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Hasegawa Y, Arinuma Y, Asakura H, Shindo R, Ino K, Kanayama Y, Tanaka T, Matsueda Y, Wada T, Oku K, Yamaoka K. Real-world efficacy of belimumab in achieving remission or low-disease activity in systemic lupus erythematosus: A retrospective study. Mod Rheumatol 2024; 34:732-740. [PMID: 37522622 DOI: 10.1093/mr/road078] [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: 05/25/2023] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES We investigated the effect of belimumab (BEL) on achieving low disease activity (LDA) and remission as an additive molecular-targeting agent to standard of care (SoC) in patients with systemic lupus erythematosus (SLE). METHODS Clinical information was retrospectively collected from patients with SLE who received BEL additive to SoC (BEL + SoC), and from patients treated with SoC alone as a control arm. Disease activity was measured by SLE-disease activity score (SLE-DAS). The proportion of patients in LDA and remission at 12 months was compared after propensity score matching. The factors contributing to LDA and remission achievement were identified by Cox proportional hazard model. RESULTS BEL + SoC significantly reduced SLE-DAS at 6 months, with a significantly higher proportion of patients achieving LDA and remission at 12 months compared to SoC alone. The presence of arthritis at baseline was significantly associated with achieving LDA and remission. Additionally, both treatment groups experienced a significant reduction in daily glucocorticoid dose. CONCLUSIONS Adding BEL to SoC was beneficial for patients with arthritis, leading to higher proportion of achieving LDA and remission, while also reducing their glucocorticoid dose. Our results indicate the utility of BEL in a treat-to-target approach for SLE patients in a real-world setting.
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Affiliation(s)
- Yasuhiro Hasegawa
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hirotomo Asakura
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Risa Shindo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kazuma Ino
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiro Kanayama
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tomoki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
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2
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024:S0085-2538(24)00389-2. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center Boston, Massachusetts, USA; Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Department of Renal Medicine, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Department of Medicine and Nephrology, Albert Einstein College Medicine, Bronx, New York, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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3
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Kesarwani V, Bukhari MH, Kahlenberg JM, Wang S. Urinary complement biomarkers in immune-mediated kidney diseases. Front Immunol 2024; 15:1357869. [PMID: 38895123 PMCID: PMC11184941 DOI: 10.3389/fimmu.2024.1357869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/09/2024] [Indexed: 06/21/2024] Open
Abstract
The complement system, an important part of the innate system, is known to play a central role in many immune mediated kidney diseases. All parts of the complement system including the classical, alternative, and mannose-binding lectin pathways have been implicated in complement-mediated kidney injury. Although complement components are thought to be mainly synthesized in the liver and activated in the circulation, emerging data suggest that complement is synthesized and activated inside the kidney leading to direct injury. Urinary complement biomarkers are likely a better reflection of inflammation within the kidneys as compared to traditional serum complement biomarkers which may be influenced by systemic inflammation. In addition, urinary complement biomarkers have the advantage of being non-invasive and easily accessible. With the rise of therapies targeting the complement pathways, there is a critical need to better understand the role of complement in kidney diseases and to develop reliable and non-invasive biomarkers to assess disease activity, predict treatment response and guide therapeutic interventions. In this review, we summarized the current knowledge on urinary complement biomarkers of kidney diseases due to immune complex deposition (lupus nephritis, primary membranous nephropathy, IgA nephropathy) and due to activation of the alternative pathway (C3 glomerulopathy, thrombotic microangiography, ANCA-associated vasculitis). We also address the limitations of current research and propose future directions for the discovery of urinary complement biomarkers.
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Affiliation(s)
- Vartika Kesarwani
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Muhammad Hamza Bukhari
- Department of Medicine, Johns Hopkins Howard County Medical Center, Columbia, MD, United States
| | - J. Michelle Kahlenberg
- Division of Rheumatology, Department of Medicine, University of Michigan, Columbia, MI, United States
| | - Shudan Wang
- Division of Rheumatology, Department of Medicine, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
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De Mutiis C, Wenderfer SE, Basu B, Bagga A, Orjuela A, Sar T, Aggarwal A, Jain A, Boyer O, Yap HK, Ito S, Ohnishi A, Iwata N, Kasapcopur O, Laurent A, Chan EYH, Mastrangelo A, Ogura M, Shima Y, Rianthavorn P, Silva CA, Trindade V, Tullus K. Development of clinical and laboratory biomarkers in an international cohort of 428 children with lupus nephritis. Pediatr Nephrol 2024:10.1007/s00467-024-06405-6. [PMID: 38802607 DOI: 10.1007/s00467-024-06405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Lupus nephritis (LN) is a very severe manifestation of lupus. There is no consensus on which treatment goals should be achieved to protect kidney function in children with LN. METHODS We retrospectively analyzed trends of commonly used laboratory biomarkers of 428 patients (≤ 18 years old) with biopsy-proven LN class ≥ III. We compared data of patients who developed stable kidney remission from 6 to 24 months with those who did not. RESULTS Twenty-five percent of patients maintained kidney stable remission while 75% did not. More patients with stable kidney remission showed normal hemoglobin and erythrocyte sedimentation rate from 6 to 24 months compared to the group without stable kidney remission. eGFR ≥ 90 ml/min/1.73m2 at onset predicted the development of stable kidney remission (93.8%) compared to 64.7% in those without stable remission (P < 0.00001). At diagnosis, 5.9% and 20.2% of the patients showed no proteinuria in the group with and without stable kidney remission, respectively (P = 0.0001). dsDNA antibodies decreased from onset of treatment mainly during the first 3 months in all groups, but more than 50% of all patients in both groups never normalized after 6 months. Complement C3 and C4 increased mainly in the first 3 months in all patients without any significant difference. CONCLUSIONS Normal eGFR and the absence of proteinuria at onset were predictors of stable kidney remission. Significantly more children showed normal levels of Hb and erythrocyte sedimentation rate (ESR) from 6 to 24 months in the group with stable kidney remission.
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Affiliation(s)
- Chiara De Mutiis
- Paediatric Unit, Maggiore Hospital, Azienda USL, Bologna, Italy.
| | - Scott E Wenderfer
- Pediatric Nephrology, The University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alvaro Orjuela
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Tanmoy Sar
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Department of Clinical Immunology and Rheumatology, Sawai Mansingh Medical College, Jaipur, India
| | - Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, Paris, France
- Néphrologie Pédiatrique, Hôpital Necker, Paris, France
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, Japan
| | - Ai Ohnishi
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Audrey Laurent
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Hospices Civils de Lyon, Lyon, France
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Pornpimol Rianthavorn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Trindade
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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5
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Pisetsky DS. Unique Interplay Between Antinuclear Antibodies and Nuclear Molecules in the Pathogenesis of Systemic Lupus Erythematosus. Arthritis Rheumatol 2024. [PMID: 38622070 DOI: 10.1002/art.42863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/19/2024] [Accepted: 04/11/2024] [Indexed: 04/17/2024]
Abstract
Systemic lupus erythematosus (SLE) is a prototypic autoimmune disease that primarily affects young women and causes a wide range of inflammatory manifestations. The hallmark of SLE is the production of antibodies to components of the cell nucleus (antinuclear antibodies [ANAs]). These antibodies can bind to DNA, RNA, and protein complexes with nucleic acids. Among ANAs, antibodies to DNA (anti-DNA) are markers for classification and disease activity, waxing and waning disease activity in many patients. In the blood, anti-DNA antibodies can bind to DNA to form immune complexes with two distinct roles in pathogenesis: (1) renal deposition to provoke nephritis and (2) stimulation of cytokine production following uptake into innate immune cells and interaction with internal nucleic acid sensors. These sensors are part of an internal host defense system in the cell cytoplasm that can respond to DNA from infecting organisms; during cell stress, DNA from nuclear and mitochondrial sources can also trigger these sensors. The formation of immune complexes requires a source of extracellular DNA in an immunologically accessible form. As shown in in vivo and in vitro systems, extracellular DNA can emerge from dead and dying cells in both a free and a particulate form. Neutrophils undergoing the process of NETosis can release DNA in mesh-like structures called neutrophil extracellular traps. In SLE, therefore, the combination of ANAs and immunologically active DNA can create new structures that can promote inflammation throughout the body as well as drive organ inflammation and damage.
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Affiliation(s)
- David S Pisetsky
- Duke University Medical Center and Durham Veterans Administration Medical Center, Durham, North Carolina
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6
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Manabe A, Sada RM, Miyake H, Akebo H, Tsugihashi Y, Hatta K. An observational study to identify causative factors for not using hydroxychloroquine in systemic lupus erythematosus. Sci Rep 2024; 14:7750. [PMID: 38565930 PMCID: PMC10987587 DOI: 10.1038/s41598-024-58463-3] [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: 12/08/2023] [Accepted: 03/29/2024] [Indexed: 04/04/2024] Open
Abstract
Hydroxychloroquine (HCQ) use is indicated for patients with systemic lupus erythematosus (SLE). Nevertheless, reports discussing the reasons for not prescribing HCQ are limited. We identified the factors that interfere with HCQ use in patients with SLE. This observational, single-center study included data from 265 patients with SLE in 2019. The patients were categorized into groups with and without a history of HCQ use. Between these groups, clinical characteristics were compared using univariate analysis and logistic regression models. Among the 265 patients, 133 (50.2%) had a history of HCQ use. Univariate analysis identified older age; longer disease duration; lower prednisolone dose, clinical SLE disease activity index 2000, and estimated glomerular filtration rate; higher C3 level; and lower anti-double-stranded DNA antibody concentration as HCQ non-use-related variables. Logistic regression models identified a positive association between HCQ non-use and longer disease duration (odds ratio [OR] 1.08), prednisolone dose ≤ 7.5 mg/day (OR 4.03), C3 level ≥ 73 mg/dL (OR 2.15), and attending physician having graduated > 10 years prior (OR 3.19). In conclusion, a longer disease duration, lower prednisolone dose, higher C3 level, and longer time since attending physicians' graduation correlated with HCQ non-use. Physicians and patients should be educated to facilitate HCQ use despite these factors.
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Affiliation(s)
- Atsushi Manabe
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuichi Minoda Sada
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan.
- Department of Infection Control, Graduate School of Medicine, Osaka University, Suita, Japan.
- Department of Transformative Protection to Infectious Disease, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hirofumi Miyake
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
| | - Hiroyuki Akebo
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
| | - Yukio Tsugihashi
- Medical Home Care Centre, Tenri Hospital, Shirakawa Branch, Tenri, Japan
| | - Kazuhiro Hatta
- Department of General Internal Medicine, Tenri Hospital, Tenri, Japan
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7
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Nell D, Wolf R, Podgorny PM, Kuschnereit T, Kuschnereit R, Dabers T, Stracke S, Schmidt T. Complement Activation in Nephrotic Glomerular Diseases. Biomedicines 2024; 12:455. [PMID: 38398059 PMCID: PMC10886869 DOI: 10.3390/biomedicines12020455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
The nephrotic syndrome holds significant clinical importance and is characterized by a substantial protein loss in the urine. Damage to the glomerular basement membrane or podocytes frequently underlies renal protein loss. There is an increasing belief in the involvement of the complement system, a part of the innate immune system, in these conditions. Understanding the interactions between the complement system and glomerular structures continually evolves, challenging the traditional view of the blood-urine barrier as a passive filter. Clinical studies suggest that a precise inhibition of the complement system at various points may soon become feasible. However, a thorough understanding of current knowledge is imperative for planning future therapies in nephrotic glomerular diseases such as membranous glomerulopathy, membranoproliferative glomerulonephritis, lupus nephritis, focal segmental glomerulosclerosis, and minimal change disease. This review provides an overview of the complement system, its interactions with glomerular structures, and insights into specific glomerular diseases exhibiting a nephrotic course. Additionally, we explore new diagnostic tools and future therapeutic approaches.
