chapter 13

The Complement
System
ART TO COME

T       

of the humoral branch of the immune system.
Research on complement began in the 1890s,
when Jules Bordet at the Institut Pasteur in Paris showed
that sheep antiserum to the bacterium Vibrio cholerae
caused lysis of the bacteria and that heating the antiserum
destroyed its bacteriolytic activity. Surprisingly, the ability Poly-C9 Complex
to lyse the bacteria was restored to the heated serum by
adding fresh serum that contained no antibodies directed ■ The Functions of Complement
against the bacterium and was unable to kill the bacterium
by itself. Bordet correctly reasoned that bacteriolytic activ- ■ The Complement Components
ity requires two different substances: first, the specific an- ■ Complement Activation
tibacterial antibodies, which survive the heating process,
and a second, heat-sensitive component responsible for the ■ Regulation of the Complement System
lytic activity. Bordet devised a simple test for the lytic ac- ■ Biological Consequences of Complement
tivity, the easily detected lysis of antibody-coated red blood Activation
cells, called hemolysis. Paul Ehrlich in Berlin indepen-
dently carried out similar experiments and coined the term ■ Complement Deficiencies
complement, defining it as “the activity of blood serum that
completes the action of antibody.” In ensuing years, re-
searchers discovered that the action of complement was
the result of interactions of a large and complex group of
proteins.
This chapter describes the complement components and receptors with complement proteins controls B-cell activi-
their activation pathways, the regulation of the complement ties gives this system a role in the highly developed acquired
system, the effector functions of various complement com- immune system. Thus we have a system that straddles in-
ponents, and the consequences of deficiencies in them. A nate and acquired immunity, contributing to each in a vari-
Clinical Focus section describes consequences of a defect in ety of ways.
proteins that regulate complement activity. After initial activation, the various complement compo-
nents interact, in a highly regulated cascade, to carry out a
number of basic functions (Figure 13-1) including:
■ Lysis of cells, bacteria, and viruses
The Functions of Complement ■ Opsonization, which promotes phagocytosis of
Research on complement now includes more than 30 solu- particulate antigens
ble and cell-bound proteins. The biological activities of ■ Binding to specific complement receptors on cells of
this system affect both innate and acquired immunity and
the immune system, triggering specific cell functions,
reach far beyond the original observations of antibody-
inflammation, and secretion of immunoregulatory
mediated lysis of bacteria and red blood cells. Structural
molecules
comparisons of the proteins involved in complement path-
ways place the origin of this system in primitive organisms ■ Immune clearance, which removes immune complexes
possessing the most rudimentary innate immune systems. from the circulation and deposits them in the spleen and
By contrast, the realization that interaction of cellular liver
300 PART III Immune Effector Mechanisms

LYSIS OPSONIZATION ACTIVATION OF INFLAMMATORY CLEARANCE OF

RESPONSE IMMUNE COMPLEXES
Complement
receptor
Bacteria Ag-Ab
complex
Complement

Degranulation
Extravasation

Tissue

Blood

Target cell Phagocyte Phagocyte

FIGURE 13-1 The multiple activities of the complement system. phagocytes; activation of inflammatory responses; and clearance of
Serum complement proteins and membrane-bound complement circulating immune complexes by cells in the liver and spleen.
receptors partake in a number of immune activities: lysis of foreign Soluble complement proteins are schematically indicated by a trian-
cells by antibody-dependent or antibody-independent pathways; gle and receptors by a semi-circle; no attempt is made to differenti-
opsonization or uptake of particulate antigens, including bacteria, by ate among individual components of the complement system here.

C5b, can occur by the classical pathway, the alternative

The Complement Components pathway, or the lectin pathway. The final steps that lead to a
membrane attack are the same in all pathways.
The proteins and glycoproteins that compose the complement
system are synthesized mainly by liver hepatocytes, although
significant amounts are also produced by blood monocytes, tis- The Classical Pathway Begins with
sue macrophages, and epithelial cells of the gastrointestinal and
genitourinary tracts. These components constitute 5% (by
Antigen-Antibody Binding
weight) of the serum globulin fraction. Most circulate in the Complement activation by the classical pathway commonly
serum in functionally inactive forms as proenzymes, or zymo- begins with the formation of soluble antigen-antibody com-
gens, which are inactive until proteolytic cleavage, which re- plexes (immune complexes) or with the binding of antibody
moves an inhibitory fragment and exposes the active site. The to antigen on a suitable target, such as a bacterial cell. IgM and
complement-reaction sequence starts with an enzyme cascade. certain subclasses of IgG (human IgG1, IgG2, and IgG3) can
Complement components are designated by numerals activate the classical complement pathway. The initial stage of
(C1–C9), by letter symbols (e.g., factor D), or by trivial activation involves C1, C2, C3, and C4, which are present in
names (e.g., homologous restriction factor). Peptide frag- plasma in functionally inactive forms. Because the compo-
ments formed by activation of a component are denoted by nents were named in order of their discovery and before their
small letters. In most cases, the smaller fragment resulting functional roles had been determined, the numbers in their
from cleavage of a component is designated “a” and the larger names do not always reflect the order in which they react.
fragment designated “b” (e.g., C3a, C3b; note that C2 is an The formation of an antigen-antibody complex induces
exception: C2a is the larger cleavage fragment). The larger conformational changes in the Fc portion of the IgM mole-
fragments bind to the target near the site of activation, and cule that expose a binding site for the C1 component of the
the smaller fragments diffuse from the site and can initiate complement system. C1 in serum is a macromolecular com-
localized inflammatory responses by binding to specific re- plex consisting of C1q and two molecules each of C1r and
ceptors. The complement fragments interact with one an- C1s, held together in a complex (C1qr2s2) stabilized by Ca2
other to form functional complexes. Those complexes that ions. The C1q molecule is composed of 18 polypeptide
have enzymatic activity are designated by a bar over the num- chains that associate to form six collagen-like triple helical
ber or symbol (e.g., C4b2a, C3bBb). arms, the tips of which bind to exposed C1q-binding sites in
the CH2 domain of the antibody molecule (Figure 13-3, on
page 302). Each C1r and C1s monomer contains a catalytic
domain and an interaction domain; the latter facilitates in-
Complement Activation teraction with C1q or with each other.
Figure 13-2 on page 301 outlines the pathways of comple- Each C1 molecule must bind by its C1q globular heads to
ment activation. The early steps, culminating in formation of at least two Fc sites for a stable C1-antibody interaction to
 The Complement System CHAPTER 13 301

Mannose-binding
Classical lectin (MBL) Lectin
pathway binds foreign surface pathway

C4
+ MBL-associated proteases
(MASP1 + 2) bind MBL,
C2 generate activated
C1-like complex
C1 binds
Activated
antigen-antibody
C1
complex
C5 convertase

C3 convertase C4b2a C4b2a3b

Major
amplification C3b C5 C5b
C3 step

C6
C3 convertase C3bBb C3bBb3b
C7
C5 convertase C8
C9
Factor D

Alternative C3bB
Membrane
pathway
attack
complex
Factor B

C3b

Spontaneous, slow,
small amounts

C3

FIGURE 13-2 Overview of the complement activation pathways. brane-attack complex (MAC) by a common sequence of terminal
The classical pathway is initiated when C1 binds to antigen-antibody reactions. Hydrolysis of C3 is the major amplification step in all path-
complexes. The alternative pathway is initiated by binding of spon- ways, generating large amounts of C3b, which forms part of C5 con-
taneously generated C3b to activating surfaces such as microbial cell vertase. C3b also can diffuse away from the activating surface and
walls. The lectin pathway is initiated by binding of the serum protein bind to immune complexes or foreign cell surfaces, where it func-
MBL to the surface of a pathogen. All three pathways generate C3 tions as an opsonin.
and C5 convertases and bound C5b, which is converted into a mem-

occur. When pentameric IgM is bound to antigen on a target providing two attachment sites for C1q. This difference ac-
surface it assumes the so-called “staple” configuration, in counts for the observation that a single molecule of IgM
which at least three binding sites for C1q are exposed. Circu- bound to a red blood cell can activate the classical complement
lating IgM, however, exists as a planar configuration in which pathway and lyse the red blood cell while some 1000 mole-
the C1q-binding sites are not exposed (Figure 13-4, on page cules of IgG are required to assure that two IgG molecules are
302) and therefore cannot activate the complement cascade. close enough to each other on the cell surface to initiate C1q
An IgG molecule, on the other hand, contains only a single binding.
C1q-binding site in the CH2 domain of the Fc, so that firm C1q The intermediates in the classical activation pathway are
binding is achieved only when two IgG molecules are within depicted schematically in Figure 13-5 (page 303). Binding of
30–40 nm of each other on a target surface or in a complex, C1q to Fc binding sites induces a conformational change in
(text continues on page 304)
302 PART III Immune Effector Mechanisms

