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Sircana MC, Erre GL, Castagna F, Manetti R. Crosstalk between Inflammation and Atherosclerosis in Rheumatoid Arthritis and Systemic Lupus Erythematosus: Is There a Common Basis? Life (Basel) 2024; 14:716. [PMID: 38929699 PMCID: PMC11204900 DOI: 10.3390/life14060716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with rheumatoid arthritis and systemic lupus erythematosus. Traditional cardiovascular risk factors, although present in lupus and rheumatoid arthritis, do not explain such a high burden of early cardiovascular disease in the context of these systemic connective tissue diseases. Over the past few years, our understanding of the pathophysiology of atherosclerosis has changed from it being a lipid-centric to an inflammation-centric process. In this review, we examine the pathogenesis of atherosclerosis in systemic lupus erythematosus and rheumatoid arthritis, the two most common systemic connective tissue diseases, and consider them as emblematic models of the effect of chronic inflammation on the human body. We explore the roles of the inflammasome, cells of the innate and acquired immune system, neutrophils, macrophages, lymphocytes, chemokines and soluble pro-inflammatory cytokines in rheumatoid arthritis and systemic lupus erythematosus, and the roles of certain autoantigens and autoantibodies, such as oxidized low-density lipoprotein and beta2-glycoprotein, which may play a pathogenetic role in atherosclerosis progression.
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Affiliation(s)
| | | | | | - Roberto Manetti
- Department of Medical, Surgical and Pharmacology, University of Sassari, 07100 Sassari, Italy; (G.L.E.); (F.C.)
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2
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Roubille C. [Management of cardiovascular comorbidities in immune-mediated inflammatory diseases]. Rev Med Interne 2024; 45:194-199. [PMID: 37981509 DOI: 10.1016/j.revmed.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 11/21/2023]
Abstract
Patients with chronic inflammatory and autoimmune diseases are at increased cardiovascular risk, which is the cause of persistent excess mortality despite increasingly effective specific treatment of the inflammatory and/or autoimmune disease. This increased cardiovascular risk is multifactorial, associated with accelerated atherosclerosis related to systemic inflammation, but also secondary to traditional cardiovascular risk factors and to the therapies used to control systemic inflammation. This justifies a coordinated, personalized management of cardiovascular risk in patients with chronic inflammatory and autoimmune diseases, based not only on the treatment of their disease to achieve the lowest level of activity, but also on the screening and management of their cardiovascular comorbidities and modifiable cardiovascular risk factors.
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Affiliation(s)
- C Roubille
- Département de médecine interne, CHU de Lapeyronie, Montpellier, France; Inserm, PhyMedExp, CNRS, CHRU Montpellier, université de Montpellier, Montpellier, France; Université de Montpellier, Montpellier, France.
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3
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Ambler WG, Kaplan MJ. Vascular damage in systemic lupus erythematosus. Nat Rev Nephrol 2024; 20:251-265. [PMID: 38172627 PMCID: PMC11391830 DOI: 10.1038/s41581-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
Vascular disease is a major cause of morbidity and mortality in patients with systemic autoimmune diseases, particularly systemic lupus erythematosus (SLE). Although comorbid cardiovascular risk factors are frequently present in patients with SLE, they do not explain the high burden of premature vascular disease. Profound innate and adaptive immune dysregulation seems to be the primary driver of accelerated vascular damage in SLE. In particular, evidence suggests that dysregulation of type 1 interferon (IFN-I) and aberrant neutrophils have key roles in the pathogenesis of vascular damage. IFN-I promotes endothelial dysfunction directly via effects on endothelial cells and indirectly via priming of immune cells that contribute to vascular damage. SLE neutrophils are vasculopathic in part because of their increased ability to form immunostimulatory neutrophil extracellular traps. Despite improvements in clinical care, cardiovascular disease remains the leading cause of mortality among patients with SLE, and treatments that improve vascular outcomes are urgently needed. Improved understanding of the mechanisms of vascular injury in inflammatory conditions such as SLE could also have implications for common cardiovascular diseases, such as atherosclerosis and hypertension, and may ultimately lead to personalized therapeutic approaches to the prevention and treatment of this potentially fatal complication.
