TABLE OF CONTENTS

INTRODUCTION............................................................................................................................. 1
HISTORY ......................................................................................................................................... 2
COMPONENTS OF COMPLEMENT ............................................................................................. 2
COMPLEMENT RECEPTORS........................................................................................................ 3
FUNCTIONS OF COMPLEMENT SYSTEM ................................................................................ 5
COMPLEMENT ACTIVATION...................................................................................................... 6
FORMATION OF MEMBRANE ATTACK COMPLEX ............................................................ 11
COMPLEMENT REGULATION .................................................................................................. 12
CONSEQUENCES OF COMPLEMENT ACTIVATION ............................................................ 15
COMPLEMENT DEFICIENCIES ................................................................................................. 17
BIBLIOGRAPHY ........................................................................................................................... 23

THE COMPLEMENT SYSTEM

INTRODUCTION:
The term complement refers to a set of serum proteins that cooperates with both the innate and the
adaptive immune systems to eliminate blood and tissue pathogens. Like the components of the blood
clotting system, complement proteins interact with one another in catalytic cascades. Various
complement components bind and opsonize bacteria, rendering them susceptible to receptormediated phagocytosis by macrophages, which express membrane receptors for complement
proteins. Other complement proteins elicit inflammatory responses, interface with components of the
adaptive immune system, clear immune complexes from the serum, and/or eliminate apoptotic cells.
Finally, a Membrane Attack Complex (MAC) assembled from complement proteins directly kills
some pathogens by creating pores in microbial membranes. The biological importance of
complement is emphasized both by the pathological consequences of mutations in the genes
encoding complement proteins as well as by the broad range of strategies that have evolved in
microorganisms to evade it.
The proteins and glycoproteins that constitute the complement system are synthesized by
hepatocytes. But significant amounts are also produced by tissue macrophages, blood monocytes,
and epithelial cells of the genitourinal tract and gastrointestinal tract. The three pathways of
activation all generate homologous variants of the protease C3-convertase. The classical complement
pathway typically requires antigen-antibody complexes (immune complexes) for activation (specific
immune response), whereas the alternative and mannose-binding lectin pathways can be activated by
C3 hydrolysis or antigens without the presence of antibodies (non-specific immune response). In all
three pathways, C3-convertase cleaves and activates component C3, creating C3a and C3b, and
causing a cascade of further cleavage and activation events. C3b binds to the surface of pathogens,
leading to greater internalization by phagocytic cells by opsonization. C5a is an important
chemotactic protein, helping recruit inflammatory cells.
C3a is the precursor of an important cytokine (adipokine) named ASP (although this is not
universally accepted) and is usually rapidly cleaved by carboxypeptidase B. Both C3a and C5a have
anaphylatoxin activity, directly triggering degranulation of mast cells as well as increasing vascular
permeability and smooth muscle contraction. C5b initiates the membrane attack pathway, which
results in the membrane attack complex (MAC), consisting of C5b, C6, C7, C8, and polymeric C9.
MAC is the cytolytic endproduct of the complement cascade; it forms a transmembrane channel,
which causes osmotic lysis of the target cell. Kupffer cells and other macrophage cell types help
clear complement-coated pathogens.

HISTORY:
Research on complement began in the 1890s, when Jules Bordet at the Institute Pasteur in Paris
showed that sheep antiserum to the bacterium Vibrio cholera caused lysis of the bacteria and that
heating the antiserum destroyed its bacteriolytic activity. Surprisingly, the ability to lyse the bacteria
was restored to the heated serum by adding fresh serum that contained no antibodies directed against
the bacterium and was unable to kill the bacterium by itself. Bordet correctly reasoned that
bacteriolytic activity requires two different substances: first, the specific antibacterial antibodies,
which survive the heating process, and a second, heat-sensitive component responsible for the lytic
activity. Bordet devised a simple test for the lytic activity, the easily detected lysis of antibodycoated red blood cells, called hemolysis. Paul Ehrlich in Berlin independently carried out similar
experiments and coined the term complement, defining it as the activity of blood serum that
completes the action of antibody. In ensuing years, researchers discovered that the action of
complement was the result of interactions of a large and complex group of proteins.

COMPONENTS OF COMPLEMENT SYSTEM:

Initiator complement components: These proteins initiate their respective complement cascades
by binding to particular soluble or membrane-bound molecules. Once bound to their activating
ligand, they undergo conformational alterations resulting in changes in their biological activity.
The C1q complex, Mannose Binding Lectin (MBL), and the ficolins are examples of initiator
complement components.
Enzymatic mediator: Several complement components, (e.g., C1r, C1s, MASP2, and factor B) are
proteolytic enzymes that cleave and activate other members of the complement cascade. Some of
these proteases are activated by binding to other macromolecules and undergoing a
conformational change. Others are inactive until cleaved by another protease enzyme and are thus
termed zymogens: proteins that are activated by proteolytic cleavage. The two enzyme complexes
that cleave complement components C3 and C5, respectively, are called the C3 and C5
convertases and occupy places of central importance in the complement cascades.
Membrane-binding components or opsonins: Upon activation of the complement cascade, several
proteins are cleaved into two fragments, each of which then takes on a particular role. For C3 and
C4, the larger fragments, C3b and C4b, serve as opsonins, enhancing phagocytosis by binding to
microbial cells and serving as binding tags for phagocytic cells bearing receptors for C3b or C4b.
As a general rule, the larger fragment of a cleaved complement component is designated with the
suffi x b, and the smaller with the suffi x a. However, there is one exception to this rule: the
larger, enzymatically active form of the C2 component is named C2a.
Inflammatory mediators: Some small complement fragments act as infl ammatory mediators.
These fragments enhance the blood supply to the area in which they are released, by binding to
receptors on endothelial cells lining the small blood vessels and inducing an increase in capillary
diameter. Th ey also attract other cells to the site of tissue damage. Because such effects can be
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harmful in excess, these fragments are called anaphylatoxins, meaning substances that cause
anaphylaxis (against protection). Examples include C3a, C5a, and C4a.
Membrane attack proteins: The proteins of the membrane attack complex (MAC) insert into the
cell membranes of invading microorganisms and punch holes that result in lysis of the pathogen.
Th e complement components of the MAC are C5b, C6, C7, C8, and multiple copies of C9.
Complement receptor proteins: Receptor molecules on cell surfaces bind complement proteins
and signal specific cell functions. For example, some complement receptors such as CR1 bind to
complement components such as C3b on the surface of pathogens, triggering phagocytosis of the
C3-bound pathogen. Binding of the complement component C5a to C5aR receptors on neutrophils
stimulates neutrophil degranulation and inflammation. Complement receptors are named with
R, such as CR1, CR2, and C5aR.
Regulatory complement components: Host cells are protected from unintended complementmediated lysis by the presence of membrane-bound as well as soluble regulatory proteins. Th ese
regulatory proteins include factor I, which degrades C3b, and Protectin, which inhibits the
formation of the MAC on host cells.