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8
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López-Domínguez R, Villatoro-García JA, Marañón C, Goldman D, Petri M, Carmona-Sáez P, Alarcón-Riquelme M, Toro-Dominguez D. Immune and molecular landscape behind non-response to Mycophenolate Mofetil and Azathioprine in lupus nephritis therapy. RESEARCH SQUARE 2024:rs.3.rs-3783877. [PMID: 38260685 PMCID: PMC10802741 DOI: 10.21203/rs.3.rs-3783877/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Lupus nephritis (LN) represents one of the most severe complications of systemic lupus erythematosus, leading to end-stage kidney disease in worst cases. Current first-line therapies for LN, including mycophenolate mofetil (MMF) and azathioprine (AZA), fail to induce long-term remission in 60-70% of the patients, evidencing the urgent need to delve into the molecular knowledge-gap behind the non-response to these therapies. A longitudinal cohort of treated LN patients including clinical, cellular and transcriptomic data, was analyzed. Gene-expression signatures behind non-response to different drugs were revealed by differential expression analysis. Drug-specific non-response mechanisms and cell proportion differences were identified. Blood cell subsets mediating non-response were described using single-cell RNASeq data. We show that AZA and MMF non-response implicates different cells and regulatory functions. Mechanistic models were used to suggest add-on therapies to improve their current performance. Our results provide new insights into the molecular mechanisms associated with treatment failures in LN.
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Affiliation(s)
- Raúl López-Domínguez
- GENYO. Centre for Genomics and Oncological Research: Pfizer, University of Granada, Andalusian Regional Government, PTS Granada
| | - Juan Antonio Villatoro-García
- GENYO. Centre for Genomics and Oncological Research: Pfizer, University of Granada, Andalusian Regional Government, PTS Granada
| | - Concepción Marañón
- Department of Medical Genomics, Center for Genomics and Oncological Research (GENYO)
| | | | | | - Pedro Carmona-Sáez
- Department of Bioinformatics, Center for Genomics and Oncological Research (GENYO)
| | | | - Daniel Toro-Dominguez
- GENYO. Centre for Genomics and Oncological Research: Pfizer, University of Granada, Andalusian Regional Government, PTS Granada
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9
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Larsen ML, Troldborg A, Toonen EJM, Hurler L, Prohaszka Z, Cervenak L, Gudmann Hansen A, Thiel S. Differentiating between activation via the lectin or the classical complement pathway in patients with systemic lupus erythematosus. Clin Exp Immunol 2023; 214:18-25. [PMID: 37407023 PMCID: PMC10711355 DOI: 10.1093/cei/uxad070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/11/2023] [Accepted: 07/05/2023] [Indexed: 07/07/2023] Open
Abstract
Complement activation is a hallmark of systemic lupus erythematosus (SLE) and can proceed through the classical (CP), lectin (LP), or alternative pathway (AP). When managing SLE patients, pathway-specific complement activation is rarely monitored as clinical assays are unavailable. In this study, we aim to differentiate between CP- or LP-mediated complement activation in SLE patients by quantifying pathway-specific protein complexes, namely C1s/C1-inhibitor (C1-INH) (CP-specific activation) and MASP-1/C1-INH (LP-specific activation). Levels for both complexes were assessed in 156 SLE patients and 50 controls using two newly developed ELISAs. We investigated whether pathway-specific complement activation was associated with disease activity and lupus nephritis (LN). Disease activity stratification was performed using SLEDAI scores assessed at inclusion. C1s/C1-INH concentrations were significantly increased in active SLE patients (SLEDAI ≥6) when compared with SLE patients with low disease activity (SLEDAI <6, P < 0.01) and correlated with SLEDAI score (r = .29, P < 0.01). In active LN, MASP-1/C1-INH plasma concentrations were significantly increased compared with nonactive LN (P = 0.02). No differences in MASP-1/C1-INH plasma concentrations were observed between active SLE patients and patients with low disease activity (P = 0.11) nor did we observe a significant correlation with disease activity (r = 0.12, P = 0.15). Our data suggest that the CP and the LP are activated in SLE. The CP is activated in active SLE disease, whereas activation of the LP might be more specific to disease manifestations like LN. Our results warrant further research into specific complement pathway activation in SLE patients to potentially improve specific-targeted and tailored-treatment approaches.
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Affiliation(s)
- Mads Lamm Larsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Troldborg
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lisa Hurler
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zoltan Prohaszka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
- Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - László Cervenak
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | | | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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10
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Wang S, Broder A, Shao D, Kesarwani V, Boderman B, Aguilan J, Sidoli S, Suzuki M, Greally JM, Saenger YM, Rovin BH, Michelle Kahlenberg J. Urine Proteomics Link Complement Activation with Interstitial Fibrosis/Tubular Atrophy in Lupus Nephritis Patients. Semin Arthritis Rheum 2023; 63:152263. [PMID: 37802003 PMCID: PMC10783434 DOI: 10.1016/j.semarthrit.2023.152263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 08/14/2023] [Accepted: 08/27/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Intrarenal complement activation has been implicated in the pathogenesis of tubulointerstitial fibrosis in lupus nephritis (LN) based on prior animal studies. The assembly of the membrane attack complex (MAC) by complement C5b to C9 on the cell membrane leads to cytotoxic pores and cell lysis, while CD59 inhibits MAC formation by preventing C9 from joining the complex. We hypothesize that complement activation and imbalance between complement activation and inhibition, as defined by increased production of individual complement components and uncontrolled MAC activation relative to CD59 inhibition, are associated with interstitial fibrosis and tubular atrophy (IFTA) in LN and correlate with the key mediators of kidney fibrosis- transforming growth factor receptors beta (TGFRβ), platelet-derived growth factor beta (PDGFβ) and platelet-derived growth factor receptor beta (PDGFRβ). METHODS We included urine samples from 46 adults and pediatric biopsy-proven lupus nephritis patients who underwent clinically indicated kidney biopsies between 2010 and 2019. We compared individual urinary complement components and the urinary C9-to-CD59 ratio between LN patients with moderate/severe IFTA and none/mild IFTA. IFTA was defined as none/mild (<25% of interstitium affected) versus moderate/severe (≥ 25% of interstitium affected). Proteomics analysis was performed using mass spectrometry (Orbitrap Fusion Lumos, Thermo Scientific) and processed by the Proteome Discoverer. Urinary complement proteins enriched in LN patients with moderate/severe IFTA were correlated with serum creatinine, TGFβR1, TGFβR2, PDGFβ, and PDGFRβ. RESULTS Of the 46 LN patients included in the study, 41 (89.1%) were women, 20 (43.5%) self-identified as Hispanic or Latino, and 26 (56.5%) self-identified as Black or African American. Ten of the 46 (21.7%) LN patients had moderate/severe IFTA on kidney biopsy. LN patients with moderate/severe IFTA had an increased urinary C9-to-CD59 ratio [median 0.91 (0.83-1.05) vs 0.81 (0.76-0.91), p=0.01]. Urinary C3 and CFI levels in LN patients with moderate/severe IFTA were higher compared to those with none/mild IFTA [C3 median (IQR) 24.4(23.5-25.5) vs. 20.2 (18.5-22.2), p= 0.02], [CFI medium (IQR) 28.8 (21.8-30.6) vs. 20.4 (18.5-22.9), p=0.01]. Complement C9, CD59, C3 and CFI correlated with TGFβR1, PDGFβ, and PDGFRβ, while C9, CD59 and C3 correlated with TGFβR2. CONCLUSION This study is one of the first to compare the urinary complement profile in LN patients with moderate/severe IFTA and none/mild IFTA in human tissues. This study identified C3, CFI, and C9-to-CD59 ratio as potential markers of tubulointerstitial fibrosis in LN.
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Affiliation(s)
- Shudan Wang
- Division of Rheumatology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA.
| | - Anna Broder
- Division of Rheumatology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Daming Shao
- Department of Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Vartika Kesarwani
- Department of Medicine, University of Wisconsin Hospital and Clinics, WI, USA
| | - Brianna Boderman
- Department of Medicine, University of Connecticut School of Medicine, CT, USA
| | - Jennifer Aguilan
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Simone Sidoli
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Masako Suzuki
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY USA
| | - John M Greally
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY USA
| | - Yvonne M Saenger
- Department of Oncology and Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY USA
| | - Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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11
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Radin M, Cecchi I, Crisafulli F, Klumb EM, de Jesús GR, Lacerda MI, Saavedra MÁ, Reyes-Navarro GV, Iaccarino L, Larosa M, Moroni G, Tamborini F, Roccatello D, Andreoli L, Sciascia S, Chighizola CB. Complement levels during the first trimester predict disease flare and adverse pregnancy outcomes in systemic lupus erythematosus: A network meta-analysis on 532 pregnancies. Autoimmun Rev 2023; 22:103467. [PMID: 37852515 DOI: 10.1016/j.autrev.2023.103467] [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: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Complement levels have been proposed as candidate biomarkers of disease activity and obstetric risk in systemic lupus erythematosus (SLE) pregnancies, but their reliability has been questioned due to the physiologic fluctuations of complement during gestation. Thus, this network meta-analysis aimed at assessing the clinical significance of complement fluctuations in lupus pregnant women. METHODS Corresponding authors of 19 studies meeting inclusion criteria were invited to contribute with additional data including C3 and C4 levels [before pregnancy, at conception, in every trimester (T) and 3 months after delivery]; data were pooled together in a network meta-analysis. RESULTS A total of 532 lupus women from four studies were included in the analysis. In SLE women, C3 and C4 increased progressively during gestation: levels remained stable during T1 and peaked in T2 to decrease in T3. Patients with previous lupus nephritis (LN) and those who experienced flares during pregnancy had significantly lower mean levels of C3 and C4 at all timepoints. The lowest levels of complement were observed, particularly during T1, in patients with LN and gestational flare. Both reduction and the lack of increase of C3 and C4 levels at T1 versus conception were associated with gestational flares, particularly in LN patients. Pregnancies with flare had a statistically significant higher rate of maternal and fetal complications(60% versus 50.3%; p = 0.03). CONCLUSIONS Low complement levels, particularly in T1, were associated with a higher frequency of gestational flare. Either reduction or smaller increase of C3 and/or C4 levels, even within normal range, might predict flares especially in early gestation.
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Affiliation(s)
- Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST SpedaliCivili of Brescia, University of Brescia, Brescia, Italy
| | - Evandro Mendes Klumb
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Miguel Ángel Saavedra
- RheumatologyDepartment, Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy; Division of Rheumatology, Department of Locomotor System, ASL3, Genoa, Italy
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy; IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | | | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, ASST SpedaliCivili of Brescia, University of Brescia, Brescia, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
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12
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Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
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Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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13
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Almaani S, Song H, Suthanthira M, Toy C, Fussner LA, Meara A, Nagaraja H, Cuthbertson D, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Monach PA, Merkel PA, Rovin B, Birmingham D. Urine and Plasma Complement Ba Levels During Disease Flares in Patients With Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis. Kidney Int Rep 2023; 8:2421-2427. [PMID: 38025219 PMCID: PMC10658281 DOI: 10.1016/j.ekir.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Although the alternative complement pathway has been implicated in the pathogenesis of antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV), the specific nature of its involvement is unclear. This study measured levels of urine and plasma complement fragment Ba at multiple time points in a group of patients with AAV. Methods The complement fragment Ba was measured by enzyme-linked immunosorbent assay in serial urine and plasma samples from 21 patients with AAV who developed a renal flare, 19 who developed a nonrenal flare, and 20 in long-term remission. Urine Ba levels were corrected for urine creatinine concentration. Changes in Ba levels were modeled using mixed linear-effect models. A logistic regression model was fit to predict a renal flare using Ba levels at the time of flare versus the nonrenal flare and long-term remission groups. Results Data from 60 patients with AAV were used for this analysis; 53% were male, 93% were White, and 74% had antiproteinase3-ANCA. Urine Ba levels increased at renal flare (P < 0.001) but remained stable during a nonrenal flare or long-term remission. Plasma Ba levels were stable over time in all groups. Urine Ba levels predicted a renal flare with an area under the curve of 0.76 (P < 0.001), with a cutoff of 12.53 ng/mg urine creatinine yielding a sensitivity of 76.2% and a specificity of 68.4%. Conclusion Urine Ba levels, but not plasma Ba levels, are increased at the time of a renal flare in AAV, suggesting intrarenal complement activation and highlighting the potential use of this biomarker for surveillance of active renal vasculitis.
