P de Moerloose

University of Geneva, Genève, Geneva, Switzerland

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Publications (380)1631.46 Total impact

  • T. Marchetti · P. de Moerloose · J.C. Gris
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    ABSTRACT: Background: Preeclampsia (PEecl) can be defined as non-severe (NS-PEecl) or severe (S-PEecl). Our study aimed at determining the prevalence of antiphospholipid antibodies (aPL) in women with a past history of NS-PE or S-PE. Patients and methods: This case-control study includes 195 control women, 199 NS-PEecl and 143 S-PEecl patients whose plasma samples were collected six months after their first delivery. Each plasma was tested for lupus anticoagulant (LA), anticardiolipin (aCL) and antiβ2GP1 antibodies as well as antibodies against phosphatidylserine/prothrombin complex (aPS/PT) and domain I of the β2GP1. Results: When compared with the control group no significant associations were found for the NS-PEecl group after adjustment of confounding variables. For the S-PEecl group, antiβ2GP1 IgG (OR 16.91, 95% CI 3.71-77.06) was associated, as well as age, obesity, smoking and multiparity. Antiβ2GP1-domain I IgG were associated with aCL, antiβ2GP1 and aPS/PT IgG in the three groups. aPS/PT IgG were associated with aCL IgG, and aPS/PT IgM were associated with aCL and antiβ2GP1 IgM in the three groups CONCLUSION: S-PEecl is a distinct entity from NS-PEecl and is mainly associated with the presence of antiβ2GP1 IgG. Antiβ2GP1 domain I correlate with other aPL IgG tests, and aPS/PT may be promising in patients in which LA tests cannot be interpreted. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Journal of Thrombosis and Haemostasis