COMPLEMENT RECEPTORS, OPSONINS AND ANAPHYLATOXINS:

Complement activation is a danger signal that alerts the host to infection or injury and initiates
appropriate responses. Complement activation products flag danger by physically binding to
pathogens, immune complexes, and other toxic bodies, and by their release into the surrounding
background; subsequent events require the interaction of these fragments with specific receptors
present on a variety of cell types.

RECEPTORS FOR THE OPSONIC FRAGMENTS OF C3 AND C4:

C3 is the most abundant complement component and the most important source of complement
fragments. C3b and its degradation products iC3b and C3d coat the target, a process called
opsonization, thereby tagging the target for recognition by cells bearing complement receptors.
CRl, described as a complement regulator, is an atypical receptor in that it modifies its own
ligand. CRl binds C3b (and C4b) coating immune complexes (ICs) via its binding sites in LHRs
1, 2, and 3, and catalyzes its cleavage by fl. Erythrocyte CR1 plays a critical role in IC handling;
the C3b-coated IC binds CRI on the erythrocyte and is held transiently until the ligated C3b is
cleaved by fI to iC3b/C3dg; binding affinity is lost and the complex is released, only to bind
again via another C3b4. This dynamic binding permits the efficient sequestration of ICs on
erythrocytes but without immobilizing them in a way that inhibits their efficient transfer to
complement receptor-bearing tissue macrophages in the spleen and liver for final disposal. CRI
on other cell types also operates by binding and processing C3b-coated ICs. On dendritic cells,
CRI localizes opsonized ICs for presentation of antigen to T cells, while on B cells, C3b coating
the IC binds CR1 and is cleaved to C3d, a ligand for another complement receptor, complement
receptor 2 (CR2; CD21), clustered with CRI and the B-cell antigen receptor (BCR).
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Simultaneous engagement of CR2 and the BCR markedly lowers the threshold for antibody
response.
CR2 is made up of either 15 or 16 SCR domains (alternative splicing removes SCRII in the
smaller isoform), a transmembrane region, and a cytoplasmic tail with important roles in
signalling. It is expressed on B cells, T-cell precursors and some mature T cells, dendritic cells,
and some other cells involved in antigen presentation, basophils and epithelia. CR2 is a rather
promiscuous receptor with numerous binding partners, including the IgE receptor (CD23),
interferon-a, and the Epstein-Barr virus; its complement ligands are C3d or iC3b, binding at a
single site in SCRI and SCR2. The key role of CR2 is to enhance the immune response to
antigens contained within the IC. On B cells, CR2 is clustered with the B cell-specific signalling
molecule CD19 in a complex held together by the tetraspanin CD81; this tri-molecular complex
interacts with the BCR to modulate the B cell response to antigen. CR2 on dendritic cells
contributes to IC trapping in lymph node germinal centres.
Complement receptor 3 (CR3; CD11b/CD18) is a heterodimer comprising a 165 kDa -chain
(CDllb) and a 95 kDa -chain (CD18); it is a member of the
-integrin family of leukocyte
surface heterodimeric proteins sharing the common -chain. CR3 is expressed on monocytes,
neutrophils, mast cells, natural killer cells, dendritic cells, and some T cells. It is notable for its
promiscuity, binding adhesion molecules (intercellular adhesion molecule [ICAM]-1 and -2),
coagulation proteins, microbial products, and carbohydrate antigens; its principal complement
ligand is iC3b, although it binds weakly to C3d. Binding of an iC3b-coated particle to CR3 on
phagocytic cells triggers the phagocytic process, leading to the elimination of the opsonized
particle. Other phagocytic receptors, including the Ig Fc receptors and CD14, certainly
contribute to the phagocytic process, and there is continuing debate around which of these
triggers are required for and most important in the phagocytic process.
Complement receptor 4 (CR4; CD11c/CD18), another -integrin expressed on myeloid cells,
resembles CR3 with regard to distribution and complement ligand binding properties. It is
possible that CR4 plays important roles in some dendritic cell processes, although it remains
something of an enigma.
Complement receptor of the immunoglobulin superfamily is a recently described receptor for
C3b/iC3b expressed exclusively on tissue-resident macrophages, including Kupffer cells in the
liver. It plays important roles in the capture and clearance of opsonized ICs and pathogens from
the circulation.

RECEPTORS FOR THE ANAPHYLACTIC FRAGMENTS OF C3AND C5:

Receptors for the small anaphylatoxin (AT) fragments released from C3 and C5 during activation
are extremely important players in the recruitment of inflammatory cells and in a growing list of
other events. C3, C4, and C5 are structurally similar molecules and are all activated in similar
ways: a single cut by the activating enzyme that releases a peptide, C3a, C4a, and CSa,
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respectively, from the amino terminus of the ex-chain. Current opinion is that there are no
receptors for C4a and that, as a consequence, it has no biological function. In contrast, specific
receptors exist for the AT molecules C3a and C5a, which mediate important biological roles.
Three AT receptors have been described to date, the C3a receptor (C3aR), the CSa receptor
(C5aR; CD88), and the C5a receptor-like 2 (C5L2). They are homologous molecules, members of
the G-protein-coupled receptor family of heptaspan membrane proteins. C3aR is expressed on all
myeloid cells and some nonmyeloid, including activated T cells, astrocytes, endothelia, epithelia,
and smooth muscle. C3aR binds C3a with nanomolar affinity but does not bind C3adesArg, C5a,
or CSadesArg. Upon binding of C3a, intracellular signaling cascades are triggered through
activation of heterotrimeric G-proteins that in turn cause increased intracellular free calcium and
other downstream events. CSaR binds C5a with nanomolar affinity and CSadesArg with tenfold
lower affinity; it does not bind C3a/C3adesArg. C5aR is expressed on all myeloid cells and
numerous nonmyeloid including endothelia, neurones, and astrocytes; expression on lymphoid
cells has been suggested but current evidence does not support this.

