antiphospholipid syndrome (aps ) michigan state university houria suzy hassouna no relevant...

Antiphospholipid Syndrome (APS )

Michigan State University Houria Suzy Hassouna

No relevant conflicts of interest to declare

We are born with what some psychologists call an “explanatory drive.” You give a baby a strange object or something that doesn’t make sense and she will become instantly absorbed; using all her abilities — taste, smell, force — to figure out how it fits in with the world.

The Question-Driven LifeBy DAVID BROOKSRift Valley, Kenya

Hassouna June 9, 2012

http://topics.nytimes.com/top/opinion/editorialsandoped/oped/columnists/davidbrooks/index.html?inline=nyt-per

Hassouna June 2012 3

Diagnosis and management of bleeding and thrombotic diseases

Professors with “ Explanatory Drive”

Shinichiro Uchiyama (not in photoAkitada Ichinose ( not in photo)

John Penner

Tadanori KawadaJin Shiomura

Antiphospholipid Syndrome ( APS)

Diagnostic Challenge

• Primary APS is an acquired thrombophilia (primary auto-immune disorder, not associated with another autoimmune disorder)

• Secondary APS Is the expression of APS in conjunction with other autoimmune disorders

Treatment Options

• Many specialties of involved physicians includes: hematology, rheumatology, obstetrics, neurology, cardiology and nephrology among others.

• Do different backgrounds influence the choice of treatment?

Hassouna June 9, 2012 4

Antiphospholipid Syndrome ( APS)

1963 Edward John Walter Bowie, MD Mayo Medical School identified APS as an acquired thrombophilia

1984 Graham Robert Vivian Hughes MD FRCP. St Thomas Hospital UK identified APS as a generalized autoimmune disorder

hassouna

Evolving history of APS

From prolonged clotting times that do not correct in mixing of SLE patient plasma

To the thromboembolic , venous and arterial events, obstetric complications and phospholipid antibodies that presently define APS


1952-1982 Several investigators reported prolonged clotting times that do not correct in mixing of SLE patient plasma with normal plasma. They named the substance

Circulating Anticoagulant, Acquired Inhibitor, Lupus Anticoagulant

Conley CL Harman RC. A hemorrhagic disorder caused by circulating anticoagulants in patients with disseminated lupus erythymatosus. J Clin Invest

1952; 31: 621-622Lechner K Acquired inhibitors in auto and isoimmune diseases.

Hemostasis 1974; 3:65-69Feinstein DI, Rappaport SI. Acquired inhibitors of blood coagulation In Sapet TN, Eds; Progress in Hemostasis and Thrombosis, 1rst ed.

Grune and Stratton New York, NY: 1982;6:263-285.


1952-1963 APS is considered a hemorrhagic disease 1963 is linked to thrombosis. 1983 LA

is identified

1952-1963 Circulating anticoagulants in SLE are named lupus anticoagulants ( LA) because they prolong the clotting times in phospholipid dependent assays. LA believed to cause clinical hemorrhagic disease

1963 LA are reported by Bowie et al to be

associated with thrombosis in SLE patients. 1983 LA are identified by Harris et al to be

antibodies that react with cardiolipin Lupus anticoagulants react with purified cardiolipin and they are identified as anticardiolipin antibodies by RIA


In 1963, Dr Bowie reported several cases of thrombosis in SLE despite circulating

anticoagulants. This was the first report of an acquired thrombophilia.

• Thrombophilia is an inherited or acquired clinical phenotype that manifests in selected individuals as a greater risk to develop thrombosis in response to an ENDOGENOUS stimulus than the general population.

• APS is an acquired thrombophilia, • ENDOGENOUS stimulus is IMMUNE AUTO-ANTIBODIES.

• Bowie EJW, Thompson JH,, Pascuzzi CA, Owen CA. Thrombosis in systemic lupus erythematosus despite circulating anticoagulants. J Lab Clin Med 1963; 62: 416-430

•


Hassouna September 7, 2011 10


Gala dinner Penner Blood Coagulation Conference held in honor of Walter Bowie.

Barbara Alving, NHLBI Walter and Trudy Bowie, Dr and Mrs. David Ginsburg, Howard Hughes Institute U of M John Penner .

11

In 1984, a group of rheumatologists led by Graham Hughes found that in their sizeable

collection of SLE patients the Lupus anticoagulant occurred with some frequency and was associated with thrombosis and thrombocytopenia and this

raised the possibility that patients with the lupus anticoagulant and anti-cardiolipin antibodies

might be a part of a larger body of patients with systemic auto-immune diseases


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Criteria that define APS

• Clinical symptoms obstetric complications, arterial and venous thrombosis. Patient is at high risk if one of the clinical symptoms is not confirmed.

• APS is confirmed by a specific biological

marker Lupus anticoagulant• Differential diagnosis Primary or secondary APS• Treatment targets the cause of the disease .