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Affiliation(s)
- Salem Almaani
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Huijuan Song
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Meshora Suthanthira
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher Toy
- Department of Soil and Crop Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Lynn A. Fussner
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexa Meara
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Haikady Nagaraja
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, Florida, USA
| | - Nader A. Khalidi
- Division of Rheumatology, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | | | - Carol A. McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Larry W. Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, Colorado, USA
| | - Christian Pagnoux
- Division of Rheumatology, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philip Seo
- Division of Rheumatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Ulrich Specks
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Antoine G. Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth J. Warrington
- Mayo Clinic College of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul A. Monach
- Veteran’s Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Peter A. Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brad Rovin
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Birmingham
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Coss SL, Zhou D, Chua GT, Aziz RA, Hoffman RP, Wu YL, Ardoin SP, Atkinson JP, Yu CY. The complement system and human autoimmune diseases. J Autoimmun 2023; 137:102979. [PMID: 36535812 PMCID: PMC10276174 DOI: 10.1016/j.jaut.2022.102979] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
Genetic deficiencies of early components of the classical complement activation pathway (especially C1q, r, s, and C4) are the strongest monogenic causal factors for the prototypic autoimmune disease systemic lupus erythematosus (SLE), but their prevalence is extremely rare. In contrast, isotype genetic deficiency of C4A and acquired deficiency of C1q by autoantibodies are frequent among patients with SLE. Here we review the genetic basis of complement deficiencies in autoimmune disease, discuss the complex genetic diversity seen in complement C4 and its association with autoimmune disease, provide guidance as to when clinicians should suspect and test for complement deficiencies, and outline the current understanding of the mechanisms relating complement deficiencies to autoimmunity. We focus primarily on SLE, as the role of complement in SLE is well-established, but will also discuss other informative diseases such as inflammatory arthritis and myositis.
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Affiliation(s)
- Samantha L Coss
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
| | - Danlei Zhou
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Gilbert T Chua
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rabheh Abdul Aziz
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA; Department of Allergy, Immunology and Rheumatology, University of Buffalo, NY, USA
| | - Robert P Hoffman
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Yee Ling Wu
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA; Department of Microbiology and Immunology, Loyola University Chicago, Maywood, IL, USA
| | - Stacy P Ardoin
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - John P Atkinson
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St Louis, MO, USA
| | - Chack-Yung Yu
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
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15
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Kitamura M, Almaani S, Challa B, Doraiswamy M, Ayoub I, Biederman L, Parikh SV, Molovic-Kokovic A, Benedict J, Mhaskar N, Khitan ZJ, Brodsky SV, Nadasdy T, Satoskar AA. The Diagnostic Conundrum of Glomerular Crescents With IgA Deposits. Kidney Int Rep 2023; 8:507-518. [PMID: 36938067 PMCID: PMC10014387 DOI: 10.1016/j.ekir.2022.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction Glomerulonephritis (GN) with crescents and IgA deposits in kidney biopsy poses a frequent diagnostic and therapeutic dilemma because of multiple possibilities. Methods Native kidney biopsies showing glomerular IgA deposition and crescents (excluding lupus nephritis) were identified from our biopsy archives between 2010 and 2021. Detailed clinicopathologic features were assessed. One-year clinical follow-up on a subset of cases was obtained. Results A total of 285 cases were identified, and these clustered into IgA nephropathy (IgAN, n = 108), Staphylococcus or other infection-associated GN/infection-related GN (SAGN/IRGN, n = 43), and antineutrophil cytoplasmic antibody-associated GN (ANCA-GN, n = 26) based on a constellation of clinicopathologic features, but 101 cases (group X) could not be definitively differentiated. The reasons have been elucidated, most important being atypical combination of clinicopathologic features and lack of definitive evidence of active infection. Follow-up (on 72/101 cases) revealed that clinicians' working diagnosis was IgAN in 43%, SAGN/IRGN in 22%, ANCA-GN in 28%, and others in 7% of the cases, but treatment approach varied from supportive or antibiotics to immunosuppression in each subgroup. Comparing these cases as "received immunosuppression" versus "non-immunosuppression," only 2 features differed, namely C3-dominant staining, and possibility of recent infection (both higher in the no-immunosuppression group) (P < 0.05). Renal loss was higher in the non-immunosuppression subgroup, but not statistically significant (P = 0.11). Conclusion Diagnostic overlap may remain unresolved in a substantial number of kidney biopsies with glomerular crescents and IgA deposits. A case-by-case approach, appropriate antibiotics if infection is ongoing, and consideration for cautious immunosuppressive treatment for progressive renal dysfunction may be needed for best chance of renal recovery.
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Affiliation(s)
- Mineaki Kitamura
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Salem Almaani
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bindu Challa
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Laura Biederman
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samir V. Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Jason Benedict
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Zeid J. Khitan
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Sergey V. Brodsky
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tibor Nadasdy
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anjali A. Satoskar
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Correspondence: Anjali A. Satoskar, Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, M015 Starling Loving Hall, 320 West 10th Avenue, Columbus, Ohio 43210, USA.
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16
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Mannemuddhu SS, Shoemaker LR, Bozorgmehri S, Borgia RE, Gupta N, Clapp WL, Zeng X, Modica RF. Does kidney biopsy in pediatric lupus patients "complement" the management and outcomes of silent lupus nephritis? Lessons learned from a pediatric cohort. Pediatr Nephrol 2023:10.1007/s00467-022-05859-w. [PMID: 36688943 PMCID: PMC10393877 DOI: 10.1007/s00467-022-05859-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 12/10/2022] [Accepted: 12/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Silent lupus nephritis (SLN) is systemic lupus erythematosus (SLE) without clinical and laboratory features of kidney involvement but with biopsy-proven nephritis. This study aims to describe and compare the baseline characteristics and outcomes of pediatric SLN with overt LN (OLN) and to identify associated risk factors and biochemical markers. METHODS In this retrospective, observational study, multivariate logistic regression and receiver operating characteristic (ROC) analyses studied age, sex, race, serum complements, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. RESULTS In our cohort of 69 patients, 47 were OLN, and 22 were SLN. OLN (OR = 4.9, p = 0.03) and non-African Americans (AA) (OR = 13.0, p < 0.01) had higher odds, and increasing C3 and C4 were associated with lower odds of proliferative nephritis (OR 0.95 and 0.65 per one unit increase in C3 and C4, respectively, p < 0.01). They demonstrated a good discriminative ability to detect proliferative nephritis as assessed by the area under the ROC curve (C3 = 0.78, C4 = 0.78). C3 and C4 in proliferative SLN and OLN were comparable and significantly lower than their non-proliferative counterparts. No association was observed between age, sex, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. Proliferative SLN and OLN patients received similar treatments. Adverse events were identified in the proliferative OLN only. CONCLUSIONS Lower complement levels are associated with proliferative lesions in pediatric LN-both SLN and OLN. The non-AA population had higher odds of having proliferative nephritis than the AA. Prospective, randomized, long-term follow-up of proliferative SLN patients is needed to ascertain the beneficial effect of early diagnosis and treatment. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sai Sudha Mannemuddhu
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA. .,Pediatric Nephrology, East Tennessee Children's Hospital, 2100 Clinch Avenue, MOB, Suite 310, Knoxville, TN, 37916, USA. .,Department of Medicine, University of Tennessee, Knoxville, TN, USA.
| | - Lawrence R Shoemaker
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Department of Medicine, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - R Ezequiel Borgia
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA.,Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nirupama Gupta
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA.,Blue Jay Pediatrics, Leesburg, VA, USA
| | - William L Clapp
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Xu Zeng
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Renee F Modica
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA
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17
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Abstract
Uncontrolled alternative pathway activation is the primary driver of several diseases, and it contributes to the pathogenesis of many others. Consequently, diagnostic tests to monitor this arm of the complement system are increasingly important. Defects in alternative pathway regulation are strong risk factors for disease, and drugs that specifically block the alternative pathway are entering clinical use. A range of diagnostic tests have been developed to evaluate and monitor the alternative pathway, including assays to measure its function, expression of alternative pathway constituents, and activation fragments. Genetic studies have also revealed many disease-associated variants in alternative pathway genes that predict the risk of disease and prognosis. Newer imaging modalities offer the promise of non-invasively detecting and localizing pathologic complement activation. Together, these various tests help in the diagnosis of disease, provide important prognostic information, and can help guide therapy with complement inhibitory drugs.
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Affiliation(s)
- Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Veronique Fremeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Immunology Biology and INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and Cancer", Paris, France
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18
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Rojas-Rivera JE, García-Carro C, Ávila AI, Espino M, Espinosa M, Fernández-Juárez G, Fulladosa X, Goicoechea M, Macía M, Morales E, Porras LFQ, Praga M. Consensus document of the Spanish Group for the Study of the Glomerular Diseases (GLOSEN) for the diagnosis and treatment of lupus nephritis. Nefrologia 2023; 43:6-47. [PMID: 37211521 DOI: 10.1016/j.nefroe.2023.05.006] [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: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 05/23/2023] Open
Abstract
A significant number of patients with systemic lupus erythematosus (between 20% and 60% according to different reported series) develop lupus nephritis in the course of its evolution, which directly influences their quality of life and vital prognosis. In recent years, the greater knowledge about the pathogenesis of systemic lupus and lupus nephritis has allowed relevant advances in the diagnostic approach and treatment of these patients, achieving the development of drugs specifically aimed at blocking key pathogenic pathways of the disease. Encouragingly, these immunomodulatory agents have shown in well-powered, randomized clinical trials good clinical efficacy in the medium-term, defined as proteinuria remission and preservation of kidney function, with an acceptable safety profile and good patient tolerability. All this has made it possible to reduce the use of corticosteroids and other potentially more toxic therapies, as well as to increase the use of combined therapies. The present consensus document carried out by the Glomerular Diseases Working Group of the Spanish Society of Nephrology (GLOSEN), collects in a practical and summarized, but rigorous way, the best currently available evidence about the diagnosis, treatment, and follow-up of lupus nephritis patients, including cases of special situations, with the main objective of providing updated information and well-founded clinical recommendations to treating physicians, to improve the diagnostic and therapeutic approach to our patients.
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Affiliation(s)
- Jorge E Rojas-Rivera
- Hospital Universitario Fundación Jiménez Díaz, Servicio de Nefrología e Hipertensión, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Servicio de Nefrología, Madrid, Spain.
| | - Clara García-Carro
- Hospital Universitario Clínico San Carlos, Servicio de Nefrología. Madrid, Spain.
| | - Ana I Ávila
- Hospital Dr. Peset, Servicio de Nefrología, Valencia, Spain
| | - Mar Espino
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain
| | - Mario Espinosa
- Hospital Universitario Reina Sofía, Servicio de Nefrología, Cordoba, Spain
| | | | - Xavier Fulladosa
- Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Servicio de Nefrología, Barcelona, Spain
| | - Marian Goicoechea
- Hospital Universitario Gregorio Marañón, Servicio de Nefrología, Madrid, Spain
| | - Manuel Macía
- Hospital Universitario Nuestra Señora de la Candelaria, Servicio de Nefrología, Tenerife, Spain
| | - Enrique Morales
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
| | - Luis F Quintana Porras
- Hospital Clínic de Barcelona, Servicio de Nefrología, Barcelona, Spain; Departamento de Medicina, Universidad de Barcelona, IDIBAPS, Servicio de Nefrología, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
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Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
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Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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20
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Association between AhR in B cells and systemic lupus erythematosus with renal damage. Int Immunopharmacol 2022; 113:109381. [DOI: 10.1016/j.intimp.2022.109381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/09/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
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21
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Documento de consenso del Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) para el diagnóstico y tratamiento de la nefritis lúpica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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22
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Rossi GM, Maggiore U, Peyronel F, Fenaroli P, Delsante M, Benigno GD, Gianfreda D, Urban ML, Manna Z, Arend LJ, Bagnasco S, Vaglio A, Fiaccadori E, Rosenberg AZ, Hasni S, Manenti L. Persistent Isolated C3 Hypocomplementemia as a Strong Predictor of End-Stage Kidney Disease in Lupus Nephritis. Kidney Int Rep 2022; 7:2647-2656. [PMID: 36506236 PMCID: PMC9727529 DOI: 10.1016/j.ekir.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/13/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Proliferative lupus nephritis (LN) progresses to end-stage kidney disease (ESKD) in roughly 10% of the cases despite treatment. Other than achieving <0.8 g/24h proteinuria at 12 months after treatment, early biomarkers predicting ESKD or death are lacking. Recent studies encompassing not only LN have highlighted the central role of the alternative complement pathway (ACP), with or without histological evidence of thrombotic microangiopathy (TMA), as a key promotor of renal death. Methods We assessed whether persistent isolated C3 hypocomplementemia (PI-LowC3), that is not accompanied by C4 hypocomplementemia, 6 months after kidney biopsy, is associated with an increased risk of death or ESKD in proliferative LN. Results We retrospectively followed-up 197 patients with proliferative LN (51 with PI-LowC3) for a median of 4.5 years (interquartile-range: 1.9-9.0), 11 of whom died and 22 reached ESKD. After adjusting for age, gender, ethnicity, hypertension, mycophenolate, or cyclophosphamide use, PI-LowC3 was associated with a hazard ratio [HR] of the composite outcome ESKD or death of 2.46 (95% confidence interval [CI]: 1.22-4.99, P = 0.012). These results were confirmed even after controlling for time-varying estimated glomerular filtration rate (eGFR) measurements in joint longitudinal-survival multiple regression models. After accounting for the competing risk of death, PI-LowC3 patients showed a strikingly increased risk of ESKD (adjusted HR 3.41, 95% CI: 1.31-8.88, P = 0.012). Conclusion Our findings support the use of PI-LowC3 as a low-cost readily available biomarker, allowing clinicians to modify treatment strategies early in the course of disease and offering a rationale for complement blockade trials in this particularly at-risk subgroup of LN patients.