RECEPTORS FOR C1q:

The most convincing candidate receptor is the Clq receptor for phagocytic enhancement (ClqRp;
CD93), a heavily glycosylated 120 kDa transmembrane sialoglycoprotein expressed on myeloid cells
and endothelia. Its extracellular region comprises a collagen recognition domain followed by five
epidermal growth factor (EGF) domains; the collagen recognition domain binds the collagenous
regions of C1q, MBL, and another lectin molecule, surfactant protein A (SpA).It is suggested that
this interaction is important in the clearance of apoptotic cells; these spontaneously bind C1q, MBL,
and likely SpA, tagging them for binding C1qRp and phagocytic clearance. Antibodies against
C1qRp inhibit apoptotic cell clearance in vitro, and mice deficient in ClqRp or Clq display delayed
apoptotic cell clearance.
Several members of the integrin family of cell adhesion molecules have been implicated as C1q
binders; of the several collagen-binding integrins, a stands out for its capacity to bind C1q and
MBL. A 60 kDa receptor for the collagenous tail of C1q, MBL, and other collectins, termed cClqR,
was shown to be identical to calreticulin, a cytoplasmic chaperone protein, raising questions about
how this molecule could associate with membranes and act as a C1q receptor. It is now suggested
that calreticulin binds the extracellular domains of CD91 to create a receptor. Other molecules
suggested to act as receptors for C1q ( MBL) include CR1 (binding the collagenous region through
its membrane-proximal SCRs) and a 33 kDa protein that binds the C1q globular heads (gClqR). The
physiological roles of these interactions are uncertain.

FUNCTIONS:
Lysis of cells, bacteria, and viruses.
Opsonization, which promotes phagocytosis of particulate antigens.
Binding to specific complement receptors on cells of the immune system, triggering specific cell
functions, inflammation, and secretion of immunoregulatory molecules.
Immune clearance, which removes immune complexes from the circulation and deposits them in
the spleen and liver.
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Functions of Complement system

COMPLEMENT ACTIVATION:
Complement activation can take place by three major pathways viz., classical pathway, the
alternative pathway or the lectin pathway.

CLASSICAL PATHWAY:
Complement activation by the classical pathway commonly begins with the formation of soluble
antigen-antibody complexes (immune complexes) or with the binding of antibody to antigen on
a suitable target, such as a bacterial cell.
IgM and certain subclasses of IgG (human IgG1, IgG2, and IgG3) can activate the classical
complement pathway.
The initial stage of activation involves C1, C2, C3, and C4, which are present in plasma in
functionally inactive forms.
The formation of an antigen-antibody complex induces conformational changes in the Fc portion
of the IgM molecule that expose a binding site for the C1 component of the complement system.
C1 in serum is a macromolecular complex consisting of C1q and two molecules each of C1r and
C1s, held together in a complex (C1qr2s2) stabilized by Ca2+ ions. The C1q molecule is
composed of 18 polypeptide chains that associate to form six collagen-like triple helical arms,
the tips of which bind to exposed C1q-binding sites in the CH2 domain of the antibody
molecule. Each C1r and C1s monomer contains a catalytic domain and an interaction domain;
the latter facilitates interaction with C1q or with each other. Each C1 molecule must bind by its
C1q globular heads to at least two Fc sites for a stable C1-antibody interaction to occur.
When pentameric IgM is bound to antigen on a target surface it assumes the so-called staple
configuration, in which at least three binding sites for C1q are exposed. Circulating IgM,
however, exists as a planar configuration in which the C1q-binding sites are not exposed and
therefore cannot activate the complement cascade.
An IgG molecule, on the other hand, contains only a single C1q-binding site in the CH2 domain
of the Fc, so that firm C1q binding is achieved only when two IgG molecules are within 3040
nm of each other on a target surface or in a complex, providing two attachment sites for C1q.
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This difference accounts for the observation that a single molecule of IgM bound to a red blood
cell can activate the classical complement pathway and lyse the red blood cell while some 1000
molecules of IgG are required to assure that two IgG molecules are close enough to each other
on the cell surface to initiate C1q binding.
Binding of C1q to Fc binding sites induces a conformational change in C1r that converts C1r to
an active serine protease enzyme, C1 , which then cleaves C1s to a similar active enzyme, C1 .
C1 has two substrates, C4 and C2. The C4 component is a glycoprotein containing three
polypeptide chains , , and .
C4 is activated when C1 hydrolyzes a small fragment (C4a) from the amino terminus of the
chain, exposing a binding site on the larger fragment (C4b). The C4b fragment attaches to the
target surface in the vicinity of C1, and the C2 proenzyme then attaches to the exposed binding
site on C4b, where the C2 is then cleaved by the neighboring C1 ; the smaller fragment (C2b)
diffuses away.
The resulting
complex is called C3 convertase, referring to its role in converting the C3
into an active form.
The smaller fragment from C4 cleavage, C4a, is an anaphylatoxin, or mediator of inflammation,
which does not participate directly in the complement cascade.
A single C3 convertase molecule can generate over 200 molecules of C3b, resulting in
tremendous amplification at this step of the sequence. Some of the C3b binds to
to form a
trimolecular complex
, called C5 convertase.
The C3b component of this complex binds to C5 and alters its conformation, so that the
component can cleave C5 into C5a, which diffuses away, and C5b, which attaches to C6 and
initiates formation of the membrane attack complex in a sequence. Some of the C3b generated
by C3 convertase activity does not associate with
; instead it diffuses away and then coats
immune complexes and particulate antigens, functioning as an opsonin.

