The Complex Relationship between C4b-Binding Protein, Warfarin, and Antiphospholipid Antibodies

Giorgia Grosso; Kerstin Sandholm; Aleksandra Antovic; Iva Gunnarsson; Agneta Zickert; Anna Vikerfors; Lennart Truedsson; Maria Bruzelius; Bo Nilsson; Kristina Nilsson-Ekdahl; Elisabet Svenungsson

doi:10.1055/a-1347-5655

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2021; 121(10): 1299-1309
DOI: 10.1055/a-1347-5655

Coagulation and Fibrinolysis

The Complex Relationship between C4b-Binding Protein, Warfarin, and Antiphospholipid Antibodies

Authors

Giorgia Grosso

¹Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
Kerstin Sandholm

²Linnaeus Center for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
Aleksandra Antovic

¹Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
Iva Gunnarsson

¹Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
Agneta Zickert

¹Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
Anna Vikerfors

³Swedish Medical Products Agency, Uppsala, Sweden
Lennart Truedsson

⁴Department of Microbiology, Immunology and Glycobiology, Lund University Hospital, Lund, Sweden
Maria Bruzelius

⁵Department of Haematology, Karolinska University Hospital, Stockholm, Sweden

⁶Department of Medicine, Karolinska Institutet, Stockholm, Sweden
Bo Nilsson

⁷Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
Kristina Nilsson-Ekdahl

²Linnaeus Center for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden

⁷Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
Elisabet Svenungsson

¹Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden

Abstract

Background Low levels of total C4b-binding protein (C4BPt), a circulating inhibitor of the classical/lectin complement pathways, were observed in patients with antiphospholipid antibodies (aPLs) and during warfarin treatment.

Objectives To investigate the associations between aPL and C4BPt in patients with persistently positive (++) aPL, with/without clinical manifestations and systemic lupus erythematosus (SLE), and in controls. Furthermore, we explored the impact of anticoagulation on C4BPt and in relation to complement activation.

Methods In a cross-sectional design we investigated defined subgroups: primary (p) antiphospholipid syndrome (APS, N = 67), aPL++ individuals without clinical manifestations (aPL carriers, N = 15), SLE-aPL++ (N = 118, among them, secondary [s] APS, N = 56), aPL negative (−) SLE (SLE-aPL−, N = 291), and 322 controls. Clinical characteristics, including treatment, were tabulated. C4BPt was determined with a magnetic bead method. Complement proteins (C1q, C2, C3, C4, C3a, C3dg, sC5b-9, factor I [FI]) were measured. A mediation analysis was performed to decompose the total effect of aPL++ on C4BPt into the direct and indirect effects of aPL++ through warfarin.

Results Overall, C4BPt is 20% decreased in aPL++ patients, regardless of SLE, APS, clinical manifestations, and aPL profile. C4BPt levels associate positively with complement proteins C1q, C2, C3, and C4, and negatively with complement activation product C3dg. In the SLE group, warfarin treatment contributes to approximately half of the C4BPt reduction (9%)

Conclusion Both aPLs and warfarin are associated with C4BPt reduction. Complement activation in aPL++ patients may partly be explained by impaired inhibition through depressed C4BPt levels. Further studies are needed to understand the clinical implications.