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Affiliation(s)
- Giovanni Maria Rossi
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
- Renal Immunopathology Laboratory “Luigi Migone,” Parma University Hospital, Parma, Italy
| | - Umberto Maggiore
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Peyronel
- Nephrology and Dialysis Unit, Meyer Children’s University Hospital, and Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Firenze, Italy
| | - Paride Fenaroli
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
- Renal Immunopathology Laboratory “Luigi Migone,” Parma University Hospital, Parma, Italy
| | - Marco Delsante
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
- Renal Immunopathology Laboratory “Luigi Migone,” Parma University Hospital, Parma, Italy
| | - Giuseppe Daniele Benigno
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Davide Gianfreda
- Nephrology and Dialysis Unit, Santa Caterina Novella Hospital, Galatina, Lecce, Italy
| | | | - Zerai Manna
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lois Johanna Arend
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serena Bagnasco
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children’s University Hospital, and Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Firenze, Italy
- Department of Biomedical Clinical and Experimental Sciences, University of Firenze, Firenze, Italy
| | - Enrico Fiaccadori
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
- Renal Immunopathology Laboratory “Luigi Migone,” Parma University Hospital, Parma, Italy
| | - Avi Z. Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarfaraz Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lucio Manenti
- Renal Unit, Parma University Hospital, and Department of Medicine and Surgery, University of Parma, Parma, Italy
- Correspondence: Lucio Manenti, Renal Unit, Parma University Hospital, Via Gramsci 14, 43126, Parma, Italy.
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Lundtoft C, Pucholt P, Martin M, Bianchi M, Lundström E, Eloranta ML, Sandling JK, Sjöwall C, Jönsen A, Gunnarsson I, Rantapää-Dahlqvist S, Bengtsson AA, Leonard D, Baecklund E, Jonsson R, Hammenfors D, Forsblad-d'Elia H, Eriksson P, Mandl T, Magnusson Bucher S, Norheim KB, Auglaend Johnsen SJ, Omdal R, Kvarnström M, Wahren-Herlenius M, Notarnicola A, Andersson H, Molberg Ø, Diederichsen LP, Almlöf J, Syvänen AC, Kozyrev SV, Lindblad-Toh K, Nilsson B, Blom AM, Lundberg IE, Nordmark G, Diaz-Gallo LM, Svenungsson E, Rönnblom L. Complement C4 Copy Number Variation is Linked to SSA/Ro and SSB/La Autoantibodies in Systemic Inflammatory Autoimmune Diseases. Arthritis Rheumatol 2022; 74:1440-1450. [PMID: 35315244 PMCID: PMC9543510 DOI: 10.1002/art.42122] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Copy number variation of the C4 complement components, C4A and C4B, has been associated with systemic inflammatory autoimmune diseases. This study was undertaken to investigate whether C4 copy number variation is connected to the autoimmune repertoire in systemic lupus erythematosus (SLE), primary Sjögren's syndrome (SS), or myositis. METHODS Using targeted DNA sequencing, we determined the copy number and genetic variants of C4 in 2,290 well-characterized Scandinavian patients with SLE, primary SS, or myositis and 1,251 healthy controls. RESULTS A prominent relationship was observed between C4A copy number and the presence of SSA/SSB autoantibodies, which was shared between the 3 diseases. The strongest association was detected in patients with autoantibodies against both SSA and SSB and 0 C4A copies when compared to healthy controls (odds ratio [OR] 18.0 [95% confidence interval (95% CI) 10.2-33.3]), whereas a weaker association was seen in patients without SSA/SSB autoantibodies (OR 3.1 [95% CI 1.7-5.5]). The copy number of C4 correlated positively with C4 plasma levels. Further, a common loss-of-function variant in C4A leading to reduced plasma C4 was more prevalent in SLE patients with a low copy number of C4A. Functionally, we showed that absence of C4A reduced the individuals' capacity to deposit C4b on immune complexes. CONCLUSION We show that a low C4A copy number is more strongly associated with the autoantibody repertoire than with the clinically defined disease entities. These findings may have implications for understanding the etiopathogenetic mechanisms of systemic inflammatory autoimmune diseases and for patient stratification when taking the genetic profile into account.
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Affiliation(s)
| | | | | | - Matteo Bianchi
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | - Emeli Lundström
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Andreas Jönsen
- Lund University and Skåne University Hospital, Lund, Sweden
| | - Iva Gunnarsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | | | | | | | | | - Roald Omdal
- Stavanger University Hospital, Stavanger, Norway
| | - Marika Kvarnström
- Karolinska Institutet, Karolinska University Hospital, and Stockholm Health Services, Region Stockholm, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Karolinska Institutet and Karolinska University Hospital Stockholm, Sweden, and University of Bergen, Bergen, Norway
| | | | | | | | - Louise Pyndt Diederichsen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, and Odense University Hospital, Odense, Denmark
| | - Jonas Almlöf
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | | | - Sergey V Kozyrev
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | - Kerstin Lindblad-Toh
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden, and Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | | | | | | | | | - Ingrid E Lundberg
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Intertwined pathways of complement activation command the pathogenesis of lupus nephritis. Transl Res 2022; 245:18-29. [PMID: 35296451 PMCID: PMC9167748 DOI: 10.1016/j.trsl.2022.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/26/2022]
Abstract
The complement system is involved in the origin of autoimmunity and systemic lupus erythematosus. Both genetic deficiency of complement components and excessive activation are involved in primary and secondary renal diseases, including lupus nephritis. Among the pathways, the classical pathway has long been accepted as the main pathway of complement activation in systemic lupus erythematosus. However, more recent studies have shown the contribution of factors B and D which implies the involvement of the alternative pathway. While there is evidence on the role of the lectin pathway in systemic lupus erythematosus, it is yet to be demonstrated whether this pathway is protective or harmful in lupus nephritis. Complement is being explored for the development of disease biomarkers and therapeutic targeting. In the current review we discuss the involvement of complement in lupus nephritis.
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Lubov JE, Jamison AS, Baltich Nelson B, Amudzi AA, Haas KN, Richmond JM. Medicinal Plant Extracts and Natural Compounds for the Treatment of Cutaneous Lupus Erythematosus: A Systematic Review. Front Pharmacol 2022; 13:802624. [PMID: 35431950 PMCID: PMC9008762 DOI: 10.3389/fphar.2022.802624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 12/19/2022] Open
Abstract
Cutaneous lupus erythematosus (CLE) is a group of autoimmune connective tissue disorders that significantly impact quality of life. Current treatment approaches typically use antimalarial medications, though patients may become recalcitrant. Other treatment options include general immunosuppressants, highlighting the need for more and more targeted treatment options. The purpose of this systematic review was to identify potential compounds that could be repurposed for CLE from natural products since many rheumatologic drugs are derived from natural products, including antimalarials. This study was registered with PROSPERO, the international prospective register of systematic reviews (registration number CRD42021251048). We comprehensively searched Ovid Medline, Cochrane Library, and Scopus databases from inception to April 27th, 2021. These terms included cutaneous lupus erythematosus; general plant, fungus, bacteria terminology; selected plants and plant-derived products; selected antimalarials; and JAK inhibitors. Our search yielded 13,970 studies, of which 1,362 were duplicates. We screened 12,608 abstracts, found 12,043 to be irrelevant, and assessed 565 full-text studies for eligibility. Of these, 506 were excluded, and 59 studies were included in the data extraction. The ROBINS-I risk of bias assessment tool was used to assess studies that met our inclusion criteria. According to our findings, several natural compounds do reduce inflammation in lupus and other autoimmune skin diseases in studies using in vitro methods, mouse models, and clinical observational studies, along with a few randomized clinical trials. Our study has cataloged evidence in support of potential natural compounds and plant extracts that could serve as novel sources of active ingredients for the treatment of CLE. It is imperative that further studies in mice and humans are conducted to validate these findings. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=251048.
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Affiliation(s)
- Janet E. Lubov
- Department of Dermatology, UMass Chan Medical School, Worcester, MA, United States
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
- *Correspondence: Janet E. Lubov, ; Jillian M. Richmond,
| | - Aisha S. Jamison
- Department of Dermatology, UMass Chan Medical School, Worcester, MA, United States
- Wright State University Boonshoft School of Medicine, Dayton, OH, United States
| | | | - Alice A. Amudzi
- Department of Dermatology, UMass Chan Medical School, Worcester, MA, United States
| | - Kelly N. Haas
- Department of Microbiology, UMass Amherst, Amherst, MA, United States
| | - Jillian M. Richmond
- Department of Dermatology, UMass Chan Medical School, Worcester, MA, United States
- *Correspondence: Janet E. Lubov, ; Jillian M. Richmond,
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Hubbard EL, Pisetsky DS, Lipsky PE. Anti-RNP antibodies are associated with the interferon gene signature but not decreased complement levels in SLE. Ann Rheum Dis 2022; 81:632-643. [PMID: 35115332 DOI: 10.1136/annrheumdis-2021-221662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/19/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The goals of these studies were to elucidate the inter-relationships of specific anti-nuclear antibody (ANA), complement, and the interferon gene signature (IGS) in the pathogenesis of systemic lupus erythematosus (SLE). METHODS Data from the Illuminate trials were analysed for antibodies to dsDNA as well as RNA-binding proteins (RBP), levels of C3, C4 and various IGS. Statistical hypothesis testing, linear regression analyses and classification and regression trees analysis were employed to assess relationships between the laboratory features of SLE. RESULTS Inter-relationships of ANAs, complement and the IGS differed between patients of African Ancestry (AA) and European Ancestry (EA); anti-RNP and multiple autoantibodies were more common in AA patients and, although both related to the presence of the IGS, relationships between autoantibodies and complement differed. Whereas, anti-dsDNA had an inverse relationship to C3 and C4, levels of anti-RNP were not related to these markers. The IGS was only correlated with anti-dsDNA in EA SLE and complement was more correlated to the IGS in AA SLE. Finally, autoantibodies occurred in the presence and absence of the IGS, whereas the IGS was infrequent in anti-dsDNA/anti-RBP-negative SLE patients. CONCLUSION There is a complex relationship between autoantibodies and the IGS, with anti-RNP associated in AA and both anti-dsDNA and RNP associated in EA. Moreover, there was a difference in the relationship between anti-dsDNA, but not anti-RBP, with complement levels. The lack of a relationship of anti-RNP with C3 and C4 suggests that anti-RNP immune complexes (ICs) may drive the IGS without complement fixation, whereas anti-dsDNA ICs involve complement consumption.
