Download Antiphospholipid Syndrome (APS) - Translational MSU Coagulation

Antiphospholipid Syndrome
(APS )
Michigan State University
Houria Suzy Hassouna
No relevant conflicts of interest to declare
The Question-Driven Life
DAVID BROOKS
Rift Valley, Kenya
By
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.
Hassouna June 9, 2012
Diagnosis and management of bleeding and
thrombotic diseases
Professors with “ Explanatory
Drive”
Shinichiro Uchiyama (not in photo
Akitada Ichinose ( not in photo)
John Penner
Tadanori Kawada
Jin Shiomura
Hassouna June 2012
3
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
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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
Hassouna June 9, 2012
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: 621-622
Lechner K Acquired inhibitors in auto
and isoimmune diseases. Hemostasis
1974; 3:65-69
Feinstein 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.
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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 June 9, 2012
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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 .
Hassouna June 9, 2012
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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
Hassouna September 7, 2011
12
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Hassouna February 2, 2010
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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 .
Hassouna June 9, 2012
Fig 2 Clinical manifestations of antiphospholipid syndrome.
Cohen D et al. BMJ 2010;340:bmj.c2541
Hassouna June 9, 2012
©2010 by British Medical Journal Publishing Group
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)
Hassouna June 9, 2012
Two mechanisms are identified in the induction of
autoimmune Antiphospholipid antibodies (a PL).
• Apoptotic phospholipid
beta 2 glycoprotein-1
complexes.
• Infection related
antiphospholipid
antibodies.
• From experiments in
mice, antiphospholipid
antibodies are produced
by binding of beta2glycoprotein 1 to
phospholipid viral or
bacterial proteins by
molecular mimicry
• Phospholipids released
from injured cells
bound to beta 2
glycoprotein 1
June 9, 2012
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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
Hassouna September 7, 2011
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Cardiolipin is a phospholipid on the inner membrane of mitochondria
first identified in bovine heart. Anticardiolipin antibodies ( lupus
anticoagulant) represent an autoimmune process
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
Beta-2 glycoprotein 1 prevents ADP induced platelet aggregation
via interaction with
Apo ER 2 platelet receptor ( anticoagulant action)
auto antibody
against beta2-glycoprotein 1
prevents dimerization and this
interaction with
Apo ER 2 enhances platelet
procoagulant activity
Hassouna June 9, 2012
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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 .
Hassouna June 9, 2012
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Antibodies to bacteria or
viruses recognize β2GPI
phospholipid binding site
Evidence 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.
Hassouna June 9, 2012
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
wire
UK-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
Hassouna June 9, 2012
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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
Hassouna June 9, 2012
Catastrophic APS Asherson Syndrome
Lupus anticoagulant
discriminates from DIC and TTP
Less than 1% of APS patients
• 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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
©2010 by British Medical Journal Publishing Group
Guillermo RI,Crowther M, Branch WKamashta NA. Antiphospholipid
Syndrome Lancet 2010: 1498-1509
Of the different antibodies
The lupus anticoagulant
Is the strongest predictor of features related
to antiphospholipid syndrome
Hassouna June 9, 2012
Significance of the Lupus
anticoagulant in the diagnosis of
APS
Hassouna June 9, 2012
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
Hassouna June 9, 2012
Identity of the Lupus
anticoagulant depends on
the capture antibody in
the ELISA
Enzyme labeled
1.
2.
3.
Anticardiolipin
antibodies directed
against antigen
cardiolipin bound to
beta-2 glycoprotein 1
Antiphospholipid
antibodies directed
against phospholipid
bound to beta2
glycoprotein 1
Anti beta2 glycoprotein
-1 antibodies directed
against antigen beta 2
glycoprotein-1
Hassouna June 9, 2012
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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
Hassouna June 9, 2012
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 .
Hassouna September 7, 2011
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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”
Hassouna June 9, 2012
Antiphospholipid Syndrome Clinical
Phenotype
•
Arterial and venous
Thrombosis
• Obstetric complications
Recurrent miscarriages
Pre-eclampsia
Intrauterine growth retardation
•
Thrombocytopenia
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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
Hassouna June 9, 2012
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