Schematic diagram of Classical pathway for Complement activation

ALTERNATIVE PATHWAY:
The alternative pathway generates bound C5b, the same product that the classical pathway
generates, but it does so without the need for antigen-antibody complexes for initiation. Because
no antibody is required, the alternative pathway is a component of the innate immune system.
This major pathway of complement activation involves four serum proteins: C3, factor B, factor
D, and properdin.

 The alternative pathway is initiated in most cases by cell-surface constituents that are foreign to
the host. For example, both gram-negative and gram-positive bacteria have cell-wall constituents
that can activate the alternative pathway.
In the alternative pathway, serum C3, which contains an unstable thioester bond, is subject to
slow spontaneous hydrolysis to yield C3a and C3b. The C3b component can bind to foreign
surface antigens (such as those on bacterial cells or viral particles) or even to the hosts own
cells. The membranes of most mammalian cells have high levels of sialic acid, which contributes
to the rapid inactivation of bound C3b molecules on host cells; consequently this binding rarely
leads to further reactions on the host cell membrane. Because many foreign antigenic surfaces
(e.g., bacterial cell walls, yeast cell walls, and certain viral envelopes) have only low levels of
sialic acid, C3b bound to these surfaces remains active for a longer time.
The C3b present on the surface of the foreign cells can bind another serum protein called factor
B to form a complex stabilized by Mg2+.
Binding to C3b exposes a site on factor B that serves as the substrate for an enzymatically active
serum protein called factor D. Factor D cleaves the C3b-bound factor B, releasing a small
fragment (Ba) that diffuses away and generating
.
The
complex has C3 convertase activity and thus is analogous to the
complex in
the classical pathway. The C3 convertase activity of
has a half-life of only 5 minutes
unless the serum protein properdin binds to it, stabilizing it and extending the half-life of this
convertase activity to 30 minutes.
The
generated in the alternative pathway can activate unhydrolyzed C3 to generate more
C3b autocatalytically. As a result, the initial steps are repeated and amplified, so that more than
2
molecules of C3b can be deposited on an antigenic surface in less than 5 minutes.
The C3 convertase activity of
generates the
complex, which exhibits C5
convertase activity, analogous to the
complex in the classical pathway. The
nonenzymatic C3b component binds C5, and the Bb component subsequently hydrolyzes the
bound C5 to generate C5a and C5b the latter binds to the antigenic surface.

Schematic diagram of Alternative pathway of Complement activation

LECTIN PATHWAY:
Lectins are proteins that recognize and bind to specific carbohydrate targets. (Because the lectin
that activates complement binds to mannose residues, it is also known as the MBLectin pathway
or mannan-binding lectin pathway.)
The lectin pathway, like the alternative pathway, does not depend on antibody for its activation.
However, the mechanism is more like that of the classical pathway, because after initiation, it
proceeds, through the action of C4 and C2, to produce a C5 convertase.
The lectin pathway is activated by the binding of mannose-binding lectin (MBL) to mannose
residues on glycoproteins or carbohydrates on the surface of microorganisms including certain
Salmonella, Listeria, and Neisseria strains, as well as Cryptococcus neoformans and Candida
albicans.
MBL is an acute phase protein produced in inflammatory responses. Its function in the
complement pathway is similar to that of C1q, which it resembles in structure.
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 After MBL binds to the surface of a cell or pathogen, MBL-associated serine proteases,MASP-1
and MASP-2, bind to MBL. The active complex formed by this association causes cleavage and
activation of C4 and C2. The MASP-1 and -2 proteins have structural similarity to C1r and C1s
and mimic their activities.

Initiation of Lectin Pathway

This means of activating the C2C4 components to form a C5 convertase without need for
specific antibody binding represents an important innate defense mechanism comparable to the
alternative pathway, but utilizing the elements of the classical pathway except for the C1
proteins.

FORMATION OF MEMBRANE ATTACK COMPLEX:

Formation of Membrane Attack Complex (MAC)

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 The terminal sequence of complement activation involves C5b, C6, C7, C8, and C9, which
interact sequentially to form a macromolecular structure called the membrane-attack complex
(MAC).
The end result of activating the classical, alternative, or lectin pathways is production of an active
C5 convertase. This enzyme cleaves C5, which contains two protein chains,
and . After
binding of C5 to the nonenzymatic C3b component of the convertase, the amino terminus of the
chain is cleaved. This generates the small C5a fragment, which diffuses away, and the large C5b
fragment, which binds to the surface of the target cell and provides a binding site for the
subsequent components of the membrane-attack complex.
The C5b component is extremely labile and becomes inactive within 2 minutes unless C6 binds to
it and stabilizes its activity.
As C5b6 binds to C7, the resulting complex undergoes a hydrophilic-amphiphilic structural
transition that exposes hydrophobic regions, which serve as binding sites for membrane
phospholipids.
Binding of C8 to membrane-bound C5b67 induces a conformational change in C8, so that it too
undergoes a hydrophilic amphiphilic structural transition, exposing a hydrophobic region, which
interacts with the plasma membrane. The C5b678 complex creates a small pore, 10 in diameter.
The final step in formation of the MAC is the binding and polymerization of C9, a perforin-like
molecule, to the C5b678 complex. As many as 1017 molecules of C9 can be bound and
polymerized by a single C5b678 complex. During polymerization, the C9 molecules undergo a
hydrophilic-amphiphilic transition, so that they too can insert into the membrane.
The completed MAC, which has a tubular form and functional pore size of 70100 , consists of
a C5b678 complex surrounded by a poly-C9 complex. Since ions and small molecules can diffuse
freely through the central channel of the MAC, the cell cannot maintain its osmotic stability and is
killed by an influx of water and loss of electrolytes.

