1
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Aringer M, Brinks R, Dörner T, Daikh D, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Schmajuk G, Tani C, Tedeschi SK, Touma Z, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Costenbader K, Johnson SR. European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance. Ann Rheum Dis 2021; 80:775-781. [PMID: 33568386 DOI: 10.1136/annrheumdis-2020-219373] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 classification criteria for systemic lupus erythematosus system showed high specificity, while attaining also high sensitivity. We hereby analysed the performance of the individual criteria items and their contribution to the overall performance of the criteria. METHODS We combined the EULAR/ACR derivation and validation cohorts for a total of 1197 systemic lupus erythematosus (SLE) and n=1074 non-SLE patients with a variety of conditions mimicking SLE, such as other autoimmune diseases, and calculated the sensitivity and specificity for antinuclear antibodies (ANA) and the 23 specific criteria items. We also tested performance omitting the EULAR/ACR criteria attribution rule, which defines that items are only counted if not more likely explained by a cause other than SLE. RESULTS Positive ANA, the new entry criterion, was 99.5% sensitive, but only 19.4% specific, against a non-SLE population that included other inflammatory rheumatic, infectious, malignant and metabolic diseases. The specific criteria items were highly variable in sensitivity (from 0.42% for delirium and 1.84% for psychosis to 75.6% for antibodies to double-stranded DNA), but their specificity was uniformly high, with low C3 or C4 (83.0%) and leucopenia <4.000/mm³ (83.8%) at the lowest end. Unexplained fever was 95.3% specific in this cohort. Applying the attribution rule improved specificity, particularly for joint involvement. CONCLUSIONS Changing the position of the highly sensitive, non-specific ANA to an entry criterion and the attribution rule resulted in a specificity of >80% for all items, explaining the higher overall specificity of the criteria set.
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Affiliation(s)
- Martin Aringer
- University Medical Center and Faculty of Medicine, Department of Medicine III, Division of Rheumatology, TU Dresden, Dresden, Germany
| | - Ralph Brinks
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - David Daikh
- Oregon Health and Sciences University and Portland VA Health Care System, Portland, Oregon, USA
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Medicine/ Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - David Wofsy
- Russell/ Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, California, USA
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Division of Nephrology, Department of Medicine, University of Cambridge, Cambridge, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine, Centre de référence maladies auto-immunes et systémiques rares d'île de France, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bevra Hahn
- Rheumatology, UCLA School of Medicine, Los Angeles, California, USA
| | - Falk Hiepe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Bizkaia, The Basque Country, Spain
| | - Jorge Sanchez-Guerrero
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico.,Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Murray Urowitz
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Heraklion, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Bimba F Hoyer
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- University Medical Center and Faculty of Medicine, Department of Medicine III, Division of Rheumatology, TU Dresden, Dresden, Germany
| | - Gabriela Schmajuk
- Department of Medicine, Division of Rheumatology, University of California at San Francisco and the VA Medical Center, San Francisco, California, USA
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Ann Elaine Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Lupus Clinical Research Program, Office of the Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Department of Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico
| | - Íñigo Rúa-Figueroa
- Rheumatology, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Raphaèle Seror
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Vasconcelos
- Centro Hospitalar do Porto, ICBAS, UMIB, University of Porto, Porto, Portugal
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Rheumatology, Istanbul Bilim Universitesi, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Fcaulty of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Karen Costenbader
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sindhu R Johnson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada .,Department of Medicine, Division of Rheumatology, Toronto Western Hospital, Toronto, Ontario, Canada
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2
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Johnson SR, Brinks R, Costenbader KH, Daikh D, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger WB, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Aringer M. Performance of the 2019 EULAR/ACR classification criteria for systemic lupus erythematosus in early disease, across sexes and ethnicities. Ann Rheum Dis 2020; 79:1333-1339. [PMID: 32816709 DOI: 10.1136/annrheumdis-2020-217162] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 Classification Criteria for systemic lupus erythematosus (SLE) have been validated with high sensitivity and specificity. We evaluated the performance of the new criteria with regard to disease duration, sex and race/ethnicity, and compared its performance against the Systemic Lupus International Collaborating Clinics (SLICC) 2012 and ACR 1982/1997 criteria. METHODS Twenty-one SLE centres from 16 countries submitted SLE cases and mimicking controls to form the validation cohort. The sensitivity and specificity of the EULAR/ACR 2019, SLICC 2012 and ACR 1982/1997 criteria were evaluated. RESULTS The cohort consisted of female (n=1098), male (n=172), Asian (n=118), black (n=68), Hispanic (n=124) and white (n=941) patients; with an SLE duration of 1 to <3 years (n=196) and ≥5 years (n=879). Among patients with 1 to <3 years disease duration, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 81%). The EULAR/ACR criteria performed well in men (sensitivity 93%, specificity 96%) and women (sensitivity 97%, specificity 94%). Among women, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 83%) and better specificity than the SLICC criteria (94% vs 82%). Among white patients, the EULAR/ACR criteria had better sensitivity than the ACR criteria (95% vs 83%) and better specificity than the SLICC criteria (94% vs 83%). The EULAR/ACR criteria performed well among black patients (sensitivity of 98%, specificity 100%), and had better sensitivity than the ACR criteria among Hispanic patients (100% vs 86%) and Asian patients (97% vs 77%). CONCLUSIONS The EULAR/ACR 2019 criteria perform well among patients with early disease, men, women, white, black, Hispanic and Asian patients. These criteria have superior sensitivity than the ACR criteria and/or superior specificity than the SLICC criteria across many subgroups.