(a) Heads (b)

C1r
C1s

C1q
Stalk

FIGURE 13-3 Structure of the C1 macromolecular complex. (a) Di- alytic domain with enzymatic activity and an interaction domain that
agram of C1qr2s2 complex. A C1q molecule consists of 18 polypep- facilitates binding with C1q or with each other. (b) Electron micro-
tide chains arranged into six triplets, each of which contains one A, graph of C1q molecule showing stalk and six globular heads. [Part (b)
one B, and one C chain. Each C1r and C1s monomer contains a cat- from H. R. Knobel et al., 1975, Eur. J. Immunol. 5:78.]

(a) (b)

(c) (d)

FIGURE 13-4 Models of pentameric IgM in planar form (a) and bound to flagella, showing the planar form (c) and staple form (d).
“staple” form (b). Several C1q-binding sites in the Fc region are [From A. Feinstein et al., 1981, Monogr. Allergy, 17:28, and 1981,
accessible in the staple form, whereas none are exposed in the pla- Ann. N.Y. Acad. Sci. 190:1104.]
nar form. Electron micrographs of IgM antiflagellum antibody
 The Complement System CHAPTER 13 303

VISUALIZING CONCEPTS

1 4
C1q binds antigen-bound antibody. C1r activates auto- The C3b component of C5 convertase binds C5, permitting
catalytically and activates the second C1r; both activate C1s C4b2a to cleave C5

C1qr2s2
C1q

C1r2s2
Antibody

FC +
C5b C5a

C5

2 C5 convertase
C1s cleaves C4 and C2. Cleaving C4 exposes the binding site
for C2. C4 binds the surface near C1 and C2 binds C4,
5
forming C3 convertase C5b binds C6, initiating the formation of the membrane-attack
complex

C4 C2
C4a C2b

C6 C7
C8
C4b2a
C3 convertase C5b C567 C5b678

3
C3 convertase hydrolyzes many C3 molecules. Some combine
with C3 convertase to form C5 convertase

C5b678

C9
Poly-C9

+
C3b C3a
C3
Membrane attack complex

C4b2a C4b2a3b
C5 convertase

FIGURE 13-5 Schematic diagram of intermediates in the classi- attack complex (MAC, bottom right) forms a large pore in the
cal pathway of complement activation. The completed membrane- membrane.
304 PART III Immune Effector Mechanisms

C1r that converts C1r to an active serine protease enzyme, The Alternative Pathway Is
C1r, which then cleaves C1s to a similar active enzyme, C1 1s . Antibody-Independent
C11s has two substrates, C4 and C2. The C4 component is a
glycoprotein containing three polypeptide chains , , and . The alternative pathway generates bound C5b, the same
C4 is activated when C11s hydrolyzes a small fragment (C4a) product that the classical pathway generates, but it does so
from the amino terminus of the  chain, exposing a binding without the need for antigen-antibody complexes for initia-
site on the larger fragment (C4b). The C4b fragment attaches tion. Because no antibody is required, the alternative path-
to the target surface in the vicinity of C1, and the C2 proen- way is a component of the innate immune system. This
zyme then attaches to the exposed binding site on C4b, where major pathway of complement activation involves four
the C2 is then cleaved by the neighboring C11s ; the smaller serum proteins: C3, factor B, factor D, and properdin. The al-
fragment (C2b) diffuses away. The resulting C4b2a  complex ternative pathway is initiated in most cases by cell-surface
is called C3 convertase, referring to its role in converting the constituents that are foreign to the host (Table 13-1). For ex-
C3 into an active form. The smaller fragment from C4 cleav- ample, both gram-negative and gram-positive bacteria have
age, C4a, is an anaphylatoxin, or mediator of inflammation, cell-wall constituents that can activate the alternative path-
which does not participate directly in the complement cas- way. The intermediates in the alternative pathway for gener-
cade; the anaphylatoxins, which include the smaller frag- ating C5b are shown schematically in Figure 13-7 (page 306).
ments of C4, C3, and C5 are described below. In the classical pathway, C3 is rapidly cleaved to C3a and
The native C3 component consists of two polypeptide C3b by the enzymatic activity of the C3 convertase. In the al-
chains,  and . Hydrolysis of a short fragment (C3a) from ternative pathway, serum C3, which contains an unstable
the amino terminus of the  chain by the C3 convertase gen- thioester bond, is subject to slow spontaneous hydrolysis to
erates C3b (Figure 13-6). A single C3 convertase molecule can yield C3a and C3b. The C3b component can bind to foreign
generate over 200 molecules of C3b, resulting in tremendous surface antigens (such as those on bacterial cells or viral par-
amplification at this step of the sequence. Some of the C3b ticles) or even to the host’s own cells (see Figure 13-6c). The
 to form a trimolecular complex C4b
binds to C4b2a  2a3b, membranes of most mammalian cells have high levels of
called C5 convertase. The C3b component of this complex sialic acid, which contributes to the rapid inactivation of
 com-
binds C5 and alters its conformation, so that the C4b2a bound C3b molecules on host cells; consequently this bind-
ponent can cleave C5 into C5a, which diffuses away, and C5b, ing rarely leads to further reactions on the host cell mem-
which attaches to C6 and initiates formation of the membrane- brane. Because many foreign antigenic surfaces (e.g., bac-
attack complex in a sequence described later. Some of the terial cell walls, yeast cell walls, and certain viral envelopes)
C3b generated by C3 convertase activity does not associate have only low levels of sialic acid, C3b bound to these sur-
; instead it diffuses away and then coats immune
with C4b2a faces remains active for a longer time. The C3b present on the
complexes and particulate antigens, functioning as an opsonin surface of the foreign cells can bind another serum protein
as described in the Clinical Focus. C3b may also bind directly called factor B to form a complex stabilized by Mg2. Bind-
to cell membranes. ing to C3b exposes a site on factor B that serves as the sub-

(a) (b) (c)

