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Streptococcus Pyogenes Chapter 4 63 UvA-DARE (Digital Academic Repository) Development of auto-antibodies towards ß2-glycoprotein I in the antiphospholipid syndrome van Os, G.M.A. Publication date 2011 Document Version Final published version Link to publication Citation for published version (APA): van Os, G. M. A. (2011). Development of auto-antibodies towards ß2-glycoprotein I in the antiphospholipid syndrome. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:27 Sep 2021 Development of auto-antibodies towards β2-Glycoprotein I in the antiphospholipid syndrome GWEN M.A. VAN OS Development of auto-antibodies towards β2-Glycoprotein I in the antiphospholipid syndrome Dissertation, University of Amsterdam, Amsterdam, The Netherlands Author: G.M.A. van Os Printing: Wöhrman Print Service ISBN: 978-90-8570-764-6 Copyright © 2011, G.M.A. van Os, Amsterdam, The Netherlands All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means, without permission of the author. Financial support by the Netherlands Heart foundation & the Academic Medical Center for the publication of this thesis is greatfully acknowlodged. Additional financial support for the printing of this thesis was provided by: Instrumentation laboratory, Novo Nordisc and the NVLE. DEVELOPMENT OF AUTO-ANTIBODIES TOWARDS β2-GLYCOPROTEIN I IN THE ANTIPHOSPHOLIPID SYNDROME ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof.dr. D.C. van den Boom ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Aula der Universiteit op vrijdag 2 december 2011, te 13.00 uur door Gwendolyn Margaretha Adriana van Os geboren te Arnhem GWEN M.A. VAN OS PromotiEcommiSSIE: Promotores: Prof. dr. J.C.M. Meijers Prof. dr. Ph.G. de Groot Overige leden: Prof. dr. S. Middeldorp Prof. dr. H. Pannekoek Prof. dr. T. van der Poll Prof. dr. P.H. Reitsma Prof. dr. C.J.M. de Vries Faculteit der Geneeskunde GWEN M.A. VAN OS CONTENTS CHAPTER 1 9 Current insights into laboratory diagnosis and pathophysiology of the antiphospholipid syndrome and aim of this thesis CHAPTER 2 19 β2-Glycoprotein I can exist in two conformations: implications for antigen recognition in the antiphospholipid syndrome CHAPTER 3 41 Induction of auto-antibodies against β2-Glycoprotein I in mice by protein H of Streptococcus pyogenes CHAPTER 4 63 β2-glycoprotein I has a protective function in situations of hyper-responsive von Willebrand Factor: Implications for TTP CHAPTER 5 83 Two different populations of domain I anti-β2GPI antibodies; one inhibits and one stimulates in vitro thrombin generation CHAPTER 6 97 Detection of lupus anticoagulant in the presence of rivaroxaban by Taipan snake venom time CHAPTER 7 105 Auto-antibodies against β2 GPI: Etiology and mechanism of action APPENDICES 121 Nederlandse samenvatting voor niet-ingewijden 123 List of publications 128 Dankwoord 131 CHAPTER 1 Current insights into laboratory diagnosis and pathophysiology of the antiphospholipid syndrome Gwen M.A. van Os, Rolf T. Urbanus, Çetin Ağar, Joost C.M. Meijers, Philip G. de Groot Hamostaseologie. 2010; 30 (3): 139-143 GWEN M.A. VAN OS 10 INTRODUCTION The antiphospholipid syndrome (APS) is a non-inflammatory autoimmune disease characterized by the presence of antiphospholipid antibodies (aPL) in the plasma of patients with venous and/or arterial thrombosis and/or recurrent complications of pregnancy1,2. The presence of aPL in plasma of patients can be detected by either a prolongation of phospholipid dependent coagulation test (lupus anticoagulant, LAC), or by solid phase immune assays against the protein β2-glycoprotein I (β2GPI) or the phospholipid cardiolipin 3 (anti-β2GPI antibody ELISA and anti-cardiolipin antibody ELISA, respectively) . For a long time there was a lot of confusion on who had the syndrome and who not. To solve this dispute, an international consensus meeting was organized in Sapporo in 1999 to formulate classification criteria for patients with the antiphospholipid syndrome4. These criteria have been updated in 2004 at another international consensus meeting in Sydney5. The classification criteria were defined for scientific purposes and were aimed to be used as inclusion criteria in patient related studies. They were not defined for diagnostic purposes. The actual practice is that these criteria are now used as a diagnostic tool. This is very unfortunate because the specificity of the different aPL assays to detect the clinical manifestations that characterize APS are disputable and one of the aims of defining the criteria was the validation as biomarker of the different assays used to detect the presence of thrombosis and pregnancy