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Affiliation(s)
- Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaulation, University of Toronto, Toronto, Ontario, Canada
| | - Ralph Brinks
- Policlinic and Hiller Research Unit of Rheumatology, Heinrich-Heine-University Duesseldorf, Düsseldorf, Germany
| | - Karen H Costenbader
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Rheumatology, Harvard Medical School, Boston, Massachusetts, USA
| | - David Daikh
- Medicine/Rheumatology, UCSF Medical Center, San Francisco, California, USA
| | - Marta Mosca
- Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Medicine/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Vienna, Austria
| | - David Wofsy
- Division of Rheumatology, , Russell/Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, California, USA
| | - Dimitrios T Boumpas
- Medicine, National and Kapodestrian University of Athens, and Biomedical Research Foundation of the Athens Academy, Athens, Greece.,Rheumatology, University of Cyprus Medical School, Nicosia, Nicosia, Cyprus
| | - Diane L Kamen
- Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Medicine, University of Cambridge, Cambridge, UK
| | - R Cervera
- Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine, Hospital Cochin, Paris, Île-de-France, France.,INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Betty Diamond
- Autoimmune and Musculoskeletal, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Medicine, University of Toronto, Toronto, Ontario, Canada.,Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Bevra Hahn
- Rheumatology, UCLA School of Medicine, Los Angeles, California, USA
| | - Falk Hiepe
- Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Department of Rheumatology, Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Rheumatology, Harvard Medical School, Boston, Massachusetts, USA.,Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | - Jorge Sanchez-Guerrero
- Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada.,Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty,Heinrich-Heine-University, Düsseldorf, Germany
| | - Murray Urowitz
- Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Crete, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Rheumatology and Clinical Immunology, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Rheumatology, Azienda Ospedaliero Universitaria Pisana, Pisa, Toscana, Italy.,Rheumatology, University of Pisa, Pisa, Toscana, Italy
| | - Sara K Tedeschi
- Rheumatology, Harvard Medical School, Boston, Massachusetts, USA.,Medicine, Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gabriela Schmajuk
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, San Francisco, California, USA
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Ann Elaine Clarke
- Rheumatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Rheumatology, NIAMS, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Rheumatology, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR, Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Íñigo Rúa-Figueroa
- Rheumatology, Dr Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Raphaèle Seror
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athinon, Greece
| | | | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D J Wallace
- Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Rheumatology, Istanbul Bilim Universitesi, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ray Naden
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Aringer
- Rheumatology, University Medical Center and Faculty of Medicine Carl Gustav Carus, Dresden, Germany
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3
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Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Fernández Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Johnson SR. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol 2019; 71:1400-1412. [PMID: 31385462 DOI: 10.1002/art.40930] [Citation(s) in RCA: 913] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 05/01/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop new classification criteria for systemic lupus erythematosus (SLE) jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS This international initiative had four phases. 1) Evaluation of antinuclear antibody (ANA) as an entry criterion through systematic review and meta-regression of the literature and criteria generation through an international Delphi exercise, an early patient cohort, and a patient survey. 2) Criteria reduction by Delphi and nominal group technique exercises. 3) Criteria definition and weighting based on criterion performance and on results of a multi-criteria decision analysis. 4) Refinement of weights and threshold scores in a new derivation cohort of 1,001 subjects and validation compared with previous criteria in a new validation cohort of 1,270 subjects. RESULTS The 2019 EULAR/ACR classification criteria for SLE include positive ANA at least once as obligatory entry criterion; followed by additive weighted criteria grouped in 7 clinical (constitutional, hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and 3 immunologic (antiphospholipid antibodies, complement proteins, SLE-specific antibodies) domains, and weighted from 2 to 10. Patients accumulating ≥10 points are classified. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%, compared with 82.8% sensitivity and 93.4% specificity of the ACR 1997 and 96.7% sensitivity and 83.7% specificity of the Systemic Lupus International Collaborating Clinics 2012 criteria. CONCLUSION These new classification criteria were developed using rigorous methodology with multidisciplinary and international input, and have excellent sensitivity and specificity. Use of ANA entry criterion, hierarchically clustered, and weighted criteria reflects current thinking about SLE and provides an improved foundation for SLE research.
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Affiliation(s)
- Martin Aringer
- University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Karen Costenbader
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Daikh
- VA Medical Center and University of California, San Francisco
| | - Ralph Brinks
- Heinrich Heine University Dusseldorf, Dusseldorf, Germany
| | | | | | | | | | - Dimitrios T Boumpas
- National and Kapodestrian University of Athens Medical School and Biomedical Research Foundation of the Academy of Athens, Athens, Greece, and University of Cyprus Medical School, Nicosia, Cyprus
| | | | | | - Ricard Cervera
- Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, New York
| | - Dafna D Gladman
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Falk Hiepe
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Elena Massarotti
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jorge Sanchez-Guerrero
- Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada, and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Murray Urowitz
- Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | - George Bertsias
- University of Crete Medical School, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany, and University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zahi Touma
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Branimir Anic
- University of Zagreb School of Medicine and University Hospital Center Zagreb, Zagreb, Croatia
| | - Florence Assan
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM 1184, Le Kremlin-Bicêtre, France
| | | | - Ann Elaine Clarke
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Sarfaraz Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | - Michelle Jung
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Xavier Mariette
- AP-HP, Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, and Université Paris-Sud, INSERM UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- University of Zagreb School of Medicine and University Hospital Center Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Raphaèle Seror
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Edward M Vital
- University of Leeds, NIHR Leeds Biomedical Research Center, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Sule Yavuz
- Istanbul Bilim University, Istanbul, Turkey
| | | | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- McMaster University, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sindhu R Johnson
- Toronto Western Hospital, University Health Network, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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4
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Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Fernández Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Johnson SR. 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Ann Rheum Dis 2019; 78:1151-1159. [PMID: 31383717 DOI: 10.1136/annrheumdis-2018-214819] [Citation(s) in RCA: 619] [Impact Index Per Article: 123.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 04/27/2019] [Accepted: 05/01/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To develop new classification criteria for systemic lupus erythematosus (SLE) jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS This international initiative had four phases. (1) Evaluation of antinuclear antibody (ANA) as an entry criterion through systematic review and meta-regression of the literature and criteria generation through an international Delphi exercise, an early patient cohort and a patient survey. (2) Criteria reduction by Delphi and nominal group technique exercises. (3) Criteria definition and weighting based on criterion performance and on results of a multi-criteria decision analysis. (4) Refinement of weights and threshold scores in a new derivation cohort of 1001 subjects and validation compared with previous criteria in a new validation cohort of 1270 subjects. RESULTS The 2019 EULAR/ACR classification criteria for SLE include positive ANA at least once as obligatory entry criterion; followed by additive weighted criteria grouped in seven clinical (constitutional, haematological, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and three immunological (antiphospholipid antibodies, complement proteins, SLE-specific antibodies) domains, and weighted from 2 to 10. Patients accumulating ≥10 points are classified. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%, compared with 82.8% sensitivity and 93.4% specificity of the ACR 1997 and 96.7% sensitivity and 83.7% specificity of the Systemic Lupus International Collaborating Clinics 2012 criteria. CONCLUSION These new classification criteria were developed using rigorous methodology with multidisciplinary and international input, and have excellent sensitivity and specificity. Use of ANA entry criterion, hierarchically clustered and weighted criteria reflect current thinking about SLE and provide an improved foundation for SLE research.