  • No preview · Article · Dec 2015 · Haemophilia
  • Alessandro Casini · Philippe de Moerloose
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    ABSTRACT: Introduction: Current treatments of rare coagulation disorders (RCD) include fresh frozen plasma, cryoprecipitates, prothrombin complex concentrates, plasma-derived concentrates and recombinant products. Single-factor concentrates are the therapy of choice since they allow administration of only the defective protein and reduce the risk of transfusion adverse effects. Specific legislation has been developed to stimulate the development of drugs for such rare diseases, the so-called “orphan drugs.” Areas covered: The focus of this review is on single factor plasma-derived and recombinant concentrates administered in patients with rare congenital coagulation deficiencies. Based on the results of pharmacokinetics, safety and efficacy studies, the pros and cons of each single-factor concentrate in selected RCD are discussed. Factor concentrates currently under development are also reviewed. Expert opinion: The development of single-factor concentrates for the management of RCD is challenging. These diseases are often poorly classified, misdiagnosed and the evidence based for their management is weak. Reaching the high number of subjects required by some authorities to achieve studies is difficult in such low-prevalence diseases. Alternative therapies such as monoclonal antibodies inhibiting anticoagulant pathway factors, engineered modified factors, peptides inhibitors and DNA or RNA aptamers are promising.
    No preview · Article · Nov 2015 · Expert Opinion on Orphan Drugs
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    Philippe de Moerloose · Daniel Arnberg · Brian O'Mahony · Brian Colvin
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    ABSTRACT: At the 2014 Annual Congress of the European Haemophilia Consortium (EHC) held in Belfast, Northern Ireland, Pfizer initiated and funded a satellite symposium entitled: 'Improving Patient Care Through Sharing Best Practice'. Co-chaired by Brian Colvin (Pfizer Global Innovative Pharma Business, Rome, Italy) and Brian O'Mahony [President of the EHC, Brussels, Belgium], the symposium provided an opportunity to consider patient care across borders, to review how patient advocacy groups can successfully engage with policymakers in healthcare decision-making and to discuss the importance of patient involvement in data collection to help shape the future environment for people with haemophilia. Professor Philippe de Moerloose (University Hospitals and Faculty of Medicine of Geneva, Switzerland) opened the session by discussing the gap between the haemophilia management guidelines and the reality of care for many patients living in Europe, highlighting the importance of sharing of best practice and building a network of treaters and patient organisations to support the improvement of care across Europe. Daniel Arnberg (SCISS AB, Hägersten, Sweden) reviewed the health technology assessment process conducted in Sweden, the first for haemophilia products, as a case study, focusing on the role of the patient organisation. Finally, Brian O'Mahony reflected on the central role of patients as individuals and also within patient organisations in shaping the future of haemophilia care. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
    Preview · Article · Oct 2015 · European Journal Of Haematology
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    ABSTRACT: Methods 7 patients with CTEPH, 17 controls (8 healthy and 9 under VKA therapy), two dysfibrinogenemic patients with known fibrinolysis resistance (Chapel-Hill/Dusart fibrinogen due to a missense mutation of the fibrinogen alpha-chain (FGA exon 5: c.1717G>C, p.Arg573Cys or Arg554Cys without the signal peptide) were included. Turbidimetric analysis (wavelength: 405 nm) was performed to define the global fibrinolytic profile. The clot formation was triggered by tissue-factor (TF) and the lysis by exogenous t-PA in two conditions: final concentrations were : 5 pM of TF, 4 uM of phospholipids (PPP reagent, Stago) and 400 ng/mL or 200 ng/mL of t-PA (Metalyse®, Boehringer Ingelheim). The plasma fibrinolytic potential was assessed by the clot lysis time (CTL), defined as the time from the midpoint of the baseline to maximum turbid transition, to the final plateau phase. All tests were performed in triplicate. All exons and intron-exon junctions of the fibrinogen genes were amplified by polymerase chain reaction and sequenced. All results are presented as median (Q1 – Q3).
    Full-text · Conference Paper · Sep 2015
  • A Casini · M Neerman-Arbez · R A Ariëns · P de Moerloose
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    ABSTRACT: Congenital dysfibrinogenemia is a qualitative congenital fibrinogen disorder characterized by normal antigen levels of a dysfunctional fibrinogen. Diagnosis is usually based on discrepancy between fibrinogen activity and antigen levels but could require more specialized techniques for the assessment of fibrinogen function due to some limitations in routine assays. Molecular abnormalities, frequently heterozygous missense mutations localized in exon 2 of FGA and exon 8 of FGG, lead to defects in one or more phases of fibrinogen to fibrin conversion, fibrin network formation and other important functions of fibrinogen. The clinical phenotype is highly heterogeneous, from no manifestations to bleeding and/or thrombotic events. Asymptomatic propositi and relatives with the predisposing genotype are at risk to develop adverse outcomes during the natural course of the disease. Correlations between genotype and phenotype have not yet been clearly established, with the exception of some abnormal fibrinogens that severely increase the risk of thrombosis. Functional analysis of polymerisation and fibrinolysis, structural studies of the fibrin network and viscoelastic properties of fibrin clot could help to predict the phenotype of congenital dysfibrinogenemia but have not yet been evaluated in detail. The management is essentially based on personal and familial history; however, even individuals still asymptomatic and without family history should be carefully assessed and monitored. Particular situations, such as pregnancy, delivery and surgery require a multidisciplinary approach. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    No preview · Article · Mar 2015 · Journal of Thrombosis and Haemostasis
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    ABSTRACT: Background Case reports on recombinant human factor VIIa (rhuFVIIa) use in women with severe postpartum hemorrhage (PPH) showed encouraging results, but no randomized controlled trial (RCT) is available.Patients and methodsEighty-four women with severe PPH unresponsive to uterotonics were randomized to receive one early single rhuFVIIa infusion (n=42) or standard care (no rhuFVIIa; n=42). The primary efficacy outcome measure was the reduction of the need of specific second-line therapies, such as interventional hemostatic procedures, of blood loss and of transfusions. The primary safety outcome measure was the number of deaths and thrombotic events during the five days following rhuFVIIa infusion.ResultsrhuFVIIa was associated with a reduction in the number of patients who needed second-line therapies compared to controls (standard care). Specifically, 39/42 (93%) patients in the standard care arm received second-line therapies and 22/42 (52%) patients in the rhuFVIIa arm (absolute difference: 41%, range 18%-63%; relative risk RR: 0.56 (0.42-0.76),). The delivery mode (vaginal or caesarean section) did not affect the primary outcome. No death occurred. Blood loss failed to be measured and transfusion needs did not differ. Two venous thrombotic events were recorded in the rhuFVIIa arm: one ovarian vein thrombosis and one deep vein thrombosis with a non-severe pulmonary embolism.Conclusion This open RCT in women with severe PPH refractory to uterotonics shows that rhuFVIIa reduces the need of specific second-line therapies in about one in three patients, with the occurrence of non-fatal venous thrombotic events in one in 20 patients.This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2015 · Journal of Thrombosis and Haemostasis
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    ABSTRACT: Fibrinogen storage disease (FSD) is characterized by hypofibrinogenemia and hepatic inclusions due to impaired release of mutant fibrinogen which accumulates and aggregates in the hepatocellular endoplasmic reticulum. Liver disease is variable. We studied a new Swiss family with fibrinogen Aguadilla. In order to understand the molecular peculiarity of FSD mutations, fibrinogen Aguadilla and the three other causative mutations, all located in the γD domain, were modelled. The proband is a Swiss girl aged 4 investigated because of fatigue and elevated liver enzymes. Protein structure models were prepared using the Swiss-PdbViewer and POV-Ray software. The proband was found to be heterozygous for fibrinogen Aguadilla: FGG Arg375Trp. Familial screening revealed that her mother and maternal grandmother were also affected and, in addition, respectively heterozygous and homozygous for the hereditary haemochromatosis mutation HFE C282Y. Models of backbone and side-chain interactions for fibrinogen Aguadilla in a 10-angstrom region revealed the loss of five H-bonds and the gain of one H-bond between structurally important amino acids. The structure predicted for fibrinogen Angers showed a novel helical structure in place of hole 'a' on the outer edge of γD likely to have a negative impact on fibrinogen assembly and secretion. The mechanism by which FSD mutations generate hepatic intracellular inclusions is still not clearly established although the promotion of aberrant intermolecular strand insertions is emerging as a likely cause. Reporting new cases is essential in the light of novel opportunities of treatment offered by increasing knowledge of the degradation pathway and autophagy. © 2015 John Wiley & Sons Ltd.
    No preview · Article · Dec 2014 · Haemophilia
  • A Lebreton · A Casini · R Alhayek · K L Kouteich · M Neerman-Arbez · P de Moerloose

