Evaluating Antiphospolipid Antibodies as contributors to Thrombotic Vascular Complications in Patients with Type 2 Diabetes Mellitus in Enugu, Nigeria

Author: Agwu O , Nwagha T , Anyim O

Category: Medicinal Article

Abstract:

Background: Vascular thrombotic events complicates uncontrolled type 2 Diabetes Mellitus (T2DM). Antiphospholipid antibodies can cause vascular thrombosis. These present a __doublequotosingdouble hit__doublequotosing of thrombotic events in T2DM. They also affect disease management and prognosis.

Aim: To check serum levels of lupus anti-coagulant (LA) and immunoglobulin Beta - 2 - glycoprotein-1- anticardiolipin antibodies (IgG-B2GPI ACA) in Type 2 DM patients.

Methods: This was a cross-sectional analytical study. We recruited 140 Type 2 DM patients and 70 healthy control subjects. The study centre was the diabetic clinic at University of Nigeria Teaching hospital. Assays for serum levels of LA and IgG__ampersandsignbeta;2GPI-ACA in the subjects were done. UNTH__ampersandsign#39;s institutional ethics committee IEC approved the study.

Results: Prevalence of LA in complicated, uncomplicated T2DM and healthy control subjects were 7.1%, 4.3%,43%. The prevalence of IgG-__ampersandsignbeta;2GP1-ACAwas 4.3% for all the groups. The risk ratio of developing LA__ampersandsign IgG-B2GPI ACA in uncomplicated T2DM patients were 1.3 (95% CI: 0.37- 4.9) and 1.0 (95% CI, 0.20 - 4.78). The RR of complicated T2DM developing LA __ampersandsign IgG-B2GPI ACA 1.67(95% CI: 0.4-6.7) and 1.72 (95% CI: 0.39-7.48). Correlation analysis of LA, IgG-B2GPI-ACAand the presence of vascular complications in T2DM was not significant. P>0.05. Conclusion: There is no causal relationship between APLS antibodies levels and vascular complications in T2DM.

Keywords: Antiphospholipid antibodies, Type 2 Diabetes Mellitus, Vascular thrombosis

Full Text:

Introduction

Antiphospholipid antibodies (APLS) are groups of acquired, different autoimmune antibodies. They react with negatively charged phospholipids (PLs) or proteins associated [1]. with phospholipids or both. Beta - 2 - glycoprotein 1 (__ampersandsignbeta;2GP1), prothrombin and annexin V are the most [2] characterised antigenic targets. Others include activated [3] protein C, thrombin and protein S. Antiphospholipid antibodies (e.g. LA, ACA and a__ampersandsignbeta;2GP1) have immunoglobulin [4,5] G, M and Asubtypes. Immunoglobulin G isotype is the most [6] sensitive in ischaemic thrombosis. . LA is most times associated with ischaemic thrombosis in -vivo. In- vitro, it prolongs phospholipid-dependent coagulation (clot-based) assays. Antiphospholipid antibodies can be persistent or transient. Transient forms feature in infectious diseases (e.g. malaria, hepatitis C) and with ingestion of some drugs (e.g. [7] fansidar, propranolol, hydralazine, chlorpromazine). The combined positivity of LA, ACA, and a__ampersandsignbeta;2GP1 associated with [4] the highest risk of ischaemic thrombosis.

Antiphospholipid antibodies manifest with varying clinical [8] features (arterial, venous or bmbosis. that oth) of throaffect every tissue and organ of the body. Clinical manifestations associated with APLS include thrombocytopenia, diabetes mellitus, adrenal insufficiency, nephropathy, neuropathy, [9,10] hypertension, and retinopathy. Other features include myocardial infarction, transient ischaemic attack (TIA), [11] stroke, and pregnancy morbidities and mortalities. . The persistent level of APLS in association with clinical features describe the phenomenon of antiphospholipid syndrome [12] (APS). Diagnosis is by the presence of a clinical feature and one or more of the APLS persisting on ? two occasions at least [13]. 12 weeks apart.

The type 2 Diabetes Mellitus (T2DM) is another important type of DM. It is due to relative insulin deficiency or insulin [14] resistance or both. It is the most common type. At present, the global burden of DM centres on T2DM, more in those from 20- [15] 79 years of age. Other types of DM are gestational diabetes mellitus, noticed during pregnancy, and those due to specific causes (e.g. drugs, chemicals, genetic defects in insulin action and disease of the exocrine pancreas). In Diabetes mellitus, there are abnormal plasma glucose levels. Diagnosis is fasting plasma glucose ? 126mg/dl (? 7.1mmol/l) on more than one occasion, or random / casual plasma glucose of ? 200mg/dl (? 11.1mmol/l) with symptoms or 2-hour post glucose load with 75gm glucose in 250ml water ? 200mg/dl (? 11.1mmol/l), or [16,17] glycated haemoglobin 1C (HbA1C), ? 6.5%. Diabetes [18] Mellitus is a hypercoagulable and prothrombotic state. An estimate of 40%, and 60% of DM patients will die of kidney and cardiovascular /diseases respectively 14 Newly referred cases already have evidence of microvascular (retinopathy, [19] neuropathy, and nephropathy) complications.

