It is abt antiphospholipid antibody syndrome.

2. Antiphospholipid syndrome was
described in full in the 1980s, after
various previous reports of specific
antibodies in people with systemic lupus
"Hughes”
erythematosus and thrombosis.
The syndrome is sometimes referred to as "Hughes syndrome",
after the rheumatologist Dr. Graham R.V. Hughes who worked
at the Louise Coote Lupus Unit at St Thomas' Hospital in London
and played a central role in the description of the condition.

3. • In young,app healthy people---for LA, antiCL is 1-5%
• Prevalence ↑ with age ,in elderly with chronic disease.
• Mean age of onset-31 yrs,Low age 8 months
• Risk of thrombosis is 0.5-30%
• Women :men is 5:1
• Females---arthritis,livedo,migraine
• Males—MI,epilepsy,lower extremity arterial thrombosis
• More common in african americans.
• Without rheumatic disease at younger age and
with rh –older
• Apl ab—30-40% in SLE---10% have APLS
• Idiopathically—ACL-24%,LA-4%

4. Antiphospholipid syndrome or antiphospholipid antibody
syndrome (APS or APLS or), often also Hughes syndrome,
is an autoimmune, hypercoagulable state caused by antibodies
against cell-membrane phospholipids that provokes blood clots
(thrombosis) in both arteries and veins as well as
pregnancy-related complications such as
miscarriage, stillbirth, preterm delivery, or severe preeclampsia.
The syndrome occurs due to the autoimmune production of
antibodies against phospholipid (aPL), a cell membrane substanc
In particular, the disease is characterised by antibodies against
cardiolipin (anti-cardiolipin antibodies) and β2 glycoprotein I.

5. Risk factors for developing antiphospholipid syndrome include:
•Primary APS
genetic marker HLA-DR7
•Secondary APS
SLE or other autoimmune disorders
Genetic markers: HLA-B8, HLA-DR2, HLA-DR3
Race: Blacks, Hispanics, Asians, and Native Americans

6. Disruption of vascular endothelial lining allows exposure of blood
to subendothelial connective tissue:
Primary hemostasis (seconds)
- Platelet plug formation at site of injury
- Stops bleeding from capillaries, small
arterioles and venules
Secondary hemostasis (minutes)
- Fibrin formation by reactions of
the plasma coagulation system

7. Defects in primary hemostasis
• Thrombocytopenia
Defects in secondary
hemostasis
• Clotting factor deficiencies
• Prethrombotic
(hypercoagulable) states

8. • Inherited
• Acquired

9. • Anti-thrombin deficiency
• Deficiencies of protein C and S
• Resistance to activated protein C
•( factor V Leiden mutation)
• Prothombin gene mutation Conditions associated with a hypercoagulable
state:
• ( G20210A) - pregnancy and postpartum
- major surgery
Homocystinemia - obesity and immobility
- malignancy
- congestive heart failure
- nephrotic syndrome
Estrogen treatment
Antiphospholipid syndrome

10. Antiphospholipid syndrome is an autoimmune disease, in which
"antiphospholipid antibodies" :
1.anticardiolipin antibodies (ACA)
2. lupus anticoagulant(LA)
react against proteins that bind to anionic phospholipids on
plasma membranes.
ACA– are directed against cardiolipin
They may be b2 gp1 dependent or independent
(Independent—syphilis)

11. • B2 gp1-----apolipoprotein H
• Bind with cardiolipin ab - thrombosis
• 2GPI a plasma protein with affinity for negatively charged
phospholipids
• anti- 2GPI: are probably the major cause of APS
• Anticardiolipn abs recognize in most assays: 2 GPI
• Lupus Anticoagulant activity is caused by autoantibodies to:
- 2 GPI
- prothrombin

12. Anionic phospholipids
The exact cause is not known, but
activation of the system of coagulation is
evident.

14. • Homeostatic regulation of blood coagulation is altered.
• 1.defect in cellular apoptosis- exposure of membrane phospholipids to
the binding of various plasma proteins---b2gp1---complex—epitope---target for
autoantibodies.
• 2.oxidized b2GP1---activates dendritic cells –autoantibodies are produced.
• 3.production of antibodies against prothrombin, proteinC, S annexins.
• 4.activation of platelets to enhance endothelial adherence.
• 5.activation of vascular endothelium—platelet and monocyte binding.
• 6.ab against oxidized LDL — atherosclerosis.

