Dawn R. Wagenknecht

Antiphospholipid antibodies are a risk factor for early renal allograft failure.

BACKGROUND Biopsy specimens of transplanted kidneys that fail to function reveal cellular infiltrates, infarcts, and thrombi. Because antibodies to phospholipids (aPA) and/or phospholipid-binding proteins have been associated with thrombosis, we asked whether aPA are a risk factor for early allograft failure. METHODS Final crossmatch sera from 56 patients with primary nonfunctioning renal allografts were tested for aPA. Serum from the next consecutive patient to undergo transplantation served as transplantation controls. Both groups were compared with aPA values obtained from testing 252 control individuals. The ELISA was designed to detect IgG, IgM, and IgA antibodies to phosphatidylserine, cardiolipin, and phosphatidylethanolamine. RESULTS Patients were evaluated based upon the aPA ELISA findings. aPA were present in 57% of the patients with early nonfunction renal allografts and 35% of the patients with functioning grafts (P=0.0234). aPA in previously hemodialyzed patients did not predict allograft failure or success (P=0.3766). In contrast, all nonhemodialysis patients who had aPA at the time of transplantation experienced early allograft failure (P=0.0022). CONCLUSIONS These data show that aPA are an important risk factor for early renal allograft failure. Furthermore, aPA-positive patients who have no history of hemodialysis are at the greatest risk. Pretransplantation aPA screening of renal transplant candidates forewarns of early graft failure and indicates which patients may benefit from anticoagulant therapy.

Phospholipid Binding Plasma Proteins Required for Antiphospholipid Antibody Detection—An Overview

PROBLEM: Antibodies to phospholipid antigens (aPA) are associated with thrombosis thrombocytopenia and recurrent pregnancy loss. Contemporary data show many aPA target phospholipid‐binding plasma proteins and not phospholipids. The purpose of this overview is to describe several phospholipid‐binding proteins and provide data to demonstrate how the interaction between phospholipids and phospholipid binding proteins results in expression of neo‐autoantigenic epitopes.

Antiphospholipid antibodies: discovery, definitions, detection and disease

Antiphospholipid antibodies (aPL) are immunoglobulins of IgG, IgM and IgA isotypes that target phospholipid (PL) and/or PL-binding plasma proteins. Detection of aPL in the laboratory is done currently by both immunoassays and functional coagulation tests. Convention defines aPL specificity in immunoassays according to the particular PL substrate present, for example aPS represents antiphosphatidylserine antibodies. This may be technically incorrect inasmuch as a particular PL may be responsible for binding and highly concentrating a specific plasma protein, the latter then becomes the target for the aPL. The binding of beta(2)GP-I (apolipoprotein H) to the negatively charged PL, cardiolipin (CL) provides a good example of this circumstance. In contrast, aPL which specifically prolong coagulation times in in vitro are called lupus anticoagulants (LA). The precise PL target(s) of the aPL responsible for LA activities are unknown and often debated. The persistent finding of aPL in patients in association with abnormal blood clotting and a myriad of neurological, obstetrical and rheumatic disorders often compounded by autoimmune diseases has led to an established clinical diagnosis termed antiphospholipid syndrome (APS). The common denominator for these APS patients is the presence of circulating aPL on two or more occasions and the observation of events attributable to abnormal or accelerated blood clotting somewhere in vivo. The purpose of this review is to collect, collate, and consolidate information concerning aPL.

Henoch–Schönlein purpura and stroke: Antiphosphatidyl-ethanolamine antibody in CSF and serum

Article abstract A 15-year-old girl with features of Henoch-Schönlein purpura and brain infarct had a transient IgA antiphosphatidylethanolamine antibody (aPE) in her serum and CSF that disappeared 5 months after presentation. Serum aPE is known to be associated with thrombotic events. The authors found no aPE in the CSF of two control individuals or in the serum of two patients with active Henoch-Schönlein purpura without neurologic involvement. The patient may represent a variant of antiphospholipid antibody syndrome.