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Affiliation(s)
- Martin Aringer
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Karen Costenbader
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Daikh
- University of California at San Francisco and VA Medical Center, San Francisco, California, USA
| | - Ralph Brinks
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef S Smolen
- Department of Rheumatology, Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Wofsy
- Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California at San Francisco, San Francisco, California, USA
| | - Dimitrios T Boumpas
- Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, and Biomedical Research Foundation of the Athens Academy, Athens, Greece.,Departments of Internal Medicine and Rheumatology, Clinical Immunology and Allergy, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Diane L Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Medicine, Toronto Western Hospital, University Health Network, Mount Sinai Hospital, University of Toronto, Toronto Scleroderma Research Program, Toronto, Ontario, Canada
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bevra Hahn
- Division of Rheumatology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Falk Hiepe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Bizkaia, The Basque Country, Spain
| | - Jorge Sanchez-Guerrero
- Division of Rheumatology, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Medicine III, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Department of Clinical and Experimental Medicine, Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gabriela Schmajuk
- University of California at San Francisco and VA Medical Center, San Francisco, California, USA
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- Department of Rheumatology, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Ann Elaine Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Hospital for Special Surgery, Ney York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Lupus Clinical Research Program, Office of the Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Department of Rheumatology, Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Department of Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Raphaèle Seror
- Department of Rheumatology, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto, ICBAS, University of Porto, Porto, Portugal
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Faculty of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- Maternal-Fetal Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sindhu R Johnson
- Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île deFrance, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité, INSERM U1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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5
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Leiss H, Salzberger W, Jacobs B, Gessl I, Kozakowski N, Blüml S, Puchner A, Kiss A, Podesser BK, Smolen JS, Stummvoll GH. MicroRNA 155-deficiency leads to decreased autoantibody levels and reduced severity of nephritis and pneumonitis in pristane-induced lupus. PLoS One 2017; 12:e0181015. [PMID: 28719617 PMCID: PMC5515414 DOI: 10.1371/journal.pone.0181015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/23/2017] [Indexed: 01/13/2023] Open
Abstract
Objective We herein examine the role of endogenous miR155 in the development of systemic manifestations in pristane induced lupus. Materials and methods Systemic lupus in miR155-deficient and wild type mice was induced upon injection of pristane and analyzed after 8 months, PBS-injected mice served as controls. Glomerulonephritis and pneumonitis were quantified using the kidney biopsy score and a newly adapted histomorphometric image analysis system; lung tissue was further analyzed by tissue cytometry. Serum levels of anti-dsDNA, anti-histone and anti-chromatin antibodies were measured by ELISA. Frequencies of B cells, activated and regulatory CD4+ T cells as well as Th1, Th2, Th17 cells were measured by flow cytometry. RT-qPCR was used to measure expression levels of interferon-signature and T-cell subset related as well as miR155-associated genes. Results After induction of lupus, miR155-deficient mice had significant less pulmonary involvement (perivascular inflammatory area in mm2/mm2 lung area 0.00092±0.00015 vs. 0.0027±0.00075, p = 0.0347) and renal disease (glomerular activity score 1.95±0.19 vs 3±0.26, p = 0.0029) compared to wild types. MiR155-deficient mice had significantly lower serum levels of disease-associated auto-antibodies and decreased frequencies of activated CD4+CD25+ (Foxp3-) cells. Upon restimulation, CD4+ cells showed a less pronounced Th2 and Th17 and a slightly decreased Th1 response in mir155-deficient mice. Pristane-treated wild types showed significantly up-regulated expression of genes related to the INF-signature (MX1, IP10, IRF7, ISG15). Conclusions MiR155-deficient mice had less severe organ involvement, lower serum auto-antibody levels, a less prominent T cell response and lower expressions of genes jointly responsible for disease development. Thus, antagonizing miR155 might be a future approach in treating SLE.
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Affiliation(s)
- Harald Leiss
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Wilhelm Salzberger
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Barbara Jacobs
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Irina Gessl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | - Stephan Blüml
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Antonia Puchner
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Bruno K. Podesser
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Josef S. Smolen
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Georg H. Stummvoll
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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6
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Hadaschik EN, Wei X, Leiss H, Heckmann B, Niederreiter B, Steiner G, Ulrich W, Enk AH, Smolen JS, Stummvoll GH. Regulatory T cell-deficient scurfy mice develop systemic autoimmune features resembling lupus-like disease. Arthritis Res Ther 2015; 17:35. [PMID: 25890083 PMCID: PMC4391674 DOI: 10.1186/s13075-015-0538-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/23/2015] [Indexed: 01/18/2023] Open
Abstract
Introduction Scurfy mice are deficient in regulatory T cells (Tregs), develop a severe, generalized autoimmune disorder that can affect almost every organ and die at an early age. Some of these manifestations resemble those found in systemic lupus erythematosus (SLE). In addition, active SLE is associated with low Treg numbers and reduced Treg function, but direct evidence for a central role of Treg malfunction in the pathophysiology of lupus-like manifestations is still missing. In the present study, we characterize the multiorgan pathology, autoantibody profile and blood count abnormalities in scurfy mice and show their close resemblances to lupus-like disease. Methods Scurfy mice have dysfunctional Tregs due to a genetic defect in the transcription factor Forkhead box protein 3 (Foxp3). We analyzed skin, joints, lung and kidneys of scurfy mice and wild-type (WT) controls by conventional histology and immunofluorescence (IF) performed hematological workups and tested for autoantibodies by IF, immunoblotting and enzyme-linked immunosorbent assay. We also analyzed the intestines, liver, spleen and heart, but did not analyze all organs known to be affected in scurfy mice (such as the testicle, the accessory reproductive structures, the pancreas or the eyes). We transferred CD4+ T cells of scurfy or WT mice into T cell-deficient B6/nude mice. Results We confirm previous reports that scurfy mice spontaneously develop severe pneumonitis and hematological abnormalities similar to those in SLE. We show that scurfy mice (but not controls) exhibited additional features of SLE: severe interface dermatitis, arthritis, mesangioproliferative glomerulonephritis and high titers of anti-nuclear antibodies, anti-double-stranded DNA antibodies, anti-histone antibodies and anti-Smith antibodies. Transfer of scurfy CD4+ T cells (but not of WT cells) induced autoantibodies and inflammation of lung, skin and kidneys in T cell-deficient B6/nude mice. Conclusion Our observations support the hypothesis that lupus-like autoimmune features develop in the absence of functional Tregs.