15. • Complement activation has been increasingly recognised as a possible significant
role in the pathogenesis of APS.
Blood. Jan 15 2007;109(2):422-30.
Nat Med. Nov 2004;10(11):1222-6.
The family of APL ab are heterogenous and the targets vary.
APS can be caused by –LA,ACA,B2GP1 or other antibodies.
There are distinct clinical ,laboratory and biochemical differences
between the disorders mediated by the different antibodies.
ACL---risk of stroke—arterial thrombosis
LA-venous
TNF alpha –pregnancy loss

16. Coagulation pathway
Annexin ˅

17. Clinically important antiphospholipid antibodies (those that
arise as a result of the autoimmune process) are associated
with thrombosis and vascular disease.
The syndrome can be divided into primary (no underlying
disease state) and secondary (in association with an underlying
disease state) forms.
Anti-ApoH and a subset of anti-cardiolipin antibodies bind to ApoH,
which in turn inhibits Protein C, a glycoprotein with regulatory
function upon the common pathway of coagulation (by degradating
activated factor V).

18. LAC antibodies bind to prothrombin , thus increasing its cleavage to
thrombin, its active form .
In APS there are also antibodies binding to: Protein S, which is
a co-factor of protein C.
Thus, anti-protein S antibodies decrease protein C efficiency;
Annexin A5, which forms a shield around negatively-charged
phospholipid molecules, thus reducing their availability for
coagulation.
Thus, anti-annexin A5 antibodies increase phospholipid-
dependent coagulation steps.

19. The Lupus anticoagulant antibodies are those that show the
closest association with thrombosis, those that target
β2glycoprotein 1 have a greater association with thrombosis
than those that target prothrombin.
Anticardiolipin antibodies are
associated with thrombosis
at moderate to high titres
(>40 GPLU or MPLU).
Patients with both Lupus anticoagulant antibodies and
moderate/high titre anticardiolipin antibodies show a greater risk
of thrombosis than with one alone .

20. APL antibodies and NF- B
• Intracellular events in EC induced
by aPL antibodies:
– aPL induce activation of
NF- B and correlates with
EC activation in vitro and
in vivo and with
thrombosis in vivo.
• Espinola RG et al: J Thromb Haemost, 2003; 1: 843-848.
• Dunoyer-Geindre S. et al. Thromb Haemost. 2002; 88:
851-857.
• Bohgaki M, et al. Int Immunol. 2004; 16: 1632-1641.

21. pathogenesis

22. In pregnancy

23. is characterized by:
• Arterial or Venous Thrombosis
• Thrombocytopenia
• Recurrent Fetal Loss
• Serum Anti-phospholipid antibodies (aPL)

24. 1. Primary antiphospholipid syndrome
APS occurs in the absence of any other related disease.
2. Secondary antiphospholipid syndrome
APS occuring in the context of other autoimmune
diseases, such as systemic lupus erythematosus (SLE).
3. Catastrophic antiphospholipid syndrome
In rare cases, APS leads to rapid organ failure due to
generalised thrombosis; this is termed (CAPS) and is
associated with a high risk of death.