Cell membrane
O
O
C S R
C3a C+ –S
α O
C4b2a O C SH
S S

S S

S S

S S

β
S S

S S

C3
Activated C3b

Bound C3b

FIGURE 13-6 Hydrolysis of C3 by C3 convertase C4b2a (a) Native fragment to bind to free hydroxyl or amino groups (R) on a cell mem-
C3. (b) Activated C3 showing site of cleavage by C4b2a resulting in brane. Bound C3b exhibits various biological activities, including
production of the C3a and C3b fragments. (c) A labile internal binding of C5 and binding to C3b receptors on phagocytic cells.
thioester bond in C3 is activated as C3b is formed, allowing the C3b
 The Complement System CHAPTER 13 305

ment binds to mannose residues, some authors designate this

Initiators of the alternative pathway
TABLE 13-1 the MBLectin pathway or mannan-binding lectin pathway.)
of complement activation
The lectin pathway, like the alternative pathway, does not de-
PATHOGENS AND PARTICLES OF MICROBIAL ORIGIN pend on antibody for its activation. However, the mechanism
is more like that of the classical pathway, because after initia-
Many strains of gram-negative bacteria tion, it proceeds, through the action of C4 and C2, to pro-
Lipopolysaccharides from gram-negative bacteria duce a C5 convertase (see Figure 13-2).
Many strains of gram-positive bacteria
The lectin pathway is activated by the binding of man-
nose-binding lectin (MBL) to mannose residues on glyco-
Teichoic acid from gram-positive cell walls
proteins or carbohydrates on the surface of microorganisms
Fungal and yeast cell walls (zymosan) including certain Salmonella, Listeria, and Neisseria strains,
Some viruses and virus-infected cells as well as Cryptococcus neoformans and Candida albicans.
Some tumor cells (Raji)
MBL is an acute phase protein produced in inflammatory
responses. Its function in the complement pathway is similar
Parasites (trypanosomes)
to that of C1q, which it resembles in structure. After MBL
NONPATHOGENS binds to the surface of a cell or pathogen, MBL-associated
serine proteases, MASP-1 and MASP-2, bind to MBL. The ac-
Human IgG, IgA, and IgE in complexes tive complex formed by this association causes cleavage and
Rabbit and guinea pig IgG in complexes activation of C4 and C2. The MASP-1 and -2 proteins have
structural similarity to C1r and C1s and mimic their activi-
Cobra venom factor
ties. This means of activating the C2–C4 components to
Heterologous erythrocytes (rabbit, mouse, chicken) form a C5 convertase without need for specific antibody
Anionic polymers (dextran sulfate) binding represents an important innate defense mechanism
Pure carbohydrates (agarose, inulin) comparable to the alternative pathway, but utilizing the ele-
ments of the classical pathway except for the C1 proteins.
SOURCE: Adapted from M. K. Pangburn, 1986, in Immunobiology of the
Complement System, Academic Press.
The Three Complement Pathways Converge
at the Membrane-Attack Complex
The terminal sequence of complement activation involves
strate for an enzymatically active serum protein called factor C5b, C6, C7, C8, and C9, which interact sequentially to form
D. Factor D cleaves the C3b-bound factor B, releasing a small a macromolecular structure called the membrane-attack
fragment (Ba) that diffuses away and generating C33 bBb. The complex (MAC). This complex forms a large channel
C33
bBb complex has C3 convertase activity and thus is analo- through the membrane of the target cell, enabling ions and
 complex in the classical pathway. The C3
gous to the C4b2a small molecules to diffuse freely across the membrane.
convertase activity of C33
bBb has a half-life of only 5 minutes The end result of activating the classical, alternative, or
unless the serum protein properdin binds to it, stabilizing lectin pathways is production of an active C5 convertase.
it and extending the half-life of this convertase activity to This enzyme cleaves C5, which contains two protein chains,
30 minutes.  and . After binding of C5 to the nonenzymatic C3b com-
The C33
bBb generated in the alternative pathway can acti- ponent of the convertase, the amino terminus of the  chain
vate unhydrolyzed C3 to generate more C3b autocatalytically. is cleaved. This generates the small C5a fragment, which dif-
As a result, the initial steps are repeated and amplified, so fuses away, and the large C5b fragment, which binds to the
that more than 2  106 molecules of C3b can be deposited surface of the target cell and provides a binding site for the
on an antigenic surface in less than 5 minutes. The C3 con- subsequent components of the membrane-attack complex
bBb generates the C33b
vertase activity of C33 Bb3b complex, (see Figure 13-5, step 5). The C5b component is extremely la-
which exhibits C5 convertase activity, analogous to the bile and becomes inactive within 2 minutes unless C6 binds

C4b2a 3b complex in the classical pathway. The nonenzy- to it and stabilizes its activity.
matic C3b component binds C5, and the Bb component Up to this point, all the complement reactions take place
subsequently hydrolyzes the bound C5 to generate C5a and on the hydrophilic surface of membranes or on immune
C5b (see Figure 13-7); the latter binds to the antigenic surface. complexes in the fluid phase. As C5b6 binds to C7, the result-
ing complex undergoes a hydrophilic-amphiphilic structural
The Lectin Pathway Originates With Host transition that exposes hydrophobic regions, which serve as
binding sites for membrane phospholipids. If the reaction
Proteins Binding Microbial Surfaces occurs on a target-cell membrane, the hydrophobic binding
Lectins are proteins that recognize and bind to specific car- sites enable the C5b67 complex to insert into the phospho-
bohydrate targets. (Because the lectin that activates comple- lipid bilayer. If, however, the reaction occurs on an immune
306 PART III Immune Effector Mechanisms

VISUALIZING CONCEPTS

1
C3 hydrolyzes spontaneously, C3b
C3
fragment attaches to foreign surface

+
C3b C3a

2
Factor B binds C3a, exposes site acted Factor B
on by Factor D. Cleavage generates
C3bBb, which has C3 convertase
activity
Factor D

3
Binding of properdin stabilizes C3bBb + Properdin
convertase
C3 convertase
C3

+
4
Convertase generates C3b; some binds
to C3 convertase activating C5'
convertase. C5b binds to antigenic C3bBb3B
surface
C3 convertase

Membrane
C5 C5b attack
+ complex

C5a

FIGURE 13-7 Schematic diagram of intermediates in the for- erdin. Conversion of bound C5b to the membrane-attack complex
mation of bound C5b by the alternative pathway of complement occurs by the same sequence of reactions as in the classical path-
activation. The C3bBb complex is stabilized by binding of prop- way (see Figure 13-5).

complex or other noncellular activating surface, then the hy- complexes mediate tissue damage will be considered in
drophobic binding sites cannot anchor the complex and it is Chapter 20.
released. Released C5b67 complexes can insert into the mem- Binding of C8 to membrane-bound C5b67 induces a con-
brane of nearby cells and mediate “innocent-bystander” lysis. formational change in C8, so that it too undergoes a hy-
Regulator proteins normally prevent this from occurring, but drophilic-amphiphilic structural transition, exposing a
in certain diseases cell and tissue damage may result from in- hydrophobic region, which interacts with the plasma mem-
nocent-bystander lysis. A hemolytic disorder resulting from brane. The C5b678 complex creates a small pore, 10 Å in di-
deficiency in a regulatory protein is explained in the Clinical ameter; formation of this pore can lead to lysis of red blood
Focus section and an autoimmune process in which immune cells but not of nucleated cells. The final step in formation of
 The Complement System CHAPTER 13 307