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Affiliation(s)
- Eva N Hadaschik
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Xiaoying Wei
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany. .,Department of Pathology, Affiliated Zhong-Da Hospital, Southeast University, 87 Dingjia Bridge, Gulou, 210009, Nanjing, China.
| | - Harald Leiss
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Britta Heckmann
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Birgit Niederreiter
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Günter Steiner
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Walter Ulrich
- Department of Pathology, Hietzing Hospital, Wolkersbergenstrasse 1, 1130, Vienna, Austria.
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Josef S Smolen
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Georg H Stummvoll
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
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Leiss H, Schwarzecker B, Gessl I, Niederreiter B, Smolen JS, Stummvoll GH. A3.10 Characterisation of CD4 +T cell response and effects of regulatory T cells in pristane induced lupus (PIL). Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2013-205124.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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8
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Leiss H, Niederreiter B, Bandur T, Schwarzecker B, Blüml S, Steiner G, Ulrich W, Smolen JS, Stummvoll GH. Pristane-induced lupus as a model of human lupus arthritis: evolvement of autoantibodies, internal organ and joint inflammation. Lupus 2014; 22:778-92. [PMID: 23817510 DOI: 10.1177/0961203313492869] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Arthritis is frequently seen in human lupus, but rarely in lupus models. Pristane-induced lupus (PIL) can be induced in various mouse strains such as BALB/c and C57BL/6. We herein characterize clinical and histological features of arthritis in the context of systemic lupus and provide a prudent comparison with models of rheumatoid arthritis (RA). METHODS A total of 57 BALB/c mice received pristane (PIL group) and were analyzed for serum autoantibodies (anti-chromatin-, -histone, -Sm, -dsDNA), as well as for clinical features and histopathology of joints, lungs and kidneys. Joint pathology was quantified by image analysis and tissue cytometry. Ten C57BL/6 mice (Bl/6-PIL) and historical groups of two different RA models were analyzed accordingly. RESULTS In BALB/c PIL, clinical arthritis started at three months, occurred finally in 79% of PIL (but not in controls, p<0.001) and correlated with areas of inflammation, erosion, cartilage damage, osteoclast numbers and total severity score (for all: r>0.7, p<0.001). After eight months, 58% of PIL (but no controls, p<0.001) had mild-erosive arthritis. In contrast to RA, the most frequent inflammatory cell type of the pannus was granulocytes (17.7%), PIL had lower numbers of osteoclasts, erosions rarely affected both layers of the cortical bone and there was no progression to complete joint destruction (even after one year of observation). Serum autoantibodies (auto-abs) preceded arthritis and became significantly elevated in all PIL; affected joints showed increased deposits of IgG (and IgM) within the inflammatory tissue, indicative of an ab-mediated process. PIL mice with arthritis also showed signs of pulmonary (100%) and renal (46%) lupus. In contrast to BALB/c, Bl/6-PIL mice did not develop any signs of arthritis. CONCLUSION PIL in BALB/c mice is characterized by severe organ involvement, typical autoabs and by a mild-erosive arthritis with similarities to, but also with distinct differences from, RA. PIL may help to study arthritis along with other key features of systemic lupus erythematosus after therapeutic interventions or in knock-out models based on a BALB/c but not on a C57BL/6 background.
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Affiliation(s)
- H Leiss
- Department of Rheumatology, Medical University of Vienna, Austria
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9
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Baerlecken NT, Nothdorft S, Stummvoll GH, Sieper J, Rudwaleit M, Reuter S, Matthias T, Schmidt RE, Witte T. Autoantibodies against CD74 in spondyloarthritis. Ann Rheum Dis 2013; 73:1211-4. [DOI: 10.1136/annrheumdis-2012-202208] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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10
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Abstract
Immunoadsorption (IAS) is used as a rescue therapy in severely ill SLE patients who are refractory to conventional therapies. This extracorporeal method aims at the rapid and extensive removal of pathogenic immunocomplexes (ICs) and (auto-)antibodies (Abs). Although past data have shown short- to mid-term efficacy and biocompatibility of IAS in (renal) SLE, it is still an experimental and rather expensive procedure – and evidence from randomized controlled trials (RCTs) is lacking. Nevertheless, IAS is successfully used in life-threatening situations because of its fast mode of action and its acceptable safety profile.
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Affiliation(s)
- GH Stummvoll
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Austria
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11
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Huter EN, Stummvoll GH, DiPaolo RJ, Glass DD, Shevach EM. Pre-differentiated Th1 and Th17 effector T cells in autoimmune gastritis: Ag-specific regulatory T cells are more potent suppressors than polyclonal regulatory T cells. Int Immunopharmacol 2009; 9:540-5. [PMID: 19539565 DOI: 10.1016/j.intimp.2009.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 01/22/2009] [Accepted: 01/22/2009] [Indexed: 12/25/2022]
Abstract
Naïve antigen-specific CD4(+) T cells (TxA23) induce autoimmune gastritis when transferred into BALB/c nu/nu mice. Transfer of in vitro pre-differentiated Th1 or Th17 TxA23 effector T cells into BALB/c nu/nu recipients induces distinct histological patterns of disease. We have previously shown that co-transfer of polyclonal naturally occurring Treg (nTreg) suppressed development of Th1-, but not Th17-mediated disease. Therefore, we analysed the suppressive capacity of different types of Treg to suppress Th1- and Th17-mediated autoimmune gastritis. We compared nTreg with polyclonal TGFbeta-induced WT Treg (iTreg) or TGFbeta-induced antigen-specific TxA23 iTreg in co-transfer experiments with Th1 or Th17 TxA23 effector T cells. 6 weeks after transfer in vitro pre-differentiated TxA23 Th1 and Th17 effector cells induced destructive gastritis. Th1-mediated disease was prevented by co-transfer of nTreg and also antigen-specific iTreg, whereas WT iTreg did not show an effect. However, Th17-mediated disease was only suppressed by antigen-specific iTreg. Pre-activation of nTreg in vitro prior to transfer did not increase their suppressive activity in Th17-mediated gastritis. Thus, antigen-specific iTreg are potent suppressors of autoimmune gastritis induced by both, fully differentiated Th1 and Th17 effector cells.
