Clinical Rheumatology

, Volume 38, Issue 2, pp 371–378 | Cite as

Added value of non-criteria antiphospholipid antibodies for antiphospholipid syndrome: lessons learned from year-long routine measurements

  • Polona ŽigonEmail author
  • Anuška Podovšovnik
  • Aleš Ambrožič
  • Matija Tomšič
  • Alojzija Hočevar
  • Nataša Gašperšič
  • Žiga Rotar
  • Sonja Praprotnik
  • Snežna Sodin Šemrl
  • Saša Čučnik
Original Article
Part of the following topical collections:
  1. Rheumatology in Slovenia: Clinical practice and translational research


The international classification criteria for definite antiphospholipid syndrome (APS) include three laboratory measurements: lupus anticoagulant (LA), IgG and IgM isotypes of anti-cardiolipin (aCL) and anti-β2glycoprotein I antibodies (anti-β2GPI). When persistently elevated, they are specific for APS; however, many patients that fulfil clinical criteria may exhibit negative serological results. These “seronegative” APS (SN-APS) are exposed to an increased thrombotic risk. The aims of our cross-sectional, retrospective study of consecutive autoimmune patients’ samples were to evaluate the association of non-criteria antiphospholipid antibodies (aPL) with thrombosis and obstetric events, to calculate the risk score for adverse events and to assess the specific contribution of single aPL positivity in SN-APS. LA, aCL, anti-β2GPI and anti-phosphatidylserine/prothrombin antibodies (aPS/PT) of IgG, IgM, and IgA isotypes were determined in sera of 323 patients with autoimmune disorders. Medical records of all patients were carefully analyzed. aCL, anti-β2GPI and aPS/PT of IgG and IgA isotypes were significantly associated with thrombosis while none of the IgM aPL showed such association. aPS/PT of all isotypes, aCL and anti-β2GPI of IgG and IgA isotype showed significant correlation to obstetric events. When considering results of aPS/PT ELISA, we could additionally identify 3% of thrombotic patients and 2% of obstetric patients. Thrombotic and obstetric risk scores were calculated showing significantly higher association to clinical events, as compared to evaluating individual risk factors. aPS/PT could represent an additional biomarker in SN-APS patients. IgA aPL are associated with thrombosis and obstetric complications. Risk scores accounting different aPL and conventional risk factors, better assesses risk for adverse event, as compared to evaluating individual factors alone.


Antiphospholipid antibodies Antiphospholipid syndrome Antiprothrombin antibodies IgA Obstetric complications Thrombosis 


Compliance with ethical standards

The study was approved by the National Medical Ethics Committee, Ljubljana, Slovenia (#99/04/15), and all patients provided informed consent. We confirm that all experiments were performed in accordance with relevant guidelines and regulations.