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Affiliation(s)
- William G Ambler
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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4
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Luo Q, Zhang Y, Yang X, Qin L, Wang H. Hypertension in connective tissue disease. J Hum Hypertens 2024; 38:19-28. [PMID: 35505225 DOI: 10.1038/s41371-022-00696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 02/23/2022] [Accepted: 04/12/2022] [Indexed: 11/10/2022]
Abstract
It is well documented that connective tissue disease (CTD) is a type of autoimmune disease characterized by chronic inflammation, which can occur across various organ systems throughout the whole body. Although the clinical manifestations of CTD are different, studies have shown that different CTD diseases have similar pathogenesis, implying that different CTD diseases may have similar clinical outcomes. Recent population-based studies have demonstrated an increased risk of cardiovascular disease (CVD) in patients with CTD compared with the control group, which is partially attributed to traditional cardiovascular risk factors, such as hypertension (HT), and that controlling the patients' blood pressure (BP) still constitutes one of the most effective means to prevent CVD. Although many studies have shown that the prevalence of HT in patients with CTD is higher than that in the general population, there is a lack of adequate data on the possible pathogenesis of HT. Also, the factors that promote the rise of BP, especially the relationship between connective tissue disease- hypertension (CTD-HT) and traditional cardiovascular risk factors (aging, sex, race, dyslipidemia, diabetes mellitus, smoking, obesity, etc.), have not been fully confirmed. In this review, we explore the mechanisms that might lead to elevated BP in patients with CTD and the factors that contribute to elevated BP and the management of CTD-HT, and we focus on whether traditional cardiovascular risk factors, the disease, and the presence of related therapeutic drugs are associated with an increased risk of HT in patients with CTD.
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Affiliation(s)
- Qiang Luo
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Yiwen Zhang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Xiaoqian Yang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Li Qin
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Han Wang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China.
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5
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Hansen RB, Falasinnu T, Faurschou M, Jacobsen S, Simard JF. Risk of End-Stage Renal Disease in Patients With Systemic Lupus Erythematosus and Diabetes Mellitus: A Danish Nationwide Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:1871-1877. [PMID: 36705445 PMCID: PMC10372193 DOI: 10.1002/acr.25091] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/10/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The risk of end-stage renal disease (ESRD) is increased in patients with systemic lupus erythematosus (SLE). This study was undertaken to determine whether diabetes mellitus (DM) increases ESRD risk in a large inception cohort of SLE patients. METHODS By means of the Danish National Patient Registry, we identified 3,178 adult patients diagnosed as having SLE between January 1, 1996, and July 31, 2018. DM was defined as the date of first hospital contact for DM or date of a first prescription of an antidiabetic drug. ESRD was defined as first registration of dialysis, renal transplant, or terminal renal insufficiency in the Danish National Patient Registry. ESRD incidence was compared between SLE patients with DM (SLE-DM) and those without DM (SLE-non-DM). Hazard ratios (HRs), adjusted for sex, age, educational level, and occupational status at baseline were calculated for sex, age, educational level, and hypertension (at baseline or during follow-up) strata. The overall hazard ratio (HR) was also adjusted for hypertension. RESULTS The SLE-DM group included 290 patients, of whom 77% were female, compared with 85% of the 2,859 patients in the SLE-non-DM group. SLE-DM patients had a 3 times higher risk of ESRD compared with SLE-non-DM patients (multivariable-adjusted HR 3.3 [95% confidence interval 1.8-6.1]). In stratified multivariable-adjusted analyses, DM increased the rate of ESRD in women and men, patients ≥50 years old at baseline, those with low educational level at baseline, and those with concomitant hypertension. CONCLUSION Our findings indicate that SLE patients with DM have a markedly higher risk of developing ESRD compared with SLE patients without DM.