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Affiliation(s)
- Eva N Huter
- Laboratory of Immunology, Cellular Immunology Section, NIAID, NIH, Bethesda, MD, USA
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Huter EN, Stummvoll GH, DiPaolo RJ, Glass DD, Shevach EM. Cutting edge: antigen-specific TGF beta-induced regulatory T cells suppress Th17-mediated autoimmune disease. J Immunol 2009; 181:8209-13. [PMID: 19050237 DOI: 10.4049/jimmunol.181.12.8209] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CD4(+) T cells from the TCR transgenic TxA23 mouse recognize a peptide from the H/K-ATPase alpha-chain. When TxA23 CD4(+) thymocytes are differentiated into Th1, Th2, and Th17 lines, all three subpopulations induced autoimmune gastritis (AIG) upon transfer into nu/nu recipients. The induction of AIG by naive T cells or by Th1 or Th2 cell lines could be prevented by the cotransfer of polyclonal Foxp3(+) T regulatory cells (nTreg), whereas Th17-induced AIG was resistant to suppression. We compared the capacity of different types of Treg to suppress Th17-mediated AIG. Cotransfer of either nTreg or polyclonal TGFbeta-induced Treg (iTreg) did not prevent AIG, while cotransfer of TGFbeta-induced Ag-specific TxA23 iTreg completely prevented the development of disease. Ag-specific iTreg were able to suppress Th17-mediated disease when injected 6 days after the Th17 effectors. The implications of these results for the use of Treg for the cellular biotherapy of autoimmune disease are discussed.
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Affiliation(s)
- Eva N Huter
- Laboratory of Immunology, Cellular Immunology Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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13
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Stummvoll GH, DiPaolo RJ, Huter EN, Davidson TS, Glass D, Ward JM, Shevach EM. Th1, Th2, and Th17 effector T cell-induced autoimmune gastritis differs in pathological pattern and in susceptibility to suppression by regulatory T cells. J Immunol 2008; 181:1908-16. [PMID: 18641328 DOI: 10.4049/jimmunol.181.3.1908] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Th cells can be subdivided into IFN-gamma-secreting Th1, IL-4/IL-5-secreting Th2, and IL-17-secreting Th17 cells. We have evaluated the capacity of fully differentiated Th1, Th2, and Th17 cells derived from a mouse bearing a transgenic TCR specific for the gastric parietal cell antigen, H(+)K(+)-ATPase, to induce autoimmune gastritis after transfer to immunodeficient recipients. We have also determined the susceptibility of the disease induced by each of the effector T cell types to suppression by polyclonal regulatory T cells (Treg) in vivo. Each type of effector cell induced autoimmune gastritis with distinct histological patterns. Th17 cells induced the most destructive disease with cellular infiltrates composed primarily of eosinophils accompanied by high levels of serum IgE. Polyclonal Treg could suppress the capacity of Th1 cells, could moderately suppress Th2 cells, but could suppress Th17-induced disease only at early time points. The major effect of the Treg was to inhibit the expansion of the effector T cells. However, effector cells isolated from protected animals were not anergic and were fully competent to proliferate and produce effector cytokines ex vivo. The strong inhibitory effect of polyclonal Treg on the capacity of some types of differentiated effector cells to induce disease provides an experimental basis for the clinical use of polyclonal Treg in the treatment of autoimmune disease in humans.
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Affiliation(s)
- Georg H Stummvoll
- Laboratory of Immunology, Cellular Immunology Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Stummvoll GH, Fritsch RD, Meyer B, Hoefler E, Aringer M, Smolen JS, Steiner G. Characterisation of cellular and humoral autoimmune responses to histone H1 and core histones in human systemic lupus erythaematosus. Ann Rheum Dis 2008; 68:110-6. [DOI: 10.1136/ard.2007.082032] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective:To address key aspects of anti-histone autoimmunity in systemic lupus erythaematosus (SLE), we performed a detailed characterisation of cellular and humoral autoreactivity to histone H1 and the four core histones H2A, H2B, H3, H4 in patients with SLE and healthy controls.Methods:Peripheral blood mononuclear cells of 41 patients with SLE and 28 healthy controls were exposed to individual histones and proliferation was measured by [3H]-thymidine incorporation. H1-reactive T cell clones were obtained by limiting dilution. Cytokines and total IgG in culture supernatants was measured by ELISA, and autoantibodies to histones were determined by ELISA and immunoblotting.Results:Proliferative responses to H1 were more frequent and more pronounced in cell cultures from patients with SLE (p<0.002), while among the core histones only the response to H2A was increased in patient cultures (p<0.01). All histones elicited a Th1-like cytokine response in patients and controls (high interferon (IFN)γ and tumour necrosis factor (TNF)α, no interleukin (IL)4) with H1 inducing the highest levels of TNFα. However, H1 stimulated production of IgG and anti-histone antibodies only in cell cultures derived from patients with SLE. H1-specific T cell clones from patients and controls showed a CD4+CD28+ phenotype and a Th1 cytokine profile. Anti-histone antibodies were detected in 51% of patients with SLE, were primarily directed to H1, H3 and H4, and predominantly of the IgG2 subtype.Conclusions:Histone H1 constitutes a major B cell and T cell autoantigen in SLE, triggering a proinflammatory Th1 response and driving autoantibody production. This suggests that histone H1 may be of considerable relevance for the pathogenesis of SLE.
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Feierl E, Smolen JS, Karonitsch T, Stummvoll GH, Ekhart H, Steiner CW, Aringer M. Engulfed cell remnants, and not cells undergoing apoptosis, constitute the LE-cell phenomenon. Autoimmunity 2007; 40:315-21. [PMID: 17516218 DOI: 10.1080/08916930701356416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The LE cell has been one of the first immunological signs of active systemic lupus erythematosus, included into the ACR criteria. LE cells consist of a phagocyte engulfing material of disputed origin, which was interpreted as either cellular remnants from necrotic cells or as early apoptotic cells. It is well established that LE cell formation is dependent on autoantibodies against the linker histone H1. In view of this fact, we investigated whether anti-histone H1 antibodies and LE cell positive sera bound to cells where apoptosis had been induced by gliotoxin or actinomycin D or which were necrotic after heating. Necrotic cell remnants, but not (early) apoptotic cells were bound by anti-histone H1 antibodies and LE cell positive sera, establishing that the process of LE cell formation, which is dependent on anti-H1 binding, leads to engulfment of necrotic (or late apoptotic) material, but not of early apoptotic cells.