Although there is no established pathophysiology for APLS in predisposing to thrombosis, several hypotheses show the impairment of interaction between anticoagulant factors such as protein C and the phosphatidylserine (PS) surface, with the resultant activated protein C (APC) resistance formation and annexin A5 antithrombotic shielding inhibition effect, through the binding of APLS to the annexin A5. This inhibition results in the inhibition of annexin A5 anticoagulant role on the vascular endothelial cells of the placenta, thus exposing the thrombogenic phospholipid to blood proteins in circulation. These can form thrombosis, ischaemia on the trophoblasts of the placenta with the resultant effect of foetal loss, and [20] stillbirth. Similarly, sustained hyperglycaemia can lead to a series of inter-related alteration that can cause evident endothelial dysfunction and vascular lesions in diabetic [21] subjects.

Studies in Nigeria have shown the association of APLS in [11] [12, 22] healthy state , pregnancy and some disease conditions [23] such as Human-immunodeficiency-virus, and Sickle Cell [7,24] Anaemia (SCA). This study, therefore, seeks to know if DM and APLS can coexist in the same individual and the presence of APLS may aggravate the thrombotic sequelae of DM. This study would provide the much-needed data as well as the platform to recommend routine screening for APLS in T2DM intending to reduce the accompanying incidence of ischaemic thrombotic complications in T2DM.

Methodology

This study was a cross-sectional analytical carried out on subjects with T2DM attending the diabetic clinic of the University of Nigeria Teaching Hospital (UNTH), Ituku – st Ozalla, Enugu, South – East Nigeria between March 1 , 2016 th and September 30 , 2016. We recruited 140 patients with T2DM and 70 healthy control subjects from blood transfusion donor unit of the Department of Haematology and Immunology of UNTH The University of Nigeria teaching hospital is one of the tertiary health institutions in South Eastern Nigeria. A major referral centre for south-eastern and middle belt zones in Nigeria.

With sample frame of diabetic clinic attendees and blood donors during the study period and using systematic sampling technique, sample population chosen consisted of the first of every three diabetic patient clinic attendee and the first of two blood donors. One hundred and forty diabetic patients (grouped into those with and those without vascular complications) and 70 blood donors were recruited for the study.The Lupus anticoagulant (LA) was assayed using commercially Dilute Russell__ampersandsign#39;s Viper Venom Time (DRVVT) reagent for the screening and confirmatory tests, manufactured by Technoclone GmbH, Austria, Vienna. The IgG –__ampersandsignbeta;2GP1 – dependent – Anticardiolipin antibody (ACA), was assayed using ELISA test kit (Anticardiolipin 1gG ELISA kit GWB – 521211, by GenWay Biotech, San Diego, USA), as recommended by the British Committee for Standardization in Haematology (BCSH)2517.

Using this formula

__doublequotosing__doublequotosing

Results:

Socio-Demographic Characteristics:

The mean age in years for complicated T2DM, uncomplicated T2DM and healthy control subjects in years were 59.5(10), 48.8(6.7) and 31.1(10.5) respectively. They were predominantly females 41 (n=70,58.6%) ,36 (n= 70, 51.4%) for both complicated and uncomplicated T2DM but more of males for healthy control 56(n=70,80.0%). See table 1 for other sociodemographic characteristics.

ghhhjk

References:

1.Bick RL. Antiphospholipid thrombosis syndromes. HematolOncolClin North Am 2003; 17 (1): 115 - 147. 2. Ricardo Forastiero. Antigen specificity of Antiphospholipid syndrome - related antiphospholipid antibodies. The Open Autoimmunity Journal 2010; 2:21 - 27 3. Nojima J, Kuratsune H, Suetisa E, FutsukaichiY, Yamanishi H, Machii T et al. Association between β2-glycoprotein I, prothrombin, protein C, protein S and annexin V in patients with systemic lupus erythematosus and thrombotic and thrombocytopenic complications. Clin Chem 2001; 47: 1008 - 1015. 4. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on the update of the classification criteria for the definite antiphospholipid syndrome (APS). J. ThrombHaemost 2006; 4: 295- 306. 5.Shahim M, EL-Diasty MA, Mabed M. Anticardiolipin antibodies in proliferative diabetic retinopathy: An additional risk factor. Saudi Journal of Ophthalmology 2009; 23: 165-169. 6. Erkan D, Barbhaiya M, Georgy D, Sammaritano L, Lockshin M. Moderate versus High titerpersistentlyanticardiolipin antibody-positive patients: are they clinically different and does high titer anti-beta 2- glycoprotein -1 antibody positivity offer additional predictive information? Lupus 2010; 19: 613 - 619. 7. Keeling D, Mackie I, Moore GW, Greer IA, Greaves M. British Committee For standards in Haematology. Guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol 2012; 157: 47 -58. 8. Ricardo Forastiero. Antigen specificity of Antiphospholipid syndrome - related antiphospholipid antibodies. The Open Autoimmunity Journal 2010; 2:21 - 27.