Dolors Tàssies

Vascular involvement in Behçet’s disease: relation with thrombophilic factors, coagulation activation, and thrombomodulin

PURPOSE Thrombosis, usually venous, occurs in 10% to 25% of patients with Behçets disease, but its pathogenesis is poorly understood. We evaluated parameters of hemostasis and their relation with thrombosis in a series of patients with Behçets disease. SUBJECTS AND METHODS We studied 38 patients with Behçets disease (13 with venous thrombosis), 38 patients with venous thrombosis without thrombophilia, and 100 control subjects. Levels or presence of protein C, protein S, antithrombin, methylenetetrahydrofolate reductase C677T, factor V Leiden, prothrombin gene G20210A, antiphospholipid antibodies, plasminogen, tissue-type plasminogen activator (tPA), type-1 tPA inhibitor (PAI-1), PAI-1 4G/5G polymorphism, prothrombin fragment 1+2, plasmin/alpha(2)-antiplasmin complexes, thrombomodulin, and activated factors VII and XII were determined. RESULTS There were no deficiencies in protein C, protein S, antithrombin, or factor V Leiden in the patients with Behçets disease, nor was there evidence of most other thrombotic abnormalities. Compared with control subjects, however, the Behçets disease group had elevated mean (+/- SD) levels of prothrombin fragment 1+2 (2091 +/- 1323 pmol/L vs. 804 +/- 398 pmol/L, P <0.001), plasmin/alpha2-antiplasmin complexes (410 +/- 220 microg/L vs. 214 +/- 92 microg/L, P <0.001), and thrombomodulin (37 +/- 24 ng/mL vs. 27 +/- 10 ng/mL, P <0.001). These levels did not differ between patients with or without thrombosis. CONCLUSIONS Thrombophilic factors do not seem to explain most thromboses in Behçets disease. There is increased thrombin generation, fibrinolysis, and thrombomodulin in Behçets disease, but these abnormalities are not related to thrombosis.

Crohn's Disease Patients Carrying Nod2/CARD15 Gene Variants Have an Increased and Early Need for First Surgery due to Stricturing Disease and Higher Rate of Surgical Recurrence

Objective:To study the predictive value of Nod2/CARD15 gene variants along with disease phenotypic characteristics for requirement of initial surgery and for surgical recurrence in Crohns disease (CD). Summary Background Data:Nod2/CARD15 gene variants play an important role in the susceptibility to CD. Studies of genotype-phenotype relationship suggest that these variants are associated with development of intestinal strictures. Preliminary reports analyzing the association between these variants and need for surgery have produced inconsistent results. Methods:A total of 170 CD patients were included prospectively in the study and followed up regularly for a mean of 7.4 ± 6.1 years. Clinical characteristics of CD, time and indication for surgery, and recurrence were registered. Nod2/CARD15 gene variants were determined by DNA sequencing analysis. Results:Surgery for stricturing disease was significantly more frequent in patients with Nod2/CARD15 variants in the univariate analysis (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.42–9.27), and it was required at an earlier time (P = 0.004). Only Nod2/CARD15 variants (OR, 3.58; 95% CI, 1.21–10.5) and stricturing phenotype at diagnosis of CD (OR, 9.34; 95% CI, 2.56–33.3) were independent predictive factors of initial surgery for stricturing lesions in the multivariate analysis. Among 70 patients that required surgery, postoperative recurrence was also more frequent in patients with Nod2/CARD15 variants in the univariate and multivariate analysis (OR, 3.29; 95% CI, 1.13–9.56), and reoperation was needed at an earlier time (P = 0.03). Conclusion:Nod2/CARD15 variants are associated with early initial surgery due to stenosis and with surgical recurrence in Crohns disease. Patients with these variants could benefit from preventive and/or early therapeutic strategies.