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Affiliation(s)
- Renata Baronaite Hansen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, and Stanford University School of Medicine, Stanford, California
| | | | - Mikkel Faurschou
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Jacobsen
- Copenhagen University Hospital, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Julia F. Simard
- Stanford University School of Medicine, Stanford, California
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Barnado A, Wheless L, Camai A, Green S, Han B, Katta A, Denny JC, Sawalha AH. Phenotype Risk Score but Not Genetic Risk Score Aids in Identifying Individuals With Systemic Lupus Erythematosus in the Electronic Health Record. Arthritis Rheumatol 2023; 75:1532-1541. [PMID: 37096581 PMCID: PMC10501317 DOI: 10.1002/art.42544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) poses diagnostic challenges. We undertook this study to evaluate the utility of a phenotype risk score (PheRS) and a genetic risk score (GRS) to identify SLE individuals in a real-world setting. METHODS Using a de-identified electronic health record (EHR) database with an associated DNA biobank, we identified 789 SLE cases and 2,261 controls with available MEGAEX genotyping. A PheRS for SLE was developed using billing codes that captured American College of Rheumatology SLE criteria. We developed a GRS with 58 SLE risk single-nucleotide polymorphisms (SNPs). RESULTS SLE cases had a significantly higher PheRS (mean ± SD 7.7 ± 8.0 versus 0.8 ± 2.0 in controls; P < 0.001) and GRS (mean ± SD 12.2 ± 2.3 versus 11.0 ± 2.0 in controls; P < 0.001). Black individuals with SLE had a higher PheRS compared to White individuals (mean ± SD 10.0 ± 10.1 versus 7.1 ± 7.2, respectively; P = 0.002) but a lower GRS (mean ± SD 9.0 ± 1.4 versus 12.3 ± 1.7, respectively; P < 0.001). Models predicting SLE that used only the PheRS had an area under the curve (AUC) of 0.87. Adding the GRS to the PheRS resulted in a minimal difference with an AUC of 0.89. On chart review, controls with the highest PheRS and GRS had undiagnosed SLE. CONCLUSION We developed a SLE PheRS to identify established and undiagnosed SLE individuals. A SLE GRS using known risk SNPs did not add value beyond the PheRS and was of limited utility in Black individuals with SLE. More work is needed to understand the genetic risks of SLE in diverse populations.
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Affiliation(s)
- April Barnado
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Lee Wheless
- Department of Dermatology, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN
| | - Alex Camai
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Green
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Bryan Han
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Anish Katta
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joshua C. Denny
- All of Us Research Program, National Institutes of Health, Bethesda, MD
| | - Amr H. Sawalha
- Departments of Pediatrics, Medicine, and Immunology & Lupus Center of Excellence, University of Pittsburgh School of Medicine, Pittsburgh, PA
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7
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Chung CP, Karakoc G, Dickson A, Liu G, Gamboa JL, Mosley JD, Cox NJ, Kawai VK. APOL1 and the risk of adverse renal outcomes in patients of African ancestry with systemic lupus erythematosus. Lupus 2023; 32:763-770. [PMID: 37105192 DOI: 10.1177/09612033231172660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) disproportionately affects individuals of African ancestry (AA) compared to European ancestry (EA). In the general population, high risk (HR) variants in the apolipoprotein L1 (APOL1) gene increase the risk of renal and hypertensive disorders in individuals of AA. Since SLE is characterized by an interferon signature and APOL1 expression is driven by interferon, we examined the hypothesis that APOL1 HR genotypes predominantly drive higher rates of renal and hypertensive-related comorbidities observed in SLE patients of AA versus those of EA. METHODS We performed a retrospective cohort study in patients with SLE of EA and AA using a genetic biobank linked to de-identified electronic health records. APOL1 HR genotypes were defined as G1/G1, G2/G2, or G1/G2 and low risk (LR) genotypes as 1 or 0 copies of the G1 and G2 alleles. To identify renal and hypertensive-related disorders that differed in prevalence by ancestry, we used a phenome-wide association approach. We then used logistic regression to compare the prevalence of renal and hypertensive-related disorders in EA and AA patients, both including and excluding patients with the APOL1 HR genotype. In a sensitivity analysis, we examined the association of end stage renal disease secondary to lupus nephritis (LN-related ESRD) with ancestry and the APOL1 genotype. RESULTS We studied 784 patients with SLE; 195 (24.9%) were of AA, of whom 27 (13.8%) had APOL1 HR genotypes. Eighteen renal and hypertensive-related phenotypes were more common in AA than EA patients (p-value ≤ 1.4E-4). All phenotypes remained significantly different after exclusion of patients with APOL1 HR genotypes, and most point odds ratios (ORs) decreased only slightly. Even among ORs with the greatest decrease, risk for AA patients without the APOL1 HR genotype remained significantly elevated compared to EA patients. In the sensitivity analysis, LN-related ESRD was more prevalent in SLE patients of AA versus EA and AA patients with the APOL1 HR genotype versus LR (p-value < .05 for both). CONCLUSION The higher prevalence of renal and hypertensive disorders in SLE patients of AA compared to those of EA is not fully explained by the presence of APOL1 high risk variants.