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Affiliation(s)
- Eva Feierl
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Vienna, Austria
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16
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Stummvoll GH, Aringer M, Smolen JS, Schmaldienst S, Jiménez-Boj E, Hörl WH, Graninger WB, Derfler K. IgG immunoadsorption reduces systemic lupus erythematosus activity and proteinuria: a long term observational study. Ann Rheum Dis 2005; 64:1015-21. [PMID: 15640267 PMCID: PMC1755551 DOI: 10.1136/ard.2004.029660] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To analyse the effects of rigorous immunoglobulin removal by immunoadsorption (IAS) on proteinuria (primary outcome variable), disease activity (SIS, SLEDAI, ECLAM), and autoantibodies to double stranded DNA (anti-dsDNA) in active systemic lupus erythematosus (SLE). METHODS 16 patients with severe SLE and renal disease, in whom cyclophosphamide was contraindicated or failed to halt disease progression, were treated with IAS for 3 months. Patients achieving at least 20% improvement in two or more of the outcome measures were considered responders and offered a 9 months' extension period. RESULTS Within 3 months, 14 patients responded and 11 opted for an extension. Proteinuria decreased from 6.7 (4.6) g/day (mean (SD)) at baseline to 4.3 (3.5) g/day at 3 months and 2.9 (2.4) g/day at 12 months (p<0.001). From baseline to 3 and 12 months, disease activity improved independently of scoring by SIS (15 (5) to 5 (2) and to 5 (2), p<0.0001), SLEDAI (21 (7) to 5 (4) and to 5 (4), p<0.0001), or ECLAM (7 (2) to 2 (1) and to 3 (1), p<0.0001). Anti-dsDNA fell from 391 (647) IU/ml to 146 (218) and to 53 (50) IU/ml at 3 and 12 months, respectively. Steroids could be tapered from 117 (159) mg/day at baseline to 29 (17) mg/day at 3 months and 9 (2) mg/day at 12 months. IAS was not associated with an excess of infections. However, one patient died of septicaemia after 1 month of treatment. CONCLUSION In this negatively selected cohort of patients with SLE, IAS was associated with a significant response shown by reduced proteinuria, improved global disease activity, decreased anti-dsDNA, and lower glucocorticoid dosages, suggesting therapeutic benefit.
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Affiliation(s)
- G H Stummvoll
- Department of Rheumatology, Internal Medicine III, University of Vienna, Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Stummvoll GH, Fritsch R, Meyer B, Aringer M, Smolen JS, Steiner G. Autoreactive T cells to histone H1 and core histones in patients with systemic lupus erythematosus. Arthritis Res Ther 2005. [PMCID: PMC2834137 DOI: 10.1186/ar1659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- GH Stummvoll
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
| | - R Fritsch
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
| | - B Meyer
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
| | - M Aringer
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
| | - JS Smolen
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
| | - G Steiner
- Department of Rheumatology, Internal Medicine III, Medical University of Vienna, Austria
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Grisar J, Aringer M, Köller MD, Stummvoll GH, Eselböck D, Zwölfer B, Steiner CW, Zierhut B, Wagner L, Pietschmann P, Smolen JS. Leflunomide inhibits transendothelial migration of peripheral blood mononuclear cells. Ann Rheum Dis 2004; 63:1632-7. [PMID: 15547088 PMCID: PMC1754829 DOI: 10.1136/ard.2003.018440] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To test whether the active metabolite of leflunomide (LEF-M), in addition to blocking the proliferation of activated lymphocytes by inhibiting dihydro-orotate dehydrogenase (DHODH), influences the transendothelial migration (TEM) of peripheral blood mononuclear cells (PBMC). METHODS In an in vitro model of PBMC transmigration through an endothelial cell (EC) barrier, PBMC were re-collected in three groups: cells not adherent to the EC, cells bound to, and cells which had migrated through, the EC layer. Experiments in which cells were pretreated with LEF-M (in the absence or in the presence of uridine) were compared with parallel experiments in the presence of medium alone. RESULTS Preincubation of EC with LEF-M led to a 36 (SEM 16)% reduction in PBMC TEM (p<0.05). Likewise, preincubation of PBMC induced a reduction in their TEM of 39 (9)% (p<0.005). Incubation of both PBMC and EC with LEF-M had an additive effect (mean reduction of 48 (6)%, p<0.005). Incubation of PBMC with LEF-M also decreased monocytic CD44 expression (p<0.005) and PBMC-hyaluronan binding (p<0.05). Incubation of cells with LEF-M and uridine in addition to LEF-M reversed the inhibition of migration, suggesting that the observed effects were due to DHODH inhibition. Fluorocytometric analysis of PBMC subsets within the migrated population showed a decrease of monocytes, but not of B or T cells, after LEF-M treatment. CONCLUSIONS LEF-M reduces monocytic adhesion molecule expression and TEM and may thus interfere with monocyte and EC activities in RA. Thus, the clinical effects of leflunomide may, at least in part, be due to blocking cell traffic into the inflamed synovia.
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Affiliation(s)
- J Grisar
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Stummvoll GH, Aringer M, Jansen M, Smolen JS, Derfler K, Graninger WB. Immunoadsorption as a rescue therapy in systemic lupus erythematosus: considerations on safety and efficacy. Wien Klin Wochenschr 2004; 116:716-24. [PMID: 15628641 DOI: 10.1007/s00508-004-0232-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In SLE, extracorporeal procedures aiming at reduction of immunoglobulin (Ig) and immune complexes (IC) are used as a rescue therapy. Plasma exchange (PE) has not been proven overall effective in SLE, and long-term treatment in particular has been associated with severe bacterial and viral infections. Immunoadsorption (IAS), in contrast, selectively removes Ig and IC and may thus be safer. We therefore investigated the rate of infections in SLE patients who were undergoing long-term IAS. METHODS 16 SLE patients were treated with > or = 10 courses of IAS, and nine patients with highly active disease received pulse cyclophosphamide (IVCP) therapy in parallel. We retrospectively analysed the records of all these patients for the occurrence of infections. Patients receiving IAS therapy plus IVCP were compared with 25 patients with similarly active disease treated with standard IVCP therapy within the same observation period. Patients receiving IAS without additional IVCP were compared with patients with similarly moderate disease activity receiving neither IAS nor IVCP. RESULTS No potentially life-threatening viral infection occurred in IAS-treated patients and episodes of herpes zoster were equally distributed. No severe infection was observed during IAS without concomittant cyclophosphamide. As expected, more patients with highly active disease receiving IVCP experienced infections than those with less active disease (16 of 34 [47%] vs. 2 of 22 [9%], p < 0.04). On comparing the two groups with highly active disease, infections were similar (IAS+IVCP: 3 of 9 patients [33%], IVCP only: 5 of 25 [20%]), but one patient receiving IAS+IVCP died of septicaemia. Disease activity significantly decreased in both groups treated with IAS. CONCLUSION IAS has an acceptable safety profile with regard to severe infections and appears safe with regard to severe viral disease. Highly active disease and IVCP therapy increase the risk of severe infections in SLE.