the MAC is the binding and polymerization of C9, a per-

forin-like molecule, to the C5b678 complex. As many as Regulation of the Complement
10–17 molecules of C9 can be bound and polymerized by
a single C5b678 complex. During polymerization, the C9
System
molecules undergo a hydrophilic-amphiphilic transition, so Because many elements of the complement system are capa-
that they too can insert into the membrane. The completed ble of attacking host cells as well as foreign cells and microor-
MAC, which has a tubular form and functional pore size of ganisms, elaborate regulatory mechanisms have evolved to
70–100 Å, consists of a C5b678 complex surrounded by a restrict complement activity to designated targets. A general
poly-C9 complex (Figure 13-8). Since ions and small mole- mechanism of regulation in all complement pathways is the
cules can diffuse freely through the central channel of the inclusion of highly labile components that undergo sponta-
MAC, the cell cannot maintain its osmotic stability and is neous inactivation if they are not stabilized by reaction with
killed by an influx of water and loss of electrolytes. other components. In addition, a series of regulatory pro-
teins can inactivate various complement components (Table
13-2). For example, the glycoprotein C1 inhibitor (C1Inh)
(a)
can form a complex with C1r2s2, causing it to dissociate from
C1q and preventing further activation of C4 or C2 (Figure
13-9a(1)).
The reaction catalyzed by the C3 convertase enzymes of the
classical, lectin, and alternative pathways is the major amplifi-
cation step in complement activation, generating hundreds of
molecules of C3b. The C3b generated by these enzymes has the
potential to bind to nearby cells, mediating damage to the
healthy cells by causing their opsonization by phagocytic cells
bearing C3b receptors or by induction of the membrane-
attack complex. Damage to normal host cells is prevented be-
cause C3b undergoes spontaneous hydrolysis by the time it has
diffused 40 nm away from the C4b2a  or C3 3
bBb convertase en-
zymes, so that it can no longer bind to its target site. The po-
tential destruction of healthy host cells by C3b is further
limited by a family of related proteins that regulate C3 conver-
tase activity in the classical and alternative pathways. These
(b)
regulatory proteins all contain repeating amino acid sequences
(or motifs) of about 60 residues, termed short consensus repeats
(SCRs). All these proteins are encoded at a single location on
chromosome 1 in humans, known as the regulators of comple-
ment activation (RCA) gene cluster.
In the classical and lectin pathways, three structurally dis-
tinct RCA proteins act similarly to prevent assembly of C3
convertase (Figure 13-9a(2)). These regulatory proteins in-
clude soluble C4b-binding protein (C4bBP) and two mem-
brane-bound proteins, complement receptor type 1 (CR1)
and membrane cofactor protein (MCP). Each of these regu-
latory proteins binds to C4b and prevents its association with
C2a. Once C4bBP, CR1, or MCP is bound to C4b, another
regulatory protein, factor I, cleaves the C4b into bound C4d
and soluble C4c (Figure 13-9a(3)). A similar regulatory se-
quence operates to prevent assembly of the C3 convertase
C33
bBb in the alternative pathway. In this case CR1, MCP, or a
regulatory component called factor H binds to C3b and pre-
FIGURE 13-8 (a) Photomicrograph of poly-C9 complex formed by vents its association with factor B (Figure 13-9a(4)). Once
in vitro polymerization of C9. (b) Photomicrograph of complement- CR1, MCP, or factor H is bound to C3b, factor I cleaves the
induced lesions on the membrane of a red blood cell. These lesions C3b into a bound iC3b fragment and a soluble C3f fragment.
result from formation of membrane-attack complexes. [Part (a) from Further cleavage of iC3b by factor I releases C3c and leaves
E. R. Podack, 1986, in Immunobiology of the Complement System, C3dg bound to the membrane (Figure 13-9a(5)). The mole-
Academic Press; part (b) from J. Humphrey and R. Dourmashkin, cular events involved in regulation of cell-bound C4b and
1969, Adv. Immunol. 11:75.] C3b are depicted in Figure 13-10 (page 310).
308 PART III Immune Effector Mechanisms

TABLE 13-2 Proteins that regulate the complement system

Type of Pathway
Protein protein affected Immunologic function

C1 inhibitor (C1Inh) Soluble Classical Serine protease inhibitor: causes C1r2s2

to dissociate from C1q
C4b-binding protein Soluble Classical and lectin Blocks formation of C3 convertase by
(C4bBP)* binding C4b; cofactor for cleavage of
C4b by factor I
Factor H* Soluble Alternative Blocks formation of C3 convertase by
binding C3b; cofactor for cleavage of
C3b by factor I

}
Complement-receptor Block formation of C3 convertase by
type 1 (CR1)* Membrane Classical, alternative, binding C4b or C3b; cofactor for
Membrane-cofactor bound and lectin factor I-catalyzed cleavage of C4b
protein (MCP)* or C3b C3bBb
Decay-accelerating Membrane Classical, alternative, Accelerates dissociation of C4b2a and
factor (DAE or CD55)* bound and lectin C3bBb (classical and alternative C3
convertases)
Factor-I Soluble Classical, alternative, Serine protease: cleaves C4b or C3b
and lectin using C4bBP, CR1, factor H, DAE,
or MCP as cofactor
S protein Soluble Terminal Binds soluble C5b67 and prevents its
insertion into cell membrane
Homologous restriction
factor (HRF)
Membrane inhibitor of
reactive lysis (MIRL
or CD59)*
} Membrane
bound
Terminal Bind to C5b678 on autologous cells,
blocking binding of C9

Anaphylatoxin inactivator Soluble Effector Inactivates anaphylatoxin activity of C3a,

C4a, and C5a by carboxypeptidase N
removal of C-terminal Arg
*An RCA (regulator of complement activation) protein. In humans, all RCA proteins are encoded on chromosome 1 and contain short consensus repeats.

Several RCA proteins also act on the assembled C3 con- tein can bind to C5b67, inducing a hydrophilic transition
vertase, causing it to dissociate; these include the previously and thereby preventing insertion of C5b67 into the mem-
mentioned C4bBP, CR1, and factor H. In addition, decay- brane of nearby cells (Figure 13-9c(1)).
accelerating factor (DAF or CD55), which is a glycoprotein an- Complement-mediated lysis of cells is more effective if
chored covalently to a glycophospholipid membrane protein, the complement is from a species different from that of the
has the ability to dissociate C3 convertase. The consequences cells being lysed. This phenomenon depends on two mem-
of DAF deficiency are described in the Clinical Focus section. brane proteins that block MAC formation. These two pro-
Each of these RCA proteins accelerates decay (dissociation) of teins, present on the membrane of many cell types, are
C3 convertase by releasing the component with enzymatic ac- homologous restriction factor (HRF) and membrane inhibitor
tivity (C2a or Bb) from the cell-bound component (C4b or of reactive lysis (MIRL or CD59). Both HRF and MIRL pro-
C3b). Once dissociation of the C3 convertase occurs, factor I tect cells from nonspecific complement-mediated lysis by
cleaves the remaining membrane-bound C4b or C3b compo- binding to C8, preventing assembly of poly-C9 and its inser-
nent, irreversibly inactivating the convertase (Figure 13-9b). tion into the plasma membrane (Figure 13-9c(2)). However,
Regulatory proteins also operate at the level of the mem- this inhibition occurs only if the complement components
brane-attack complex. The potential release of the C5b67 are from the same species as the target cells. For this reason,
complex poses a threat of innocent-bystander lysis to healthy MIRL and HRF are said to display homologous restriction,
cells. A number of serum proteins counter this threat by for which the latter was named. As discussed in Chapter 21,
binding to released C5b67 and preventing its insertion into homologous restriction poses a barrier to the use of organs
the membrane of nearby cells. A serum protein called S pro- from other species for clinical transplantation.
 The Complement System CHAPTER 13 309

VISUALIZING CONCEPTS C1r2s2

C1qr2s2 C1Inh
Regulation of the Complement System
(a) Before assembly of convertase activity
1
C1 inhibitor (C1Iab) binds C1r2s2, causing dissociation
from C1q
Antibody

C4bBP, CRI, or MCP C4c

2 Factor 1
Association of C4b and C2a is blocked by binding C4b-binding +
protein (C4bBP), complement receptor type I, or membrane C2a C4b C4d
cofactor protein (MCP)

3
Inhibitor-bound C4b is cleaved by Factor 1
C3 convertase

CRI, MCP, Factor H

4 C3f
Factor 1
In alternative pathway, CR1, MCP, or Factor H prevent +
binding of C3b and Factor B Factor C3b iC3b
B
5 Factor 1
Inhibitor-bound C3b is cleaved by Factor 1

C3 convertase C3c C3dg

(b) After assembly of convertase

C4bBP, CR2 Dissociation of convertase;
Factor H, DAF
C3 convertases are dissociated by C4bBP, CR1, Factor H, and remaining C4b or C3b
decay-accelerating Factor (DAF) cleaved by Factor 1

(c) Regulation at assembly of membrane-attack complex (MAC)

1
S protein prevents insertion of C5b67 MAC component into Cannot attack nearby cells
the membrane
S protein
C5b67

2 HRF, C5b678
Homologous restriction factor
MIRL
(HRF) and membrane inhibitor
C9
of reactive lysis (MIRL or
CD59) bind C81, preventing C8
assembly of poly-C9 and
blocking formation of MAC C5b67 C5b678 Poly-C9

Membrane attack complex

FIGURE 13-9 Regulation of the complement system by regulatory proteins (black).