25. • Venous thromboembolism:
Arterial Occlusion:
Deep Vein Thrombosis Stroke and TIAs are
the most common
Pulmonary Embolism

26. • Pregnancy morbidity
Recurrent fetal loss
• In women with recurrent miscarriage due to APS
fetal loss rate: as high as 90%
• antiphospholipid abs are associated with:
- placental insufficiency
- early preeclamapsia
- IUGR- intrauterine growth restriction

28. Sydney revsion of Sapporo criteria 2006
aPL associated manifestations
(individual diagnosis)
• Thrombocytopenia (occurs in
up to 50%)
• Cardiac valve disease
• Livedo reticularis
• Nephropathy ( late
manifestation)
Livedo reticularis with necrotic finger tips
in Antiphospholipid syndrome

29. not included in criteria
• Transverse myelitis
• Migraine
• Chorea
• Leg ulcers
• UBOs (white matter lesions) on brain MRI

30. • Infection:
- Syphilis, TB, Q-fever, Spotted Fever, Klebsiella, HCV,
Leprosy,HIV.
- The abs are usually transient, not 2 GPI dependent
• Malignancy:
Lymphoma, paraproteinemia
• Drug induced:
phenothiazines, procainamide, quinidine, phenytoin,
hydralazine

31. Common auto immune diseases ass with APL ab are
• 1.SLE-25-50%
• 2.sjogren‘s –42%
• 3.RA-33%
• 4.AITP-30%
• 5.AIHA-unknown
• 6.MCD-22%
• 7.behcet-20%

33. • Spontaneous venous thromboembolism
• Recurrent VT, even in presence of other risk factors
• Stroke or peripheral arterial occlusive event at < 50 yrs
• In all SLE patients
• In women with > 3 consecutive pregnancy losses
loss of morphologically normal fetus at II-III trimester
early severe preeclampsia
low prevalence in general obstetric
severe placental insufficiency
population (< 2% ): screening not warranted

34. • APA---IgG,IgA,IgM
• SEVERAL antibodies are recognised
• Recently—antibodies against annexin V,protein C
• IgM acl---HEMOLYTIC ANEMIA.
• IgG ACL –thrombosis
• False positive test result for syphilis
• ACL—membrane phospholipids
• LA-plasma coagulation molecules
• Elongates APTT,Kaolin clotting time,dilute russells viper venom
time.

35. • Advantages
– Overwhelming majority of APS patients are anti cardiolipin positive
– Test can be performed reproducibly.
– Clinicians and laboratories generally familiar with units of
measurement.
• Disadvantages
– Relatively nonspecific (particularly low positive, IgM positive).
– Intra-laboratory and Inter-laboratory variability.
– Problems with false positive results: aCL positive in a wide variety of
infectious diseases and in non-APS related autoimmune diseases.

36. Solid phase assays usually anti-Cardiolipin abs

37. Predictive value of IgG aCL for thrombosis in
patients with SLE
• IgG aCL levels below 21.4 = probability of thrombosis 0.07
• IgG aCL levels >21.4 and < 65.0 GPL = probability of thrombosis
0.20
• IgG aCL levels >65.1 GPL units = probability of thrombosis 0.75

38. • Perform coagulation screen to detect prolongation
in phospholipid dependent coagulation assay (usually use: APTT)
• If APTT is prolonged: Mix with normal plasma
- If due to factor deficiency: corrected
- If due to inhibitor (antibody) not corrected
• Confirm inhibitor is phospholipid dependent :
corrected by mixing with platelets or phospholipids
• Perform second test: KCT or DRVVT

39. No LAC shows 100% specificity and
sensitivity because aPLs are
• APTT: heterogeneous.
- variability in reagents result in
More than 1 test system is needed
inconsistent sensitivity.
- acute phase reaction and pregnancy may shorten APTT and
mask
a weak LAC
A normal APTT does not exclude LAC
• KCT- Kaolin clotting time
more sensitive to presence of anti-II
• DRVVT- Dilute Russell‘s viper venom time
more sensitive to presence of 2 GPI
• TTI - Tissue thromboplastin inhibition test

40. Diluted Russells viper venom test

41. Kaolin clotting test

42. Principle
• Based on observation that antiphospholipid antibodies cross-
react with negatively charged phospholipids but syphilis and
other infectious diseases sera largely limited to cardiolipin
binding (no cross-reactivity)
• Construction of a kit with negatively charged phospholipids
might eliminate non-specific binding.
• Antigen composed of mixture of phospholipids instead of cardiolipin
• Sensitivity of APS (greater than 90%)
• More specific than anticardiolipin test and at least as specific (or
more) compared to anti-ß2GPI
• Incorporation of an in-house positive control
• Can be utilized for first line testing, and certainly important in
confirmation of APS

