Complement System

What is the complement system?

The complement system is a network of >30 proteins (both in plasma and on cell membranes). These proteins act
sequentially like a cascade, each one activating the next, to eliminate pathogens.
Innate immunity:
Complement is part of the Complement is part innate immune defense because it provides immediate, non-specific
protection against microbes.
Bridge to adaptive immunity:
Although innate, it also interacts with the adaptive immune system by enhancing antibody responses and helping immune
cells communicate.
What forms part of the complement activities?
This slide shows the four major effector functions of complement activation:
 1. Lysis (cell killing)
Complement proteins form the Membrane Attack Complex (MAC) on target cells (like bacteria).
This punches holes in the membrane → cell death.
2. Opsonization (tagging pathogens for phagocytosis)
Complement proteins (especially C3b) coat bacteria.
Phagocytes (like macrophages and neutrophils) have complement receptors that recognize C3b → enhanced engulfment
of microbes.
3. Activation of inflammatory response
Complement fragments (C3a, C5a) act as anaphylatoxins.
They cause mast cell degranulation, histamine release, vasodilation, increased vascular permeability, and
chemotaxis of immune cells to the infection site.
4. Clearance of immune complexes
Complement binds to antigen-antibody (Ag-Ab) complexes.
This prevents them from depositing in tissues (which could cause inflammation) and promotes clearance by phagocytes in
the spleen and liver.
Which pathways activate the complement system?
1. Classical pathway
Triggered by antigen–antibody complexes (Ag–Ab).
Links adaptive immunity (antibodies) with innate complement defense.
2. Lectin pathway
Triggered when mannose-binding lectin (MBL) binds to sugars (mannose residues) on microbial surfaces.
Does not require antibodies → purely innate.
3. Alternative pathway
Triggered directly by pathogen surfaces.
Constantly active at low levels, and ramps up when microbes are present.
➡ All three pathways converge at Complement activation (C3 cleavage into C3a and C3b), leading to:
Inflammation (via C3a, C5a),
Opsonization (via C3b),
Lysis (via MAC, C5b-C9 complex).
What is C3?
C3 is the key hub of the complement system.
Two major C3 convertases cleave C3 into C3a and C3b:
C4b2a (from classical and lectin pathways)
C3bBb (from alternative pathway)
Products:
C3a → anaphylatoxin → promotes inflammation, chemotaxis, histamine release.
C3b → opsonin (tags microbes for phagocytosis) and forms part of the C5 convertase, continuing the cascade to MAC
formation.
Thus, C3 activation is the central convergence point of all three pathways.
Describe all 3 activation pathways in detail:
1. Classical pathway
Triggered by C1q binding to antibodies (IgG or IgM) attached to antigen on pathogens/cell surfaces.
Can also be activated by:
 Apoptotic cells
CRP (C-reactive protein) bound to bacteria or fungi.
2. Lectin pathway
Activated when mannose-binding lectin (MBL) binds to sugar residues on pathogens.
Antibody-independent → part of innate immunity.
3. Alternative pathway
Triggered by direct recognition of bacterial, fungal, or viral surfaces.
Represents the first innate immune response, before antibody formation.
Requires spontaneous hydrolysis of C3 (“tick-over” mechanism).
What is the C1 complex?
The C1 complex is the initiator of the classical pathway.
Structure:
C1q: recognition component → binds to Fc region of IgG/IgM in Ag–Ab complexes.
C1r and C1s: serine proteases that become activated once C1q binds antibodies.
Once activated, C1s cleaves C4 and C2, generating C4b2a (C3 convertase).
The diagram shows:
C1q stalk and heads (bind to antibodies).
C1r and C1s (enzymatic activators).
The electron micrograph on the right shows C1q molecules with their bouquet-like structure (six arms with globular heads).
Which antibodies activate complement?
Activation of complement by IgM and IgG
Key point: Not all antibodies activate complement. Only IgM and certain subclasses of IgG (IgG1, IgG3, some IgG2) can.
IgA and IgE do not activate complement.
Why?
Soluble IgM (free in plasma) → Fc region is hidden → C1 cannot bind → No activation.
Antigen-bound IgM → changes shape (staple form), exposes C1q binding sites → Yes, complement activation.
Soluble IgG → Fc portions are too far apart when free → No activation.
Antigen-bound IgG → at least two adjacent IgG Fc regions must be close enough for C1q binding → Yes, complement
activation.