    No preview · Article · Dec 2014 · Haemophilia
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    ABSTRACT: Combined coagulation factor VII (FVII) and factor X (FX) deficiency (combined FVII/FX deficiency) belongs to the group of bleeding disorders in which both factors show reduced plasma activity. It may arise from coincidental inheritance of separate coagulation factor deficiencies or a common cause as large deletions comprising both gene loci. The F7 and F10 genes are located on the long arm of chromosome 13. Here, we describe 10 cases with combined FVII/FX deficiency representing both genetic mechanisms of occurrence. Genetic analyses included direct sequencing of the F7 and F10 genes and MLPA (multiplex ligation-dependent probe amplification) for detection of heterozygous large deletions. In four patients, the combined deficiency was due to a large deletion within the terminal end of chromosome 13. In the remaining six cases the deficiency resulted from coincidental inheritance of different genetic alterations affecting both genes independently. In most cases, the genetic defects were heterozygous, presenting with prolonged PT, normal aPTT and mild or no bleeding symptoms. Only in one case compound heterozygous mutations were detected in the F10, resulting in prolonged aPTT and a more severe bleeding phenotype. To avoid a misdiagnosis of combined FVII/FX deficiency, analyses of single factor activities have to be performed in all cases with prolonged PT even if aPTT is normal. Genetic analyses are substantial for correct prediction of an inheritance pattern and a proper genetic counselling.
    No preview · Article · Dec 2014 · Haemophilia
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    ABSTRACT: We conducted a multicentre study of 101 subjects with Congenital Dysfibrinogenemia (CD) to characterize the incidence of hemorrhagic and thrombotic events as well as complications of pregnancy and surgery. At the time of diagnosis, 10.9% and 13.9% had experienced major bleeding and thrombotic events, respectively. During a mean follow-up of 8.8 years after CD diagnosis, the incidence of major bleeding and of thrombotic events was 2.5 and 18.7 per 1000 patient-years respectively, with estimated cumulative incidences at an age of 50 years of 19.2% and 30.1%. We identified 111 pregnancies with an overall incidence of spontaneous abortions and post-partum hemorrhage of 19.8% and 21.4%, respectively. The risk of post-partum hemorrhage was associated with a previously identified bleeding phenotype (OR 5.8; 95%CI 1.2-28.0). Among 137 surgical procedures analyzed, 9 (6.5%) were complicated by abnormal bleeding. Propositi versus relatives, sex, mutation hotspots, fibrinogen levels and activity:antigen ratios were not associated with the risk of thrombotic or bleeding outcomes. In conclusion, the results of our study, the largest in genotyped CD and the first including long term history, indicate that propositi with CD and their relatives carry not only a high risk of major bleeding, including post-partum hemorrhage, but also of thrombotic event.
    Preview · Article · Oct 2014 · Blood
  • Tess Marchetti · Philippe de Moerloose · Marie Cohen

