Neutrophil activation and nucleosomes as markers of systemic inflammation in paroxysmal nocturnal hemoglobinuria: effects of eculizumab

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by complement-mediated hemolysis and a high risk of life-threatening venous and arterial thrombosis. Uncontrolled complement activation and the release of cell-free heme may result in systemic inflammation, neutrophil activation, and the release of procoagulant neutrophilic proteases. Eculizumab, an antibody to complement factor C5, inhibits hemolysis and reduces thrombotic risk. Objectives: To study neutrophil activation and nucleosome levels in relation to thrombosis in PNH patients before and during treatment with eculizumab. Patients/methods: In 51 untreated PNH patients, including 20 patients before and after commencing eculizumab treatment, we have assessed neutrophil activation by measuring elastase-(1)-antitrypsin (EA) complexes and circulating nucleosomes, as established markers for systemic inflammation and cell death. Results: Nucleosomes (median; range; 95% confidence interval [CI]), but not EA complexes, were higher in PNH patients with a history of thrombosis (16; 7-264; 0.3-94 U mL(-1), n = 12) than in those without (6; 6-35; 7-11 U mL(-1), n = 39) or controls (8; 6-23; 7-12 U mL(-1), n = 17). EA complexes, but not nucleosomes, decreased promptly and markedly upon eculizumab treatment. EA complexes (estimated marginal means; 95% CI) remained low at >= 12weeks (50; 34-67) compared with baseline (12; -6 to 29). Conclusions: The increased nucleosome levels in PNH patients with a history of thrombosis suggest systemic inflammation and/or cell death. Neutrophil activation markers did not differ between patients with and without a history of thrombosis and healthy controls. Interestingly, basal neutrophil activation in PNH patients significantly decreases on treatment with eculizumab, indicating that neutrophil activation is C5a driven.