Fig 2 Clinical manifestations of antiphospholipid syndrome.

Cohen D et al. BMJ 2010;340:bmj.c2541

©2010 by British Medical Journal Publishing GroupHassouna June 9, 2012

In 1963 Walter Bowie reported several cases of thrombosis in SLE despite ‘Lupus Anticoagulants”

( circulating anticoagulants)

Lupus anticoagulant generates a prolonged clotting time in patient plasma that does not correct when mixed in equal volume with pooled normal plasma.

The identity of the lupus anticoagulant remained a mystery until 1983 ( 20 years)


Two mechanisms are identified in the induction of autoimmune Antiphospholipid

antibodies (a PL).

• Apoptotic phospholipid beta 2 glycoprotein-1 complexes.

• Phospholipids released from injured cells bound to beta 2 glycoprotein 1

• Infection related antiphospholipid antibodies.

• From experiments in mice, antiphospholipid antibodies are produced by binding of beta2-glycoprotein 1 to phospholipid viral or bacterial proteins by molecular mimicry

June 9, 2012 17

In 1983 Lupus anticoagulant was identified by the anticardiolipin test to be autoimmune

antiphospholipid antibodies

• Introduction of the anticardiolipin test identified the lupus anticoagulant as auto-antibodies directed at cardiolipin, a phospholipid in inner mitochondrial membranes

• Harris EN, Gharavi AE, Boey ML . Anticardiolipin antibodies: detection by radioimmunoassay and association with thrombosis in systemic lupus erythematosus. Lancet 1983; 2: 1211-1214


Cardiolipin is a phospholipid on the inner membrane of mitochondria first identified in bovine heart. Anticardiolipin antibodies ( lupus anticoagulant) represent an autoimmune

process


Autoimmune anti-phospholipid antibodies are generated by apoptotic phospholipid protein complexes in mitochondria and other cellular

components

• Increased apoptosis as observed in blood of SLE patients, followed by enhanced phosphatidyl serine exposure provides molecular signal to macrophages and other antigen presenting cells leading to autoimmune antiphospholipid antibodies


Antiphospholipid antibodies The most significant target antigen is the

Beta 2 glycoprotein-1

In 1990 Monica Galli and her group in Bergamo, Italy reported that the true antigenic targets of antiphospholipid antibodies are not the phospholipids but a plasma protein beta 2 glycoprotein-1 bound to an anionic surface.

Galli M,Comfurius P, Massen C et al. Anticardiolipin antibodies (ACA) directed not to cardiolipin but to a plasma protein co-factor. Lancet 1990;334: 1544-1547


Beta-2 glycoprotein 1, also known as apolipoprotein H is an anticoagulant plasma protein belonging to the complement control protein family, and it is present in plasma at a concentration of approximately 150-300 micrograms per milliliter It is the major brain anticoagulant


Beta 2 glycoprotein 1 prevents clotting factor assembly on phospholipid membranes and clotting activation

• Beta-2 glycoprotein 1 anticoagulant action is by interaction with anionic phospholipids via a lysine rich region in the extra 20 amino acid C-terminal loop of the fifth domain that prevents thrombin amplification by the prothrombinase activity


Beta-2 glycoprotein 1 prevents ADP induced platelet aggregation via interaction with

Apo ER 2 platelet receptor ( anticoagulant action)

auto antibodyagainst beta2-glycoprotein 1prevents dimerization and thisinteraction withApo ER 2 enhances platelet procoagulant activity


Antiphospholipid Syndrome has 3 components:

Lupus anticoagulant is a term applied to a prolonged clotting time in a phospholipid dependent clotting test

Antiphospholipid antibodies is a general term applied to antibodies generated by an autoimmune or an infectious process

An acquired thrombophilia ( arterial and venous thrombosis, recurrent pregnancy loss, thrombocytopenia) caused by autoimmune or infectious processes that generate antibodies harmful to endothelium and platelets .


Antibodies to bacteria or viruses recognize β2GPI phospholipid binding siteEvidence in animal models that antibodies binding to β2GPI 15 amino acid sequence GDKV a major β2GPI phospholipid binding site is induced by molecular mimicry . Immunization of BALB/c mice with•Hemophilus influenza •Neisseria gonorrhoeae•Tetanus toxoid Resulted in high titer antibody to β2GPI 15 amino acid sequence GDKV a major β2GPI phospholipid binding site synthesized by Gharavi et al.


Computer generated model of autoimmune anti-phospholipid antibody UK4

UK 4 is directed at β2GPI 15 amino acid sequence GDKV a major β2GPI phospholipid binding site synthesized by Gharavi et al.