Keywords

complement - antiphospholipid antibodies - coagulation

Full Text

References

References
1 Miyakis S, Lockshin MD, Atsumi T. et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4 (02) 295-306
2 Ames PRJ, Alves JD, Gentile F. Coagulation and complement in antiphospholipid syndrome. Thromb Res 2017; 158: 149-151
3 Oikonomopoulou K, Ricklin D, Ward PA, Lambris JD. Interactions between coagulation and complement--their role in inflammation. Semin Immunopathol 2012; 34 (01) 151-165
4 de Groot PG, Meijers JC. β(2) -Glycoprotein I: evolution, structure and function. J Thromb Haemost 2011; 9 (07) 1275-1284
5 Gropp K, Weber N, Reuter M. et al. β₂-glycoprotein I, the major target in antiphospholipid syndrome, is a special human complement regulator. Blood 2011; 118 (10) 2774-2783
6 Ermert D, Blom AM. C4b-binding protein: the good, the bad and the deadly. Novel functions of an old friend. Immunol Lett 2016; 169: 82-92
7 Blom AM, Villoutreix BO, Dahlbäck B. Complement inhibitor C4b-binding protein-friend or foe in the innate immune system?. Mol Immunol 2004; 40 (18) 1333-1346
8 Nelson RM, Long GL. Binding of protein S to C4b-binding protein. Mutagenesis of protein S. J Biol Chem 1992; 267 (12) 8140-8145
9 García de Frutos P, Alim RI, Härdig Y, Zöller B, Dahlbäck B. Differential regulation of alpha and beta chains of C4b-binding protein during acute-phase response resulting in stable plasma levels of free anticoagulant protein S. Blood 1994; 84 (03) 815-822
10 Dahlbäck B. C4b-binding protein: a forgotten factor in thrombosis and hemostasis. Semin Thromb Hemost 2011; 37 (04) 355-361
11 Hessing M. The interaction between complement component C4b-binding protein and the vitamin K-dependent protein S forms a link between blood coagulation and the complement system. Biochem J 1991; 277 (Pt 3): 581-592
12 Schwalbe R, Dahlbäck B, Hillarp A, Nelsestuen G. Assembly of protein S and C4b-binding protein on membranes. J Biol Chem 1990; 265 (27) 16074-16081
13 Trouw LA, Bengtsson AA, Gelderman KA, Dahlbäck B, Sturfelt G, Blom AM. C4b-binding protein and factor H compensate for the loss of membrane-bound complement inhibitors to protect apoptotic cells against excessive complement attack. J Biol Chem 2007; 282 (39) 28540-28548
14 Webb JH, Blom AM, Dahlbäck B. Vitamin K-dependent protein S localizing complement regulator C4b-binding protein to the surface of apoptotic cells. J Immunol 2002; 169 (05) 2580-2586
15 Mohlin FC, Mercier E, Fremeaux-Bacchi V. et al. Analysis of genes coding for CD46, CD55, and C4b-binding protein in patients with idiopathic, recurrent, spontaneous pregnancy loss. Eur J Immunol 2013; 43 (06) 1617-1629
16 Buil A, Trégouët D-A, Souto JC. et al. C4BPB/C4BPA is a new susceptibility locus for venous thrombosis with unknown protein S-independent mechanism: results from genome-wide association and gene expression analyses followed by case-control studies. Blood 2010; 115 (23) 4644-4650
17 Bertina RM, van Wijngaarden A, Reinalda-Poot J, Poort SR, Bom VJ. Determination of plasma protein S--the protein cofactor of activated protein C. Thromb Haemost 1985; 53 (02) 268-272
18 Takahashi H, Tatewaki W, Wada K, Shibata A. Plasma protein S in disseminated intravascular coagulation, liver disease, collagen disease, diabetes mellitus, and under oral anticoagulant therapy. Clin Chim Acta 1989; 182 (02) 195-208
19 Takahashi H, Wada K, Hayashi S, Hanano M, Tatewaki W, Shibata A. Behavior of protein S during long-term oral anticoagulant therapy. Thromb Res 1988; 51 (03) 241-249
20 Zöller B, García de Frutos P, Dahlbäck B. Evaluation of the relationship between protein S and C4b-binding protein isoforms in hereditary protein S deficiency demonstrating type I and type III deficiencies to be phenotypic variants of the same genetic disease. Blood 1995; 85 (12) 3524-3531
21 Carlsson S, Dahlbäck B. Dependence on vitamin K-dependent protein S for eukaryotic cell secretion of the beta-chain of C4b-binding protein. J Biol Chem 2010; 285 (42) 32038-32046
22 Idborg H, Zandian A, Sandberg A-S. et al. Two subgroups in systemic lupus erythematosus with features of antiphospholipid or Sjögren's syndrome differ in molecular signatures and treatment perspectives. Arthritis Res Ther 2019; 21 (01) 62
23 Tan EM, Cohen AS, Fries JF. et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982; 25 (11) 1271-1277
24 Marks SD, Pilkington C, Woo P, Dillon MJ. The use of the British Isles Lupus Assessment Group (BILAG) index as a valid tool in assessing disease activity in childhood-onset systemic lupus erythematosus. Rheumatology (Oxford) 2004; 43 (09) 1186-1189