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Affiliation(s)
- Erika L Hubbard
- AMPEL BioSolutions LLC, Charlottesville, Virginia, USA.,RILITE Foundation, Charlottesville, Virginia, USA
| | - David S Pisetsky
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Rheumatology, Durham VA Medical Center, Durham, North Carolina, USA
| | - Peter E Lipsky
- AMPEL BioSolutions LLC, Charlottesville, Virginia, USA .,RILITE Foundation, Charlottesville, Virginia, USA
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Ayoub I, Rovin BH. The Use of Serological Tests in the Care of Patients with Lupus Nephritis. Clin J Am Soc Nephrol 2022; 17:305-307. [PMID: 34853061 PMCID: PMC8823947 DOI: 10.2215/cjn.13431021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Isabelle Ayoub
- Division of Nephrology, Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Brad H. Rovin
- Division of Nephrology, Department of Medicine, The Ohio State University, Columbus, Ohio
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Kostopoulou M, Ugarte-Gil MF, Pons-Estel B, van Vollenhoven RF, Bertsias G. The association between lupus serology and disease outcomes: A systematic literature review to inform the treat-to-target approach in systemic lupus erythematosus. Lupus 2022; 31:307-318. [PMID: 35067068 DOI: 10.1177/09612033221074580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Serological markers such as anti-double stranded (ds)DNA antibodies and complement fractions C3/C4, are integral components of disease activity assessment in patients with systemic lupus erythematosus (SLE). However, it remains uncertain whether treatment should aim at restoration of serological abnormalities. OBJECTIVES To analyze and critically appraise the literature on the prognostic impact of active lupus serology despite clinical disease quiescence. METHODS A systematic literature review was performed in PubMed and EMBASE using the PICOT(S) (population, index, comparator, outcome(s), timing, setting) system to identify studies evaluating the association of serum anti-dsDNA, C3 and C4 levels assessed at the time of clinical remission or during the disease course, against the risk for impending flares and organ damage. Risk of bias was determined by the Quality in Prognosis Studies and ROB2 tools for observational and randomized controlled studies, respectively. RESULTS Fifty-three studies were eligible, the majority having moderate (70.6%) or high (11.8%) risk of bias and not adequately controlling for possible confounders. C3 hypocomplementemia during stable/inactive disease was associated with increased risk (2.0 to 3.8-fold) for subsequent flare in three out of seven relevant studies. Three out of four studies reported a significant effect of C4 hypocomplementemia on flare risk, including one study in lupus nephritis (likelihood ratio-positive 12.0). An increased incidence of flares (2.0 to 2.8-fold) was reported in 11 out of 16 studies assessing the prognostic effect of high anti-dsDNA, and similarly, the majority of studies yielded significant relationships with renal flares. Six studies examined the effect of combined (rather than individual) serological activity, confirming the increased risk (2.0 to 2.7-fold) for relapses. No consistent association was found with organ damage. CONCLUSION Notwithstanding the heterogeneity and risk of bias, existing evidence indicates a modest association between abnormal serology and risk for flare in patients with stable/inactive SLE. These findings provide limited support for inclusion of serology in the treat-to-target approach but rationalize to further investigate their prognostic implications especially in lupus nephritis.
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Affiliation(s)
- Myrto Kostopoulou
- Medical School, 393206National and Kapodistrian University of Athens, Athens, Greece
| | - Manuel F Ugarte-Gil
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, Lima, Peru.,School of Medicine, Universidad Científica del Sur, Lima, Peru
| | - Bernardo Pons-Estel
- Department of Rheumatology, Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Santa Fe, Argentina
| | - Ronald F van Vollenhoven
- Department of Rheumatology, 571155Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - George Bertsias
- Rheumatology and Clinical Immunology, 37778University Hospital of Heraklion and University of Crete Medical School, Heraklion, Greece.,54570Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece
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Wang S, Wu M, Chiriboga L, Zeck B, Goilav B, Wang S, Jimenez AL, Putterman C, Schwartz D, Pullman J, Broder A, Belmont HM. Membrane attack complex (MAC) deposition in renal tubules is associated with interstitial fibrosis and tubular atrophy: a pilot study. Lupus Sci Med 2022; 9:9/1/e000576. [PMID: 34996855 PMCID: PMC8744090 DOI: 10.1136/lupus-2021-000576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/23/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Treatment failures for lupus nephritis (LN) are high with 10%-30% of patients progressing to end-stage renal disease (ESRD) within 10 years. Interstitial fibrosis/tubular atrophy (IFTA) is a predictor of progression to ESRD. Prior studies suggest that tubulointerstitial injury secondary to proteinuria in LN is mediated by complement activation in the tubules, specifically through the membrane attack complex (MAC). This study aimed to investigate the associations between tubular MAC deposition with IFTA and proteinuria. METHODS In this cross-sectional study, LN kidney biopsies were assessed for MAC deposition by staining for Complement C9, a component of the MAC. Chromogenic immunohistochemistry was performed on paraffin-embedded human renal biopsy sections using unconjugated, murine anti-human Complement C9 (Hycult Biotech, clone X197). Tubular C9 staining intensity was analysed as present versus absent. IFTA was defined as minimal (<10%), mild (10%-24%), moderate (25%-50%) and severe (>50%). RESULTS Renal biopsies from 30 patients with LN were studied. There were 24 (80%) female sex, mean age (SD) was 33 (12) years old and 23 (77%) had pure/mixed proliferative LN. Tubular C9 staining was present in 7 (23%) biopsies. 27 patients had minimal-to-mild IFTA and 3 patients had moderate IFTA. Among the C9 + patients, 3 (43%) had moderate IFTA as compared with none in the C9- group, p=0.009. C9 + patients had higher median (IQR) proteinuria as compared with C9- patients: 6.2 g (3.3-13.1) vs 2.4 g (1.3-4.6), p=0.001 at the time of biopsy. There was no difference in estimated glomerular filtration rate (eGFR) between the C9 + and C9- groups. CONCLUSION This study demonstrated that tubular MAC deposition is associated with higher degree of IFTA and proteinuria, which are predictors of progression to ESRD. These results suggest that tubular MAC deposition may be useful in classification of LN. Understanding the role of complement in tubulointerstitial injury will also identify new avenues for LN treatment.
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Affiliation(s)
- Shudan Wang
- Rheumatology, Montefiore Medical Center, Bronx, New York, USA .,Rheumatology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ming Wu
- Pathology, NYU Langone Health, New York, New York, USA
| | | | - Briana Zeck
- Pathology, NYU Langone Health, New York, New York, USA
| | - Beatrice Goilav
- Nephrology, The Children's Hospital at Montefiore, Bronx, New York, USA
| | - Shuwei Wang
- Rheumatology, Morristown Medical Center, Morristown, New Jersey, USA
| | - Alejandra Londono Jimenez
- Rheumatology, Montefiore Medical Center, Bronx, New York, USA.,Rheumatology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Chaim Putterman
- Rheumatology, Albert Einstein College of Medicine, Bronx, New York, USA.,Bar-Ilan University, Ramat Gan, Tel Aviv, Israel
| | | | - James Pullman
- Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Anna Broder
- Rheumatology, Montefiore Medical Center, Bronx, New York, USA.,Rheumatology, Albert Einstein College of Medicine, Bronx, New York, USA
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Jiang H, Chen Q, Zheng S, Guo C, Luo J, Wang H, Zheng X, Weng Z. Association of Complement C3 with Clinical Deterioration Among Hospitalized Patients with COVID-19. Int J Gen Med 2022; 15:849-857. [PMID: 35115811 PMCID: PMC8801723 DOI: 10.2147/ijgm.s348519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/12/2022] [Indexed: 12/15/2022] Open
Abstract
Background The role of the complement system in coronavirus disease 2019 (COVID-19) remains controversial. This study aimed to evaluate the relationship between serum complement C3 levels, clinical worsening, and risk of death in hospitalized patients with COVID-19. Methods Data were collected from 216 adults with COVID-19 admitted to a designated clinical center in Wuhan Union Hospital (China) between February 13, 2020, and February 29, 2020. Their complement C3 levels were measured within 24 h of admission. The primary outcome was a clinical worsening of 2 points on a 6-point ordinal scale. The secondary outcome was all-causes of death. Inverse probability of treatment weighting (IPTW) analysis was conducted to adjust for the baseline confounders. Results The median value of C3 was 0.89 (interquartile range, 0.78–1.01) g/L. Clinical worsening occurred in 12.3% (7/57) and 2.5% (4/159) of patients with baseline C3 levels < and ≥0.79 g/L, respectively (hazard ratio [HR], 5.22; 95% confidence interval [CI], 1.53–17.86). After IPTW adjustment, the risk for clinical worsening was 4-fold greater (weighted HR, 4.61; 95% CI, 1.16–18.4) in patients with C3 levels less than 0.79 g/L comparatively. The sensitivity analyses revealed the robustness of the results. No significant associations between C3 levels and death were observed on unadjusted (HR, 2.92; 95% CI, 0.73–11.69) and IPTW analyses (weighted HR, 3.78; 95% CI, 0.84–17.04). Conclusion Low complement C3 levels are associated with a higher risk for clinical worsening among inpatients with COVID-19. The serum C3 levels may contribute to the identification of patient populations that could benefit from therapeutic complement inhibition.
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Affiliation(s)
- Hongbo Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Qiaosen Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Shaoping Zheng
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Chunxia Guo
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Jinzhuo Luo
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Hua Wang
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Xin Zheng
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Zhihong Weng
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Correspondence: Zhihong Weng, Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 JieFang Avenue, Wuhan, 430022, People’s Republic of China, Email
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31
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Jeswani G, Chablani L, Gupta U, Sahoo RK, Nakhate KT, Ajazuddin. Development and optimization of paclitaxel loaded Eudragit/PLGA nanoparticles by simplex lattice mixture design: Exploration of improved hemocompatibility and in vivo kinetics. Biomed Pharmacother 2021; 144:112286. [PMID: 34653755 DOI: 10.1016/j.biopha.2021.112286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/24/2021] [Accepted: 10/05/2021] [Indexed: 01/17/2023] Open
Abstract
Anemia is the most common hematological abnormality of chemotherapy, which is responsible for poor clinical outcomes. To overcome this complication, the present study was aimed for developing a Eudragit/polylactic-co-glycolic acid (PLGA) based nanoparticulate system for a model drug paclitaxel (PTX). The study was planned using a simplex lattice mixture design. PTX nanoparticles (PTXNp) were evaluated in vitro for physicochemical properties, hemolytic effects and cytotoxic effects. Further, the nanoparticles were subjected to in vivo screening using rats for hemocompatibility, pharmacokinetic profile, and biodistribution to the vital organs. The PTXNps were 65.77-214.73 nm in size, showed more than 60% sustained drug release in 360 h and caused less than 8% hemolysis. The parameters like red blood cell count, activated partial thromboplastin time (aPTT), prothrombin time (PT) and C3 complement were similar to the negative control. Cytotoxicity results suggested that all the PTXNp demonstrated drug concentration-dependent cytotoxicity. The in vivo pharmacokinetic study concluded that PTXNp formulations had significantly higher blood AUC (93.194.55-163,071.15 h*ng/mL), longer half-lives (5.80-6.35 h) and extended mean residence times (6.05-8.54 h) in comparison to PTX solution (p < 0.05). Overall, the study provides a nanoparticulate drug delivery system to deliver PTX safely and effectively along with reducing the associated hematological adverse effects.
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Affiliation(s)
- Gunjan Jeswani
- Rungta College of Pharmaceutical Sciences and Research, Kohka-Kurud Road, Bhilai, Chhattisgarh 490024, India; Faculty of Pharmaceutical Sciences, Shri Shankaracharya Technical Campus, Bhilai, Chhattisgarh 490020, India
| | - Lipika Chablani
- Department of Pharmaceutical Sciences, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY 14618, USA.
| | - Umesh Gupta
- Department of Pharmacy, School of Chemical Sciences and Pharmacy, Central University of Rajasthan, Bandarsindri, Ajmer, Rajasthan 305817, India
| | - Rakesh K Sahoo
- Department of Pharmacy, School of Chemical Sciences and Pharmacy, Central University of Rajasthan, Bandarsindri, Ajmer, Rajasthan 305817, India
| | - Kartik T Nakhate
- Department of Pharmacology, Shri Vile Parle Kelavani Mandal's Institute of Pharmacy, Dhule, Maharashtra 424001, India
| | - Ajazuddin
- School of Pharmacy and Technology Management, SVKM's NMIMS, Shirpur, Maharashtra 425405, India.