Take-home: Complement activation by the classical pathway requires antigen binding to expose Fc domains properly
What is IgM?
IgM is a pentamer, with 10 antigen-binding sites.
Free IgM → looks like a “planar star” → C1q cannot bind Fc.
When bound to antigen (on a pathogen surface), IgM changes conformation → Fc regions stick out → C1q binding sites are
exposed.
This makes IgM a very efficient complement activator → just one IgM molecule bound to antigen can activate complement,
while IgG requires at least two [Link] can
How is the Classical pathway activated w/o antibodies?
The classical pathway can also be triggered without Ig, via C1q binding to other ligands:
1. C-reactive protein (CRP) → binds to bacterial/fungal cell walls. CRP can then recruit C1q.
2. Apoptotic cells → exposed molecules like DNA, phosphatidylserine, etc. act as signals for C1q. This helps in apoptotic
cell clearance.
3. Extracellular matrix proteins → such as fibromodulin, fibronectin, chondroadherin can also interact with C1q.
 Significance: Complement not only fights pathogens but also helps in Complement not onlyhousekeeping functions like
apoptotic cell disposal and tissue [Link] cel
Describe the Lectin pathway:
Lectin pathway:
Triggered when mannose-binding lectin (MBL) binds to mannose/sugar residues on microbial surfaces.
MBL is a Pattern Recognition Receptor (PRR) of the innate immune system → it recognizes conserved microbial
carbohydrate patterns (Pathogen-Associated Molecular Patterns, PAMPs).innate immune system → it recognizes c
MBL-associated serine proteases (MASPs) activate the cascade, generating the C3 convertase (C4b2a) similar to the
classical pathway.
Comparison:
Classical pathway → needs antibodies or CRP.
Lectin pathway → antibody-independent, uses MBL as a sensor.
Alternative pathway → spontaneous tick-over of C3, amplifies complement activity.
Describe the MBL pathway:
Mannose-binding lectin (MBL) recognizes mannose sugars present on the surfaces of many bacteria, viruses, and fungi (not
common on mammalian cells).
Structure: MBL associates with MASPs (MBL-associated serine proteases) → MASP-1 and MASP-2.
When MBL binds to mannose residues on microbes, MASPs are activated, which then cleave complement proteins (C4, C2) to
initiate the cascade.
Key concept: MBL pathway = innate recognition of microbial sugars → antibody-independent defense.
Describe the Activation pathways:
Alternative pathway:
Triggered directly by microbial surfaces (bacteria, fungi, viruses).
Functions as the first line of defense of the innate immune system (before antibodies are produced).
Mechanism: relies on spontaneous hydrolysis of C3 (“tick-over”), producing C3b which attaches to pathogen surfaces.
This is amplified by Factor B, Factor D, and Properdin → forming C3 convertase (C3bBb).
Importance: Provides rapid amplification of complement activation, independent of antibodies.
Describe the classical pathway in detail:
Triggered when IgM or IgG binds antigen → exposes Fc region → C1 complex binds (C1q + C1r + C1s).
Activated C1s cleaves:
C4 → C4a + C4b (C4b binds to pathogen surface).
C2 → C2a + C2b (C2a binds C4b).
This forms C3 convertase (C4b2a).
C3 convertase cleaves C3 → C3a + C3b.
C3a = inflammation mediator.
C3b = opsonization, phagocytosis, and part of C5 convertase.
Downstream → formation of C5 convertase → eventually MAC (C5b-9) → pathogen lysis.
Describe the lectin pathway in detail:
Mechanism is almost identical to classical pathway, except it’s triggered by MBL binding sugars, not antibodies.
MASP-2 (instead of C1s) cleaves:
C4 → C4a + C4b (C4b binds to pathogen surface).
C2 → C2a + C2b.
Forms the same C3 convertase (C4b2a) as the classical pathway.
 C3 convertase (C4b2a) → cleaves C3 → C3a + C3b.
Key similarity:
Classical pathway C3 convertase = C4b2a.
Lectin pathway C3 convertase = C4b2a.
Only difference is the recognition step:
Classical = antibody/CRP binding.
Lectin = MBL binding to sugars.
How does C3 cleavage happen?
The C3 convertase (C4b2a) formed in the classical or lectin pathways is highly efficient.
One C4b2a molecule can cleave ~1000 molecules of C3 into C3a + C3b.
C3b inserts into microbial membranes → opsonization (pathogen tagging for phagocytosis).