43. Patient Laboratory Data
PT 20.6 sec aPTT 100.3
sec
TCT 8.8 sec DRVVT „No clot‟
Factor „Inhibitory‟ Factor IX <1.6%
VIII
Factor XI <1.6% Bethesda 2.8 U
titer
Platelets 120,000/ Factor X 68%
l

44. Additional Laboratory Data
Factor V (aPTT) “Inhibitory”
Factor V (PT) 115%
Factor II 38%
Fibrinogen 795.6 mg/dl
D-dimer >4.37 mcg
FEU/ml
Repeat DRVVT (ratio) 3.23
DRVVT Confirm (ratio) 2.17

45. Alternative strategies to
identify a lupus anticoagulant
• Platelet neutralization procedure (PNP; uses platelet
membranes).
• Hexagonal phase phospholipid assay (StaClot LA; uses PE
in a hexagonal phase conformation).
• Textarin/Ecarin clot time.
• Factor V analysis by PT and aPTT-based assays.

46. What if LA,ACL are negative
• If patient experiencing thrombosis or recurrent miscarriages
• Order
• Antibodies to b2 gp1
• Ab to phosphatidyl serine,ethonalamine,glycerol,inositol
• Annexin V
• Phosphatidyl choline.

47. Imaging studies
• For confirmation
• USG
• COLOR DOPPLER
• CT SCAN
• MRI
• 2D ECHO
• Histology----
• non inflammatory bland thrombosis with no signs of perivascular
inflammation or leukocytoclastic vasculitis.

48. • Lupus anticoagulant detected and confirmed.
• Multiple factor deficiencies in aPTT pathway
reflect high-titer lupus anticoagulant.
• Prolonged PT reflects mild factor II deficiency
and lupus anticoagulant effect.
• Elevated D-dimer reflects recent thrombosis.
• Elevated inhibitor titer due to lupus
anticoagulant.

49. DIFFERENTIAL DIAGNOSIS
• Think of any other thrombophilic states before
making a diagnosis of APLS.
• Malignancy
• OCP
• Homocysteinemia
• Antithrombin 111 def
• Protein C,S def
• Factor V leiden mutation

51. Incidental finding of antiphospholipid antibodies
• Anti-thrombotic therapy not usually indicated
• Low threshold for thromboprophylaxis at times of
high risk
• Some suggest low dose Aspirin prophylaxis
• Reduce other risk factors for thrombosis

52. INR
• The ISI—1.0-2.0
• INR—5 high chance of bleeding
• 0.5--- clot formation
• Normal range is 0.9-1.3
• Warfarin ---2.0-3.0
• Prosthetic valves—3.0-4.0

53. Prophylactic therapy
• Eliminate other risk factors, such as oral contraceptives,
smoking, hypertension, or hyperlipidemia.
• Low-dose aspirin is used widely in this setting; however, the
effectiveness of low-dose aspirin as primary prevention for
APS remains unproven.
• Clopidogrel has anecdotally been reported to be helpful in
persons with APS and may be useful in patients allergic to
aspirin.
• In patients with SLE, consider hydroxychloroquine, which
may have intrinsic antithrombotic properties.
•Consider the use of statins, especially in patients with
hyperlipidemia.

54. Thrombosis
• Perform full anticoagulation with intravenous or subcutaneous
heparin followed by warfarin therapy.
• Based on the most recent evidence, a reasonable target for the
international normalized ratio (INR) is 2.0-3.0 for venous thrombosis
and 3.0 for arterial thrombosis.
• Patients with recurrent thrombotic events, while well maintained
on the above regimens, may require an INR of 3.0-4.0.
• For severe or refractory cases, a combination of warfarin and
aspirin may be used.
•Treatment for significant thrombotic events in patients with APS is
generally lifelong.