    No preview · Article · Sep 2014 · Placenta
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    ABSTRACT: Background The HemosIL AcuStar Antiphospholipid assay (Instrumentation Laboratory, Bedford, USA) is a fully automated assay using chemiluminescent technology for the detection of anticardiolipin and anti-β2GPI antibodies. This assay showed excellent agreement between results of different laboratories. The cut-off values to define positivity were calculated in 250 healthy blood bank donors but were associated with large confidence intervals (CI).Objective The objective of this study was to more precisely determine the cut-off values of the HemosIL AcuStar Antiphospholipid assay by increasing the number of healthy blood bank donors through a multicenter study and by applying a normalization procedure of the distribution of each antibody.Methods Five laboratories participated to this study allowing the inclusion of 626 samples. We used a Box-Cox power transformation method to normalize the distribution and calculate the 99th percentile and the corresponding 95%CI for each antibody.ResultsThe revised cut-off values were overall lower than those initially calculated with more stringent CI and yielded a 4.2%-increase of sensitivity with a 2.7% decrease of specificity regarding thrombotic events or obstetrical complications.Conclusions We provide refined cut-off values for the detection of anticardiolipin and anti-β2GPI antibodies with the HemosIL AcuStar Antiphospholipid assay that should be preferred for routine use.This article is protected by copyright. All rights reserved.
    Full-text · Article · Sep 2014 · Journal of Thrombosis and Haemostasis
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    ABSTRACT: Introduction Point of care devices (POCT) are used for coagulation evaluation in adults. Reduced blood volumes and the direct use of whole blood allow studies when venous puncture is difficult, such as in newborns. Elimination of sample transport is attractive for use in emergencies and intensive care. Objective To prospectively compare neonatal coagulation parameters measured by the GEM®PCL POCT versus a central laboratory. Materials and Methods Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) were performed on whole cord blood (POCT) and plasma (central laboratory) collected from consecutive newborns at Geneva University Hospital. Agreement was assessed with a Bland & Altman plot and intra-class correlation coefficient (ICC) in 213 newborns cord blood; intra-assay variability (repeatability) was assessed using ICC and coefficient of variation (CV). Results 189 samples were available for the agreement analysis, 24 were excluded for technical problems. The 95% limits of agreements in the Bland & Altman plot ranged from -5.6 to 11.6 and from -39.6 to 11.6 seconds for the PT and aPTT, respectively. The ICC between the two methods was 0.28 (CI 95% 0.06 to 0.47) for PT and 0.20 (CI 95% -0.06 to 0.42) for aPTT. Repeatability (ICC) on the 43 eligible samples was 0.46 (CI 95% 0.19 to 0.67) for PT and 0.52 (CI 95% 0.26 to 0.71) for aPTT. The CV was 10.6% and 12% for PT and aPTT, respectively. Conclusions In newborn cord blood, PT and aPTT measurements with the GEM®PCL POCT had poor agreement with the central laboratory and poor repeatability.
    No preview · Article · Aug 2014 · Thrombosis Research
  • A. Naz · M. Neerman-Arbez · V Ivaskevicius · T. N. Khan · S. Ahmed · P. de Moerloose · J. Oldenburg · S. Tariq · N. Saqlain · N. Ahmed · [...] · Marguerite Neerman-Arbez · Vytautas Ivaskevicius · Tehmina Nafees Khan · Shariq Ahmed · Philippe De Moerloose · Johannes Oldenburg · Shehla Tariq · Nazish Saqlain · Nisar Ahmed · Tahir S. Shamsi ·

