Update on the pathogenesis and treatment of the antiphospholipid syndrome.

PURPOSE OF REVIEW: Many advancements in our understanding of the pathogenic mechanisms of the antiphospholipid syndrome (APS) have been accomplished over the recent months. Such progresses are paralleled by the development of innovative pharmacological tools that could provide novel therapeutic windows in APS management. The most recent and innovative findings about the biologic effects of antiphospholipid antibodies (aPLs) and the treatment APS will be hereby critically appraised. RECENT FINDINGS: Antibodies against the domain I of ß2 glycoprotein I (ß2GPI) are increasingly recognized as the main pathogenic subset; pioneer therapeutic options exploiting the pathogenicity of anti-domain I antibodies have been developed. AnnexinA2 and toll-like receptor (TLR)4 have been identified as the main receptors for ß2GPI/anti-ß2GPI antibodies on target cells; additional co-receptors might include TLR1, TLR2 and TLR6. Upon binding, aPLs engage intracellular mediators as nuclear factor kappa B and mammalian target of rapamycin, which provide potential therapeutic targets. Current innovative treatment options include novel oral anticoagulants and the complement inhibitor eculizumab. The addition to standard treatment of pleiotropic agents such as hydroxychloroquine, statins and vitamin D could allow better disease control. SUMMARY: The lively and intense research in the APS field opens new frontiers in aPL pathogenic mechanisms, as well as diagnosis and treatment of the syndrome. VIDEO ABSTRACT: http://links.lww.com/COR/A26.

Clinical characterization of antiphospholipid syndrome by detection of IgG antibodies against ß2 -glycoprotein i domain 1 and domain 4/5: ratio of anti-domain 1 to anti-domain 4/5 as a useful new biomarker for antiphospholipid syndrome.

OBJECTIVE: It has been suggested that only antibodies against domain 1 (D1) of ß2 -glycoprotein I (ß2 GPI) are pathogenic and diagnostic. The role of antibodies against other ß2 GPI domains is still debated. This study was undertaken to evaluate the clinical relevance of domain specificity profiling of anti-ß2 GPI IgG antibodies in antiphospholipid syndrome (APS) patients and in control groups of patients with systemic autoimmune rheumatic diseases and in asymptomatic antiphospholipid antibody (aPL) carriers. METHODS: We evaluated 159 subjects with persistently positive, medium or high-titer anti-ß2 GPI IgG, including 56 patients with thrombotic (obstetric or nonobstetric) primary APS, 31 women with obstetric primary APS, 42 aPL-positive patients with systemic autoimmune rheumatic diseases, and 30 asymptomatic aPL carriers. One hundred healthy donors were included. Anti-ß2 GPI D1 and D4/5 IgG were tested on research enzyme-linked immunosorbent assays containing recombinant ß2 GPI domains. RESULTS: As compared to other groups, aPL carriers displayed higher frequency/titer of anti-D4/5 IgG. Unlike anti-D4/5, anti-D1 IgG antibodies were more frequent and at higher titer in triple than in single or double aPL-positive subjects. An anti-D1 to anti-D4/5 ratio of ≥1.5 was predictive of systemic autoimmunity (odds ratio 3.25 [95% confidence interval 1.45-7.49], P = 0.005). Neither anti-D1 nor anti-D4/5 antibodies were associated with APS clinical criteria. CONCLUSION: Anti-D1 IgG is the preferential specificity not only in vascular and obstetric primary APS, but also in patients with systemic autoimmune rheumatic disease with no clinical features of APS. Conversely, aPL carriers do not have a polarized profile toward D1. Combined testing for anti-ß2 GPI IgG with different domain specificity allows a more accurate aPL profiling, with polarization toward anti-D1 IgG as a possible fingerprint of systemic autoimmunity.

ß2-glycoprotein I, lipopolysaccharide and endothelial TLR4: three players in the two hit theory for anti-phospholipid-mediated thrombosis.