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Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology and Immunology, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Healthcare System - Nashville Campus, Nashville, TN, USA
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Rheumatology, University of Miami, Miami, FL, USA
- Miami VA Healthcare System, Miami, FL, USA
| | - Gul Karakoc
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alyson Dickson
- Division of Rheumatology and Immunology, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ge Liu
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jorge L Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D Mosley
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Nancy J Cox
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vivian K Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
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8
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Clemmer JS, Hillegass WB, Taylor EB. Antihypertensive effects of immunosuppressive therapy in autoimmune disease. J Hum Hypertens 2023; 37:300-306. [PMID: 35396536 PMCID: PMC9899545 DOI: 10.1038/s41371-022-00682-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/18/2022] [Accepted: 03/24/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder that primarily affects women of childbearing age. While immune system dysfunction has been implicated in the development of hypertension (HTN) in SLE, the effect of immunomodulatory drugs on blood pressure (BP) control in SLE patients is unknown. In the present study, we hypothesized that first-line immunomodulatory therapies prescribed to SLE patients would have a beneficial impact on BP. We retrospectively analyzed the Research Data Warehouse containing de-identified patient data (n = 1,075,406) from the University of Mississippi Medical Center for all patients with a clinical diagnosis of SLE. BP responses were analyzed in SLE patients that were initially prescribed a single therapy (methotrexate, hydroxychloroquine, azathioprine, mycophenolate mofetil (MMF), or prednisone). Of the 811 SLE patients who met criteria, most were hypertensive (56%), female (94%), and black (65%). Individuals prescribed MMF or hydroxychloroquine had significantly decreased BP and improved BP control at follow-up (>7 days and <3 months after initial visit). Our results suggest that MMF and hydroxychloroquine have beneficial effects on BP, independent of adjunctive antihypertensive therapies and existing renal disease.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, 39216, USA
| | - William B Hillegass
- Departments of Data Science and Medicine, University of Mississippi Medical Center, Jackson, MS, 39216, USA
- John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, 39216, US
| | - Erin B Taylor
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, 39216, USA.
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9
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Abstract
Systemic lupus erythematosus (SLE) is a devastating autoimmune disease that can result in substantial morbidity and mortality. Diagnosis and treatment of SLE are clinical challenges. Patient presentation and response to therapy are heterogeneous because of the complex immune dysregulation that results in SLE disease pathogenesis. An intricate interplay between genetic risk and skewing of adaptive and innate immune system responses leads to overproduction of type I interferons and other cytokines, complement activation, immune-complex deposition, and ultimately inflammation and tissue damage. Here, we review the classification criteria as well as standard and emerging diagnostic tools available to identify patients with SLE. We then focus on medical management, including novel therapeutics, nonpharmacologic interventions, and comorbidity management.
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Affiliation(s)
- Stephanie Lazar
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA;
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10
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Chaudhari S, Pham GS, Brooks CD, Dinh VQ, Young-Stubbs CM, Shimoura CG, Mathis KW. Should Renal Inflammation Be Targeted While Treating Hypertension? Front Physiol 2022; 13:886779. [PMID: 35770194 PMCID: PMC9236225 DOI: 10.3389/fphys.2022.886779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Despite extensive research and a plethora of therapeutic options, hypertension continues to be a global burden. Understanding of the pathological roles of known and underexplored cellular and molecular pathways in the development and maintenance of hypertension is critical to advance the field. Immune system overactivation and inflammation in the kidneys are proposed alternative mechanisms of hypertension, and resistant hypertension. Consideration of the pathophysiology of hypertension in chronic inflammatory conditions such as autoimmune diseases, in which patients present with autoimmune-mediated kidney inflammation as well as hypertension, may reveal possible contributors and novel therapeutic targets. In this review, we 1) summarize current therapies used to control blood pressure and their known effects on inflammation; 2) provide evidence on the need to target renal inflammation, specifically, and especially when first-line and combinatory treatment efforts fail; and 3) discuss the efficacy of therapies used to treat autoimmune diseases with a hypertension/renal component. We aim to elucidate the potential of targeting renal inflammation in certain subsets of patients resistant to current therapies.