Effects of human monoclonal anticardiolipin antibodies on platelet function and on tissue factor expression on monocytes

OBJECTIVE To investigate the effect of human monoclonal anticardiolipin antibodies (aCL) on platelet interaction with the subendothelium under flow conditions and on tissue factor (TF) expression on normal monocytes. METHODS Three monoclonal IgM aCL (TM1B3, GR1D5, and EY2C9) and 2 affinity-purified IgM aCL were studied. Immunoglobulins were added to normal blood and perfused through chambers containing denuded vascular segments. Platelet interactions were morphometrically evaluated by determining the percentage of total surface covered by platelets (PCS) or by large aggregates of thrombi platelets (TP). Expression of TF on monocytes was measured after immunoglobulin incubation with normal mononuclear cells. RESULTS Significant increases in the total PCS and expression of TF were observed using all aCL. Increased levels of TP were induced by all aCL except EY2C9 (obtained from a patient without thrombosis). Previous incubations of these aCL with subendothelial surfaces did not increase platelet interaction. CONCLUSION The effects of aCL on platelet function may help to explain the pathophysiology of thrombosis in the antiphospholipid syndrome.

Clinical study and follow-up of 100 patients withthe antiphospholipid syndrome

Abstract Objectives: To study the clinical characteristics at diagnosis and during follow-upof patients with the antiphospholipid syndrome (APS) and to analyze the influence of treatment on their outcome. Patients: One hundred patients with APS were included (86% female and 14%male; mean age, 36 years). Sixty-two percent had primary APS and 38% had APS associated with systemic lupus erythematosus (SLE). The median length of follow-up was 49 months. Results: Fifty-three percent of the patients had thromboses, 52% had thrombocytopenia, and 60% of the women had pregnancy losses. Patients with APS associated with SLE had a higher prevalence of hemolytic anemia ( P = .02), thrombocytopenia (platelet count lower than 100 × 10 9 /L) ( P = .004), antinuclear antibodies ( P = .0002), and low complement levels. Fifty-three percent of the patients with thrombosis had recurrent episodes (86% in the same site as the previous thrombotic event). Recurrences were observed in 19% of the episodes treated with long-term oral anticoagulation, in 42% treated prophylactically with aspirin, and in 91% in which anticoagulant/antiaggregant treatment was discontinued ( P = .0007). Multivariate analysis showed that prophylactic treatment and older age had an independent predictive value for rethrombosis. Prophylactic treatment during pregnancy (usually with aspirin) increased the live birth rate from 38% to 72% ( P = .0002). Conclusions: Patients with APS have a high risk of recurrent thromboses. Long-term oral anticoagulation seems to be the best prophylactic treatment to prevent recurrences. Prophylactic treatment with aspirin during pregnancy reduced the rate of miscarriages remarkably.

Hypercoagulable State in Patients With Antiphospholipid Syndrome Is Related to High Induced Tissue Factor Expression on Monocytes and to Low Free Protein S

Antiphospholipid antibodies (aPLs) are associated with thrombosis, but the mechanisms of this thrombotic tendency are unknown. We studied 56 patients 612 with systemic lupus erythematosus [SLE] and aPLs and previous thrombosis, 12 with SLE and aPLs but no thrombosis, 15 with SLE without aPLs or thrombosis, 11 with primary antiphospholipid syndrome with thrombosis, and 6 asymptomatic subjects with aPLs) to investigate the ability of aPLs to induce tissue factor (TF) expression on human normal monocytes. A double direct immunofluorescence technique (anti-CD14 and anti-TF) was used, and procoagulant activity in viable and disrupted cells was measured after plasma incubation for 6 hours at 37 degrees C with normal mononuclear cells. Hemostasis regulatory proteins, prothrombin fragment 1 + 2, and thrombin-antithrombin III complex levels were determined. Increased TF expression and procoagulant activity were observed using plasma samples from SLE patients with aPLs and thrombosis (P < .01) and from primary antiphospholipid syndrome patients (P < .01) but not from patients with SLE and aPLs but no thrombosis, patients with SLE without aPLs, or asymptomatic patients with aPLs. Purified aPL immunoglobulins from one primary antiphospholipid syndrome and two SLE patients added to normal plasma showed a significant increase in both TF expression and procoagulant activity (P < .05) compared with purified aPL from two SLE patients without thrombosis. The addition of nonspecific IgG from three SLE patients without aPLs and from three control subjects did not increase TF expression. Low free protein S was seen in eight patients. Increased TF expression and low free protein S correlated with thrombosis (P < .01) and with higher prothrombin fragment 1 + 2 and thrombin-antithrombin III values (P < .01). These observations may contribute to a further understanding of the thrombotic risk in aPL patients.