COMPLEMENT REGULATION:
Complement is designed to efficiently target and destroy pathogens and other foreign cells; however,
the nature of the system dictates that it also targets host cells and thus has the potential to cause
tissue damage and disease-a double-edged sword. Damage to self is minimized by the presence of
numerous regulatory proteins and control mechanisms. Complement regulatory proteins are present
both on host cell membranes and in the fluid phase, collaborating to minimize activation and
suppress amplification of complement. Each stage of each of the complement pathways is controlled
through inhibition or accelerated decay of complement enzymes or by physical interference.
CONTROL OF INITIATION OF THE CLASSICAL PATHWAY AND ALTERNATIVE
PATHWAY:
Activated Cl is regulated by a plasma serine protease inhibitor called Cl inhibitor (Clinh), a 100
kDa heavily glycosylated single-chain protein present in plasma at around 150 mg/L. Clinh
binds Clr and Cls in activated Cl and forms a tight complex (Clinh-Clr2Cl~), simultaneously
stripping them from the Ig-bound Clq. Like other serine protease inhibitors, Clinh undergoes an
autocatalytic cleavage event during formation of the complex that stabilizes its binding to
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substrate; it thus behaves as a suicide inhibitor, inactivated during the process of inhibition.
Clinh also inhibits the LP, binding to and removing MASP-2 from the activated MBL/ficolin
MASP complex to switch off activation.
CONTROL OF THE CP/LP C3 CONVERTASE
The CP/LP C3 convertase, C4b2a, is regulated by inhibitors present in the fluid phase and on
membranes. C4b binding protein (C4bp) is a complex, multi-chain plasma protein present in
plasma at about 200 mg/L. Each of the -chains in C4bp contains a binding site in its three
amino-terminal SCRs that can bind C4b in the C4b2a complex. C4bp exerts two different
inhibitory activities: first, it displaces C2a from C4b, termed "accelerated decay," and second, it
acts as a cofactor for enzymatic cleavage of C4b by the plasma enzyme factor I (fl), a two-chain
(heavy, 50 kDa; light, 38 kDa), disulphide-bonded serine protease present at about 30 mg/L in
plasma. C4b is inactivated by cleavage at two sites in the ex' -chain straddling the thioester,
thereby releasing a large fragment, C4c, to the fluid phase and leaving the small C4d fragment
attached to membrane neither C4c nor C4d are of particular biological relevance. The -chain of
C4bp binds and inactivates Protein S, an important anticoagulation protein, one of many
fascinating links between complement and coagulation.
Two homologous cell surface complement inhibitors act in tandem to regulate the C4b2a
complex. Decay accelerating factor (DAF; CD55) is a broadly distributed glycosyl
phosphoinositol (GPI)-linked membrane. As the name implies, DAF accelerates decay of the
convertase; it binds membrane-associated C4b2a and displaces C2a, then releases because its
affinity for C4b alone is low. Decay allows the second inhibitor, membrane cofactor protein
(MCP; CD46), access to bind membrane-associated C4b. As its name implies, it is a cofactor for
fl-mediated cleavage of C4b to C4c and C4d. This two-step regulation is important because
decay alone leaves intact C4b on the surface, which can recruit more C2 and form a new
convertase; in contrast, fl cleavage destroys C4b, thereby switching off activation.
Another membrane protein, complement receptor 1 (CRl; CD35), can also regulate the C4b2a
enzyme through decay and cofactor activities. The functionally important parts of CRI are the
C3b-/C4b-binding sites contained in the first four SCRs of the first three LHRs; although
differing in relative activities and ligand binding affinities, each of these sites can both decay the
C4b2a convertase and bind C4b to catalyze its cleavage by fI.

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Regulation of Complement system

CONTROL OF THE ALTERNATIVE PATHWAY C3 CONVERTASE

The AP C3 convertase, C3bBb, is regulated in a very similar manner to the CP convertase. C4bp
has only very low affinity for C3b or C3bBb, likely of no physiological relevance. Its role is
taken by another plasma protein, factor H (fH), an elongated, single-chain protein made up
entirely of 20 SCRs, present in plasma at about 300 mg/l. The complement regulatory activity of
fH resides in SCRs 1 to 4; these four domains bind the C3bBb convertase, displace Bb from C3b
(accelerated decay), and act as cofactor for fi to cleave C3b at two internal sites in the -chain,
generating the large membrane-bound fragment, iC3b, and releasing a small peptide, C3f. iC3b
14

cannot drive further complement activation but is an important ligand for complement receptors.
On membranes, the C3bBb convertase is regulated by the same proteins that control C4b2a.
DAF binds C3bBb, displaces Bb, and is then released (decay acceleration); MCP binds C3b and
catalyzes its cleavage by fI to yield iC3b and C3f. CRl, through its C3b-/C4b-binding sites, both
decays C3bBb and binds C3b to catalyze its cleavage by fI. Importantly, CRl catalyzes a second
fI cleavage event, an additional cut that releases the large fragment, C3c to the fluid phase,
leaving a small piece of the
chain, C3dg, attached to the membrane through the thioester.
Plasma proteases then chew C3dg down further to C3d, an important ligand for complement
receptors.
CONTROL OF TERMINAL PATHWAY:
The vast majority of the C5b67 complexes formed never bind membrane, the site is hydrolysed or
the plasma scavenger proteins S- protein (also called vitronectin) and/ or clusterin bind and block
the site. Perhaps the most efficient fluid phase inhibitor of the Terminal pathway is the next
component in the sequence, C8. If C8 binds C5b67 before it attaches to membrane, the binding
site is lost. Because the process is so inefficient, large amounts of the waste product, the terminal
complement complex (TCC) containing all the terminal pathway components, clusterin and Sproteins, are found in plasma when complement activation occurs invivo. TCC levels in plasma
can be measured and provide an excellent index of ongoing complement activation. Despite the
attention of these fluid phase inhibitors, some C5b67 complexes will bind the membrane, usually
on the same cell and close to the triggering convertase, but occurring occasionally on adjacent,
innocent bystander cells. C8 then binds, and with recruitment of multiple C9 molecules, the
Membrane Attack complex forms. Membrane regulation of this process is provided by CD59, a
small, compact GPI- anchored molecule widely expressed on most cell types. CD 59, by moving
randomly in the membrane, will encounter the forming MAC at the C5b-8 stage and lock firmly
to it, preventing the recruitment of multiple C9 molecules and the assembly of the MAC lytic
pore.