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Affiliation(s)
| | | | | | | | | | | | - Keisa W. Mathis
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX, United States
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11
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Barnado A, Hubbard J, Green S, Camai A, Wheless L, Osmundson S. Systemic Lupus Erythematosus Delivery Outcomes Are Unchanged Across Three Decades. ACR Open Rheumatol 2022; 4:711-720. [PMID: 35670028 PMCID: PMC9374054 DOI: 10.1002/acr2.11447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/08/2022] [Accepted: 04/13/2022] [Indexed: 12/14/2022] Open
Abstract
Objective Using a large, de‐identified electronic health record database with over 3.2 million patients, we aimed to identify trends of systemic lupus erythematosus (SLE) medication use during pregnancy and birth outcomes from 1989 to 2020. Methods Using a previously validated algorithm for SLE deliveries, we identified 255 pregnancies in patients with SLE and 604 pregnancies in controls with no known autoimmune diseases. We examined demographics, medications, SLE comorbidities, and maternal and fetal outcomes in SLE and control deliveries. Results Compared with control deliveries, SLE deliveries were more likely to be complicated by preterm delivery (odds ratio [OR]: 6.71; 95% confidence interval [CI]: 4.31‐10.55; P < 0.001) and preeclampsia (OR: 3.22; 95% CI: 1.83‐5.66; P < 0.001) after adjusting for age at delivery, race, and parity. In a longitudinal analysis, medication use during SLE pregnancies remained relatively stable, with some increased use of hydroxychloroquine over time but no increase in aspirin use. For SLE deliveries, preterm delivery and preeclampsia rates remained stable. Conclusion We observed rates of preeclampsia and preterm delivery in SLE that were five times higher than the general population and higher compared with other prospective SLE cohorts. Furthermore, we did not observe improved outcomes over time with preeclampsia and preterm delivery. Despite increasing evidence for universal use of hydroxychloroquine and aspirin, we did not observe substantially higher use of these medications over time, particularly for aspirin. Our results demonstrate the continued need to prioritize educational and implementation efforts to improve adverse pregnancy outcomes in SLE.
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Affiliation(s)
- April Barnado
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Janie Hubbard
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Sarah Green
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Alex Camai
- Vanderbilt University Medical CenterNashvilleTennessee
| | - Lee Wheless
- Vanderbilt University Medical CenterNashvilleTennessee
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12
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Alsultan M, Basha K. Resistant hypertension and PRES syndrome induced by carbamazepine in a patient with SLE: A case report and literature review. Ann Med Surg (Lond) 2022; 78:103767. [PMID: 35600172 PMCID: PMC9117529 DOI: 10.1016/j.amsu.2022.103767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mohammad Alsultan
- Department of Nephrology, Al Assad and Al Mouwasat University Hospitals, Damascus University- Faculty of Medicine, Damascus, Syria
- Corresponding author.
| | - Kassem Basha
- Nephrology Department, Al Mouwasat University Hospitals, Damascus University- Faculty of Medicine, Damascus, Syria
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13
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Sairam S, Sureen A, Gutierrez J, Dang TQ, Mishra K. Cardiovascular Outcomes in Systemic Lupus Erythematosus. Curr Cardiol Rep 2022; 24:75-83. [PMID: 35028818 DOI: 10.1007/s11886-021-01626-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF THE REVIEW To review cardiovascular outcomes (CVE) in systemic lupus erythematosus (SLE) that evolves over time. RECENT FINDINGS Inception cohorts now report long-term data, and large population registries add to our knowledge. Mortality and cardiovascular morbidity remain high with a risk ratio of 2-3. SLE disease activity-related inflammation accounts for higher CVE incidence ratio in the first year following diagnosis with accelerated atherosclerosis contributing to CVE in about a quarter to a third of the patients later in the disease course. Immunomodulation and disease control are associated with improved cardiovascular outcomes. Validation of modified risk stratification tools and studies evaluating primary prevention with aspirin and hydroxychloroquine are reported. Increased awareness of high mortality associated with cardiac inflammation, improved outcomes with early disease control, aggressive management of risk factors, hypertension, obesity, and high cholesterol with modifying risk stratification will result in more favorable outcomes in SLE patients.