Beta 2 glycoprotein 1 Purple wireUK-4 white. Contact in light chain Yellow

Kumar S, Nagl SCB, Kalsi JK, Ravirajan CT et al. Beta 2-glycoprotiein specificity of human antiphospholipid antibody resides on the light chain Molecualr immunology 42: 39-48


Experimental APS is induced in naive mice by molecular mimicry Immunization with microbial particles and tetanus toxoid having sequence homology to β2GPI 15 amino acid sequence GDKV a major β2GPI phospholipid binding site synthesized by Gharavi et al. causes thrombocytopenia, fetal loss and prolonged APTT


Catastrophic APS Asherson Syndrome

Lupus anticoagulant discriminates from DIC and TTP

• There is a small group of APS patients who present with occlusive events at multiple sites over a short period of time resulting in multi organ failure. The majority of catastrophic episodes are preceded by a precipitating events mainly infections

Less than 1% of APS patients


Fig 1 Classic histological findings in a patient with catastrophic antiphospholipid syndrome.

Lupus anticoagulant differentiates fulminant DIC from Catastrophic APS. Clinical symptoms are identical

Cohen D et al. BMJ 2010;340:bmj.c2541

©2010 by British Medical Journal Publishing GroupHassouna June 9, 2012

Guillermo RI,Crowther M, Branch WKamashta NA. Antiphospholipid Syndrome Lancet 2010: 1498-1509

Of the different antibodies The lupus anticoagulantIs the strongest predictor of features relatedto antiphospholipid syndrome


Significance of the Lupus anticoagulant in the

diagnosis of APS


Lupus anticoagulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the APS syndrome: a systemic review of the literature. Monica Galli, David Luciani, et al Blood 2003;101: 1827-1832

Clinical Utility of Laboratory tests used to identify APS antibodies and to diagnose the

APS

Galli M Semin Thromb Hemost 2008; 34: 329-334

• Lupus Anticoagulant is essentially a measure of the functional activity of subgroups of auto-immune antibodies directed against beta2-glycoprotein 1



Identity of the Lupus anticoagulant depends on the capture antibody in the ELISA

Enzyme labeled1.Anticardiolipin antibodies directed against antigen cardiolipin bound to beta-2 glycoprotein 1 2.Antiphospholipid antibodies directed against phospholipid bound to beta2 glycoprotein 1 3.Anti beta2 glycoprotein -1 antibodies directed against antigen beta 2 glycoprotein-1

37

Special Coagulation Laboratory Recipe for APS diagnosis

• APTT clotting times must be prolonged at least twice control plasma clotting times (correlates with high antibody titer)

• APTT prolonged clotting times does not correct in mixing patient plasma with pooled normal plasma

• ELISA identifies beta2-glycoprotein 1 antigen and auto-antibodies.

• Testing is repeated as indicated.• APS induced by viral or bacterial proteins

disappears after infection is cured


Summary Antiphospholipid Syndrome has 3 components:

Lupus anticoagulant is a term applied to a prolonged clotting time in a phospholipid dependent clotting test. Clotting times correlate with antibody titer

Antiphospholipid antibodies is a general term applied to antibodies generated by an autoimmune or an infectious process

An acquired thrombophilia ( arterial and venous thrombosis, recurrent pregnancy loss, thrombocytopenia) caused by autoimmune or infectious processes that generate antibodies harmful to endothelium and platelets .


Summary

Lupus Anticoagulant

is the “ identifier” or “ biomarker” unique to the Antiphospholipid syndrome

Auto-antibodies that prolong clotting times in phospholipid dependent clotting

assays are termed “lupus anticoagulant”


Antiphospholipid Syndrome Clinical Phenotype

• Arterial and venous Thrombosis

• Obstetric complicationsRecurrent miscarriagesPre-eclampsiaIntrauterine growth retardation

• Thrombocytopenia


Intensity and duration of anticoagulation therapy in antiphospholipid syndrome (APS)Les I,Ruiz-Irastorza G, Khamashata M.A. Semin Thromb Hemost 2012:38:339-347

Intensity and duration of anticoagulation therapy in antiphospholipid syndrome (APS)

Les I,Ruiz-Irastorza G, Khamashata M.A. Semin Thromb Hemost 2012:38:339-347


Conclusion

• Diagnosis is absolutely necessary for the proper clinical management

• A patient with Lupus anticoagulant and without thrombosis or recurrent obstetric complications is at high risk for APS, and should be managed accordingly

• In our experience, it is possible to remove antibodies in APS induced by molecular mimicry after complete eradication of the bacteria by pheresis (plasma exchange). Success is indicated by APTT clotting times significantly shortened to ( almost baseline levels over 6 months


Bergamo was built by Emperor Justinian ( 527-565)

Monastery of St Catherine in the Sinai was built by the Emperor Justinian I ( 527-565) at the site where Moses is supposed to

have seen the burning bush

antiphospholipid syndrome (aps ) michigan state university houria suzy hassouna no relevant...

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