Rheumatoid factor, complement, and mixed cryoglobulinemia

Peter D Gorevic, Peter D Gorevic

Abstract

Low serum level of complement component 4 (C4) that occurs in mixed cryoglobulinemia (MC) may be due to in vivo or ex vivo activation of complement by the classical pathway. Potential activators include monoclonal IgM rheumatoid factor (RF), IgG antibodies, and the complexing of the two in the cold, perhaps modulated by the rheology and stoichiometry of cryocomplexes in specific microcirculations. There is also the potential for activation of complement by the alternative and lectin pathways, particularly in the setting of chronic infection and immune stimulation caused by hepatitis C virus (HCV). Engagement of C1q and interaction with specific cell surface receptors serve to localize immune complexes (ICs) to the sites of pathology, notably the cutaneous and glomerular microcirculations. Defective or saturated clearance of ICs by CR1and/or Fc receptors may explain persistence in the circulation. The phlogistic potential of cryoprecipitable ICs depends upon the cleavage of complement components to generate fragments with anaphylatoxin or leukocyte mobilizing activity, and the assembly of the membrane attack complex (C5b-9) on cell surfaces. A research agenda would include further characterization of the effector arm of complement activation in MC, and elucidation of activation mechanisms due to virus and viral antigens in HCV infection.

Figures

Figure 1
Figure 1
C3, C4, and factor Bb levels determined by hemolytic assay in patients with type 2 MC (4).
Figure 2
Figure 2
Total hemolytic complement activity was determined after reconstitution of varied molar ratios of separated IgM and IgG from two type 2 cryoglobulins (Vi; Bu). Separated IgM was 100% monoclonal IgMk with RF activity; the IgG fraction had immunoblot reactivity to multiple HCV linear antigens. Isolated cryoglobulin was significantly (40 and 60% total serum RNA by RT-PCR) enriched in HCV RNA. Separated IgM and IgG fractions were mixed at 37 and cooled O/N to 4 C. Results are compared to control IgG and IgM, the latter from a patient with Waldenströms macroglobulinemia without RF activity. Both cryoglobulins were obtained from patients chronically infected with HCV, with active cutaneous vasculitis and membranoproliferative glomerulonephritis. (courtesy of Dr. B. Ghebrehiwet).

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