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Affiliation(s)
- Georg H Stummvoll
- Deptartment of Rheumatology, University of Vienna, Vienna General Hospital, Vienna, Austria.
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Abstract
BACKGROUND CD4+ T lymphocytes play an important part in the pathogenesis of scleroderma (systemic sclerosis, SSc) and predominate in perivascular SSc skin lesions. Both soluble and membrane bound adhesion molecules are overexpressed in SSc, possibly influencing lymphocyte/endothelial cell (EC) contact. OBJECTIVE To assess the transendothelial migration capacity of peripheral lymphocytes in vitro. PATIENTS AND METHODS Collagen was covered with human umbilical vein endothelial cells (HUVEC), and peripheral blood mononuclear cells (PBMC) of patients and matched healthy controls (HC) were added in parallel experiments. Before and after fractionated harvest of non-adherent, bound, and migrated lymphocytes, the CD4/CD8 ratio and the lymphocytic expression of activation markers and adhesion molecules were analysed by fluorocytometry. RESULTS 13 (SD 12)% of the SSc PBMC migrated compared with only 5 (5)% HC PBMC (p<0.0002); this increase was primarily due to the migration of CD3+ T lymphocytes and mainly to a larger proportion of CD4+ cells within this CD3+ fraction (71 (SD 14)% for SSc v 56 (14)% for HC, p<0.03), leading to an increased CD4/CD8 ratio among migrated SSc lymphocytes in comparison with controls (3.3 (1.5) v 1.62 (0.93), p<0.006). Among migrated SSc CD4+ T lymphocytes, the frequency of HLA-DR+ cells was increased; migrated lymphocytes highly expressed the adhesion molecules CD11a, CD49d, CD29, and CD44. CONCLUSION Transendothelial migration of CD4+ T lymphocytes is enhanced in SSc, and migrating cells exhibit an activated phenotype. The data suggest that activated CD3+CD4+ lymphocytes as found in SSc peripheral blood are prone to transvascular migration, thus contributing to the formation of typical perivascular lymphocytic infiltrates.
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Affiliation(s)
- G H Stummvoll
- Department of Rheumatology, Internal Medicine III, Unviersity of Vienna, Vienna, Austria
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Aringer M, Feierl E, Steiner G, Stummvoll GH, Höfler E, Steiner CW, Radda I, Smole JS, Graninger WB. Increased bioactive TNF in human systemic lupus erythematosus: associations with cell death. Lupus 2002; 11:102-8. [PMID: 11958572 DOI: 10.1191/0961203302lu160oa] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In systemic lupus erythematosus (SLE) serum TNF is increased and correlates with its soluble receptors and with disease activity. We therefore investigated (i) whether the TNF in SLE serum is bioactive, (ii) whether SLE cells react to TNF and (iii) whether there are associations with cell death, which is regarded as pathogenic in SLE. Sera from active SLE patients induced an increase in fibroblast CD54, which was abolished by blocking antibodies against TNF, suggesting TNF bioactivity. SLE lymphocytes had a similar surface expression of TNF-RI as healthy lymphocytes, their expression of TNF-RII was slightly increased. Recombinant TNF induced cell death in PBMC of SLE patients, suggesting functional receptors. Serum levels of sTNF-RII (as a surrogate marker for TNF activity) correlated with sTNF-RI and disease activity, as expected, and also correlated with the percentage of dying lymphocytes and with lymphocytic CD95. SLE sera contain increased amounts of biologically active TNF. Peripheral blood lymphocytes of SLE patients express functional TNF receptors. Finally, associations with cell death and CD95 receptors suggest that TNF may be pathogenic in SLE.
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Affiliation(s)
- M Aringer
- Department of Rheumatology, Internal Medicine II, University of Vienna, Austria.
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Abstract
Systemic Sclerosis (SSc) or Scleroderma is a generalized autoimmune disease with variable involvement of the skin and major organs. Etiology and pathogenesis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena can be observed, and a pivotal role of T lymphocytes in SSc pathogenesis is postulated. The rarity of the disease, the wide spectrum of clinical manifestations and severity as well as a variable course render therapy in SSc a major challenge. In view of the immunopathogenesis of SSc, many (presumed) immunomodulatory agents have been used, but no single agent has been proven to be convincingly effective. Trials with extracorporeal therapies (such as photopheresis, plasmapheresis) or even stem cell transplantation are in progress. In contrast to the hitherto unsuccessful therapeutic approaches for the overall disease course, some life-threatening organ manifestations can often be treated successfully, e.g. interstitial pneumonitis with i.v. cyclophosphamide and scleroderma renal crisis with ACE inhibitors and haemodialysis, respectively. Furthermore, pharmacological and supportive treatment of Raynaud's phenomenon and gastrointestinal involvement can alleviate the burden of the disease. Current therapeutic options as well as hitherto investigated immunomodulators are reviewed in this article.
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Affiliation(s)
- G H Stummvoll
- Division of Rheumatology, Department of Internal Medicine III, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna.
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Abstract
Malignancy-associated musculoskeletal syndromes can present in a variety of ways which are not distinguishable from idiopathic rheumatic diseases. Furthermore, there are some rare, but typical syndromes with a high association with neoplasms. To perform a quick and exact diagnosis while avoiding useless invasive and expensive diagnostic procedures is a major challenge for the clinician. This article focuses on the clinical features of paraneoplastic musculoskeletal syndromes and theories about the underlying pathogenesis. We try to highlight those clinical and laboratory aspects which could be a clue to hidden malignancies. Paraneoplastic rheumatic syndromes are rare conditions, but timely recognition can save lives.