The thrombogenic effect of ß2-glycoprotein I (ß2GPI)-dependent anti-phospholipid antibodies (aPL) in animal models was found to be LPS dependent. Since ß2GPI behaves as LPS scavenger, LPS/ß2GPI complex was suggested to account for in vitro cell activation through LPS/TLR4 involvement being LPS the actual bridge ligand between ß2GPI and TLR4 at least in monocytes/macrophages. However, no definite information is available on the interaction among ß2GPI, LPS and endothelial TLR4 in spite of the main role of endothelial cells (EC) in clotting. To analyse at the endothelial level the need of LPS, we investigated the in vitro interaction of ß2GPI with endothelial TLR4 and we assessed the role of LPS in such an interaction. To do this, we evaluated the direct binding and internalization of ß2GPI by confocal microscopy in living TLR4-MD2 transfected CHO cells (CHO/TLR4-MD2) and ß2GPI binding to CHO/TLR4-MD2 cells and human umbilical cord vein EC (HUVEC) by flow cytometry and cell-ELISA using anti-ß2GPI monoclonal antibodies in the absence or presence of various concentrations of exogenous LPS. To further investigate the role of TLR4, we performed anti-ß2GPI antibody binding and adhesion molecule up-regulation in TLR4-silenced HUVEC. Confocal microscopy studies show that ß2GPI does interact with TLR4 at the cell membrane and is internalized in cytoplasmic granules in CHO/TLR4-MD2 cells. ß2GPI binding to CHO/TLR4-MD2 cells and HUVEC is also confirmed by flow cytometry and cell-ELISA, respectively. The interaction between ß2GPI and TLR4 is confirmed by the reduction of anti-ß2GPI antibody binding and by the up-regulation of E-selectin or ICAM-1 by TLR4 silencing in HUVEC. ß2GPI binding is not affected by LPS at concentrations comparable to those found in both ß2GPI and antibody preparations. Only higher amount of LPS that can activate EC and up-regulate TLR4 expression are found to increase the binding. Our findings demonstrate that ß2GPI interacts directly with TLR4 expressed on EC, and that such interaction may contribute to ß2GPI-dependent aPL-mediated EC activation. At variance of monocytic cells, we also showed a threshold effect for the action of LPS, that is able to enhance anti-ß2GPI antibody EC binding only at cell activating concentrations, shown to increase TLR4 expression. This in vitro model may explain why LPS behaves as a second hit increasing the expression of ß2GPI in vascular tissues and triggering aPL-mediated thrombosis in experimental animals.

Pathogenesis of antiphospholipid syndrome: understanding the antibodies.

Antiphospholipid antibodies (aPL) are both diagnostic markers for, and pathogenic drivers of, antiphospholipid syndrome (APS). Although the presence of aPL is a necessary pre-condition, APS-associated clotting is seemingly triggered by an additional 'second hit', frequently related to innate inflammatory immune responses. ß(2) glycoprotein I (ß(2)GPI)-dependent aPL, the most important subset of these antibodies, mediate several--not necessarily alternative--thrombogenic mechanisms, mainly on the basis of their reactivity with ß(2)GPI expressed on the membrane of cells that participate in the coagulation cascade. Recurrent pregnancy complications associated with aPL cannot be explained solely by thrombosis, and alternative pathogenic mechanisms have been reported. Although one in vivo model of fetal loss suggests a mechanism of aPL-mediated acute placental inflammation, other models and the histopathological examination of APS placentae do not support a widespread inflammatory signature. ß(2)GPI-dependent aPL are thought to recognize their antigen on placental tissues, inhibit the growth and differentiation of trophoblasts, and eventually cause defective placentation. Why antibodies with similar antigen specificity produce different clinical manifestations is not clear. Characterization of the molecular basis of the pathogenic mechanisms involved, including the putative second hits and the role of complement activation, might offer an answer to this question.

Anti-beta-2 glycoprotein I antibodies affect Bcl-2 and Bax trophoblast expression without evidence of apoptosis.

Antiphospholipid antibodies (aPLs) reacting with beta-2 glycoprotein I (beta2GPI) have been associated with recurrent fetal loss and pregnancy complications. The aim of the study was to investigate whether aPLs with anti-beta2GPI specificity induce apoptosis of human trophoblasts in vitro. To this end, human anti-beta2GPI monoclonal IgM derived from a patient with antiphospholipid syndrome and a human irrelevant monoclonal IgM were incubated with human trophoblast cell cultures for 24, 48, and 72 h. In all the cultures we evaluated: (i) Bcl-2 and Bax mRNA and protein expression by Western blot and reverse transcription polymerase chain reaction (RT-PCR), respectively; (ii) DNA fragmentation by a commercial ELISA kit and by agarose gel electrophoresis; and (iii) the percentage of cells reactive with the monoclonal antibody (MAb) M30 by indirect immunofluorescence. The results were: Bcl-2/Bax ratio increased in untreated trophoblast cells during the time of culture, showing the highest values detectable after 72 h (2.68 and 2.28 at protein and mRNA levels, respectively). Cell incubation with anti-beta2GPI MAbs induced a significant Bcl-2/Bax ratio reduction in comparison with untreated cells (1.22 and 1.28 at protein and mRNA levels, respectively, after 72 h incubation). No significant difference was detected after cell exposure to irrelevant MAbs. However, neither DNA fragmentation nor increase in cells positive for the caspase-cleaved epitope of cytokeratin 18 cytoskeletal protein (M30) was found. In Conclusion, anti-beta2GPI antibodies react with trophoblast cells and reduce the Bcl-2/Bax ratio, but without any clear apoptotic effect.