CONSEQUENCES OF COMPLEMENT ACTIVATION:

CELL LYSIS:
The membrane-attack complex formed by complement activation can lyse gram-negative
bacteria, parasites, viruses, erythrocytes, and nucleated cells.
Antibody and complement do play a role in host defense against viruses and are often crucial in
containing viral spread during acute infection and in protecting against reinfection.
The complement system is generally quite effective in lysing gram-negative bacteria. However,
some gram-negative bacteria and most gram-positive bacteria have mechanisms for evading
complement-mediated damage.
For example, a few gram-negative bacteria can develop resistance to complement-mediated lysis
that correlates with the virulence of the organism.

15

 INFLAMMATION:
Cleavage Products of Complement Components Mediate Inflammation.
The smaller fragments resulting from complement cleavage, C3a, C4a, and C5a, called
anaphylatoxins, bind to receptors on mast cells and blood basophils and induce degranulation,
with release of histamine and other pharmacologically active mediators.
The anaphylatoxins also induce smooth-muscle contraction and increased vascular permeability.
Activation of the complement system thus results in influxes of fluid that carries antibody and
phagocytic cells to the site of antigen entry.
C3a, C5a, and C5b67 can each induce monocytes and neutrophils to adhere to vascular
endothelial cells, extravasate through the endothelial lining of the capillary, and migrate toward
the site of complement activation in the tissues. C5a is most potent in mediating these processes,
effective in picomolar quantities.
OPSONIZATION:
C3b is the major opsonin of the complement system, although C4b and iC3b also have
opsonizing activity. The amplification that occurs with C3 activation results in a coating of C3b
on immune complexes and particulate antigens.
Phagocytic cells, as well as some other cells, express complement receptors (CR1, CR3, and
CR4) that bind C3b, C4b, or iC3b.
Antigen coated with C3b binds to cells bearing CR1. If the cell is a phagocyte (e.g., a neutrophil,
monocyte, or macrophage), phagocytosis will be enhanced.
Activation of phagocytic cells by various agents, including C5a anaphylatoxin, has been shown
to increase the number of CR1s from 5000 on resting phagocytes to 50,000 on activated cells,
greatly facilitating their phagocytosis of C3b-coated antigen.
C3b targets the antigen directly to the phagocyte, enhancing the initiation of antigen processing
and accelerating specific antibody production.
VIRAL NEUTRALIZTION:
For most viruses, the binding of serum antibody to the repeating subunits of the viral structural
proteins creates particulate immune complexes ideally suited for complement activation by the
classical pathway.
Some viruses (e.g., retroviruses, Epstein-Barr virus, Newcastle disease virus, and rubella virus)
can activate the alternative, lectin, or even the classical pathway in the absence of antibody.
The complement system mediates viral neutralization by a number of mechanisms. Some degree
of neutralization is achieved through the formation of larger viral aggregates, simply because
these aggregates reduce the net number of infectious viral particles.
The binding of antibody and/or complement to the surface of a viral particle creates a thick
protein coating that can be visualized by electron microscopy. This coating neutralizes viral
infectivity by blocking attachment to susceptible host cells. The deposits of antibody and
complement on viral particles also facilitate binding of the viral particle to cells possessing Fc or
type 1 complement receptors (CR1).
In the case of phagocytic cells, such binding can be followed by phagocytosis and intracellular
destruction of the ingested viral particle. Finally, complement is effective in lysing most, if not
16

all, enveloped viruses, resulting in fragmentation of the

envelope and disintegration of the nucleocapsid.
SOLUBILISATION OF IMMUNE COMPLEXES:
The importance of the complement system in clearing
immune complexes is seen in patients with the
autoimmune disease systemic lupus erythematosus (SLE).
These individuals produce large quantities of immune
complexes and suffer tissue damage as a result of
complement-mediated lysis and the induction of type II or
type III hypersensitivity.
Although complement plays a significant role in the
development of tissue damage in SLE, the paradoxical
finding is that deficiencies in C1, C2, C4, and CR1
predispose an individual to SLE; indeed, 90% of
individuals who completely lack C4 develop SLE.

Clearance of circulating Immune complexes

COMPLEMENT DEFICIENCIES, MUTATIONS AND AUTO ANTIBODIES

Mutations in complement proteins are rare events that can be catastrophic and cause partial or total
deficiency of the protein, or more subtle, altering the expression level or functional efficiency of the
protein. Polymorphisms are common variations in protein composition that may or may not have
functional consequences. The most dramatic outcome of a mutation in a complement protein is
deficiency, which may involve a loss of protein product (Type I deficiency) or the production of a
functionally inactive protein (Type II deficiency).

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Complement Deficiencies

CLASSICAL PATHWAY COMPONENT DEFICIENCIES

Deficiencies of CP component proteins {C1, C4, C2) remove the capacity for efficient activation
of complement on ICs and are strongly associated with lupus-like IC disease and infections.
Clq deficiency is rare (only a dozen or so families have been described, and all affected
homozygous individuals develop severe lupus-like disease with rashes, renal failure, and other
sequelae before adulthood).
Deficiencies of either Clr or Cls are similarly rare and often combined because of linkage and
coordinate expression of the genes; symptoms and penetrance are as for C1q deficiency.
Total C4 deficiency is also rare because there are two C4 genes (C4A, C4B) each with two
alleles, requiring co-inheritance of four mutations for complete deficiency. These rare
individuals will all develop lupus-like disease early. Mutations leading to loss of expression of
one of more C4 alleles (null alleles) are relatively common in the population: 35% have one null
allele, 8% two null alleles, and 1% three null alleles; these latter individuals will have low
plasma C4 levels and an increased tendency to develop IC disease, greater in those with more
null alleles and in those null at the C4A gene. Genetic testing for C4 gene copy number is
therefore a useful adjunct to measuring plasma levels in testing for C4 deficiency.
C2 deficiency is the most common complement deficiency among Caucasians; C2 null alleles
are present in some 1% of individuals, giving a predicted incidence of deficiency of 1:10,000 in
the population. Although C2 deficiency does increase the risk of developing IC disease, the
majority of C2-deficient individuals are healthy, detected at routine screening because their
plasma lacks CP hemolytic activity.
The strong association of classical pathway deficiencies with lupus-like disease has led to the
assertion that lupus, not only in complement deficiency but also in classical systemic lupus
erythematosus (SLE), is caused by the defective clearance of immune complexes and apoptotic
cells which then become sources of autoantigens.