310 PART III Immune Effector Mechanisms

(a)
Cell membrane

NH NH

S S
S S

S S
S S

S S
S S
O C SH O C

C4bBP or
CR1 or MCP C4d
S S

S S

S S

S S

S S

S S
Factor I

Bound C4b C4c C4c

(b)
Cell membrane

R R R

O O C3f O
O C SH O C SH O C SH

Factor H or
CR1 or MCP Factor I C3dg

S S

S S
S S

S S

S S

S S

S S

S S
Factor I

Bound C3b iC3b C3c C3c

FIGURE 13-10 Inactivation of bound C4b and C3b by regulatory pathway, factor H, CR1, or MCP bind to Ccb and act as cofactors
proteins of the complement system. (a) In the classical pathway, for factor I–mediated cleavage of C4b. Free diffusible fragments
C4bBP (C4b-binding protein), CR1 (complement receptor type 1), are shown in dark shades; membrane bound components in light
or MCP (membrane cofactor protein) bind to C4b and act as cofac- shades.
tors for factor I–mediated cleavage of C4b. (b) In the alternative

The Membrane-Attack Complex Can Lyse a

Biological Consequences of Broad Spectrum of Cells
Complement Activation The membrane-attack complex formed by complement acti-
Complement serves as an important mediator of the hu- vation can lyse gram-negative bacteria, parasites, viruses,
moral response by amplifying the response and converting erythrocytes, and nucleated cells. Because the alternative and
it into an effective defense mechanism to destroy invad- lectin pathways of activation generally occur without an ini-
ing microorganisms. The MAC mediates cell lysis, while tial antigen-antibody interaction, these pathways serve as im-
other complement components or split products participate portant innate immune defenses against infectious micro-
in the inflammatory response, opsonization of antigen, organisms. The requirement for an initial antigen-antibody
viral neutralization, and clearance of immune complexes reaction in the classical pathway supplements these nonspe-
(Table 13-3, page 312). cific innate defenses with a more specific defense mecha-
Many of the biological activities of the complement sys- nism. In some instances, the requirement for antibody in the
tem depend on the binding of complement fragments to activating event may be supplied by so-called natural anti-
complement receptors, which are expressed by various cells. bodies, which are raised against common components of
In addition, some complement receptors play an important ubiquitous microbes.
role in regulating complement activity by binding biologi- The importance of cell-mediated immunity in host de-
cally active complement components and degrading them fense against viral infections has been emphasized in previ-
into inactive products. The complement receptors and their ous chapters. Nevertheless, antibody and complement do
primary ligands, which include various complement compo- play a role in host defense against viruses and are often
nents and their proteolytic breakdown products, are listed in crucial in containing viral spread during acute infection
Table 13-4 (page 312). and in protecting against reinfection. Most—perhaps
 The Complement System CHAPTER 13 311

CLINICAL FOCUS

Paroxymal Nocturnal them would be rarer than the 1 in

Hemoglobinuria: a Defect in 100,000 incidence of PNH. The answer
is that neither protein itself is defective in
Regulation of Complement PNH; the defect lies in a posttransla-
tional modification of the peptide anchor
Lysis that binds them to the cell membrane.
While most proteins that are expressed
on the surface of cells have hydrophobic
plement-mediated cell lysis, but act at
Common conditions
associated with deficiency in the comple-
different stages of the process. DAF in-
hibits cell lysis by causing dissociation
sequences that traverse the lipid bilayer
in the cell membrane, some proteins are
bound by glycolipid anchors (glycosyl
ment components include increased and inactivation of the C3 convertases of phosphatidylinositol, or GPI) attached to
susceptibility to bacterial infections and the classical, lectin, and alternative path- amino acid residues in the protein. With-
systemic lupus erythematosus which is ways (see Figure 13-9b). MIRL acts later out the ability to form GPI anchors, pro-
related to the inability to clear immune in the pathway by binding to the C5b678 teins that attach in this manner will be
complexes. Deficiency in the proteins complex, which inhibits C9 binding and absent from the cell surface, including
that regulate complement activity can prevents formation of the pores that de- both DAF and MIRL.
cause equally serious disorders. An ex- stroy the cell under attack. Both proteins The defect identified in PNH lies early
ample is paroxymal nocturnal hemoglo- are expressed on erythrocytes as well as in the enzymatic path to formation of a
binuria, or PNH, which manifests as a number of other hematopoetic cell GPI anchor and resides in the pig-a gene
increased fragility of erythrocytes, lead- types. Deficiency in these proteins leads (phosphatidylinositol glycan comple-
ing to chronic hemolytic anemia, pancy- to highly increased sensitivity of host mentation class A gene). Transfection of
topenia (loss of blood cells of all types) cells to the lytic effects of the host’s com- cells from PNH patients with an intact
and venous thrombosis (formation of plement activity. PNH, the clinical con- pig-a gene restored the cells’ resistance
blood clots). The name PNH derives sequence of deficiency in DAF and MIRL, to host complement lysis. Examination
from the presence of hemoglobin in the is a chronic disease with a mean sur- of pig-a sequences in PNH patients re-
urine, most commonly observed in the vival time between 10 and 15 years. The veals a number of different defects in
first urine passed after a night’s sleep. most common causes of mortality in this X-linked gene, indicating somatic
The cause of PNH is a general defect in PNH are venous thrombosis affecting rather than genetic origin of the defect.
synthesis of cell-surface proteins, which hepatic veins and progressive bone- This description of PNH underscores
affects the expression of two regulators marrow failure. the fact that the complement system is a
of complement, DAF (decay accelerating An obvious question about this rare powerful defender of the host but also a
factor or CD55) and MIRL (membrane but serious disease concerns the fact dangerous one. Complex systems of reg-
inhibitor of reactive lysis or CD59). that two different proteins are involved ulation are necessary to protect host
DAF and MIRL are cell-surface pro- in its pathogenesis. The simultaneous cells from the activated complement
teins that function as inhibitors of com- occurrence of a genetic defect in each of complexes generated to lyse intruders.

all—enveloped viruses are susceptible to complement- damage (Table 13-5). For example, a few gram-negative bac-
mediated lysis. The viral envelope is largely derived from teria can develop resistance to complement-mediated lysis
the plasma membrane of infected host cells and is there- that correlates with the virulence of the organism. In Es-
fore susceptible to pore formation by the membrane- cherichia coli and Salmonella, resistance to complement is as-
attack complex. Among the pathogenic viruses susceptible sociated with the smooth bacterial phenotype, which is
to lysis by complement-mediated lysis are herpesviruses, characterized by the presence of long polysaccharide side
orthomyxoviruses, paramyxoviruses, and retroviruses. chains in the cell-wall lipopolysaccharide (LPS) component.
The complement system is generally quite effective in It has been proposed that the increased LPS in the wall of re-
lysing gram-negative bacteria (Figure 13-11). However, sistant strains may prevent insertion of the MAC into the
some gram-negative bacteria and most gram-positive bac- bacterial membrane, so that the complex is released from the
teria have mechanisms for evading complement-mediated bacterial cell rather than forming a pore. Strains of Neisseria
312 PART III Immune Effector Mechanisms

TABLE 13-3 Summary of biological effects mediated by complement products

Effect Complement product mediating*

Cell lysis C5b–9, the membrane-attack complex (MAC)