  1. 1.
    Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RH, De Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA (2006) International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). JThrombHaemost 4(2):295–306CrossRefGoogle Scholar
  2. 2.
    Hughes GR, Khamashta MA (2003) Seronegative antiphospholipid syndrome. Ann Rheum Dis 62(12):1127CrossRefGoogle Scholar
  3. 3.
    Bertolaccini ML, Amengual O, Atsumi T, Binder WL, de LB FR, Kutteh WH, Lambert M, Matsubayashi H, Murthy V, Petri M, Rand JH, Sanmarco M, Tebo AE, Pierangeli SS (2011) ‘Non-criteria’ aPL tests: report of a task force and preconference workshop at the 13th International Congress on Antiphospholipid Antibodies, Galveston, TX, USA, April 2010. Lupus 20(2):191–205CrossRefGoogle Scholar
  4. 4.
    Zohoury N, Bertolaccini ML, Rodriguez-Garcia JL, Shums Z, Ateka-Barrutia O, Sorice M, Norman GL, Khamashta M (2017) Closing the serological gap in the antiphospholipid syndrome: the value of “non-criteria” antiphospholipid antibodies. J Rheumatol 44(11):1597–1602. CrossRefGoogle Scholar
  5. 5.
    Zigon P, Ambrozic A, Cucnik S, Kveder T, Rozman B, Bozic B (2011) Modified phosphatidylserine-dependent antithrombin ELISA enables identification of patients negative for other antiphospholipid antibodies and also detects low avidity antibodies. Clin Chem Lab Med 49(6):1011–1018CrossRefGoogle Scholar
  6. 6.
    Zigon P, Cucnik S, Ambrozic A, Kveder T, Semrl SS, Rozman B, Bozic B (2013) Detection of antiphosphatidylserine/prothrombin antibodies and their potential diagnostic value. Clin Dev Immunol 2013:8–8. CrossRefGoogle Scholar
  7. 7.
    Zigon P, Cucnik S, Ambrozic A, Sodin Semrl S, Kveder T, Bozic B (2012) Antibodies to phosphatidylserine/prothrombin complex as an additional diagnostic marker of APS? Lupus 21(7):790–792. CrossRefGoogle Scholar
  8. 8.
    Zigon P, Perdan Pirkmajer K, Tomsic M, Kveder T, Bozic B, Sodin Semrl S, Cucnik S, Ambrozic A (2015) Anti-phosphatidylserine/prothrombin antibodies are associated with adverse pregnancy outcomes. J Immunol Res 2015:975704–975708. CrossRefGoogle Scholar
  9. 9.
    Ciesla M, Wypasek E, Undas A (2014) IgA antiphospholipid antibodies and anti-domain 1 of Beta 2 glycoprotein 1 antibodies are associated with livedo reticularis and heart valve disease in antiphospholipid syndrome. Adv Clin Exp Med 23(5):729–733CrossRefGoogle Scholar
  10. 10.
    Hood DB, Snyder KR, Buckner TR, Hurley BL, Pitts KR, Lopez LR (2015) Differential assay reactivity of immunglobulin a anti-beta(2) glycoprotein I antibodies: implications for the clinical interpretation of antiphospholipid antibody testing. Eur J Rheumatol 2(4):135–138. CrossRefGoogle Scholar
  11. 11.
    Mavropoulos A, Sully G, Cope AP, Clark AR (2005) Stabilization of IFN-gamma mRNA by MAPK p38 in IL-12- and IL-18-stimulated human NK cells. Blood 105(1):282–288. CrossRefGoogle Scholar
  12. 12.
    Meijide H, Sciascia S, Sanna G, Khamashta MA, Bertolaccini ML (2013) The clinical relevance of IgA anticardiolipin and IgA anti-beta2 glycoprotein I antiphospholipid antibodies: a systematic review. Autoimmun Rev 12(3):421–425. CrossRefGoogle Scholar
  13. 13.
    Despierres L, Beziane A, Kaplanski G, Granel B, Serratrice J, Cohen W, Bretelle F, Rossi P, Morange PE, Weiller PJ, Robert Harle J, Bongrand P, Bardin N (2014) Contribution of anti-beta2glycoprotein I IgA antibodies to the diagnosis of anti-phospholipid syndrome: potential interest of target domains to discriminate thrombotic and non-thrombotic patients. Rheumatology (Oxford) 53(7):1215–1218. CrossRefGoogle Scholar
  14. 14.
    Paulmyer-Lacroix O, Despierres L, Courbiere B, Bardin N (2014) Antiphospholipid antibodies in women undergoing in vitro fertilization treatment: clinical value of IgA anti-beta2glycoprotein I antibodies determination. Biomed Res Int 2014:314704–314705. CrossRefGoogle Scholar
  15. 15.
    Andreoli L, Fredi M, Nalli C, Piantoni S, Reggia R, Dall'Ara F, Franceschini F, Tincani A (2013) Clinical significance of IgA anti-cardiolipin and IgA anti-beta2glycoprotein I antibodies. Curr Rheumatol Rep 15(7):343. CrossRefGoogle Scholar
  16. 16.
    Otomo K, Atsumi T, Amengual O, Fujieda Y, Kato M, Oku K, Horita T, Yasuda S, Koike T (2012) Efficacy of the antiphospholipid score for the diagnosis of antiphospholipid syndrome and its predictive value for thrombotic events. Arthritis Rheum 64(2):504–512. CrossRefGoogle Scholar
  17. 17.