25 Gustafsson JT, Herlitz Lindberg M, Gunnarsson I. et al. Excess atherosclerosis in systemic lupus erythematosus,-A matter of renal involvement: case control study of 281 SLE patients and 281 individually matched population controls. PLoS One 2017; 12 (04) e0174572
26 Pengo V, Ruffatti A, Legnani C. et al. Clinical course of high-risk patients diagnosed with antiphospholipid syndrome. J Thromb Haemost 2010; 8 (02) 237-242
27 Sandholm K, Persson B, Skattum L. et al. Evaluation of a novel immunoassay for quantification of C1q for clinical diagnostic use. Front Immunol 2019; 10: 7
28 Johnson U, Truedsson L, Gustavii B. Complement components in 100 newborns and their mothers determined by electroimmunoassay. Acta Pathol Microbiol Immunol Scand C 1983; 91 (02) 147-150
29 Vanderweele TJ, Vansteelandt S. Conceptual issues concerning mediation, interventions and composition. Stat Interface 2009; 2 (04) 457-468
30 Arvieux J, Pernod G, Regnault V, Darnige L, Garin J. Some anticardiolipin antibodies recognize a combination of phospholipids with thrombin-modified antithrombin, complement C4b-binding protein, and lipopolysaccharide binding protein. Blood 1999; 93 (12) 4248-4255
31 Guerin JSR, Feighery C, Jackson J. Antibody recognition of complement regulatory proteins, factor H, CR1 and C4BP in antiphospholipid syndrome patients. Lupus 1998; A031: S180
32 Atsumi T, Khamashta MA, Ames PR, Ichikawa K, Koike T, Hughes GR. Effect of beta 2glycoprotein I and human monoclonal anticardiolipin antibody on the protein S/C4b-binding protein system. Lupus 1997; 6 (04) 358-364
33 Pengo V, Ruffatti A, Legnani C. et al. Incidence of a first thromboembolic event in asymptomatic carriers of high-risk antiphospholipid antibody profile: a multicenter prospective study. Blood 2011; 118 (17) 4714-4718
34 Oku K, Atsumi T, Bohgaki M. et al. Complement activation in patients with primary antiphospholipid syndrome. Ann Rheum Dis 2009; 68 (06) 1030-1035
35 Breen KA, Seed P, Parmar K, Moore GW, Stuart-Smith SE, Hunt BJ. Complement activation in patients with isolated antiphospholipid antibodies or primary antiphospholipid syndrome. Thromb Haemost 2012; 107 (03) 423-429
36 Fair DS, Revak DJ. Quantitation of human protein S in the plasma of normal and warfarin-treated individuals by radioimmunoassay. Thromb Res 1984; 36 (06) 527-535
37 Weiss P, Soff GA, Halkin H, Seligsohn U. Decline of proteins C and S and factors II, VII, IX and X during the initiation of warfarin therapy. Thromb Res 1987; 45 (06) 783-790
38 Tedesco F, Borghi MO, Gerosa M. et al. Pathogenic role of complement in antiphospholipid syndrome and therapeutic implications. Front Immunol 2018; 9: 1388
39 Lim W. Complement and the antiphospholipid syndrome. Curr Opin Hematol 2011; 18 (05) 361-365
40 Fischetti F, Durigutto P, Pellis V. et al. Thrombus formation induced by antibodies to beta2-glycoprotein I is complement dependent and requires a priming factor. Blood 2005; 106 (07) 2340-2346
41 Svenungsson E, Gustafsson JT, Grosso G. et al. Complement deposition, C4d, on platelets is associated with vascular events in systemic lupus erythematosus. Rheumatology 2020; 59 (11) 3264-3274
42 Petri MA, Conklin J, O'Malley T, Dervieux T. Platelet-bound C4d, low C3 and lupus anticoagulant associate with thrombosis in SLE. Lupus Sci Med 2019; 6 (01) e000318
43 Tektonidou MG, Andreoli L, Limper M. et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019; 78 (10) 1296-1304
44 Maurissen LFA, Thomassen MCLGD, Nicolaes GAF. et al. Re-evaluation of the role of the protein S-C4b binding protein complex in activated protein C-catalyzed factor Va-inactivation. Blood 2008; 111 (06) 3034-3041
45 Gross P, Ecker EE. Anticomplementary action of purified heparin. Proc Soc Exp Biol Med 1929; 26 (06) 508-509
46 Kazatchkine MD, Fearon DT, Metcalfe DD, Rosenberg RD, Austen KF. Structural determinants of the capacity of heparin to inhibit the formation of the human amplification C3 convertase. J Clin Invest 1981; 67 (01) 223-228
47 Weiler JM, Edens RE, Linhardt RJ. et al. Heparin and modified heparin inhibit complement activation in vivo. J Immunol 1992; 148 (10) 3210-3215
48 Girardi G, Redecha P, Salmon JE. Heparin prevents antiphospholipid antibody-induced fetal loss by inhibiting complement activation. Nat Med 2004; 10 (11) 1222-1226
49 Vargas-Hitos JA, Ateka-Barrutia O, Sangle S, Khamashta MA. Efficacy and safety of long-term low molecular weight heparin in patients with antiphospholipid syndrome. Ann Rheum Dis 2011; 70 (09) 1652-1654
50 Shapira I, Andrade D, Allen SL, Salmon JE. Brief report: induction of sustained remission in recurrent catastrophic antiphospholipid syndrome via inhibition of terminal complement with eculizumab. Arthritis Rheum 2012; 64 (08) 2719-2723

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