Heterogeneity of the apolipoprotein H*3 allele and its role in affecting the binding of apolipoprotein H (β2-glycoprotein I) to anionic phospholipids

Apolipoprotein H (apoH, protein; APOH, gene) has been implicated as a necessary cofactor for the binding of certain autoimmune antiphospholipid antibodies to anionic phospholipids. APOH exhibits genetically determined structural polymorphism with the occurrence of four alleles. Recently three IgG1k monoclonal antibodies (mAb) to human apoH, designated 3G9, 1B4, and 3D11, have been produced. The mAb 3D11 does not recognize apoH bound to anionic phospholipids in contrast to mAb 3G9 and 1B4, which recognize free and phospholipid-bound apoH. In this investigation we have determined the reactivity of the three mAb with four APOH allele products and the binding ability of these allele products with anionic phospholipids. The mAb 3G9 and 1B4, like the polyclonal anti-apoH, were equally reactive with all four allelic products, but the 3D11 recognized only the APOH*3 allele product. In the 159 APOH*3 carriers tested from five ethnic groups, the reactivity of mAb 3D11 was observed with all the Chinese but none of the African blacks. For the U.S. whites and Polynesians 89% and 75%, respectively, of the APOH*3 allele products were recognized by 3D11, while 87% of the U.S. blacks with this allele had no 3D11 reactivity. These data show that the APOH*3 allele, originally identified as a single entity by the polyclonal anti-apoH, is heterogeneous with at least one distinct variation based on mAb 3D11 reactivity. Our data also demonstrate that the apoH from certain homozygous APOH*3 individuals is unable to bind to anionic phospholipids. Such ethnic-specific apoH variations could play a significant role in the binding properties of autoimmune antiphospholipid antibodies to anionic phospholipids.Apolipoprotein H (apoH, protein; APOH, gene) has been implicated as a necessary cofactor for the binding of certain autoimmune antiphospholipid antibodies to anionic phospholipids. APOH exhibits genetically determined structural polymorphism with the occurrence of four alleles. Recently three IgG1k monoclonal antibodies (mAb) to human apoH, designated 3G9, 1B4, and 3D11, have been produced. The mAb 3D11 does not recognize apoH bound to anionic phospholipids in contrast to mAb 3G9 and 1B4, which recognize free and phospholipid-bound apoH. In this investigation we have determined the reactivity of the three mAb with four APOH allele products and the binding ability of these allele products with anionic phospholipids. The mAb 3G9 and 1B4, like the polyclonal anti-apoH, were equally reactive with all four allelic products, but the 3D11 recognized only the APOH*3 allele product. In the 159 APOH*3 carriers tested from five ethnic groups, the reactivity of mAb 3D11 was observed with all the Chinese but none of the African blacks. For the U.S. whites and Polynesians 89% and 75%, respectively, of the APOH*3 allele products were recognized by 3D11, while 87% of the U.S. blacks with this allele had no 3D11 reactivity. These data show that the APOH*3 allele, originally identified as a single entity by the polyclonal anti-apoH, is heterogeneous with at least one distinct variation based on mAb 3D11 reactivity. Our data also demonstrate that the apoH from certain homozygous APOH*3 individuals is unable to bind to anionic phospholipids. Such ethnic-specific apoH variations could play a significant role in the binding properties of autoimmune antiphospholipid antibodies to anionic phospholipids.

Heparin and Pregnancy in Women with a History of Repeated Miscarriages

Many patients who experience recurrent spontaneous abortions (RSA) have high titered antibodies to trophoblast antigens and/or negatively charged phospholipids. Pregnancy success has been documented in some of these patients subsequent to heparin treatment. The effect of heparin on in vitro assays used to detect antibodies to phospholipids and trophoblast antigens has been investigated. We have found that complement-mediated detection of antibodies to trophoblast and lymphocyte antigens is inhibited by absorption of sera with solid-phase heparin. The data show that such inhibition involves an inhibitor and a heparin-sensitive regulator of the inhibitor. Heparin inhibits binding of antiphospholipid antibodies to phospholipids in solid-phase ELISA. The mechanism for this inhibition appears to involve an interaction between heparin and antibody to phospholipid. These findings reveal novel heparin-mediated reactions that bridge immunological and hematological interactions. The extent of heparin modulation of these antibody reactivities should be clarified in future clinical trials involving heparin treatment for RSA.