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32
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Abdelati AA, Eshak NY, Donia HM, El-Girby AH. Urinary Cellular Profile as a Biomarker for Lupus Nephritis. J Clin Rheumatol 2021; 27:e469-e476. [PMID: 32976199 DOI: 10.1097/rhu.0000000000001553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE A search for the ideal biomarker for lupus nephritis (LN) is still underway, one that can be used for early detection and correlate with the class and activity of LN. Urine is normally devoid of leukocytes; however, it has been observed that macrophages and T lymphocytes are routinely present in the urine of LN patients and those with other proliferative renal diseases. This provides the idea for their potential use as biomarkers for proliferative LN. Here, we measured the urinary CD4+, CD8+ T lymphocytes, and CD14+ monocytes in patients with systemic lupus erythematosus (SLE) as potential biomarkers for LN. METHODS A longitudinal case-control study included 30 SLE patients with LN, 30 SLE patients without past or current LN, and 20 healthy subjects as a control group. The flow cytometric analysis was done using BD FACS Calibur multiparameter flow cytometer equipped with BD CellQuest Pro software for data analysis. RESULTS CD14+ cells were the most abundant cells in the urine of LN patients. The mean numbers of urinary CD8+, CD4+, and CD14+ cells/mL were significantly higher in patients with LN than in those without. The cell counts correlated significantly with proteinuria. Urinary CD14+ cells seem to occur in much higher counts in class IV than class III LN. CONCLUSIONS Urinary CD8+, CD4+, and CD14+ cells are highly sensitive and specific markers for detecting proliferative LN. A low CD4:CD8 ratio provides a further clue. Urinary CD14 cell counts may be a potential biomarker to differentiate between the different classes of proliferative LN.
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Affiliation(s)
- Abeer Ali Abdelati
- From the Department of Internal Medicine, Rheumatology and Clinical Immunology Unit
| | - Nouran Y Eshak
- From the Department of Internal Medicine, Rheumatology and Clinical Immunology Unit
| | - Hanaa M Donia
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Amira H El-Girby
- From the Department of Internal Medicine, Rheumatology and Clinical Immunology Unit
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33
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Circulating C1q levels in health and disease, more than just a biomarker. Mol Immunol 2021; 140:206-216. [PMID: 34735869 DOI: 10.1016/j.molimm.2021.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/03/2021] [Accepted: 10/11/2021] [Indexed: 12/21/2022]
Abstract
C1q is the recognition molecule of the classical pathway of the complement system. By binding to its targets, such as antigen-bound immunoglobulins or C-reactive protein, C1q contributes to the innate defense against infections. However, C1q also plays several other roles beyond its traditional role in complement activation. Circulating levels of C1q are determined in routine diagnostics as biomarker in several diseases. Decreased C1q levels are present in several autoimmune conditions. The decreased levels reflect the consumption of C1q by complement activation and serves as a biomarker for disease activity. In contrast, increased C1q levels are present in infectious and inflammatory diseases and may serve as a diagnostic biomarker. The increased levels of C1q are still incompletely understood but are suggested to modulate the adaptive immune response as C1q is known to impact on the maturation status of antigen-presenting cells and C1q impacts directly on T cells leading to decreased T-cell activity in high C1q conditions. In this review, we provide a comprehensive overview of the current literature on circulating levels of C1q in health and disease, and discuss how C1q can both protect against infections as well as maintain tolerance by regulating adaptive immunity.
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34
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Mejia-Vilet JM, Malvar A, Arazi A, Rovin BH. The lupus nephritis management renaissance. Kidney Int 2021; 101:242-255. [PMID: 34619230 DOI: 10.1016/j.kint.2021.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022]
Abstract
Over the past year, and for the first time ever, the US Food and Drug Administration approved 2 drugs specifically for the treatment of lupus nephritis (LN). As the lupus community works toward understanding how to best use these new therapies, it is also an ideal time to begin to rethink the overall management strategy of LN. In addition to new drugs, this must include how to use kidney biopsies for management and not just diagnosis, how molecular technologies can be applied to interrogate biopsies and how such data can impact management, and how to incorporate LN biomarkers into management paradigms. Herein, we will review new developments in these areas of LN and put them into perspective for disease management now and in the future.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology, Instituto Nacional de Ciencas Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Ana Malvar
- Department of Nephrology, Hospital Fernandez, Buenos Aires, Argentina
| | - Arnon Arazi
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Brad H Rovin
- Department of Medicine and Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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35
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Toy CR, Song H, Nagaraja HN, Scott J, Greco J, Zhang X, Yu CY, Tumlin JA, Rovin BH, Hebert LA, Birmingham DJ. The Influence of an Elastase-Sensitive Complement C5 Variant on Lupus Nephritis and Its Flare. Kidney Int Rep 2021; 6:2105-2113. [PMID: 34386659 PMCID: PMC8344111 DOI: 10.1016/j.ekir.2021.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction A C5 polymorphism (rs17611, 2404G>A) exists where the G allele associates with enhanced C5a-like production by neutrophil elastase. This cohort study investigated the influence of this polymorphism as a risk factor for lupus nephritis (LN), and on C5a and membrane attack complex (MAC) levels in LN during flare. Methods A cohort of lupus patients (n = 155) was genotyped for the 2404G>A polymorphism. A longitudinal LN subset (n = 66) was tested for plasma and urine levels of C5a and MAC 4 and/or 2 months before and at nonrenal or LN flare. Results The 2404G allele and 2404-GG genotype were associated with LN in black, but not white, lupus patients. In the longitudinal cohort, neither urine nor plasma C5a levels changed at nonrenal flare regardless of 2404G>A genotype or race. Urine (but not plasma) C5a levels increased at LN flare independent of race, more so in 2404-GG patients where 8 of 30 LN flares exhibited very high C5a levels. Higher proteinuria and serum creatinine levels also occurred in these eight flares. Urine (but not plasma) MAC levels also increased at LN flare in 2404-GG patients and correlated with urine C5a levels. Conclusions The C5 2404-G allele/GG genotype is a potential risk factor for LN uniquely in black lupus patients. The GG genotype is associated with sharp increases in urine C5a and MAC levels in a subset of LN flares that correspond to higher LN disease indices. The lack of corresponding changes in plasma suggests these increases reflect intrarenal complement activation.
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Affiliation(s)
- Chris R Toy
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Huijuan Song
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Haikady N Nagaraja
- Division of Biostatistics, Ohio State University College of Public Health, Columbus, Ohio, USA
| | - Julia Scott
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Jessica Greco
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Xiaolan Zhang
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Chack-Yung Yu
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, and Department of Pediatrics, Ohio State University, Columbus, Ohio, USA
| | - James A Tumlin
- NephroNet Clinical Research Consortium, Atlanta, Georgia, USA
| | - Brad H Rovin
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Lee A Hebert
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Daniel J Birmingham
- Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, Ohio, USA
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LncRNA MIAT enhances systemic lupus erythematosus by upregulating CFHR5 expression via miR-222 degradation. Cent Eur J Immunol 2021; 46:17-26. [PMID: 33897280 PMCID: PMC8056357 DOI: 10.5114/ceji.2021.105242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/02/2020] [Indexed: 11/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE), a complex polygenic autoimmune disease, is associated with increased complement activation. Complement factor H related protein 5 (CFHR5) may contribute to dysfunctional complement activation, thus predisposing to SLE. The expression levels of anti-dsDNA, C3 and CFHR5 in blood samples from 50 SLE patients and 50 healthy individuals were evaluated, and also their expression levels were measured in an MRL/lpr mouse model and control MRL/MPJ mice. The results showed that CFHR5 expression increased in SLE patients together with the increase of anti-dsDNA in comparison with the healthy control. Furthermore, CFHR5 expression was inversely correlated with C3, down-regulation of which was associated with worse SLE. Previous studies indicated that long noncoding RNA (lncRNA) regulates mRNA synthesis via microRNA (miRNA) inhibition. The present bioinformatics analysis revealed that the target miRNA (miR-222) was combined with both lncRNA MIAT and mRNA CFHR5. H&E staining of the kidney tissues of the MRL/lpr mice revealed that lncRNA MIAT, as a competitive inhibitor of miR-222, enhanced SLE by upregulating CFHR5 expression through the degradation of miR-222 in vivo. Thus, our study revealed for the first time the role of lncRNA MIAT in regulating CFHR5 expression in SLE in vivo and provided new insights into the role of lncRNA in regulation and complement function of SLE pathogenesis.
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37
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Tailliar M, Schanstra JP, Dierckx T, Breuil B, Hanouna G, Charles N, Bascands JL, Dussol B, Vazi A, Chiche L, Siwy J, Faguer S, Daniel L, Daugas E, Jourde-Chiche N. Urinary Peptides as Potential Non-Invasive Biomarkers for Lupus Nephritis: Results of the Peptidu-LUP Study. J Clin Med 2021; 10:jcm10081690. [PMID: 33920017 PMCID: PMC8071029 DOI: 10.3390/jcm10081690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Lupus nephritis (LN) is a severe manifestation of Systemic Lupus Erythematosus (SLE). The therapeutic strategy relies on kidney biopsy (KB) results. We tested whether urinary peptidome analysis could non-invasively differentiate active from non-active LN. Design: Urinary samples were collected from 93 patients (55 with active LN and 38 with non-active LN), forming a discovery (n = 42) and an independent validation (n = 51) cohort. Clinical characteristics were collected at inclusion and prospectively for 24 months. The urinary peptidome was analyzed by capillary-electrophoresis coupled to mass-spectrometry, comparing active LN to non-active LN, and assessing chronic lesions and response to therapy. The value of previously validated prognostic (CKD273) and differential diagnostic (LN172) signatures was evaluated. Results: Urinary peptides could not discriminate between active and non-active LN or predict early response to therapy. Tubulo-interstitial fibrosis was correlated to the CKD273. The LN172 score identified 92.5% of samples as LN. Few patients developed new-onset CKD. Conclusions: We validated the CKD273 and LN172 classifiers but did not identify a robust signature that could predict active LN and replace KB. The value of urinary peptidome to predict long-term CKD, or renal flares in SLE, remains to be evaluated.
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Affiliation(s)
- Maxence Tailliar
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
| | - Joost P. Schanstra
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
| | - Tim Dierckx
- Laboratory of Clinical and Epidemiological Virology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, 3000 Leuven, Belgium;
| | - Benjamin Breuil
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
| | - Guillaume Hanouna
- AP-HP, Service de Néphrologie, Hôpital Bichat, DMU VICTOIRE, 75018 Paris, France; (G.H.); (E.D.)
| | - Nicolas Charles
- Centre de Recherche sur l’Inflammation, Université de Paris, INSERM UMRS1149, CNRS ERL8252, Labex INFLAMEX, DHU FIRE, 75890 Paris, France;
| | - Jean-Loup Bascands
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1188-Université de La Réunion, 97490 Saint-Denis, France;
| | - Bertrand Dussol
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
- Centre d’Investigation Clinique, CHU Conception, AP-HM, 13005 Marseille, France;
| | - Alain Vazi
- Centre d’Investigation Clinique, CHU Conception, AP-HM, 13005 Marseille, France;
| | - Laurent Chiche
- Médecine Interne, Hôpital Européen, 13003 Marseille, France;
| | - Justyna Siwy
- Mosaiques Diagnostics GmbH, 30659 Hannover, Germany;
| | - Stanislas Faguer
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
- CHU de Toulouse, Service de Néphrologie, 31300 Toulouse, France
| | - Laurent Daniel
- AP-HM, Laboratoire d’Ananatomie Pathologique, Hôpital de la Timone, 13005 Marseille, France;
- Center for CardioVascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM, INRAE, 13005 Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, DMU VICTOIRE, 75018 Paris, France; (G.H.); (E.D.)