58. • Mild to moderate- Platelets > 50,000:
No treatment
• Severe- <50,000:
- corticosteroids
- corticosteroid resistant cases:
HCQ , IVIG, Immunosuppressive drugs,
Splenectomy

59. Management of aPL positive patients with
adverse pregnancy history
• Poor obstetric history - the most important
predictor
• The risk of fetal loss is related to aCL ab titer
• Presence of aPL are a marker for a high risk
pregnancy
• Once APS is diagnosed, serial aPL testing is not
useful

60. Current Recommendations
Pregnancy Fetal protection
• Asymptomatic aPL no treatment
• Single loss <10wks no treatment
• Recurrent loss* <10wks prophylactic heparin +ASA
up to 6-12 wks postpartum, ASA
after(?)
• Recurrent loss < 10 wks therapeutic heparin + ASA,
+ thrombosis warfarin postpartum
• Prior thrombosis therapeutic heparin + ASA
warfarin postpartum
* Late fetal loss
IUGR
severe pre-
eclampsia

61. Other therapies for aPL associated pregnancy loss
• Corticosteroids :
- associated with significant maternal and fetal morbidity
- ineffective
• Immunosuppression:
azathioprine, plasmapheresis:
numbers treated too small for conclusion
• IVIG:
may be salvage therapy in women who fail on
Heparin + Aspirin

62. Fetal Monitoring
• US monitoring of fetal growth and amniotic fluid
every 4 weeks
• US monitoring of uteroplacental blood flow:
uterine artery waveforms assessed at 20-24 wks
• If early diastolic notch seen: do 2 weekly growth
scans due to high risk of IUGR

63. FOLLOW UP
• Frequent check ups
• Adequate patient education
• Avoidance of smoking
• Strict control with anticoagulants.
• In case of bleeding –hospital.
• Normal healthy life

65. Prognosis
With appropriate medication and lifestyle modifications, most
individuals with primary antiphospholipid syndrome (APS) lead
normal healthy lives.
However, subsets of patients continue to have thrombotic events
despite aggressive therapies. In these patients and in patients with
CAPS, the disease course can be devastating, often leading to
significant morbidity or early death.
A retrospective study suggested that hypertension or medium-to-high
titers of IgG anticardiolipin antibody are risk factors for a first
thrombotic event in asymptomatic patients with antiphospholipid
(aPL) antibodies.[18] Primary prophylaxis against thrombosis appears
to offer significant protection in such cases.

66. Patients with secondary APS carry a prognosis similar to
that of patients with primary APS; in the former, however,
morbidity and mortality may also be influenced by these
patients' underlying autoimmune or rheumatic condition. In
patients with SLE and APS, aPL antibodies have been
associated with neuropsychiatric disease and have been
recognized as a major predictor of irreversible organ
damage.
Women with aPL antibodies who experience recurrent
miscarriages may have favorable prognoses in subsequent
pregnancies if treated with aspirin and heparin.

67. Future Directions
• Can we predict which patients with
antiphospholipid antibodies will develop
thromboembolic complications?
• Is there an inherited predisposition to
developing antiphospholipid antibody
syndrome?

68. Genomic strategy
• Whole blood RNA prepared using PAXgene
system from patients with APS and selected
control populations.
• RNA extracted and validated.
• Oligonucleotide arrays printed at the Duke
Microarray Facility, using the Operon Human
Genome Oligo Set Version 3.0 (Operon,
Huntsville, AL).
-- Potti, et al., Blood, 2006; 107: In press.

69. Discovery Mode
Preliminary data with patients and ‗controls‘
Controls with VTE APS aPLA Normal
Up regulated Down regulated
-- Potti, et al., Blood, 2006; 107: 1391.

70. Family history
Mother developed arterial
thrombosis and thrombocytopenia
prior to her death.
Asymptomatic
daughter tests
positive for a
lupus
anticoagulant.

71. Familial Antiphospholipid Syndrome
• Family members of patients with APS have an
increased incidence of autoimmune disorders.
• ―Genetics of APS‖ is a clinical trial being
developed by the Rare Thrombotic Diseases
Clinical Research Consortium.