When an extra C3b binds to C4b2a, the complex becomes a C5 convertase (C4b2a3b).
This C5 convertase cleaves C5 → C5a + C5b, initiating the terminal pathway leading to membrane attack complex (MAC).
Describe the alternative pathway in detail:
(C3 convertase formation)
The alternative pathway begins with spontaneous hydrolysis of C3 → produces C3b.
C3b binds pathogen surfaces.
Factor B binds to surface-bound C3b.
Factor D cleaves Factor B → produces Bb fragment, leaving C3bBb, which is the C3 convertase of the alternative pathway.
C3bBb cleaves more C3 → generating additional C3b → amplification loop.
Properdin (Factor P, not shown here yet) stabilizes the convertase, increasing activity.
(C5 convertase formation)
The C3 convertase (C3bBb) continues producing more C3b.
When C3bBb binds an extra C3b, it becomes the C5 convertase (C3bBbC3b).
C5 convertase cleaves C5 → C5a + C5b.
C5a: strong anaphylatoxin → powerful inflammation, chemotaxis.
C5b: initiates the terminal pathway (C5b-C9) → Membrane Attack Complex (MAC).
Now summarise all 3 pathways:
Classical pathway: IgM/IgG (via C1q, C1r, C1s) → C4b2a (C3 convertase).
Lectin pathway: MBL + MASPs → C4b2a (same convertase as classical).
Alternative pathway: Spontaneous C3 hydrolysis + Factor B, D, Properdin → C3bBb (different convertase).
All three pathways generate C3 convertases, leading to massive cleavage of C3 into C3a + C3b.
C3b joins convertases → formation of C5 convertases.
C5 cleavage:
C5a = inflammatory mediator, chemotaxis.
C5b = seeds assembly of MAC (C5b-C9).
MAC = pore-forming complex → lyses bacteria, especially Gram-negative bacteria.
How does MAC form?
The MAC (C5b-9 complex) forms pores in target cell membranes.
Assembly:
C5b binds C6, C7, C8, and multiple C9 molecules.
This complex inserts into the lipid bilayer.
 Function:
Creates a pore that disrupts ionic balance (Na⁺, K⁺, Cl⁻ flux).
Causes osmotic lysis of the target cell.
How is MAC activated?
Stepwise assembly:
1. C5b recruits C6, C7, C8.
2. Several C9 molecules polymerize into a pore structure.
3. The pore has a diameter of ~100 Å (10 nm).
Left: schematic showing how poly-C9 forms the channel.
Right: electron microscopy image showing ring-like pores on a cell surface made by MAC.
What are the targets of MAC?
Able to lyse:
Red blood cells (basis for lab complement hemolysis tests).
Gram-negative bacteria (due to their exposed outer membrane).
Not effective against:
Nucleated host cells (they have repair mechanisms and protective regulators).
Encapsulated bacteria (their thick polysaccharide capsule shields them from complement attack).
What is the importance of MAC vs C3b?
MAC (C5b-9):
Essential for killing only a few bacteria, especially Neisseria meningitis.
This is why patients with terminal complement deficiencies (C5–C9) are highly susceptible to Neisseria infections.
C3b opsonisation:
Much more broadly important.
C3b tags a wide variety of pathogens for phagocytosis.
Therefore, C3 deficiency is more dangerous than MAC deficiency, because it impairs clearance of many microbes.
Describe what Anaphylatoxins are:
(C5a, C3a, C4a)
These small complement fragments cause inflammation:
Smooth muscle contraction (e.g., bronchospasm).
Increased vascular permeability → swelling and extravasation.
C3a and C5a induce expression of adhesion molecules on endothelial cells → helps leukocyte recruitment.
C5a is the most potent: activates leukocytes, induces chemotaxis.
They trigger mast cell degranulation (histamine release).
If produced in excess → systemic inflammatory reaction similar to anaphylaxis (complement-related shock).
List the complement receptors:
CR1 (CD35):
Ligands: C3b, C4b.
Functions: Immune complex clearance, enhances phagocytosis.
Cells: RBCs, macrophages, PMNs, follicular dendritic cells (FDC), B lymphocytes.
CR2 (CD21):
Ligands: C3b breakdown fragments (C3d, C3dg, iC3b).
Functions: Co-receptor on B cells → lowers threshold for B-cell activation. Also receptor for EBV (Epstein-Barr Virus).
 Cells: B cells, FDCs.