- Centre de Recherche sur l’Inflammation, Université de Paris, INSERM UMRS1149, CNRS ERL8252, Labex INFLAMEX, DHU FIRE, 75890 Paris, France;
| | - Noémie Jourde-Chiche
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
- Center for CardioVascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM, INRAE, 13005 Marseille, France
- Correspondence:
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Abstract
Purpose of Review Complement activation is a key event in the pathogenesis of tissue inflammation and injury in systemic lupus erythematosus (SLE). This review is aimed at comparing the usefulness of measurement of complement proteins in serum/plasma (C3, C4) to complement activation (split) products in plasma and on circulating blood cells for SLE diagnosis, disease monitoring, and prognosis. Recent Findings Complement split products, C3dg, iC3b, and C4d, are elevated in SLE, and C3dg/C3 and iC3b/C3 ratios correlate with active SLE. C4d also is higher in patients with lupus nephritis. An elevated level of the alternative pathway split product, Bb, in early lupus pregnancy is a predictor of adverse outcomes in SLE patients with antiphospholipid antibodies. Elevated levels of cell-bound complement activation products (CB-CAPs), namely, B cell-bound C4d (BC4d) and erythrocyte-bound C4d (EC4d), within a multiparameter assay panel, may predict transition to SLE more than other lupus biomarkers. EC4d better correlates with lupus disease activity than low plasma complement levels. Elevated platelet-bound C4d (PC4d) correlates with thrombosis in SLE. Both EC4d and PC4d are increased in primary and secondary anti-phospholipid syndrome, and anti-beta2glycoproteinI antibodies may directly activate the complement system. Summary Abnormal levels of plasma complement split products and CB-CAPs support complement activation as an important pathogenetic mechanism in SLE and the antiphospholipid syndromes. These tests show promise for the diagnosis of SLE and monitoring of disease activity.
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Affiliation(s)
- Arthur Weinstein
- Loma Linda University, Loma Linda, CA, USA. .,Georgetown University, Washington, DC, USA. .,Exagen Inc., Vista, CA, USA.
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Expanding the Role of Complement Therapies: The Case for Lupus Nephritis. J Clin Med 2021; 10:jcm10040626. [PMID: 33562189 PMCID: PMC7915321 DOI: 10.3390/jcm10040626] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/14/2022] Open
Abstract
The complement system is an innate immune surveillance network that provides defense against microorganisms and clearance of immune complexes and cellular debris and bridges innate and adaptive immunity. In the context of autoimmune disease, activation and dysregulation of complement can lead to uncontrolled inflammation and organ damage, especially to the kidney. Systemic lupus erythematosus (SLE) is characterized by loss of tolerance, autoantibody production, and immune complex deposition in tissues including the kidney, with inflammatory consequences. Effective clearance of immune complexes and cellular waste by early complement components protects against the development of lupus nephritis, while uncontrolled activation of complement, especially the alternative pathway, promotes kidney damage in SLE. Therefore, complement plays a dual role in the pathogenesis of lupus nephritis. Improved understanding of the contribution of the various complement pathways to the development of kidney disease in SLE has created an opportunity to target the complement system with novel therapies to improve outcomes in lupus nephritis. In this review, we explore the interactions between complement and the kidney in SLE and their implications for the treatment of lupus nephritis.
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40
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Xie W, Xiao Z, Xu J, Hong G, Xu X, Zhang Y, Zhang X. The clinical characteristics of low C4 alone in patients with systemic lupus erythematosus. Clin Rheumatol 2021; 40:793-796. [PMID: 32856201 DOI: 10.1007/s10067-020-05367-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Weiji Xie
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Zeen Xiao
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jing Xu
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Guitian Hong
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaochang Xu
- Department of Nephrology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yimin Zhang
- Department of Nephrology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xialan Zhang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China.
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41
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Luo KL, Yang YH, Lin YT, Hu YC, Yu HH, Wang LC, Chiang BL, Lee JH. Differential parameters between activity flare and acute infection in pediatric patients with systemic lupus erythematosus. Sci Rep 2020; 10:19913. [PMID: 33199770 PMCID: PMC7670442 DOI: 10.1038/s41598-020-76789-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) patients are vulnerable to infections. We aim to explore the approach to differentiate active infection from disease activity in pediatric SLE patients. Fifty pediatric SLE patients presenting with 185 clinical visits were collected. The associations between both clinical and laboratory parameters and the outcome groups were analyzed using generalized estimating equations (GEEs). These 185 visits were divided into 4 outcome groups: infected-active (n = 102), infected-inactive (n = 11), noninfected-active (n = 59), and noninfected-inactive (n = 13) visits. Multivariate GEE (generalized estimating equation) analysis showed that SDI, SLEDAI-2K, neutrophil‐to‐lymphocyte ratio (NLR), hemoglobin, platelet, RDW-to-platelet ratio (RPR), and C3 are predictive of flare (combined calculated AUC of 0.8964 and with sensitivity of 82.2% and specificity of 90.9%). Multivariate GEE analysis showed that SDI, fever temperature, CRP, procalcitonin (PCT), lymphocyte percentage, NLR, hemoglobin, and renal score in SLEDAI-2k are predictive of infection (combined calculated AUC of 0.7886 and with sensitivity of 63.5% and specificity of 89.2%). We can simultaneously predict 4 different outcome with accuracy of 70.13% for infected-active group, 10% for infected-inactive group, 59.57% for noninfected-active group, and 84.62% for noninfected-inactive group, respectively. Combination of parameters from four different domains simultaneously, including inflammation (CRP, ESR, PCT), hematology (Lymphocyte percentage, NLR, PLR), complement (C3, C4), and clinical status (SLEDAI, SDI) is objective and effective to differentiate flares from infections in pediatric SLE patients.
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Affiliation(s)
- Kai-Ling Luo
- Department of Pediatrics, Cathay General Hospital, Taipei, 10630, Taiwan, ROC
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Yu-Tsan Lin
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Ya-Chiao Hu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Hsin-Hui Yu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Li-Chieh Wang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, 10002, Taiwan, ROC
| | - Jyh-Hong Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC.
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42
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Yip TCF, Saria S, Petri M, Magder LS. Predictors of the start of declining eGFR in patients with systemic lupus erythematosus. Lupus 2020; 30:15-24. [PMID: 33115373 DOI: 10.1177/0961203320966393] [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: 11/15/2022]
Abstract
OBJECTIVE To characterize the longitudinal trajectory of estimated glomerular filtration rate (eGFR) in patients with systemic lupus erythematosus (SLE) and identify predictors of the change in eGFR trajectory. METHODS The longitudinal eGFR levels of patients in the Hopkins Lupus Cohort were modelled by piecewise linear regression to evaluate the slope of different line segments. The slopes were classified into declining (≤-4 mL/min/1.73 m2 per year), stable (-4 to 4 mL/min/1.73 m2 per year), and increasing (≥4 mL/min/1.73 m2 per year) states. The transition rate between states and the impact of clinical parameters were estimated by a Markov model. RESULTS The analysis was based on 494 SLE patients. At a mean follow-up of 8.8 years, 347 (70.2%), 107 (21.7%), 33 (6.7%), and 7 (1.4%) patients had zero, one, two, and three state transitions, respectively. In patients with no transition, 37 (10.7%), 308 (88.8%), and 2 (0.6%) were in declining, stable, and increasing state, respectively. In patients with one transition, 43 (40.2%) changed from declining to stable state while 29 (27.1%) changed from stable to declining state. When patients were in a non-declining GFR state, those who were younger and African Americans were more likely to transition to a declining GFR state. In adjusted analyses, high blood pressure, C4 and low hematocrit were associated with change from non-declining to declining state. High urine protein-to-creatinine ratio also tended to be associated with change from non-declining to declining state. African American patients were less likely to move from declining to non-declining state. Use of prednisone was associated with change from declining to non-declining state. CONCLUSIONS Patients with high blood pressure, low complement C4, low haematocrit, and high urine protein-to-creatinine ratio are more likely to have a declining eGFR trajectory, while the use of prednisone stabilizes the declining eGFR trajectory.
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Affiliation(s)
- Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Suchi Saria
- Departments of Computer Science & Statistics, Whiting School of Engineering, Baltimore, MD, USA.,Department of Health Policy, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michelle Petri
- Division of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology & Public Health, School of Medicine, University of Maryland, Baltimore, MD, USA
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43
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Martin M, Trattner R, Nilsson SC, Björk A, Zickert A, Blom AM, Gunnarsson I. Plasma C4d Correlates With C4d Deposition in Kidneys and With Treatment Response in Lupus Nephritis Patients. Front Immunol 2020; 11:582737. [PMID: 33133102 DOI: 10.3389/fimmu.2020.582737] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/03/2020] [Indexed: 01/09/2023] Open
Abstract
Objective To examine whether C4d plasma levels correlate with treatment response and C4d kidney deposition in systemic lupus erythematosus (SLE) with lupus nephritis (LN). Methods C4d plasma levels were analyzed by a unique assay specifically detecting C4d arising from complement activation and C4 plasma levels were quantified with competitive ELISA. SLE patients with LN (71) and active SLE patients without LN (22) plus 145 controls were included. For 52 LN patients samples were available both at baseline and after immunosuppressive treatment. C4d kidney deposition was detected using immunohistochemistry in two matching kidney biopsies of 12 LN patients. Results In comparison to population-based controls, plasma C4d levels were significantly increased in SLE patients (0.33 mg/L versus 0.94 mg/ml, p < 0.0001) with significantly higher levels in LN patients (1.02 mg/L) than in non-renal SLE patients (0.57 mg/L, p = 0.004). The C4d/C4 ratio was also significantly higher in LN (11.2) than in non-renal SLE patients (2.5, p = 0.0002). According to ROC curve analysis, C4d was found to be an accurate marker to discriminate LN from non-renal SLE patients (p = 0.004). The C4d/C4 ratio displayed even higher specificity, sensitivity and overall accuracy as marker for LN than C4d and C4 alone. At baseline, C4d levels correlated significantly with urine-albumin to creatinine ratio (r s = 0.43, p = 0.011) and with renal activity index (r s = 0.37, p = 0.002). Immunohistochemical staining showed glomerular deposits of C4d in kidney biopsies, which strikingly correlated with plasma C4d levels (r s = 0.7, p = 0.0002). Plasma C4d declined significantly after treatment in patients that experienced favorable clinical and histopathological response (p < 0.0001), while levels remained mainly unchanged in non-responders. Conclusion Plasma C4d discriminates LN from active non-renal SLE, correlates with C4d kidney deposits and appears valuable in monitoring responsiveness to various treatments. The C4d/C4 ratio might be superior to C4d alone.
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Affiliation(s)
- Myriam Martin
- Department of Translational Medicine, Section of Medical Protein Chemistry, Lund University, Malmö, Sweden.,Region Skåne, Laboratory Medicine, Clinical Chemistry, Malmö, Sweden
| | - Rebecca Trattner
- Department of Translational Medicine, Section of Medical Protein Chemistry, Lund University, Malmö, Sweden.,Region Skåne, Laboratory Medicine, Clinical Chemistry, Malmö, Sweden
| | - Sara C Nilsson
- Department of Translational Medicine, Section of Medical Protein Chemistry, Lund University, Malmö, Sweden
| | - Albin Björk
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Zickert
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna M Blom
- Department of Translational Medicine, Section of Medical Protein Chemistry, Lund University, Malmö, Sweden.,Region Skåne, Laboratory Medicine, Clinical Chemistry, Malmö, Sweden
| | - Iva Gunnarsson
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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44
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Complement activation in human autoimmune diseases and mouse models; employing a sandwich immunoassay specific for C3dg. J Immunol Methods 2020; 486:112866. [PMID: 32941885 DOI: 10.1016/j.jim.2020.112866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/29/2020] [Accepted: 09/07/2020] [Indexed: 12/21/2022]
Abstract
In human autoimmune diseases, low plasma levels of complement factors C3 and C4 are commonly used as a proxy for complement activation. The measurements of C3 and C4 concentrations (the result of synthesis and consumption) however, show low sensitivity in patient follow-up. We find that the estimation of the C3dg fragment released during complement activation is a better parameter for complement activation. Available techniques for measuring the activation fragment C3dg, e.g. immune-electrophoresis or involving PEG-precipitation, are time-consuming and difficult to standardize. Here we examine the specificity and use of an antibody with mono-specificity for a neoepitope at the N-terminus of C3dg, which is only exposed after cleavage of C3. We present a stable, reproducible, and easy-to-use, time-resolved immunoassay with specificity for C3dg that can be used to directly evaluate ongoing complement activation. We demonstrate that the assay can be applied to clinical samples with a high specificity (95%) and a positive likelihood ratio of 10. It can also differentiate the complement related disease Systemic Lupus Erythematosus from controls and other immune-mediatedimmune mediated diseases like Rheumatoid Arthritis (86% specificity) and Spondyloarthritis (91% specificity). Further, we establish how the assay may also be used for experimental research in in vivo mouse models.