    No preview · Article · Jun 2014 · Journal of Thrombosis and Haemostasis
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    M. Shima · C. Hermans · P. de Moerloose
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    ABSTRACT: The primary major issue in haemophilia treatment remains the development of inhibitors. Recently two novel bypassing products have been developed. First, a humanized bispecific antibody against FIXa and FX, termed hBS23, was produced utilizing these two molecules placed into a spatially appropriate position to mimic FVIIIa, and recently this mimetic activity and the pharmacokinetics of the original antibody were improved by engineering the charge properties of the variable region within the immunoglobulin. Using the new antibody, termed ACE910, a phase 1 study in 64 Japanese and Caucasian healthy adults was performed and data from this trial suggested that the product had medically acceptable safety and tolerability profiles. The other new bypassing agent is named MC710, and consists of a mixture of plasma-derived FVIIa and FX. Preclinical studies using in vitro and in vivo haemophilia B inhibitor monkey models indicated that the haemostatic effects of FVIIa and FX were enhanced by simultaneous administration. Results from phase I and II clinical studies suggested that MC710 had equal or greater pharmacokinetic (PK), pharmacodynamic (PD), efficacy and safety profiles than conventional bypassing agents in the treatment of joint bleeding in haemophilia patients with inhibitors. Another significant current issue in this context is the increased medical cost of conventional treatment due to the higher consumption of concentrates. Biosimilar products may offer advantages in these circumstances and may offer a less expensive alternative. Regulatory issues, however, together with acceptability of biosimilar materials and reimbursement policies as well as supply and demand incentives remain to be considered. Rare bleeding disorders (RBDs) have attracted less attention from the pharmaceutical industry than haemophilia or von Willebrand disease due to the limited number of patients involved. Many cases of this type have been treated, therefore, using fresh frozen plasma (FFP) or prothrombin complex concentrates (PCCs) which carry serious risks of infections, allergic reactions and fluid overload. Several specific plasma-derived or recombinant products including fibrinogen, FVIIa, FXI and FXIII have now become available, however, and a phase III clinical study of recombinant FXIIIa has recently been completed demonstrating safety and efficacy of substances of this nature.
    Full-text · Article · May 2014 · Haemophilia
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    ABSTRACT: Introduction Causative mutations leading to congenital quantitative fibrinogen are frequently clustered in FGA encoding the fibrinogen Aα-chain. Mutations of FGB encoding the Bβ-chain are less common and of interest since the Bβ chain is considered the rate-limiting factor in the hepatic production of the fibrinogen hexamer. Method Four novel FGB mutations were identified in two afibrinogenemic (one new-born and one 30 years old male) and hypofibrinogenemic (a 49 years old female) patient, with heterogeneous thrombotic and bleeding phenotype. The human fibrinogen beta chain precursor protein sequence (P02675) was obtained from the UniProt database. The resulting models were analysed in SwissPdbViewer 4.1 and POV-Ray 3.7. Results The FGB c.895 T > C p.Y299H (numbering from the initiator Met) and the FGB c.1415G > T p.G472V were predicted to be deleterious by SIFT analysis. The first replaces an uncharged aromatic amino acid side chain by a positively charged side chain modifying the balance in the distribution of hydrophobic and hydrophilic of the 10 Å neighbourhood residues. The second replaces one non-charged aliphatic side chain by another without any changes for the 10 Å surrounding region. The FGB c.352C > T p.Q118X leads to a severe premature termination codon and the FGB intron 4: IVS4-1G > C (c719-1G > C) leads to skipping of exon 5 or usage of a cryptic acceptor site located upstream or downstream of the normal site. Conclusions The continuous characterization of novel molecular defects responsible for fibrinogen deficiency combined with modelling of mutant proteins will continue to provide a better comprehension of the complexity of fibrinogen synthesis and physiology.
    Full-text · Article · May 2014 · Thrombosis Research
  • P. Bolton‐Maggs · J. Goudemand · C. Hermans · M. Makris · P. de Moerloose