CR3 and CR4:
Ligand: iC3b.
Functions: Promote phagocytosis.
Cells: Macrophages, PMNs, FDCs.
How is Immune complex clearing prevented?
Complement prevents immune complex deposition in tissues (which could cause damage, e.g., lupus).
Mechanism:
1. Antibody + antigen = immune complex.
2. Complement activation deposits C3b on the complex.
3. CR1 on erythrocytes binds C3b-tagged complexes.
4. RBCs transport complexes to liver and spleen.
5. Phagocytes (Kupffer cells, splenic macrophages) remove and degrade immune complexes.
This protects tissues from immune complex-mediated inflammation.
How does the complement system affect phagocytosis?
Complement helps phagocytes ingest microbes.
Mechanism:
Microbes are coated with IgG (antibody) and C3b (complement opsonin).
Phagocytes have:
Fc receptors → bind IgG Fc region.
CR1 (complement receptor 1) → binds C3b.
Dual engagement (Fc + CR1) strongly activates phagocytosis.
Outcome: Microbe is engulfed, killed, and digested in phagolysosome.
How are B lymphocytes activated?
Complement enhances B-cell activation.
Process:
Bacterial antigen binds to the B-cell receptor (BCR).
Same antigen may also be coated with C3b breakdown fragments (C3d, C3dg).
These fragments are recognized by CR2 (CD21), which is part of the B-cell co-receptor complex (CR2, CD19, CD81).CR2,
When BCR and CR2 are engaged simultaneously → stronger signaling → more efficient B-cell activation.
Significance: Lowers the threshold for B-cell activation → enhances adaptive immunity.
Highest concentration proteins?
C3 (1.2 g/L) → central, most abundant complement component.
C4 (0.3 g/L).
Lower concentrations: C1q, C1r, C1s, C2, C5–C9.
What happens when the complement system ↑/ ↓?
Complement increase:
Seen in inflammatory diseases without consumption.
Not very clinically useful (just means acute-phase response).
Complement decrease:
More important.
Causes:
 Genetic deficiency (rare).
Consumption in immune complex diseases, e.g.:
SLE (systemic lupus erythematosus).
Anticardiolipin syndrome.
Sjögren’s syndrome.
Mixed connective tissue disease (MCTD).
Vasculitis.
Mixed cryoglobulinemia.
Serum sickness.
Glomerulonephritis (including post-streptococcal).
Take-home: Low C3/C4 levels are clinically important markers of autoimmune and immune complex-mediated diseases.
Name some Complement Deficiencies: (Activating protein deficiencies)
Classical pathway
C1 deficiency (autosomal recessive): defect in Ig binding & activation initiation → leads mainly to autoimmunity (immune
complex diseases).
C4 deficiency (autosomal recessive): defective opsonisation & immune complex (IC) removal → strong risk of
autoimmune diseases and some bacterial infections.
C2 deficiency (autosomal codominant): defective C3 activation & IC removal → bacterial infections (variable severity)
and some immune complex disease.
Lectin pathway
MBL deficiency (autosomal codominant): impaired carbohydrate recognition & activation initiation → bacterial infections
in young children.
Alternative pathway
Factor D deficiency (autosomal recessive): defective C3 activation → recurrent Neisserial infections.
Properdin deficiency (X-linked): defective C3 convertase stabilisation → severe Neisserial infections (+++).
Name some Complement Deficiencies: (Common Pathway)
C3 deficiency (autosomal recessive):
Functional defect: impaired opsonisation & complement activation.
Pathological consequence: severe infections with encapsulated bacteria (++++) and high risk of autoimmunity (+++).
C5 deficiency (autosomal recessive):
Functional defect: impaired membrane attack complex (MAC) formation.
Pathological consequence: Neisserial infections (+++).
C6–C9 deficiency (autosomal recessive):
Functional defect: impaired terminal complement pathway & MAC.
Pathological consequence: recurrent Neisserial infections (+++); sometimes mild autoimmunity (±).
👉 Key point:
C3 deficiency is the most severe (affects both infection defence & immune complex clearance), while terminal pathway (C5–C9)
deficiencies mainly predispose to Neisseria infections.
How is complement regulated?
Complement molecules are unstable after activation (short half-life).
If complement is not tightly controlled → risk of host cell damage and excessive inflammation.
Therefore, regulatory proteins (RCA: Regulators of Complement Activation) exist to maintain balance.