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Affiliation(s)
- Shrilekha Sairam
- Division of Rheumatology, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, El Paso, TX, USA.
| | - Amit Sureen
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Jesus Gutierrez
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - The Q Dang
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Kunal Mishra
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
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14
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Liu JL, Pineau CA, Grenier LP, Vinet E, Kalache F, Lukusa L, Bernatsky S. Treatment patterns and control of hypertension in systemic lupus erythematosus (SLE): a cross-sectional study. BMJ Open 2021; 11:e048384. [PMID: 34725073 PMCID: PMC8562504 DOI: 10.1136/bmjopen-2020-048384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Hypertension (HTN) is common in systemic lupus erythematosus (SLE), representing a key risk factor for cardiovascular and renal disease. We described HTN treatment patterns in SLE, evaluated uncontrolled HTN according to Canadian and American guidelines and identified factors associated with uncontrolled HTN. METHODS We performed a cross-sectional study, identifying all McGill Lupus Clinic registry patients with an annual visit between January 2017 and May 2019 who were taking HTN medications. We excluded those taking medications only for another indication (eg, Raynaud's). We determined the frequency of uncontrolled HTN according to Canadian and American College of Cardiology/American Heart Association guidelines. Multivariate logistic regression (adjusted for age, sex and race/ethnicity) evaluated if uncontrolled HTN was more common with high body mass index (BMI), longer SLE duration, high disease activity, renal damage, multiple concomitant antihypertensives, prednisone and non-steroidal anti-inflammatory drugs. RESULTS Of 442 patients with SLE, 108 were taking medications to treat HTN, and 38 took multiple medications concurrently. Angiotensin-receptor blockers were most common, followed by calcium channel blockers, diuretics, angiotensin-converting enzyme inhibitors and beta blockers. Among the 108 patients, 39.8% (n=43) had blood pressure (BP) >140/90 mm Hg, while 66.7% (n=72) had BP >130/80 mm Hg. In multivariate analyses, uncontrolled HTN (>130/80 mm Hg) was more likely in Caucasians (OR 2.72, 95% CI 1.12 to 6.78) and patients with higher BMI (OR 1.08, 95% CI 1.00 to 1.19). Patients with renal damage had better HTN control (OR 0.39, 95% CI 0.16 to 0.97). We could not draw definitive conclusions regarding other variables. CONCLUSION Caucasians and patients with higher BMI had more uncontrolled HTN. The negative association with renal damage is reassuring, as controlled BP is key for renal protection.
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Affiliation(s)
- Jia Li Liu
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Christian A Pineau
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
- Centre for Innovative Medicine, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Louis-Pierre Grenier
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Evelyne Vinet
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Fares Kalache
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luck Lukusa
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sasha Bernatsky
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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15
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Boesen EI, Kakalij RM. Autoimmune-mediated renal disease and hypertension. Clin Sci (Lond) 2021; 135:2165-2196. [PMID: 34533582 PMCID: PMC8477620 DOI: 10.1042/cs20200955] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022]
Abstract
Hypertension is a major risk factor for cardiovascular disease, chronic kidney disease (CKD), and mortality. Troublingly, hypertension is highly prevalent in patients with autoimmune renal disease and hastens renal functional decline. Although progress has been made over the past two decades in understanding the inflammatory contributions to essential hypertension more broadly, the mechanisms active in autoimmune-mediated renal diseases remain grossly understudied. This Review provides an overview of the pathogenesis of each of the major autoimmune diseases affecting the kidney that are associated with hypertension, and describes the current state of knowledge regarding hypertension in these diseases and their management. Specifically, discussion focuses on Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN), Immunoglobulin A (IgA) Nephropathy, Idiopathic Membranous Nephropathy (IMN), Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated glomerulonephritis, and Thrombotic Thrombocytopenic Purpura (TTP). A summary of disease-specific animal models found to exhibit hypertension is also included to highlight opportunities for much needed further investigation of underlying mechanisms and novel therapeutic approaches.
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Affiliation(s)
- Erika I Boesen
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
| | - Rahul M Kakalij
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
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16
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Abstract
PURPOSE OF REVIEW Patients with chronic inflammatory disease have an increased risk of cardiovascular disease. This article reviews the current evidence of cardiovascular prevention in three common systemic inflammatory disorders (SIDs): psoriasis, rheumatoid arthritis, and systemic lupus erythematosus. RECENT FINDINGS General population cardiovascular risk assessment tools currently underestimate cardiovascular risk and disease-specific risk assessment tools are an area of active investigation. A disease-specific cardiovascular risk estimator has not been shown to more accurately predict risk compared with the current guidelines. Rheumatoid arthritis-specific risk estimators have been shown to better predict cardiovascular risk in some cohorts and not others. Systemic lupus erythematosus-specific scores have also been proposed and require further validation, whereas psoriasis is an open area of active investigation. The current role of universal prevention treatment with statin therapy in patients with SID remains unclear. Aggressive risk factor modification and control of disease activity are important interventions to reduce cardiovascular risk. SUMMARY A comprehensive approach that includes cardiovascular risk factor modification, control of systemic inflammation, and increased patient and physician awareness is needed in cardiovascular prevention of chronic inflammation. Clinical trials are currently underway to test whether disease-specific anti-inflammatory therapies will reduce cardiovascular risk.