    Sciascia S, Sanna G, Murru V, Roccatello D, Khamashta MA, Bertolaccini ML (2013) GAPSS: the global anti-phospholipid syndrome score. Rheumatology (Oxford) 52(8):1397–1403. CrossRefGoogle Scholar
  18. 18.
    Oku K, Amengual O, Bohgaki T, Horita T, Yasuda S, Atsumi T (2015) An independent validation of the global anti-phospholipid syndrome score in a Japanese cohort of patients with autoimmune diseases. Lupus 24(7):774–775. CrossRefGoogle Scholar
  19. 19.
    Zuily S, de Laat B, Mohamed S, Kelchtermans H, Shums Z, Albesa R, Norman GL, Lamboux-Matthieu C, Rat AC, Ninet J, Magy-Bertrand N, Pasquali JL, Lambert M, Lorcerie B, Kaminsky P, Guillemin F, Regnault V, Wahl D (2015) Validity of the global anti-phospholipid syndrome score to predict thrombosis: a prospective multicentre cohort study. Rheumatology (Oxford) 54(11):2071–2075. CrossRefGoogle Scholar
  20. 20.
    Zigon P, Ambrozic A, Cucnik S, Kveder T, Rozman B, Bozic B (2011) Modified phosphatidylserine-dependent antiprothrombin ELISA enables identification of patients negative for other antiphospholipid antibodies and also detects low avidity antibodies. Clin Chem Lab Med 49(9):1573CrossRefGoogle Scholar
  21. 21.
    Bozic B, Kveder T, Stegnar M, Morosini-Berus E, Kos-Golja M, Peternel P, Rozman B (1997) Influence of degraded phosphatidylserine on binding of antiphospholipid antibodies. IntArchAllergy Immunol 112(1):19–26CrossRefGoogle Scholar
  22. 22.
    Čučnik S, Krizaj I, Rozman B, Kveder T, Božič B (2004) Concomitant isolation of protein C inhibitor and unnicked beta2-glycoprotein I. ClinChemLab Med 42(2):171–174Google Scholar
  23. 23.
    Reber G, Schousboe I, Tincani A, Sanmarco M, Kveder T, De MP, Boffa MC, Arvieux J (2002) Inter-laboratory variability of anti-beta2-glycoprotein I measurement. A collaborative study in the frame of the European forum on antiphospholipid antibodies standardization group. ThrombHaemost 88(1):66–73Google Scholar
  24. 24.
    Chighizola CB, Raschi E, Banzato A, Borghi MO, Pengo V, Meroni PL (2016) The challenges of lupus anticoagulants. Expert Rev Hematol 9(4):389–400. CrossRefGoogle Scholar
  25. 25.
    Mattia E, Ruffatti A, Tonello M, Meneghel L, Robecchi B, Pittoni M, Gallo N, Salvan E, Teghil V, Punzi L, Plebani M (2014) IgA anticardiolipin and IgA anti-beta2 glycoprotein I antibody positivity determined by fluorescence enzyme immunoassay in primary antiphospholipid syndrome. Clinical chemistry and laboratory medicine : CCLM / FESCC 52:1329–1333. CrossRefGoogle Scholar
  26. 26.
    Sciascia S, Sanna G, Murru V, Roccatello D, Khamashta MA, Bertolaccini ML (2013) Anti-prothrombin (aPT) and anti-phosphatidylserine/prothrombin (aPS/PT) antibodies and the risk of thrombosis in the antiphospholipid syndrome: a systematic review. Thrombosis and Haemostasis 111(2):354–364. CrossRefGoogle Scholar
  27. 27.
    Amengual O, Forastiero R, Sugiura-Ogasawara M, Otomo K, Oku K, Favas C, Delgado Alves J, Zigon P, Ambrozic A, Tomsic M, Ruiz-Arruza I, Ruiz-Irastorza G, Bertolaccini ML, Norman GL, Shums Z, Arai J, Murashima A, Tebo AE, Gerosa M, Meroni PL, Rodriguez-Pinto I, Cervera R, Swadzba J, Musial J, Atsumi T (2016) Evaluation of phosphatidylserine-dependent antiprothrombin antibody testing for the diagnosis of antiphospholipid syndrome: results of an international multicentre study. Lupus 26:266–276. CrossRefGoogle Scholar
  28. 28.
    Zigon P, Ambrozic A, Mali P, Tomsic M, Sodin Semrl S, Cucnik S (2017) The prevalence and clinical significance of Iga anti-phosphatidylserine/ prothrombin antibodies in systemic autoimmune diseases. Immunome research 13:130. Google Scholar

Copyright information

© International League of Associations for Rheumatology (ILAR) 2018

Authors and Affiliations

  • Polona Žigon
    • 1
    Email author
  • Anuška Podovšovnik
    • 1
  • Aleš Ambrožič
    • 1
  • Matija Tomšič
    • 1
    • 2
  • Alojzija Hočevar
    • 1
  • Nataša Gašperšič
    • 1
  • Žiga Rotar
    • 1
  • Sonja Praprotnik
    • 1
  • Snežna Sodin Šemrl
    • 1
    • 3
  • Saša Čučnik
    • 1
    • 4
  1. 1.Department of Rheumatology, Immunology LaboratoryUniversity Medical Centre LjubljanaLjubljanaSlovenia
  2. 2.Faculty of MedicineUniversity of LjubljanaLjubljanaSlovenia
  3. 3.Faculty of Mathematics, Natural Sciences and Information TechnologiesUniversity of PrimorskaKoperSlovenia
  4. 4.Faculty of Pharmacy, Chair of Clinical BiochemistryUniversity of LjubljanaLjubljanaSlovenia

Personalised recommendations