Clinical Information

Antiphospholipid syndrome (APS) has traditionally been described as a systemic autoimmune disease characterized by thrombosis or specific pregnancy-related morbidities associated with persistent documentation of "criterial" antiphospholipid antibody (aPL) tests.(1-2) Based on the 2006 revised Sapporo consensus classification, the "criterial" aPL antibody tests include lupus anticoagulant (LAC), and IgG/IgM antibodies to the cardiolipin (aCL) and beta-2-glyocoprotein I (anti-B2GPI) with all tests carrying equal diagnostic significance for disease.(1) In 2023, the American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) published new classification criteria for APS, which includes an entry criterion of at least one positive aPL antibody test within 3 years of identification of an aPL-associated clinical criterion, followed by additive weighted criteria (score range 1-7 points each) clustered into 6 clinical domains (macrovascular venous thromboembolism, macrovascular arterial thrombosis, microvascular, obstetric, cardiac valve, and hematologic) and 2 laboratory domains (LAC functional coagulation assays and solid-phase enzyme-linked immunosorbent assays [ELISA] for IgG/IgM aCL and/or IgG/IgM anti-B2GPI).(3) Of note, aPL antibodies also occur in patients with autoimmune diseases with significant prevalence in systemic lupus erythematosus (SLE) as well as other clinical manifestations (eg, heart valve disease, livedo reticularis, thrombocytopenia, nephropathy and neurological) often associated with APS.(1-3) Thus, in addition to the 2023 APS classification criteria, the 2012 derivation and validation of the Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE recommends testing for the criteria aPL antibody tests as well as aCL IgA and anti-B2GPI IgA.(4)

B2GPI is a 326-amino acid protein that is synthesized by hepatocytes, endothelial cells, and trophoblast cells.(5) It contains 5 repetitive structures or "sushi domains," termed domain 1 through 5, for a combined molecular weight of 54 kDa.(5-7) Autoantibodies to B2GPI may be detected by solid-phase immunoassays (SPA) and functional coagulation assays. Unlike the LAC, the SPA provides quantitative measurements and antibody isotype class determinations that are important for risk assessment. Immunoassays for the detection and quantification of anti-B2GPI antibodies can be performed using either a composite substrate comprised of B2GPI plus anionic phospholipid (ie, cardiolipin-dependent B2GPI) or B2GPI alone. Antibodies detected using B2GPI substrate without another phospholipid (direct assays) are referred to simply as "anti-B2GPI 1 antibodies." Some anti-B2GPI antibodies are capable of inhibiting clot formation in functional coagulation assays that contain low concentrations of phospholipid cofactors.(6) Antibodies detected by functional coagulation assays are commonly referred to as LAC. Anti-B2GPI antibodies associated with thromboembolic events target domain 1 of the molecule and are responsible for LAC (functional, phospholipid-dependent prolongation of the clotting time) and aCL-dependent B2GPI antibody positivity.(2)

For the detection of anti-B2GPI IgG and IgM antibodies, the APS guidance advocates for the use of values above the 99th percentile of the laboratory's population in the establishment of reference intervals for tests. While this recommendation may be used for anti-B2GPI IgA immunoassays, there is no consensus for their determination.(6) aPL antibodies were traditionally determined using the classic ELISA, with more diverse methods recently developed and adapted for clinical testing. Recognizing the analytical and diagnostic challenges associated with aPL antibody testing, initiatives to support assay harmonization and utilization, including the development of calibrators, test development, and validation efforts as well as preanalytical, analytical, and postanalytical measures have been published.(7) The interpretation and relevance of aPL antibody tests are dependent on factors such as the type of aPL (LAC, aCL or anti-B2GPI), the source of cardiolipin and/or B2GPI, aPL antibody class (IgG, IgM or IgA) and level, as well as whether antibody positivity is single, double or triple.(1-3,7,8)

The 2023 ACR/EULAR classification criteria for APS are meant for clinical studies and may not be appropriate for routine patient evaluation and management. Therefore, in clinical practice, if suspicion for disease is high but criteria aPL antibody tests are inconclusive or negative, deviation from the APS classification criteria may be justified. This may include testing for non-criteria aPL antibody tests, such the aCL IgA and anti-B2GPI IgA recommended in 2012 SLICC guidance for SLE or evaluation of other non-criteria aPL antibody tests.(4,9,10) However, there is no formal guidance for the measurement and interpretation of aCL and anti-B2GPI IgA antibodies in patients with APS or SLE. Some clinical relevance between APS-related clinical symptoms and the presence of aCL/anti-B2GPI IgA have been reported; however, the added value is minimal.(10,11) Isolated aPL IgA is rare, and these antibodies are usually found in association with IgG or IgM.