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 LECTIN PATHWAY COMPONENT DEFICIENCIES:

Plasma levels of MBL vary widely in the population due to a complex set of mutations and
polymorphisms in the constituent chains. Three mutations clustered in exon 1 of the MBL gene
individually disrupt the capacity to form the higher oligomers necessary for MBL function and,
in homozygosity or compound heterozygosity, result in complete deficiency of MBL.
Complete MBL deficiency predisposes to bacterial infections, particularly in individuals who are
otherwise compromised ( eg, neonates, the elderly, patients with cystic fibrosis, and patients
with acquired immunodeficiency syndrome).
A number of common polymorphisms in MBL can also profoundly affect MBL plasma levels
and oligomerization status, and those inheriting an extreme set of variants can have profoundly
low MBL levels, with the same resultant problems as those totally deficient in MBL.
Genetic mutations leading to deficiencies of ficolin-2 and ficolin-3 were recently reported and
shown to cause defective LP activation in plasma. Mutations in the MASP2 gene leading to
complete or subtotal deficiency of this key LP enzyme MASP-2 were also described, but their
clinical relevance remains unclear.

C3 DEFICIENCY
C3 is the most abundant and most critical of the complement proteins, essential for activation
through all pathways. It is therefore not surprising that total C3 deficiency, a very rare finding
restricted to a few dozen families, is devastating Individuals present in childhood with severe,
recurrent bacterial infections that, if not promptly treated, will progress to uncontrolled sepsis and
death. Supportive care and antibiotics can permit survival into adulthood, but IC disease and renal
injury then become apparent.

ALTERNATIVE PATHWAY COMPONENT DEFICIENCIES

Deficiencies of the AP components are rare, with just a few individuals or families reported for
each. Total deficiency of fB has not been reported, although a recent abstract described total or
subtotal deficiency in a teenager with meningitis. Each of the ill-deficient cases have presented
with Neisserial infection, most often fulminant septicaemia, suggesting that AP amplification is
particularly important in dealing with bacteria of this genus; however, numbers of cases are
small, and it is possible that AP deficiencies have broader consequences for susceptibility to
bacterial infections.
Deficiency of the AP stabilizer, properdin, is also associated with severe Neisserial infections,
meningitis, and septicaemia. Inherited in an X-linked manner, it is almost exclusively seen in
young males, usually presenting in childhood. It is rare but probably underascertained. Properdin
deficiency may be associated with a complete absence of the protein (Type 1), presence of very
low levels of normal protein (Type II), or presence of near-normal levels of a nonfunctional
protein (Type III). Patients who survive the initial infectious episode tend to do reasonably well
thereafter as anti-Neisserial antibodies develop, permitting recruitment of the CP in subsequent
exposures.

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 TERMINAL PATHWAY COMPONENT DEFICIENCIES

Deficiencies of TP components (C5, C6, C7, C8, and C9) are relatively common and all
predispose to Neisserial infections.
C5, though not a true TP component, is included here because consequences of deficiency are
similar; C5 deficiency has been identified in a few dozen families from across the globe, perhaps
more common in Africans and African Americans. Deficiency predisposes to Neisserial
infections, including meningitis and septicaemia, and perhaps other infections; unlike AP
deficiencies, infections tend to be recurrent and often involve unusual serotypes of Neisseria.
C6 deficiency is the second most common complement deficiency in Caucasians, predicted from
null allele frequency to have an incidence of around 1:10,000 in the population; in African
Americans, it may be even more common, with a predicted incidence greater than 1:2,000.
Consequences are similar to those of CS deficiency: recurrent Neisserial infections. Subtotal
deficiency of C6 has also been described, with levels a few percent of normal and with or
without linked deficiency of C7; the frequency and relevance of these is uncertain.
C7 deficiency is also common in some racial groups, with a predicted incidence of 1:10,000 in
Israelis of Moroccan Jewish descent. The frequency of total deficiency in Caucasians is not well
defined, but personal experience suggests it is considerably less common that C6 deficiency in
the United Kingdom. Clinical consequences are identical to C6 deficiency. Subtotal C7
deficiency is common in Caucasians, with a defined mutation at an allele frequency of about
1%.
A few cases of combined deficiency of C6 and C7 have been described as a consequence of the
close linkage of the genes.
C8-deficient individuals can lack either C8 or C8 chain; the former is rare in Caucasians, the
latter more common. In all C8 -deficient individuals characterized to date, the mutation is in
the C8A gene. Plasma contains no detectable C8 and very low amounts of C8, indicating that
this chain is labile in isolation in plasma. C8P-deficient individuals have no detectable C8 in
plasma but variable amounts of C8, often approaching normal. In either case, plasma
haemolytic activity is completely lost. Presenting symptoms are identical to those of other TP
deficiencies noted previously.
C9 deficiency is rare in most ethnic groups with only a handful of cases reported in Caucasians,
but it is by far the most common complement deficiency in Japanese and other Oriental races,
the result of a single, ancient non-sense mutation (R95X) in the gene. Frequency of the null
mutation is about 2% in Koreans and 1% in Chinese; however, in Japanese, null allele frequency
is 6.7%, giving a predicted incidence ofC9 deficiency of about 1:260 of the population! This
incredible frequency implies some selective advantage of the null allele in these populations;
most compelling is the suggestion that C9 deficiency blunts the sometimes overvigorous
complement response to infection, making C9-deficient individuals less susceptible to the
development of sepsis.