ANTIPHOSPHOLIPID ANTIBODIES: Risk Assessments for Solid Organ, Bone Marrow, and Tissue Transplantation

The literature pertaining to transplantation of solid organs, bone marrow, and other tissues in aPL-positive patients has been reviewed. The effects that aPL have relative to BMT are altogether different than those ascribed to solid organs and tissues. By definition, the transplantation of allogeneic bone marrow serves to reconstitute the recipient with a completely new and genetically different repertoire of antibody-producing cells. Previously aPL-positive bone marrow recipients become aPL-negative subsequent to transplantation assuming that the marrow donor is aPL-negative. These observations are the basis for contemporary experimental approaches to curing certain autoimmune diseases with BMT. Similarly, it would follow that an aPL-negative patient provided cells from an aPL-positive donor could become aPL-positive and suffer increased risk for thrombosis. From the data provided in most of the non-bone marrow publications, the presence of aPL should be considered a grave risk factor for any potential solid organ or tissue transplant candidate. Peritoneal dialysis patients seem to be at maximal risk. Given the serious emotional and economic impact of irreversible thrombotic loss suffered by organ transplant recipients, these factors alone should justify the modest expense of pretransplant aPL screening. In the United States, the average cost of losing a kidney transplant to aPL-associated thrombosis was estimated from 1996 data to be

Risk of early renal allograft failure is increased for patients with antiphospholipid antibodies

82,000. The cost of losing a heart or liver is measured not only in dollars but often in the patients life. The encouraging news, however, is that once aPL are identified before transplantation, prophylactic anticoagulation seems to be capable of forestalling untoward aPL-associated allograft events. Clearly, much remains to be discovered in exploring the pathobiologic characteristics of aPL in the laboratory as well as in neutralizing their procoagulant effects at the bedside.

Increased incidence of antiphospholipid antibodies in left ventricular assist system recipients

Abstract Renal allograft thrombosis can cause transplant failure. Because antiphospholipid antibodies (aPA) are associated with thrombosis, we investigated pretransplant sera from patients with early renal allograft failure to determine if aPA were present. Fifty‐six final crossmatch (FxM) sera from patients whose transplant failed within 16 days were compared to FxM sera from the next sequential transplant patients. The sera were tested for IgG, IgM, and IgA antibodies to cardiolipin, phosphatidylserine, and phosphatidylethanolamine. aPA were identified in 57 % of FxM sera from patients with early non‐function versus 35 % of FxM sera from patients with functioning grafts (P = 0.02). Historical sera from 11 aPA‐positive patients contained aPA up to 18 months prior to transplantation. Since aPA were present in historical sera, testing for aPA can identify certain patients at risk for early allograft failure. The involvement of aPA in early allograft loss is supported by studies demonstrating aPA recovery from an explanted failed transplant.

Antiphospholipid and glutamic acid decarboxylase antibodies in patients with focal epilepsy

BACKGROUND Antiphospholipid antibodies are associated with thrombosis. Because thromboembolic complications are often observed in recipients of a left ventricular assist system, we questioned if antiphospholipid antibodies were present in these patients. We report results from 10 patients who received a Novacor left ventricular assist system. METHODS Serum samples were collected before left ventricular assist system placement and weekly thereafter until discharge after cardiac transplantation. Samples were tested for IgG, IgA, and IgM antiphosphatidylserine, anticardiolipin, and antiphosphatidylethanolamine using an enzyme-linked immunosorbent assay. RESULTS Development of phospholipid-binding plasma protein-dependent antiphospholipid antibodies was observed in 9 of the 10 patients. Before placement of the assist system, 3 patients had IgG antiphospholipid antibodies, and 9 were positive after placement. None had IgA antiphospholipid antibodies before placement, whereas 5 seroconverted for IgA after placement. One patient had IgM antiphospholipid antibodies before placement, and 1 additional patient became positive after placement. In patients with a preexisting antibody, increased titers and additional specificities developed subsequent to placement. CONCLUSIONS All but 1 patient showed development of phospholipid-binding plasma protein-dependent antiphospholipid antibodies after left ventricular assist system placement.