This slide maps where regulatory proteins act:
 C1-INH: inhibits C1 (classical) and MASPs (lectin) → prevents early activation.
C4-BP, DAF, MCP: inhibit C3 convertase formation and accelerate decay.
Factor H: regulates the alternative pathway by displacing Bb from C3b and promoting its cleavage.
CD59 (Protectin): blocks MAC (C5b-9) assembly, protecting host cells.
Carboxypeptidase: inactivates anaphylatoxins (C3a, C5a).
👉 Clinical note:
Defects in these regulators → uncontrolled complement activation, leading to diseases like hereditary angioedema (C1-INH
deficiency), atypical HUS (Factor H mutation), and PNH (CD59 deficiency).
Name some examples of Complement Inhibitory Protein Deficiencies:
C1 INH (C1 inhibitor)
Target: C1q (Classical Pathway)C1q (Cla
Defect: Without C1 INH, there is uncontrolled activation of the classical pathway (CP), coagulation, and kinin pathways.
Pathology: Leads to hereditary angioedema (episodes of swelling in skin, mucosa, airway).
Factor H
Target: C3b (Alternative Pathway)
Defect: Prevents regulation of alternative pathway near glomerular basement membrane. Without it, C3 activation
continues unchecked.
Pathology: Causes Hemolytic-Uremic Syndrome (HUS) and Glomerulonephritis.
What happens in the alternative pathway?
Key points:
C3 undergoes spontaneous low-level hydrolysis → produces C3b (weakly active).
If C3b binds to a membrane, Factor B binds → then cleaved by Factor D → C3bBb (C3 convertase) forms.
This C3 convertase amplifies complement activation.
Host vs. Bacteria regulation:
On host cells: CR1, MCP, DAF, and plasma Factor H stop further complement activation (protection).MCP, DAF, and
plasma Factor H stop further comp
On bacterial cells: No inhibitors present → complement cascade continues.
Properdin acts as an amplification factor stabilizing the convertase.
How is it controlled?
Shows difference between host cell and bacterial cell wall:
Host cell: C3b binds but is quickly inactivated by Factor H & I → prevents self-damage.
Bacterial cell: No regulators, so C3b binds stably, Factor B joins, Factor D cleaves → active C3 convertase (C3bBb)
forms → cascade proceeds.
Properdin stabilizes convertase, boosting response.
Inset (Thioester bond):
Closed (inactive) vs activated (exposed, reacts with nearby surfaces). This is how C3b attaches to cell surfaces.
What happens when there is a Factors H & I Deficiency?
Stepwise effect:
1. Deficiency → uncontrolled complement activation.
2. Increased C3 consumption.
3. Leads to secondary/acquired C3 deficiency.
4. Patients become highly susceptible to bacterial infections (especially encapsulated bacteria).
C1 inhibitor deficiency leads to?
 Images: Patients with hereditary angioedema (HAE) showing swelling of face and tongue.
Mechanism:
C1-INH normally inhibits C1 activation (classical pathway) and kallikrein system.
Deficiency → uncontrolled production of bradykinin → increased vascular permeability → angioedema.
Clinical picture:
Recurrent swelling of skin, upper airway mucosa, and GI tract.
Attacks may cause airway obstruction → potentially fatal asphyxiation.
Important: not histamine-mediated (so antihistamines/steroids are ineffective).

How does angioedema form?

Shows where C1-INH acts:
C1 complex → prevents uncontrolled complement activation.
Factor XIIa & kallikrein system → prevents excessive bradykinin formation.
Plasminogen/plasmin system → prevents fibrinolysis overactivation.
Without C1-INH:
More kallikrein → more bradykinin → vasodilation + edema.
Explains why bradykinin is the key mediator in hereditary angioedema.
Describe normal complement physiology vs pathology:
Normal physiology (green boxes):
Elimination of microbes & immune complexes (CICs).
Clearance of damaged cells without harming host.
Protection of host cells (via regulators like Factor H, I, CD55, CD59).
If regulators/activators fail (pink boxes):
Absence of activators → infections, autoimmunity (failure to clear CICs).
Acquisition of regulators (by pathogens) → immune evasion.
Absence/inefficiency of regulators → host cell injury (e.g., atypical HUS, paroxysmal nocturnal hemoglobinuria).
Summary: Balance between activation and regulation determines outcome:
Too little → infection/autoimmunity.
Too much/uncontrolled → host damage.