Inflammatory response
Degranulation of mast cells and basophils† C3a,C4a, and C5a (anaphylatoxins)
Degranulation of eosinophils C3a, C5a
Extravasation and chemotaxis of leukocytes at inflammatory site C3a, C5a, C5b67
Aggregation of platelets C3a, C5a
Inhibition of monocyte/macrophage migration and induction Bb
of their spreading
Release of neutrophils from bone marrow C3c
Release of hydrolytic enzymes from neutrophils C5a
Increased expression of complement receptors C5a
type 1 and 3 (CR1 and CR3) on neutrophils
Opsonization of particulate antigens, increasing their phagocytosis C3b, C4b, iC3b
Viral neutralization C3b, C5b–9 (MAC)
Solubilization and clearance of immune complexes C3b
*Boldfaced component is most important in mediating indicated effect.
†
Degranulation leads to release of histamine and other mediators that induce contraction of smooth muscle and increased permeability of vessels.

gonorrheae resistant to complement-mediated killing have Gram-positive bacteria are generally resistant to comple-
been associated with disseminated gonococcal infections in ment-mediated lysis because the thick peptidoglycan layer in
humans. Some evidence suggests that the membrane pro- their cell wall prevents insertion of the MAC into the inner
teins of resistant Neisseria strains undergo noncovalent in- membrane. Although complement activation can occur on
teractions with the MAC that prevent its insertion into the the cell membrane of encapsulated bacteria such as Strepto-
outer membrane of the bacterial cells. These examples of coccus pneumoniae, the capsule prevents interaction between
resistant gram-negative bacteria are the exception; most C3b deposited on the membrane and the CR1 on phagocytic
gram-negative bacteria are susceptible to complement- cells. Some bacteria possess an elastase that inactivates C3a
mediated lysis. and C5a, preventing these split products from inducing an

TABLE 13-4 Complement-binding receptors

Receptor Major ligands Activity Cellular distribution

CR1 (CD35) C3b, C4b Blocks formation of C3 Erythrocytes, neutrophils,

convertase; binds immune monocytes, macrophages,
complexes to cells eosinophils, follicular dendritic
cells, B cells, some T cells
CR2 (CD21) C3d, C3dg,* Part of B-cell coreceptor; B cells, follicular dendritic
iC3b binds Epstein-Barr virus cells, some T cells
CR3 (CD11b/18)

CR4 (CD11c/18) } iC3b

Bind cell-adhesion molecules
on neutrophils, facilitating their
extravasation; bind immune
complexes, enhancing their
Monocytes, macrophages,
neutrophils, natural killer
cells, some T cells

phagocytosis
C3a/C4a receptor C3a, C4a Induces degranulation of mast Mast cells, basophils, granulocytes
cells and basophils
C5a receptor C5a Induces degranulation of mast Mast cells, basophils, granulocytes,
cells and basophils monocytes, macrophages,
platelets, endothelial cells
*Cleavage of C3dg by serum proteases generates C3d and C3g.
 The Complement System CHAPTER 13 313

(a) (b) (c)

Killed

Alive Killed

FIGURE 13-11 Scanning electron micrographs of E. coli showing Note membrane blebbing on lysed cells. [From R. D. Schreiber et
(a) intact cells and (b, c) cells killed by complement-mediated lysis. al., 1979, J. Exp. Med. 149:870.]

inflammatory response. In addition to these mechanisms of Lysis of nucleated cells requires formation of multiple
evasion, various bacteria, viruses, fungi, and protozoans con- membrane attack complexes, whereas a single MAC can lyse
tain proteins that can interrupt the complement cascade on a red blood cell. Many nucleated cells, including the majority
their surfaces, thus mimicking the effects of the normal com- of cancer cells, can endocytose the MAC. If the complex is
plement regulatory proteins C4bBP, CR1, and DAF. removed soon enough, the cell can repair any membrane

TABLE 13-5 Microbial evasion of complement-mediated damage

Microbial component Mechanism of evasion Examples

GRAM-NEGATIVE BACTERIA

Long polysaccharide chains Side chains prevent insertion of Resistant strains of E. coli and
in cell-wall LPS MAC into bacterial membrane Salmonella
Outer membrane protein MAC interacts with membrane Resistant strains of Neisseria
protein and fails to insert into gonorrhoeae
bacterial membrane
Elastase Anaphylatoxins C3a and C5a are Pseudomonas aeruginosa
inactivated by microbial elastase

GRAM-POSITIVE BACTERIA

Peptidoglycan layer of cell wall Insertion of MAC into bacterial Streptococcus

membrane is prevented by thick
layer of peptidoglycan
Bacterial capsule Capsule provides physical barrier Streptococcus pneumoniae
between C3b deposited on
bacterial membrane and CR1
on phagocytic cells

OTHER MICROBES

Proteins that mimic complement Protein present in various bacteria, Vaccinia virus, herpes simplex,
regulatory proteins viruses, fungi, and protozoans Epstein-Barr virus, Trypanosoma
inhibit the complement cascade cruzi, Candida albicans
KEY: CR1  type 1 complement receptor; LPS  lipopolysaccharide; MAC  membrane-attack complex (C5b–9).
314 PART III Immune Effector Mechanisms

damage and restore its osmotic stability. An unfortunate con- C3a, C5a, and C5b67 can each induce monocytes and
sequence of this effect is that complement-mediated lysis by neutrophils to adhere to vascular endothelial cells, ex-
antibodies specific for tumor-cell antigens, which offers a po- travasate through the endothelial lining of the capillary, and
tential weapon against cancer, may be rendered ineffective by migrate toward the site of complement activation in the tis-
endocytosis of the MAC (see Chapter 22). sues. C5a is most potent in mediating these processes, effec-
tive in picomolar quantities. The role of complement in
Cleavage Products of Complement leukocyte chemotaxis is discussed more fully in Chapter 15.
Components Mediate Inflammation
C3b and C4b Binding Facilitates
The complement cascade is often viewed in terms of the fi-
nal outcome of cell lysis, but various peptides generated
Opsonization
during formation of the MAC play a decisive role in the de- C3b is the major opsonin of the complement system, al-
velopment of an effective inflammatory response (see Table though C4b and iC3b also have opsonizing activity. The am-
13-3). The smaller fragments resulting from complement plification that occurs with C3 activation results in a coating
cleavage, C3a, C4a, and C5a, called anaphylatoxins, bind to of C3b on immune complexes and particulate antigens.
receptors on mast cells and blood basophils and induce de- Phagocytic cells, as well as some other cells, express comple-
granulation, with release of histamine and other pharmaco- ment receptors (CR1, CR3, and CR4) that bind C3b, C4b, or
logically active mediators. The anaphylatoxins also induce iC3b (see Table 13-4). Antigen coated with C3b binds to cells
smooth-muscle contraction and increased vascular perme- bearing CR1. If the cell is a phagocyte (e.g., a neutrophil,
ability. Activation of the complement system thus results in monocyte, or macrophage), phagocytosis will be enhanced
influxes of fluid that carries antibody and phagocytic cells (Figure 13-12). Activation of phagocytic cells by various
to the site of antigen entry. The activities of these highly re- agents, including C5a anaphylatoxin, has been shown to in-
active anaphylatoxins are regulated by a serum protease crease the number of CR1s from 5000 on resting phagocytes
called carboxypeptidase N, which cleaves an Arg residue to 50,000 on activated cells, greatly facilitating their phagocy-
from the C terminus of the molecules, yielding so-called tosis of C3b-coated antigen. Recent studies indicate that
des-Arg forms. The des-Arg forms of C3a and C4a are com- complement fragment C3b acts as an adjuvant when coupled
pletely inactive while that of C5a retains about 10% of its with protein antigens. C3b targets the antigen directly to the
chemotactic activity and 1% of its ability to cause smooth phagocyte, enhancing the initiation of antigen processing
muscle contraction. and accelerating specific antibody production.