Prevalence of hepatitis C virus infection in patients with antiphospholipid syndrome

BACKGROUND/AIMS The aim of this study was to determine the prevalence and clinical significance of hepatitis C virus (HCV) infection in patients with the antiphospholipid syndrome (APS). METHODS A series of 88 consecutive patients (78 female and 10 male), with a mean age of 39 years (range 15-79), was prospectively studied. All patients had been diagnosed with APS: 54 (61%) primary APS and 34 (39%) APS associated with systemic lupus erythematosus. A group of 200 apparently healthly blood donors was included in the study. Anti-HCV antibodies were investigated in the serum of all patients using a third-generation ELISA and confirmed by recombinant immunoblot assay. RNA-HCV was investigated in anti-HCV positive samples by polymerase chain reaction. Anticardiolipin, anti-beta2-glycoprotein I and antiprothrombin antibodies were evaluated by ELISA. Lupus anticoagulant was studied by coagulometric assays. RESULTS Only 2 (2.2%) patients showed positivity for anti-HCV antibodies, but none of them had clinical or biochemical signs of liver disease. Furthermore, RNA-HCV was not detected in serum of any of these patients. Lupus anticoagulant was positive in 57% of patients. Anticardiolipin antibodies were positive in 60% of patients, anti-beta2-glycoprotein I antibodies in 43% of patients, and antiprothrombin antibodies in 56% of patients. The prevalence of anti-HCV in blood donors was 1%. CONCLUSIONS The prevalence of anti-HCV in patients with APS is low and similar to that in healthy people in our area. HCV infection does not seem to be involved in the etiopathogenesis of this syndrome.

Budd-Chiari syndrome secondary to antiphospholipid syndrome: clinical and immunologic characteristics of 43 patients.

Budd-Chiari syndrome (BCS) is characterized by structural and functional abnormalities of the liver caused by obstruction to the outflow of hepatic venous blood (13). The consequent liver dysfunction depends on the extension and velocity of instauration of the obstruction. BCS is clinically characterized by abdominal pain, hepatomegaly, and ascites, and the clinical presentation may range from nearly asymptomatic to fulminant liver failure (9, 21). The etiology is unknown in a limited proportion of patients, and several myeloproliferative disorders and hypercoagulable states have been implicated, including polycythemia vera, essential thrombocythemia, paroxysmal nocturnal hemoglobinuria, antithrombin, protein C and protein S deficiency, resistance to activated protein C, factor V Leiden, G20210A factor II gene mutation, use of oral contraceptives, pregnancy, and postpartum state (11, 13, 34, 58). In some studies (41, 53), a relationship between BCS and elevated levels of antiphospholipid antibodies (aPL) has been suggested. The latter are a group of autoantibodies directed to a complex of phospholipids and proteins and include lupus anticoagulant (LA) and anticardiolipin antibodies (aCL). Several studies have shown that patients with aPL are prone to repeated episodes of thrombosis and spontaneous fetal losses. The association of aPL with these clinical events has been termed the antiphospholipid syndrome (APS) (28), and it is considered “primary” if not associated with other underlying disease (4) or “secondary” if it appears in association with other autoimmune disorders, mainly systemic lupus erythematosus (SLE) (17). In this report, we describe 4 new cases of patients with BCS and aPL. In addition, we review the literature supporting the idea that such an association may be a feature of APS, and present the clinical and immunologic characteristics of 43 patients with this association.

Thrombomodulin and induced tissue factor expression on monocytes as markers of diabetic microangiopathy: A prospective study on hemostasis and lipoproteins in insulin-dependent diabetes mellitus