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17
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Kawai VK, Shi M, Liu G, Feng Q, Wei W, Chung CP, Walunas TL, Gordon AS, Linneman JG, Hebbring SJ, Harley JB, Cox NJ, Roden DM, Stein CM, Mosley JD. Pleiotropy of systemic lupus erythematosus risk alleles and cardiometabolic disorders: A phenome-wide association study and inverse-variance weighted meta-analysis. Lupus 2021; 30:1264-1272. [PMID: 33977795 PMCID: PMC8205989 DOI: 10.1177/09612033211014952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
OBJECTIVES To test the hypothesis that genetic predisposition to systemic lupus erythematosus (SLE) increases the risk of cardiometabolic disorders. METHODS Using 41 single nucleotide polymorphisms (SNPs) associated with SLE, we calculated a weighted genetic risk score (wGRS) for SLE. In a large biobank we tested the association between this wGRS and 9 cardiometabolic phenotypes previously associated with SLE: atrial fibrillation, ischemic stroke, coronary artery disease, type 1 and type 2 diabetes, obesity, chronic kidney disease, hypertension, and hypercholesterolemia. Additionally, we performed a phenome-wide association analysis (pheWAS) to discover novel clinical associations with a genetic predisposition to SLE. Findings were replicated in the Electronic Medical Records and Genomics (eMERGE) Network. To further define the association between SLE-related risk alleles and the selected cardiometabolic phenotypes, we performed an inverse variance weighted regression (IVWR) meta-analysis. RESULTS The wGRS for SLE was calculated in 74,759 individuals of European ancestry. Among the pre-selected phenotypes, the wGRS was significantly associated with type 1 diabetes (OR [95%CI] =1.11 [1.06, 1.17], P-value = 1.05x10-5). In the PheWAS, the wGRS was associated with several autoimmune phenotypes, kidney disorders, and skin neoplasm; but only the associations with autoimmune phenotypes were replicated. In the IVWR meta-analysis, SLE-related risk alleles were nominally associated with type 1 diabetes (P = 0.048) but the associations were heterogeneous and did not meet the adjusted significance threshold. CONCLUSION A weighted GRS for SLE was associated with an increased risk of several autoimmune-related phenotypes including type I diabetes but not with cardiometabolic disorders.
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Affiliation(s)
- Vivian K. Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ge Liu
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - QiPing Feng
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - WeiQi Wei
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Cecilia P. Chung
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Rheumatology, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Healthcare System - Nashville Campus
| | - Theresa L. Walunas
- Center for Health Information Partnerships, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Adam S. Gordon
- Center for Genetic Medicine, Northwestern University, Chicago, IL
| | - James G. Linneman
- Office of Research, Computing, and Analytics, Marshfield Clinic Research Institute, Marshfield, WI
| | - Scott J. Hebbring
- Center for Precision Medicine Research, Marshfield Clinic Research Institute, Marshfield, Wisconsin USA
| | - John B. Harley
- Center for Autoimmune Genomics and Etiology (CAGE), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Cincinnati VA Medical Center, Cincinnati, OH, USA
| | - Nancy J. Cox
- Vanderbilt Genetics Institute, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Dan M. Roden
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - C. Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D. Mosley
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
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18
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Carranza-Leon DA, Oeser A, Wu Q, Stein CM, Ormseth MJ, Chung CP. Ambulatory blood pressure in patients with systemic lupus erythematosus: Association with markers of immune activation. Lupus 2020; 29:1683-1690. [PMID: 32842866 PMCID: PMC7642148 DOI: 10.1177/0961203320951274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objectives: Ambulatory blood pressure monitoring measures 24-hour blood pressure, night-time blood pressure, and impaired dipping of nocturnal blood pressure, parameters that better predict cardiovascular risk than standard office blood pressure measurements. Systemic lupus erythematosus is characterized by immune system hyperactivity, elevated cardiovascular risk and high prevalence of hypertension; however, little is known about ambulatory blood pressure in lupus patients and its relationship to immune activation. Methods: We studied 26 patients with lupus and 26 control subjects. We obtained ambulatory 24-hour blood pressure measurements and report plasma concentrations of 77 markers of immune activation using a multiplex immunoassay and assessed their association with blood pressure measurements. Results: Despite similar office blood pressure measurements in patients with lupus and controls, lupus patients had higher 24-hour systolic [median (interquartile range) 129 (113 - 140) vs. 116 (111 - 121) mmHg, p = 0.03] and diastolic blood pressure [80 (69 - 86) vs. 72 (64 - 75) mmHg, p = 0.006] as well as less nocturnal dipping [7.8% (5.1 - 14.2%) vs. 12.0% (8.1 20.0%)] p = 0.03], compared to controls. In patients with lupus, markers of the innate (monocyte chemotactic protein-3) and adaptive immune systems [CUB domain-containing protein-1 and Interleukin-15 receptor subunit-α,] were associated with nocturnal blood pressure measurements and attenuated nocturnal dipping. In conclusion, 24-hour systolic and diastolic blood pressure was higher and nocturnal blood pressure dipping was attenuated in patients with lupus compared to control subjects. Conclusion: In patients with SLE, nocturnal blood pressure and attenuated nocturnal blood pressure dipping were significantly associated with several innate and adaptive immune system biomarkers.
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Affiliation(s)
- Daniel A. Carranza-Leon
- Department of Medicine, Vanderbilt University Medical Center (DAC, AO, CMS, MJO, and CPC) and Tennessee Valley Healthcare System, US. Department of Veterans Affairs (MJO and CPC)
| | - Annette Oeser
- Department of Medicine, Vanderbilt University Medical Center (DAC, AO, CMS, MJO, and CPC) and Tennessee Valley Healthcare System, US. Department of Veterans Affairs (MJO and CPC)
| | - Qiong Wu
- Department of Medicine, Vanderbilt University Medical Center (DAC, AO, CMS, MJO, and CPC) and Tennessee Valley Healthcare System, US. Department of Veterans Affairs (MJO and CPC)
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University Medical Center (DAC, AO, CMS, MJO, and CPC) and Tennessee Valley Healthcare System, US. Department of Veterans Affairs (MJO and CPC)
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19
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Dent EL, Taylor EB, Turbeville HR, Ryan MJ. Curcumin attenuates autoimmunity and renal injury in an experimental model of systemic lupus erythematosus. Physiol Rep 2020; 8:e14501. [PMID: 32652896 PMCID: PMC7354090 DOI: 10.14814/phy2.14501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder with prevalent hypertension and renal disease. To avoid side effects of immunosuppressive drugs, alternative therapies are needed. Curcumin has been used in Eastern medicine for its anti‐inflammatory and antioxidant properties. This study tested whether oral curcumin administration attenuates autoimmunity and renal injury during SLE. Female NZBWF1 (model of SLE) and NZW/LacJ (control) mice were administered curcumin (500 mg kg‐1 day‐1, oral gavage) for 14 days in two separate groups beginning at either 26 or 32 weeks of age. Body weight and composition were monitored throughout the study. Immune activity was assessed by spleen weight, circulating dsDNA autoantibodies, and B lymphocytes. Renal injury (albumin excretion, glomerulosclerosis, blood urea nitrogen (BUN)) was measured as a hemodynamic function (glomerular filtration rate (GFR), mean arterial pressure (MAP)) in conscious mice. Body weight and composition were maintained in curcumin‐treated SLE mice, but decreased in vehicle‐treated SLE mice. Curcumin‐treated SLE mice had lower spleen weight and renal injury (glomerulosclerosis) compared to vehicle‐treated SLE mice when treatment started at 26 weeks of age. When curcumin treatment started at 32 weeks of age, renal injury (glomerulosclerosis, BUN) was reduced in SLE mice compared to vehicle‐treated SLE mice. GFR was reduced, and MAP was increased in vehicle‐treated SLE mice compared to controls; however, these were not improved with curcumin. No significant changes were observed in curcumin‐treated control mice. These data suggest that curcumin modulates autoimmune activity and may lessen renal injury in female mice with SLE.
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Affiliation(s)
- Elena L Dent
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Erin B Taylor
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Hannah R Turbeville
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael J Ryan
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS, USA.,GV (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, Mississippi, USA
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