(a) (b)

Coated
virus
particle
Bacterium
Complement
activation CR1
Fc receptor
IgG C3b
Phagocyte

Phagocytosis

Nucleus

FIGURE 13-12 (a) Schematic representation of the roles of C3b C3b receptor (CR1) on a B lymphocyte. [Part (b) from N. R. Cooper
and antibody in opsonization. (b) Electron micrograph of Epstein- and G. R. Nemerow, 1986, in Immunobiology of the Complement
Barr virus coated with antibody and C3b and bound to the Fc and System, Academic Press.]
 The Complement System CHAPTER 13 315

The Complement System Also The Complement System Clears Immune

Neutralizes Viral Infectivity Complexes from Circulation
For most viruses, the binding of serum antibody to the re- The importance of the complement system in clearing im-
peating subunits of the viral structural proteins creates par- mune complexes is seen in patients with the autoimmune dis-
ticulate immune complexes ideally suited for complement ease systemic lupus erythematosus (SLE). These individuals
activation by the classical pathway. Some viruses (e.g., retro- produce large quantities of immune complexes and suffer tis-
viruses, Epstein-Barr virus, Newcastle disease virus, and sue damage as a result of complement-mediated lysis and the
rubella virus) can activate the alternative, lectin, or even the induction of type II or type III hypersensitivity (see Chapter
classical pathway in the absence of antibody. 16). Although complement plays a significant role in the devel-
The complement system mediates viral neutralization by opment of tissue damage in SLE, the paradoxical finding is
a number of mechanisms. Some degree of neutralization is that deficiencies in C1, C2, C4, and CR1 predispose an indi-
achieved through the formation of larger viral aggregates, vidual to SLE; indeed, 90% of individuals who completely lack
simply because these aggregates reduce the net number of in- C4 develop SLE. The complement deficiencies are thought to
fectious viral particles. Although antibody plays a role in the interfere with effective solubilization and clearance of immune
formation of viral aggregates, in vitro studies show that the complexes; as a result, these complexes persist, leading to tissue
C3b component facilitates aggregate formation in the pres- damage by the very system whose deficiency was to blame.
ence of as little as two molecules of antibody per virion. For The coating of soluble immune complexes with C3b is
example, polyoma virus coated with antibody is neutralized thought to facilitate their binding to CR1 on erythrocytes. Al-
when serum containing activated C3 is added. though red blood cells express lower levels of CR1 (~5  102
The binding of antibody and/or complement to the sur- per cell) than granulocytes do (~5  104 per cell), there are
face of a viral particle creates a thick protein coating that can about 103 red blood cells for every white blood cell; therefore,
be visualized by electron microscopy (Figure 13-13). This erythrocytes account for about 90% of the CR1 in the blood.
coating neutralizes viral infectivity by blocking attachment For this reason, erythrocytes play an important role in binding
to susceptible host cells. The deposits of antibody and com- C3b-coated immune complexes and carrying these complexes
plement on viral particles also facilitate binding of the viral to the liver and spleen. In these organs, immune complexes are
particle to cells possessing Fc or type 1 complement receptors stripped from the red blood cells and are phagocytosed,
(CR1). In the case of phagocytic cells, such binding can be thereby preventing their deposition in tissues (Figure 13-14).
followed by phagocytosis and intracellular destruction of the In SLE patients, deficiencies in C1, C2, and C4 each contribute
ingested viral particle. Finally, complement is effective in to reduced levels of C3b on immune complexes and hence in-
lysing most, if not all, enveloped viruses, resulting in frag- hibit their clearance. The lower levels of CR1 expressed on the
mentation of the envelope and disintegration of the nucleo- erythrocytes of SLE patients also may interfere with the proper
capsid. binding and clearance of immune complexes.

(a) (b) (c)

FIGURE 13-13 Electron micrographs of negatively stained prepara- [From N. R. Cooper and G. R. Nemerow, 1986, in Immunobiology of the
tions of Epstein-Barr virus. (a) Control without antibody. (b) Antibody- Complement System, Academic Press.]
coated particles. (c) Particles coated with antibody and complement.
316 PART III Immune Effector Mechanisms

BLOOD FIGURE 13-14 Clearance of circulating immune complexes by reac-

Ig tion with receptors for complement products on erythrocytes and re-
Ag moval of these complexes by receptors on macrophages in the liver
Soluble immune complex and spleen. Because erythrocytes have fewer receptors than macro-
phages, the latter can strip the complexes from the erythrocytes as they
pass through the liver or spleen. Deficiency in this process can lead to
Complement activation renal damage due to accumulation of immune complexes.

C3b complex diseases, individuals with such complement deficien-

cies may suffer from recurrent infections by pyogenic (pus-
forming) bacteria such as streptococci and staphylococci. These
organisms are gram-positive and therefore resistant to the lytic
effects of the MAC. Nevertheless, the early complement com-
ponents ordinarily prevent recurrent infection by mediating a
localized inflammatory response and opsonizing the bacteria.
Deficiencies in factor D and properdin—early components of
the alternative pathway—appear to be associated with Neisseria
infections but not with immune-complex disease.
Patients with C3 deficiencies have the most severe clinical
manifestations, reflecting the central role of C3 in activation
of C5 and formation of the MAC. The first patient identified
Erythrocyte
CR1 with a C3 deficiency was a child suffering from frequent se-
vere bacterial infections and initially diagnosed as having
agammaglobulinemia. After tests revealed normal immuno-
globulin levels, a deficiency in C3 was discovered. This case
LIVER highlights the critical function of the complement system in
AND
SPLEEN
converting a humoral antibody response into an effective de-
fense mechanism. The majority of patients with C3 deficiency
have recurrent bacterial infections and may have immune-
complex diseases.
Individuals with homozygous deficiencies in the compo-
nents involved in the MAC develop recurrent meningococcal
and gonococcal infections caused by Neisseria species. In
normal individuals, these gram-negative bacteria are gener-
ally susceptible to complement-mediated lysis or are cleared
by the opsonizing activity of C3b. MAC-deficient individuals
Phagocyte rarely have immune-complex disease, which suggests that
they produce enough C3b to clear immune complexes. Inter-
estingly, a deficiency in C9 results in no clinical symptoms,
suggesting that the entire MAC is not always necessary for
complement-mediated lysis.
Congenital deficiencies of complement regulatory proteins
have also been reported. The C1 inhibitor (C1Inh) regulates
activation of the classical pathway by preventing excessive C4
Complement Deficiencies and C2 activation by C1. Deficiency of C1Inh is an autosomal
Genetic deficiencies have been described for each of the com- dominant condition with a frequency of 1 in 1000. The defi-
plement components. Homozygous deficiencies in any of the ciency gives rise to a condition called hereditary angioedema,
early components of the classical pathway (C1q, C1r, C1s, C4, which manifests clinically as localized edema of the tissue, of-
and C2) exhibit similar symptoms, notably a marked increase ten following trauma, but sometimes with no known cause.
in immune-complex diseases such as systemic lupus erythe- The edema can be in subcutaneous tissues or within the bowel,
matosus, glomerulonephritis, and vasculitis. These deficiencies where it causes abdominal pain, or in the upper respiratory
highlight the importance of the early complement reactions in tract, where it causes obstruction of the airway.
generating C3b, and the critical role of C3b in solubilization Studies in humans and experimental animals with ho-
and clearance of immune complexes. In addition to immune- mozygous deficiencies in complement components have
 The Complement System CHAPTER 13 317

