. Arthritis Rheumatol 2022; 74:1132-1138. [PMID: 35174669 PMCID: PMC9082472 DOI: 10.1002/art.42094] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/01/2022] [Accepted: 02/13/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE While endothelial dysfunction has been implicated in the widespread thrombo-inflammatory complications of coronavirus disease-19 (COVID-19), the upstream mediators of endotheliopathy remain for the most part cryptic. Our aim was to identify circulating factors contributing to endothelial cell activation and dysfunction in COVID-19. METHODS Human endothelial cells were cultured in the presence of serum or plasma from 244 patients hospitalized with COVID-19 and plasma from 100 patients with non-COVID sepsis. Cell adhesion molecules (E-selectin, VCAM-1, and ICAM-1) were quantified by in-cell ELISA. RESULTS Serum and plasma from patients with COVID-19 increased surface expression of cell adhesion molecules. Furthermore, levels of soluble ICAM-1 and E-selectin were elevated in patient serum and tracked with disease severity. The presence of circulating antiphospholipid antibodies was a strong marker of the ability of COVID-19 serum to activate endothelium. Depletion of total IgG from antiphospholipid antibody-positive serum markedly restrained upregulation of cell adhesion molecules. Conversely, supplementation of control serum with patient IgG was sufficient to trigger endothelial activation. CONCLUSION These data are the first to suggest that some patients with COVID-19 have potentially diverse antibodies that drive endotheliopathy, adding important context regarding thrombo-inflammatory effects of autoantibodies in severe COVID-19.
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Affiliation(s)
- Hui Shi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sherwin Navaz
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alyssa Harbaugh
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Claire K Hoy
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alex A Gandhi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Gautam Sule
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelsey Gockman
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jacqueline A Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jintao Wang
- Division of Intramural Research National Heart, Lung and Blood Institute Bethesda, Maryland, USA
| | - Melanie Zuo
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yue Shi
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung and Blood Institute Bethesda, Maryland, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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5
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Shi H, Zuo Y, Navaz S, Harbaugh A, Hoy C, Gandhi AA, Sule G, Yalavarthi S, Gockman K, Madison JA, Wang J, Zuo M, Shi Y, Maile MD, Knight JS, Kanthi Y. Endothelial cell-activating antibodies in COVID-19. medRxiv 2021. [PMID: 33501469 DOI: 10.1101/2021.01.18.21250041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives Patients with coronavirus disease 19 ( COVID-19 ) are at high risk for fibrin-based occlusion of vascular beds of all sizes. Considering endothelial cell activation has regularly been described as part of the COVID-19 thrombo-inflammatory storm, we aimed to find upstream mediators of this activation. Methods Cultured endothelial cells were exposed to sera or plasma from 244 patients hospitalized with COVID-19 or plasma from 100 patients in the intensive care unit with sepsis. Cell adhesion molecules E-selectin, VCAM-1, and ICAM-1 were detected by in-cell ELISA. Soluble E-selectin was measured in serum. Results As compared with healthy controls, sera and plasma from patients with COVID-19, and to a lesser extent plasma from patients with sepsis, increased expression of E-selectin, VCAM-1, and ICAM-1 on cultured endothelial cells. We found modest correlations between serum neutrophil extracellular trap (NET) remnants and upregulation of cell adhesion molecules on endothelial cells. A stronger marker of the ability of COVID-19 serum to activate endothelial cells was the presence of circulating antiphospholipid antibodies, specifically anticardiolipin IgG and IgM and anti-phosphatidlyserine/prothrombin (anti-PS/PT) IgG and IgM. Depletion of total IgG from anticardiolipin-positive and anti-PS/PT-positive samples markedly restrained upregulation of E-selectin, VCAM-1, and ICAM-1. At the same time, supplementation of control serum with patient IgG was sufficient to trigger endothelial cell activation. Conclusions These data are the first to suggest that some patients with COVID-19 have potentially diverse antibodies that drive endothelial cell activation in COVID-19. The data also add important context regarding thrombo-inflammatory effects of autoantibodies in severe COVID-19. KEY MESSAGES What is already known about this subject?: Patients with COVID-19 are at high risk for fibrin-based occlusion of vascular beds of all sizes.Endothelial cell activation has regularly been described as part of the COVID-19 thrombo-inflammatory storm.What does this study add?: The presence of circulating antiphospholipid antibodies may be a predictor of the ability of a patient’s total antibody profile to activate endothelial cells.Purified COVID-19 IgG with high levels of anticardiolipin and anti-PS/PT activity trigger a pro-adhesive phenotype in endothelial cells.How might this impact on clinical practice or future developments?: Patients might be screened for antiphospholipid antibodies to evaluate their risk of having an antibody profile likely to activate endothelial cells.Patients with high antiphospholipid antibody titers might benefit from treatments used in traditional cases of severe APS such as therapeutic anticoagulation, corticosteroids, and plasmapheresis.
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Zuo Y, Yalavarthi S, Navaz S, Hoy C, Harbaugh A, Gockman K, Zuo M, Madison JA, Shi H, Kanthi Y, Knight JS. Autoantibodies stabilize neutrophil extracellular traps in COVID-19. medRxiv 2021:2021.03.31.21254692. [PMID: 33851189 PMCID: PMC8043486 DOI: 10.1101/2021.03.31.21254692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The release of neutrophil extracellular traps ( NETs ) by hyperactive neutrophils is recognized to play an important role in the thromboinflammatory milieu inherent to severe presentations of COVID-19. At the same time, a variety of functional autoantibodies have been observed in individuals with severe COVID-19 where they likely contribute to immunopathology. Here, we aimed to determine the extent to which autoantibodies might target NETs in COVID-19 and, if detected, to elucidate their potential functions and clinical associations. We measured anti-NET antibodies in 328 individuals hospitalized with COVID-19 alongside 48 healthy controls. We found high anti-NET activity in the IgG and IgM fractions of 27% and 60% of patients, respectively. There was a strong correlation between anti-NET IgG and anti-NET IgM (r=0.4, p<0.0001). Both anti-NET IgG and IgM tracked with high levels of circulating NETs, impaired oxygenation efficiency, and high circulating D-dimer. Furthermore, patients who required mechanical ventilation had a greater burden of anti-NET antibodies than did those not requiring oxygen supplementation. Levels of anti-NET IgG (and to a lesser extent anti-NET IgM) demonstrated an inverse correlation with the efficiency of NET degradation by COVID sera. Furthermore, purified IgG from COVID sera with high levels of anti-NET antibodies impaired the ability of healthy control serum to degrade NETs. In summary, many individuals hospitalized with COVID-19 have anti-NET antibodies, which likely impair NET clearance and may potentiate SARS-CoV-2-mediated thromboinflammation.
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