PLASMA REGULATORY PROTEIN DEFICIENCIES

The most common by far is Clinh deficiency, which has a prevalence in Caucasian populations
of 1:50,000. Deficiency of Clinh is common primarily because it presents as an autosomal
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dominant, heterozygous deficiency is sufficient to cause disease. Deficiency of Clinh causes the
disease hereditary angioedema (HAE), characterized by recurrent, acute episodes of localized
swelling of the skin and/or mucous membranes. Clinh is not only the sole plasma protease
inhibitor of activated Clr/s and the MASP enzymes, but also inhibits enzyme cascades involved
in coagulation, fibrinolysis, and the contact system. Inflammation or injury triggers activation of
complement and these other proteolytic cascades in tissues, leading to the consumption of
C1inh, a suicide inhibitor. In the presence of only a single normal C1INH gene, synthesis of
C1inh cannot keep up with triggered consumption and plasma levels fall precipitously, leading
to loss of control of the multiple cascades. Active products of the cascades, particularly the
kinins, cause localized tissue edema, the hallmark symptom of HAE. Many different mutations
in C1INH have been described in patients with HAE. In about 80% of cases, these are null
mutations with no protein product (Type I); in about 20%, a protein is produced but is inactive
(Type II).
Deficiency of fI, the key enzyme responsible for the inactivation of the convertase enzymes of
the AP and CP, is a rare but devastating problem. Tickover complement activation and AP
amplification proceed unchecked, leading to complete consumption of C3; this secondary C3
deficiency predisposes to bacterial infections and IC disease, precisely as in primary C3
deficiency. The plasma regulator of the AP convertase, fH, is essential for fluid-phase AP
regulation. Complete deficiency of fH is rare and, like fi deficiency, results in uncontrolled AP
amplification and consumption of C3. Secondary C3 deficiency predisposes to infection and
immune complex disease, but fH deficiency uniquely affects the kidney, causing a characteristic
set of renal pathologies, including various subtypes of membranoproliferative
glomerulonephritis and atypical hemolytic uremic syndrome (aHUS). aHUS is much more
strongly associated with mutations in the carboxy-terminal SCRs of fH that do not cause
deficiency but do reduce or ablate the capacity of fH to bind surfaces; these binding mutants of
fH are the most common genetic finding in aHUS, responsible for up to half of all cases and
causing disease even in heterozygosity.
Deficiencies of other members of the fH gene family have recently been described and in some
cases associated with disease. Combined deletion of the FHRl and FHR3 genes is a common
finding, present in about 5% of Caucasians and even more common in some racial groups.
Absence of fHRl and fHR3 is associated with aHUS, apparently because it predisposes to the
development of anti-H autoantibodies; the same deficiency is protective for the common eye
disease age-related macular degeneration (AMD). Deficiencies of other fHR proteins are much
less common and of uncertain clinical relevance.
Deficiencyof C4bp, the fluid phase regulator of the CP, is extremely rare with only two case
reports to date; in neither case were the presenting symptoms compatible with a complement
defect, suggesting that they were ascertainment artifacts.

COMPLEMENT PROTEIN POINT MUTATIONS

Point mutations that affect function of a complement protein in more subtle ways are also
sometimes of clinical importance. Perhaps the best example is that of fH, where the carboxyterminal SCRs appear to be "hotspots" for point mutations that have no direct effect on the
21

complement regulating capacity of fH, but profoundly reduce its capacity to bind surfaces. Even
in heterozygosity, these mutations predispose the individual to the development of aHUS,
particularly when combined with other complement polymorphisms or mutations that alone have
little effect.
Another intriguing example is a recent report describing an unusual renal disease in Greek
Cypriots; search for a genetic cause identified a mutation in FHR5.The mutant protein was
present in plasma but was dysfunctional, unable to bind efficiently surface-bound C3b; quite
how this functional deficit in an apparently minor member of the fH family causes such major
pathology remains to be determined.

COMPLEMENT AUTOANTIBODIES
Autoantibodies against complement components, regulators, and complexes have been found in
and linked with disease. Nephritic factors (NeFs) are autoantibodies that bind and stabilize the
AP (and rarely CP) C3 convertase. They are, as the name implies, associated with renal disease,
usually present in patients with DDD (Dense Deposit Disease), and sometimes found in other
types of membranoproliferative glomerulonephritis. NeFs are also found in the rare disease
partial lipodystrophy where peripheral adipose tissue is lost. NeF stabilizes the convertase both
by slowing natural decay and by preventing accelerated decay mediated by fH and other
regulators. Complement is therefore consumed systemically and/or locally, and this in turn
causes renal pathology.
Autoantibodies against Fh are increasingly recognized in association with renal disease,
particularly aHUS. Almost all anti-fH-positive aHUS patients lack fHRl and fHR3; this appears
to be necessary but not sufficient for anti-fH production because most individuals with this
common gene deletion do not make anti-fH antibodies. The anti-fH antibodies predominantly
target the carboxy-terminal SCRs of fH and inhibit fH binding to surfaces, mimicking the effects
of the aHUS-associated mutations in fH.
Anti-Clq autoantibodies are associated with a number of autoimmune and renal disease, notably
lupus nephritis and poststreptococcal glomerulonephritis. Anti-Clq antibodies are a useful
marker of disease activity, but their contribution to the disease process is uncertain.
Anti-Clinh autoantibodies are associated with a rare, acquired form of angioedema mimicking
HAE; the autoantibodies target the reactive center of Clinh thereby blocking its function.

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BIBLIOGRAPHY:
Kubys Immunology by Owen, Punt and Stranford; Edition: Sixth; Publication: W. H. Freeman
and Company; Chapter 13: The Complement System; Page no. 299

Fundamental Immunology by William E. Paul; Edition: Seventh; Publication: Lippincott

Williams and Wilkins; Chapter 36: Complement; Page no. 863

Immunology by David Male, Jonathan Brostoff, David B Roth and Ivan Roitt; Edition: Seventh;
Chapter 4: Complement; Page no. 87
Lippincott's Illustrated Reviews: Immunology by Thao Doan, Roger Melvold, Susan Viselli and
Carl Waltenbaugh; Edition: Second; Publication: Lippincott Williams and Wilkins; Chapter 5:
Innate Immune System; Page no. 45
www.ncbi.nlm.nih.gov NCBI Literature Bookshelf
users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/Complement.htm
http://www.britannica.com/science/complement-immune-system-component

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