been the major source of information concerning the role of Lokki, M. L., and H. R. Colten. 1995. Genetic deficiencies of
individual complement components in immunity. These complement. Ann. Med. 27:451.
findings have been greatly extended by studies using knock- Matsumoto, M., et al. 1997. Abrogation of the alternative com-
out mice genetically engineered to lack expression of specific plement pathway by targeted deletion of murine factor B. Proc.
complement components. Investigations of in vivo comple- Natl. Acad. Sci. U.S.A. 94:8720.
ment activity in these animals has allowed dissection of the Molina, H., and V. M. Holers. 1996. Markedly impaired humoral
complex system of complement proteins and the assignment immune response in mice deficient in complement receptors 1
of precise biologic roles to each. and 2. Proc. Natl. Acad. Sci. U.S.A. 93:3357.
Muller-Eberhard, H. J. 1988. Molecular organization and
function of the complement system. Annu. Rev. Biochem.
SUMMARY 57:321.
■ The complement system comprises a group of serum pro-
Nielsen, C. H., E. M. Fischer, and R. G. Q. Leslie. 2000.The role
of complement in the acquired immune response. Immunol-
teins, many of which exist in inactive forms.
ogy 100:4.
■ Complement activation occurs by the classical, alternative, Nonaka, M. 2000. Origin and evolution of the complement sys-
or lectin pathways, each of which is initiated differently. tem. Curr. Top. Microbiol. Immunol. 248:37.
■ The three pathways converge in a common sequence of Pickering, M. C., and M. J. Walport. 2000. Links between com-
events that leads to generation of a molecular complex that plement abnormalities and system lupus erythematosus.
causes cell lysis. Rheumatology 39:133.
■ The classical pathway is initiated by antibody binding to a Rautemaa, R., and S. Meri. 1999. Complement-resistance mech-
cell target; reactions of IgM and certain IgG subclasses ac- anisms of bacteria. Microbes and Infection/Institut Pasteur
tivate this pathway. 1:785.
■ Activation of the alternative and lectin pathways is anti- Sloand, E. M., et al. 1998. Correction of the PNH Defect by GPI-
body-independent. These pathways are initiated by reac- anchored protein transfer. Blood 92:4439.
tion of complement proteins with surface molecules of Turner, M. W. 1998. Mannose-binding lectin (MBL) in health
microorganisms. and disease. Immunobiol. 199:327.
■ In addition to its key role in cell lysis, the complement sys-
tem mediates opsonization of bacteria, activation of in- USEFUL WEB SITES
flammation, and clearance of immune complexes.
■ Interactions of complement proteins and protein frag- http://www.complement-genetics.uni-mainz.de/
ments with receptors on cells of the immune system con-
The Complement Genetics Homepage from the University of
trol both innate and acquired immune responses. Mainz gives chromosomal locations and information on ge-
■ Because of its ability to damage the host organism, the netic deficiencies of complement proteins.
complement system requires complex passive and active
http://www.cehs.siu.edu/fix/medmicro/cfix.htm
regulatory mechanisms.
A clever graphic representation of the basic assay for comple-
■ Clinical consequences of inherited complement deficien- ment activity using red blood cell lysis, from D. Fix at Univer-
cies range from increases in susceptibility to infection to sity of Southern Illinois, Carbondale.
tissue damage caused by immune complexes.
http://www.gla.ac.uk/Acad/Immunology/compsyst.htm
Notes from D. F. Lappin at University of Glasgow, UK, on the
References complement system. The site includes a listing of all comple-
Ahearn, J. M., and D. T. Fearon. 1989. Structure and function of ment proteins and their molecular properties.
the complement receptors CR1 (CD35) and CR2 (CD21). Adv.
Immunol. 46:183.
Study Questions
Carroll, M. C. 2000. The role of complement in B-cell activation
and tolerance. Adv. Immunol. 74:61. CLINICAL FOCUS QUESTION Explain why complement disorders
involving regulatory components such as PNH may be more se-
Laurent, J., and M. T. Guinnepain. 1999. Angioedema associated rious than deficiencies in the active complement components.
with C1 inhibitor deficiency. Clin. Rev. Allergy. & Immunol.
17:513. 1. Indicate whether each of the following statements is true or
false. If you think a statement is false, explain why.
Lindahl, G., U. Sjobring, and E. Johnsson. 2000. Human comple-
ment regulators: a major target for pathogenic microorgan- a. A single molecule of bound IgM can activate the C1q com-
isms. Curr. Opin. Immunol. 12:44. ponent of the classical complement pathway.

Go to www.whfreeman.com/immunology Self-Test
Review and quiz of key terms
318 PART III Immune Effector Mechanisms

b. C3a and C3b are fragments of C3. i. ______C3a, C5a, and C5b67
c. The C4 and C2 complement components are present in j. ______C3a, C4a, and C5a
the serum in a functionally inactive proenzyme form. k. ______C4b2a
d. Nucleated cells tend to be more resistant to complement- l. ______C3b  B → C3bBb  Ba
mediated lysis than red blood cells.
Descriptions
e. Enveloped viruses cannot be lysed by complement be-
cause their outer envelope is resistant to pore formation (1) Reaction that produces major amplification during
by the membrane-attack complex. activation
f. C4-deficient individuals have difficulty eliminating im- (2) Are early components of alternative pathway
mune complexes. (3) Compose the membrane-attack complex
(4) Mediates opsonization
2. Explain why serum IgM cannot activate complement by itself. (5) Are early components of classical pathway
(6) Has perforin-like activity
3. Would you expect a C1 or C3 complement deficiency to be (7) Binds to Fc region of antibodies
more serious clinically? Why? (8) Have chemotactic activity
(9) Has C3 convertase activity
4. Some microorganisms produce enzymes that can degrade the
(10) Induce degranulation of mast cells (are anaphylatoxins)
Fc portion of antibody molecules. Why would such enzymes
(11) Has C5 convertase activity
be advantageous for the survival of microorganisms that pos-
(12) Reaction catalyzed by factor D
sess them?
(13) Reaction catalyzed by C1qr2s2
5. Complement activation can occur via the classical, alterna-
9. You have prepared knockout mice with mutations in the
tive, or lectin pathway.
genes that encode various complement components. Each
a. How do the three pathways differ in the substances that knockout strain cannot express one of the complement
can initiate activation? components listed across the top of the table below. Predict
b. Which portion of the overall activation sequence differs the effect of each mutation on the steps in complement acti-
in the three pathways? Which portion is similar? vation and on the complement effector functions indicated
c. How do the biological consequences of complement acti- in the table below using the following symbols: NE  no
vation via these pathways differ? effect; D  process/function decreased but not abolished;
A  process/function abolished.
6. Enucleated cells, such as red blood cells, are more susceptible
to complement-mediated lysis than nucleated cells.
a. Explain why the red blood cells of an individual are not Component knocked out
normally destroyed as the result of innocent-bystander ly-
sis by complement. C1q C4 C3 C5 C6 C9 Factor B
b. Under what conditions might complement cause lysis of COMPLEMENT ACTIVATION
an individual’s own red blood cells?
7. Briefly explain the mechanism of actionÏ of the following Formation of
complement regulatory proteins. Indicate which pathway(s) C3 convertase
each protein regulates. in classical
pathway
a. C1 inhibitor (C1Inh) Formation of
b. C4b-binding protein (C4bBP) C3 convertase
c. Homologous restriction factor (HRF) in alternative
d. Decay-accelerating factor (DAF) pathway
e. Factor H Formation of
f. Membrane cofactor protein (MCP) C5 convertase
in classical
8. For each complement component(s) or reaction (a–l), select pathway
the most appropriate description listed below (1–13). Each Formation of
description may be used once, more than once, or not at all. C5 convertase
in alternative
Complement Component(s)/Reactions pathway
a. ______C3b
EFFECTOR FUNCTIONS
b. ______C1, C4, C2, and C3
c. ______C9 C3b-mediated
d. ______C3, factor B, and factor D opsonization
e. ______C1q Neutrophil
f. ______C4b2a3b chemotaxis
g. ______C5b, C6, C7, C8, and C9
Cell lysis
h. ______C3 → C3a  C3b