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45
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Mihaylova G, Vasilev V, Kosturkova MB, Stoyanov GS, Radanova M. Long Non-Coding RNAs as New Biomarkers in Lupus Nephritis: A Connection Between Present and Future. Cureus 2020; 12:e9003. [PMID: 32775083 PMCID: PMC7402529 DOI: 10.7759/cureus.9003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE). LN often leads to kidney failure, affecting the quality of a patient's life. There are several classical biomarkers that assist nephrologists’ daily practice. For more than 50 years, anti-double stranded DNA antibodies and complement components C3 and C4 have been used for LN disease activity evaluation. The major obstacle in the usage of conventional biomarkers is that none of them have both high specificity and high sensitivity. Moreover, an invasive kidney biopsy is still the gold standard for renal involvement detection in SLE patients. Therefore, new non-invasive biomarkers are needed for the early and accurate establishment of LN. Among the promising candidates are long non-coding RNAs (lncRNAs). Their dysregulation appears to have predictive and diagnostic potential. Furthermore, these biomarkers like other conventional biomarkers give insight into the pathogenesis of LN. This review aims to summarize the available information on lncRNAs in SLE patients and to present their future opportunities to add to the conventional biomarkers in the diagnosis and monitoring of LN.
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Affiliation(s)
- Galya Mihaylova
- Biochemistry, Molecular Medicine and Nutrigenomics, Medical University of Varna, Varna, BGR
| | - Vasil Vasilev
- Nephrology, "Tsaritsa Yoanna - ISUL" University Hospital, Sofia, BGR
| | | | - George S Stoyanov
- General and Clinical Pathology/Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
| | - Maria Radanova
- Biochemistry, Molecular Medicine and Nutrigenomics, Medical University of Varna, Varna, BGR
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46
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The clinical and serological associations of hypocomplementemia in a longitudinal sle cohort. Semin Arthritis Rheum 2020; 50:1081-1086. [PMID: 32916558 DOI: 10.1016/j.semarthrit.2020.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 04/24/2020] [Accepted: 06/17/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND In SLE, low complement is an important serological manifestation. Recent classification criteria include hypocomplementemia and one gives additional weight if both C3 and C4 are low. We evaluated patients with a history of, and those with persistently, low complement. As complement activation occurs in the antiphospholipid antibody syndrome, an analysis was also performed on those with positive antiphospholipid antibodies to evaluate thrombotic outcomes. METHODS In a longitudinal SLE cohort, organ manifestations, damage, C3, C4 and antiphospholipid antibodies were assessed quarterly. Using univariate and multivariate methods we compared those with and without a history of low C3, low C4 and both. We evaluated those who had a history of low complement at any time point, and those who had persistent hypocomplementemia. Further analysis considered thrombotic outcomes in patients with positive antiphospholipid antibodies and a history of low complement. RESULTS 2399 patients were evaluated. Fifty-five percent had a history of low C3 and 47% low C4; 83 (4%) had persistently low C3 and 65 (3.2%) had persistently low C4. Hematological, renal and serological abnormalities associated with a history of low C3 but not low C4. With anticardiolipin antibodies, a history of hypocomplementemia (both C3 and C4 low) associated with stroke and deep venous thrombosis. CONCLUSION Low C4 was a weak marker in terms of the associated clinical and serological manifestations. Low C3 associated with renal involvement and poor renal outcomes. A history of both low C3 and C4 associated with stroke in the presence of lupus anticoagulant or anticardiolipin antibodies, and low C4 with digital gangrene (with lupus anticoagulant).
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47
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Kamitaki N, Sekar A, Handsaker RE, de Rivera H, Tooley K, Morris DL, Taylor KE, Whelan CW, Tombleson P, Loohuis LMO, Boehnke M, Kimberly RP, Kaufman KM, Harley JB, Langefeld CD, Seidman CE, Pato MT, Pato CN, Ophoff RA, Graham RR, Criswell LA, Vyse TJ, McCarroll SA. Complement genes contribute sex-biased vulnerability in diverse disorders. Nature 2020; 582:577-581. [PMID: 32499649 PMCID: PMC7319891 DOI: 10.1038/s41586-020-2277-x] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
Many common illnesses differentially affect men and women for unknown reasons. The autoimmune diseases lupus and Sjögren’s syndrome affect nine times more women than men1, whereas schizophrenia affects men more frequently and severely2. All three illnesses have their strongest common genetic associations in the Major Histocompatibility Complex (MHC) locus, an association that in lupus and Sjögren’s syndrome has long been thought to arise from alleles of the human leukocyte antigen (HLA) genes at that locus3–6. Here we show that the complement component 4 (C4) genes, which are also in the MHC locus and were recently found to increase risk for schizophrenia7, generate 7-fold variation in risk for lupus (95% CI: 5.88–8.61; p < 10−117 in total) and 16-fold variation in risk for Sjögren’s syndrome (95% CI: 8.59–30.89; p < 10−23 in total) among individuals with common C4 genotypes, with C4A protecting more strongly than C4B in both illnesses. The same alleles that increase risk for schizophrenia greatly reduced risk for lupus and Sjögren’s syndrome. In all three illnesses, C4 alleles acted more strongly in men than in women: common combinations of C4A and C4B generated 14-fold variation in risk for lupus, 31-fold variation in risk for Sjögren’s syndrome, and 1.7-fold variation in schizophrenia risk among men (vs. 6-fold, 15-fold, and 1.26-fold among women respectively). At a protein level, both C4 and its effector C3 were present at greater levels in men than women in cerebrospinal fluid (p < 10−5 for both C4 and C3) and plasma8,9 among adults ages 20–50, corresponding to the ages of differential disease vulnerability. Sex differences in complement protein levels may help explain the larger effects of C4 alleles in men, women’s greater risk of SLE and Sjögren’s, and men’s greater vulnerability in schizophrenia. These results implicate the complement system as a source of sexual dimorphism in vulnerability to diverse illnesses.
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Affiliation(s)
- Nolan Kamitaki
- Department of Genetics, Harvard Medical School, Boston, MA, USA. .,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
| | - Aswin Sekar
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Robert E Handsaker
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Heather de Rivera
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Katherine Tooley
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David L Morris
- Department of Medical and Molecular Genetics, King's College London, London, UK
| | - Kimberly E Taylor
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, Division of Rheumatology, UCSF School of Medicine, San Francisco, CA, USA
| | - Christopher W Whelan
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Philip Tombleson
- Department of Medical and Molecular Genetics, King's College London, London, UK
| | - Loes M Olde Loohuis
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Center for Neurobehavioral Genetics, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | | | - Michael Boehnke
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, MI, USA
| | - Robert P Kimberly
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth M Kaufman
- Center for Autoimmune Genomics and Etiology (CAGE), Department of Pediatrics, Cincinnati Children's Medical Center & University of Cincinnati and the US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - John B Harley
- Center for Autoimmune Genomics and Etiology (CAGE), Department of Pediatrics, Cincinnati Children's Medical Center & University of Cincinnati and the US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christine E Seidman
- Department of Genetics, Harvard Medical School, Boston, MA, USA.,Howard Hughes Medical Institute, Chevy Chase, MD, USA.,Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Roel A Ophoff
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Center for Neurobehavioral Genetics, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | | | - Lindsey A Criswell
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, Division of Rheumatology, UCSF School of Medicine, San Francisco, CA, USA
| | - Timothy J Vyse
- Department of Medical and Molecular Genetics, King's College London, London, UK.
| | - Steven A McCarroll
- Department of Genetics, Harvard Medical School, Boston, MA, USA. .,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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Yang SR, Hua KF, Chu LJ, Hwu YK, Yang SM, Wu CY, Lin TJ, Weng JC, Zhao H, Hsu WH, Liu FC, Liaw WJ, Ma D, Ka SM, Chen A. Xenon blunts NF-κB/NLRP3 inflammasome activation and improves acute onset of accelerated and severe lupus nephritis in mice. Kidney Int 2020; 98:378-390. [PMID: 32622527 DOI: 10.1016/j.kint.2020.02.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 01/20/2023]
Abstract
Xenon, an inert anesthetic gas, is increasingly recognized to possess desirable properties including cytoprotective and anti-inflammatory effects. Here we evaluated the effects of xenon on the progression of lupus nephritis (LN) in a mouse model. A two hour exposure of either 70% xenon or 70% nitrogen balanced with oxygen was administered daily for five weeks to female NZB/W F1 mice that had been induced to develop accelerated and severe LN. Xenon treatment improved kidney function and renal histology, and decreased the renal expression of neutrophil chemoattractants, thereby attenuating glomerular neutrophil infiltration. The effects of xenon were mediated primarily by deceasing serum levels of anti-double stranded DNA autoantibody, inhibiting reactive oxygen species production, NF-κB/NLRP3 inflammasome activation, ICAM-1 expression, glomerular deposition of IgG and C3 and apoptosis, in the kidney; and enhancing renal hypoxia inducible factor 1-α expression. Proteomic analysis revealed that the treatment with xenon downregulated renal NLRP3 inflammasome-mediated cellular signaling. Similarly, xenon was effective in improving renal pathology and function in a spontaneous LN model in female NZB/W F1 mice. Thus, xenon may have a therapeutic role in treating LN but further studies are warranted to determine applicability to patients.
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Affiliation(s)
- Shin-Ruen Yang
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Feng Hua
- Department of Biotechnology and Animal Science, National Ilan University, Ilan, Taiwan
| | - Lichieh Julie Chu
- Molecular Medicine Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital at Linkou, Gueishan, Taoyuan, Taiwan
| | - Yeu-Kuang Hwu
- Institute of Physics, Academia Sinica, Taipei, Taiwan
| | - Shun-Min Yang
- Institute of Physics, Academia Sinica, Taipei, Taiwan; Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Yao Wu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Tsai-Jung Lin
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jui-Chun Weng
- Graduate Institute of Aerospace and Undersea Medicine, Academy of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hailin Zhao
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Wan-Han Hsu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Feng-Cheng Liu
- Department of Rheumatology/Immunology and Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Jinn Liaw
- Department of Medical Quality, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, Academy of Medicine, National Defense Medical Center, Taipei, Taiwan.
| | - Ann Chen
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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49
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Assessment of a high-avidity IgG ANAs for the diagnosis and activity prediction of systemic lupus erythematosus. Clin Rheumatol 2020; 39:2619-2629. [DOI: 10.1007/s10067-020-05040-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/26/2020] [Accepted: 03/06/2020] [Indexed: 01/07/2023]
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50
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Caster DJ, Powell DW. Utilization of Biomarkers in Lupus Nephritis. Adv Chronic Kidney Dis 2019; 26:351-359. [PMID: 31733719 DOI: 10.1053/j.ackd.2019.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 08/22/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022]
Abstract
Lupus nephritis (LN) occurs in up to 60% of SLE patients, and is a leading cause of disability and death. Current treatment of LN consists of a combination of high dose corticosteroids that non-specifically decrease inflammation and cytotoxic medications that reduce auto-antibody production. That combination of therapy is associated with significant side effects while remission rates remain inadequate. Since the introduction of biologics into the pharmacological armamentarium, there has been hope for less toxic and more effective therapies for LN. Unfortunately, after multiple clinical trials, no biologic has improved efficacy over standard of care therapies for LN. This is likely, in part, due to disease heterogeneity. The utilization of biomarkers in LN may provide a way to stratify patients and guide therapeutic options. In this review, we summarize traditional and novel LN biomarkers and discuss how they may be used to diagnose, stratify, and guide therapy in patients with LN, bringing precision medicine to the forefront of LN therapy.
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