morbidity. The progress made recently on this important topic will be discussed in the next chapter. LABORATORY DIAGNOSTICS APS is an exceptional syndrome because the clinical symptoms such as thrombosis occur relatively often but are in most cases not due to the presence of antiphospholipid antibodies. As a consequence, the detection of the presence of aPL in plasma of a patient with thrombosis or complications of pregnancy is the essential step to define the syndrome. aPL is a generic term that describes a collection of closely related but not identical antibodies: 6 LAC activity, anti-cardiolipin antibodies (aCL) or anti-β2GPI antibodies . The fact that the three assays do not measure the same population of antibodies immediately raises two fundamental questions: what are the differences between the different types of antibodies detected with the three assays and which of these three assays is the most relevant one. Meta analyses, case-control cohort studies and prospective studies on the predictive value of the different types of aPL have shown that the antibodies that induce LAC activity correlate by far the best with a history of thrombo-embolic complications7-10. Apparently, an assay that measures a functional activity, inhibition of a clotting reaction, better predicts a thrombotic risk than assays that measure the presence of a heterogeneous population of auto-antibodies that comprise both those that influence a functional activity and those that do not. Another possible reason why the ELISAs developed to detect the presence of PATHOPHYSIOLOGY OF THE ANTIPHOSPHOLIPID SYNDROME anti-cardiolipin or anti-β2GPI antibodies perform so badly in these association studies 11 is that they are poorly standardized11-13. A plasma sample that scored positive in one 1 laboratory can score negative in another. Even between laboratories with extensive experience in the detection of aPL antibodies, discordant findings with samples with low titre antibodies are more a rule than an exception. Reliable detection of low titre CHAPTER aCL and anti-β2GPI antibodies is not possible until now. Based on these observations, a number of researchers including one of us, expressed serious doubts whether the aCL ELISA, as it is performed today with the available commercial kits, is specific enough to detect the antiphospholipid syndrome14. From 1990 on it is known that a subpopulation of aCL is directed against β2GPI and there are many indications that the anti-β2GPI antibodies are in fact the pathological antibodies. However, anti-β2GPI antibodies are also a heterogeneous group of antibodies. Antibodies were found directed against all five domains of the protein. A number of studies from different laboratories have suggested that antibodies directed against an epitope around amino acids Arg39 and Arg43 within domain I of β2GPI correlates best with the observed clinical manifestation of APS15-17. Moreover, addition of isolated domain I to plasma of mice inhibits thrombus formation in a murine model of the antiphospholipid syndrome18. Apparently, antibodies directed against domain I of β2GPI are more relevant antibodies to measure than antibodies against whole β2GPI, although we cannot exclude that besides antibodies against domain I other pathological subpopulations of auto-antibodies circulate in blood of APS patients. From the studies published so far it is evident that LAC is the assay of choice to measure clinically relevant aPL. However, patients that are not only positive for LAC but also positive for anti-β2GPI antibodies have a higher risk for recurrent thrombosis than patients positive in only one assay19. This is not really a surprise because LAC can not only be caused by antibodies directed against β2GPI but also by antibodies against prothrombin20. There is consensus that the anti-prothrombin antibodies are passive bystanders in the syndrome5, however, not everybody agrees 21 on this point . Nevertheless, the combination LAC and anti-β2GPI antibodies identify those anti-β2GPI antibodies that are able to induce LAC, a subpopulation of aPL that is thought to be responsible for the pathophysiology of APS. In the next paragraph we will discuss how these antibodies could induce a deregulation of the hemostatic balance. PATHOPHYSIOLOGY Initially it was thought that aPL were directed against anionic phospholipids. We now know that the antibodies are directed against the glycoprotein β2GPI bound to anionic GWEN M.A. VAN OS 22,23 12 surfaces . β2GPI is a plasma protein with no obvious function and persons or mice lacking this protein seem to be completely healthy24,25.
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