Although liver involvement in lupus is rare, abnormal liver function tests in APS are seen frequently. Although these can presage serious liver thrombosis, such as Budd-Chiari syndrome or the HELLP syndrome in pregnancy warning of impending catastrophic APS, more commonly, they have a more benign prognosis.35,36
One very positive case history: Back in the early 1980s, I saw a teenage girl with a DVT, positive aPL and Budd-Chiari syndrome.
Prognosis poor?
Thirty-plus years on, she remains well—on careful lifelong warfarin managed by her physicians in Portugal.
Goldblatt’s disease, the kidney & APS—Renal artery stenosis, seen on a clear background of otherwise normal arteries, can mimic Goldblatt’s early observations on the development of hypertension in animals with experimentally occluded renal arteries. The discovery of renal artery stenosis localized lesions by Sangle led to similar findings in other vessels, leading to theories about localized thrombotic/endothelial pathology.37
Skin: livedo reticularis, an enigma—Although skin ulcers, dilated veins and subungual splinter hemorrhages are well-known sequelae of skin thrombosis in APS, livedo reticularis has an aura of mystery.38,39
Diagnostically, its presence is an important clue in patients suspected of having Hughes syndrome—including seronegative APS.
Looking back over some of the conditions mentioned in this article—MS, migraine, multiple fractures, memory problems—for example, one wonders whether careful noting of the presence or absence of livedo might prove significant in the differential diagnosis of these conditions.
One thing is certain: The presence of livedo adds an extra dimension to the severity of the clinical picture.
Pregnancy
Of course, the headline story of the syndrome is in pregnancy, where the success rate of healthy deliveries in aPL-positive pregnancies has soared from under 15% to over 90%. Without a doubt, diagnosis and treatment of these cases has been a significant advance in the world of obstetrics.40
Sadly, all of us working with APS have looked after aPL-positive patients (some of whom had suffered early miscarriages) who lost a baby late in the pregnancy. Stillbirth.
Two years ago, The Times of London published a lead article titled, “The Stillbirth Scandal,” highlighting the poor stillbirth figures in the U.K.41 Yet some cases of stillbirth in the aPL-positive women could have been prevented. For example, a recent study from Utah found that aPL pregnancies had a three- to fivefold increased odds of stillbirth.42
Would more routine aPL testing in pregnancy help? Cost considerations apply. Miscarriage is common, and there are numerous causes. Thus, the current recommendation is to reserve testing for those women with three or more miscarriages. This does seem harsh. Perhaps a simple screening process might help.