Vascular complications are the main cause of morbidity in diabetes mellitus. To evaluate lipoprotein and hemostatic parameters and their relationship with clinically detectable microangiopathy, we studied 58 insulin‐dependent diabetes mellitus patients and 60 controls matched for age, sex, and body mass index. Thirteen patients presented clinically detectable microangiopathy (8 retinopathy and 5 both retinopathy and microalbuminuria). A cross‐sectional study of lipid profile, coagulation parameters, and a flow‐cytometric evaluation of tissue factor expression in normal monocytes induced by patient plasma were performed. Patients were re‐evaluated for microangiopathy in a 3‐year median follow‐up. Patients showed triglyceride enrichment in low (P = 0.00002) and high density lipoproteins (P = 0.004) and increased levels of D‐dimer (P < 0.00001), prothrombin fragment 1 + 2 (P < 0.00001), and thrombin‐antithrombin III complex (P = 0.0001). Patients with clinically detectable microangiopathy had increased type 1 plasminogen activator inhibitor (P = 0.00001), thrombomodulin (P = 0.02), and induced monocyte tissue factor expression (P < 0.00001). Nine patients developed clinically detectable microangiopathy in the follow‐up and the only predictive variable was increased induced tissue factor expression. In conclusion, in these patients elevated thrombin and fibrin generation reflects a hypercoagulable state but clinically detectable microangiopathy seems related to endothelial cell injury markers and to increased induced tissue factor expression on monocytes. Am. J. Hematol. 56:93–99, 1997.

The 4G/5G polymorphism of the type 1 plasminogen activator inhibitor gene and thrombosis in patients with antiphospholipid syndrome.

OBJECTIVE To investigate the relationship between the 4G/5G polymorphism of the type 1 plasminogen activator inhibitor (PAI-1) gene and thrombotic manifestations in patients with antiphospholipid syndrome (APS). METHODS We studied a total of 247 patients included in the following 4 groups: 70 patients with primary APS, 104 patients with systemic lupus erythematosus (40 with antiphospholipid antibodies [aPL] and clinical [secondary] APS, 13 with aPL but without clinical APS, and 51 with neither detectable aPL nor a history of thrombosis), 14 asymptomatic individuals with aPL, and 59 patients with thrombosis but without known thrombosis risk factors. A control group of 100 healthy individuals was also analyzed. PAI-1 4G/5G polymorphism was determined by polymerase chain reaction and endonuclease digestion. RESULTS The allele frequency of 4G/5G in controls was 0.47/0.53. There were no differences in allele distribution among patient groups or between patients and controls. However, a higher frequency of the 4G allele was observed in APS patients with versus those without thrombosis (0.57 versus 0.39; P < 0.05) (odds ratio [OR] 2.83, 95% confidence interval [95% CI] 1.18-6.76). This higher frequency of the 4G allele was attributable to the higher frequency in patients with versus those without arterial thrombosis (0.64 versus 0.43; P < 0.01) (OR 5.96, 95% CI 1.67-21.32), while patients with venous thrombosis had an allele distribution similar to that of those without venous thrombosis (0.49 versus 0.50; P not significant). There was a trend toward higher PAI-1 antigen and activity levels in APS patients and controls with the 4G/4G genotype, but this did not reach statistical significance. CONCLUSION The presence of the 4G allele of the 4G/5G polymorphism of the PAI-1 gene may be an additional risk factor for the development of arterial thrombosis in APS.

Hepatitis G virus infection in chronic hepatitis C: frequency, features and response to interferon therapy

BACKGROUND/AIMS The pathogenic relevance of the hepatitis G virus (HGV) and its sensitivity to interferon are currently under investigation. This study aimed to investigate the prevalence of HGV infection in patients with chronic hepatitis C and to elucidate if HGV co-infection modifies the clinical course and the response to interferon therapy in this disease. METHODS HGV-RNA was investigated by reverse transcription-polymerase chain reaction in serum from 143 consecutive patients who received interferon alpha-2b (3 MU t.i.w.) for 24 weeks. Baseline features and response to therapy in HGV-infected and non-infected patients were compared. To assess the antiviral effect of interferon, serial quantitative measurement of HCV-RNA and HGV-RNA in serum was performed in patients co-infected with HCV and HGV. RESULTS Eight patients (5.6%) presented HGV-RNA sequences in serum. No significant differences were found between HGV-infected and non-infected patients in relation to age, sex, source of infection, liver function tests, liver histology and HCV genotype, nor in the biochemical response to interferon, which was sustained in 12% and 15%, transient in 37% and 30% and absent in 50% and 55% of HGV-infected and non-infected patients, respectively. HGV-RNA became negative in all treated patients, but sustained viral inhibition was observed only in those with low viral load. CONCLUSIONS The prevalence of HGV infection in HCV-infected patients is relatively low in our geographical area. HGV co-infection does not appear to modify the clinical presentation nor the response to interferon in chronic hepatitis C. HGV is sensitive to interferon, particularly if pre-treatment viral load is low.