    No preview · Article · May 2014 · Haemophilia
  • T. Marchetti · A. Ruffatti · C. Wuillemin · P. de Moerloose · M. Cohen
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    ABSTRACT: Background Obstetrical antiphospholipid syndrome (APS) is defined by pregnancy complications associated with antiphospholipid antibodies (aPL). The mechanisms of the pathogenic effects of aPL in pregnancy are poorly understood. Toll-like receptors (TLR) have been implicated previously in APS.Objectives The aims of our study were: 1) to determine aPL effects on trophoblastic cell fusion and differentiation, 2) to identify which TLR is involved in this process and 3) to evaluate the efficacy of hydroxychloroquine (HCQ) to counteract the effects of aPL.Methods BeWo cells are a model for trophoblast fusion and differentiation. Fusion index (FI) was assessed by immunocytochemistry; and biochemical differentiation by ELISA measuring β-human choronic gonadotropin (β-hCG) hormone secretion. We used three types of aPL to study their effect on cell fusion and differentiation: aPL derived from obstetrical APS patients, affinity purified and polyclonal rabbit anti-β2-glycoprotein-1 (anti-β2GP1) antibodies. Experiments on fusion were confirmed on primary cytotrophoblastic cells.ResultsAll types of aPL used decreased fusion index in BeWo and primary trophoblastic cells (respectively 64%, 52%, 41% for BeWo cells and 67%, 62% for primary cells) and anti-β2GP1 antibodies decreased hCG secretion in BeWo cells (41%). To block TLR4 antibodies or to abolish TLR4 cell surface expression restored fusion index in both cell types and hCG excretion in BeWo cells. HCQ treatment induced the same effect and decreased TLR4 mRNA (resp. 40%; 35%) and protein expressions (resp. 62%; 42%) in BeWo cells.Conclusion Anti-β2GP1 antibodies decrease trophoblastic differentiation via TLR4. This effect is restored by HCQ suggesting its therapeutic interest in APS pregnancies.This article is protected by copyright. All rights reserved.
    No preview · Article · Mar 2014 · Journal of Thrombosis and Haemostasis
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    ABSTRACT: The antiphospholipid antibody syndrome (APS) is an auto-immune disease associated with arterial or venous thrombosis and/or recurrent fetal loss and is caused by pathogenic antiphospholipid antibodies (aPLA). We recently demonstrated that Toll-like receptor 2 (TLR2) and CD14 contribute to monocyte activation aPLA. To study the mechanisms of cell activation by aPLA leading to pro-coagulant and pro-inflammatory responses. For this study, we used purified antibodies from plasmas of ten different patients with APS and from healthy donors. We demonstrate that aPLA but not control IgG, colocalizes with TLR2 and TLR1 or TLR6 on human monocytes. Blocking antibodies to TLR2, TLR1 or TLR6, but not to TLR4 decreased TNF and Tissue Factor (TF) responses to aPLA. Pharmacological and siRNA approaches revealed the importance of the clathrin/dynamin-dependent endocytic pathway in cell activation by aPLA. In addition, soluble aPLA induced NF-kB activation, while bead-immobilized aPLA-beads, which cannot be internalized, were unable to activate NF-kB. Internalization of aPLA in monocytes and NF-kB activation was dependent on the presence of CD14. We show that TLR2 and its co-receptors, TLR1 and TLR6, contribute to the pathogenicity of aPLA, that aPLA are internalized via clathrin- and CD14-dependent endocytosis and that endocytosis is required for NF-kB activation. Our results contribute to a better understanding of the APS and provide a possible therapeutic approach. This article is protected by copyright. All rights reserved.
    Full-text · Article · Feb 2014 · Journal of Thrombosis and Haemostasis

Publication Stats

9k Citations
1,631.46 Total Impact Points


  • 1991-2015
    • University of Geneva
      • • Division of Angiology and Hemostasis
      • • Faculty of Medicine
      • • Department of Internal Medicine
      • • Division of Radio-oncology
      Genève, Geneva, Switzerland
  • 2000-2013
    • Hôpitaux Universitaires de Genève
      • • Service d'anesthésiologie
      • • Service d'angiologie et d'hémostase
      Genève, GE, Switzerland
  • 2010
    • Hackensack University Medical Center
      Хакенсак, New Jersey, United States
  • 2005
    • The Ottawa Hospital
      Ottawa, Ontario, Canada
  • 2004
    • Spedali Civili di Brescia
      Brescia, Lombardy, Italy
    • Centre Hospitalier Régional Universitaire de Lille
      Lille, Nord-Pas-de-Calais, France
  • 1990-2000
    • Cantonal Hospital of Schwyz
      Schwyz, Schwyz, Switzerland