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Affiliation(s)
- G H Stummvoll
- Klinische Abteilung für Rheumatologie, Universitätsklinik für Innere Medizin III, Währinger Gürtel 18-20, A-1090 Wien.
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Aringer M, Stummvoll GH, Steiner G, Steiner CW, Radda I, Smolen JS, Graninger WB. T lymphocytes of patients with SLE lack Stat4. Arthritis Res Ther 2001. [PMCID: PMC3273299 DOI: 10.1186/ar205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Stummvoll GH, Aringer M, Grisar J, Steiner CW, Smolen JS, Knobler R, Graninger WB. Enhanced transendothelial in vitro migration of scleroderma lymphocytes. Arthritis Res Ther 2001. [PMCID: PMC3273290 DOI: 10.1186/ar232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Grisar J, Stummvoll GH, Smolen JS. Leflunomide leads to inhibition of transendothelial migration. Arthritis Res Ther 2001. [PMCID: PMC3273217 DOI: 10.1186/ar224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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27
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Aringer M, Stummvoll GH, Steiner G, Köller M, Steiner CW, Höfler E, Hiesberger H, Smolen JS, Graninger WB. Serum interleukin-15 is elevated in systemic lupus erythematosus. Rheumatology (Oxford) 2001; 40:876-81. [PMID: 11511756 DOI: 10.1093/rheumatology/40.8.876] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate if interleukin-15 (IL-15) (rather than IL-2) is increased in systemic lupus erythematosus (SLE) and might be responsible for immunological abnormalities of SLE such as the increased lymphocytic expression of Bcl-2 and CD25. METHODS Serum IL-15, IL-2 and tumour necrosis factor (TNF) levels of 65 SLE patients, 20 healthy persons and 10 rheumatoid arthritis (RA) patients were measured by enzyme-linked immunosorbent assay (ELISA). For 25 SLE patients, the percentage of CD25 + lymphocytes and the lymphocytic Bcl-2 levels were simultaneously determined by fluorocytometry. Peripheral blood mononuclear cells (PBMC) of 15 SLE patients were incubated with or without recombinant IL-15 and the influence on Bcl-2 and CD25 was determined. RESULTS IL-15 was found to be elevated in 25 SLE sera (38%), but in none of the 20 healthy sera (P = 0.0005) and none of the 10 RA sera. Both lymphocyte CD25 and Bcl-2 expression significantly correlated with serum IL-15 and were increased by recombinant IL-15. CONCLUSION Serum IL-15 may in part be responsible for the immunological abnormalities seen in active SLE.
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Affiliation(s)
- M Aringer
- Department of Rheumatology, Internal Medicine III, University of Vienna, Austria
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Stummvoll GH, Aringer M, Machold KP, Smolen JS, Raderer M. Cancer polyarthritis resembling rheumatoid arthritis as a first sign of hidden neoplasms. Report of two cases and review of the literature. Scand J Rheumatol 2001; 30:40-4. [PMID: 11252691 DOI: 10.1080/030097401750065319] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Recent onset arthritis reminiscent of rheumatoid arthritis (RA) may be an early manifestation of an occult malignancy. In this report, we present two patients with cancer-associated polyarthritis. Both suffered from symmetric polyarthritis when initially visiting their physicians and did not achieve relief when treated with non-steroidal anti-rheumatic drugs (NSAIDs). In both patients, subsequent work-up led to the diagnosis of an underlying malignancy. One patient suffered from small cell lung cancer (SCLC), while the other was diagnosed with adenocarcinoma of the colon. In both, the arthritis spontaneously disappeared after successful treatment of the malignancy, i.e. chemotherapy and tumor resection, respectively. We discuss these cases in view of the existing literature, since awareness of the entity of cancer polyarthritis is necessary for its timely treatment and may potentially be life-saving.
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Affiliation(s)
- G H Stummvoll
- Department of Rheumatology, Internal Medicine III, University of Vienna, Austria
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Redlich K, Kiener HP, Schett G, Tohidast-Akrad M, Selzer E, Radda I, Stummvoll GH, Steiner CW, Gröger M, Bitzan P, Zenz P, Smolen JS, Steiner G. Overexpression of transcription factor Ets-1 in rheumatoid arthritis synovial membrane: regulation of expression and activation by interleukin-1 and tumor necrosis factor alpha. Arthritis Rheum 2001; 44:266-74. [PMID: 11229456 DOI: 10.1002/1529-0131(200102)44:2<266::aid-anr43>3.0.co;2-g] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the expression of the transcription factor Ets-1 in synovial tissue and cultured synovial fibroblasts from patients with rheumatoid arthritis (RA) and osteoarthritis (OA) and to study the regulation of Ets-1 expression and activation in synovial fibroblasts by proinflammatory cytokines. METHODS In situ expression of Ets-1 in synovial tissue from RA and OA patients was examined by double immunohistochemistry. The effects of interleukin-1 (IL-1) or tumor necrosis factor alpha (TNFalpha) on Ets-1 expression and activation (DNA binding) in cultured synovial fibroblasts were analyzed by Western blotting and DNA gel shift assay, respectively. In addition, the intracellular location of Ets-1 in synovial fibroblasts was determined by immunofluorescence. RESULTS Pronounced expression of Ets-1 was detected in synovial tissues from all RA patients evaluated, particularly in the synovial lining layer and the sublining areas. Ets-1 was expressed by both fibroblasts and macrophages as well as by endothelial cells, while only a few T cells stained positive for Ets-1. In synovial specimens from OA patients, Ets-1 expression was much less frequently observed and was largely restricted to vascular cells. Ets-1 was expressed to a similar degree in cultured synovial fibroblasts from RA and OA patients, as demonstrated by reverse transcriptase-polymerase chain reaction and Western blotting. Both IL-1 and TNFalpha induced pronounced up-regulation of Ets-1 in synovial fibroblasts. Moreover, binding of Ets-1 to its specific DNA binding site was induced by both cytokines, although with different time courses. Immunofluorescence staining revealed a dominant nuclear localization of Ets-1 in IL-1- or TNFalpha-stimulated synovial fibroblasts. CONCLUSION The overexpression of Ets-1 observed in RA synovial tissue appears to be caused by TNFalpha and IL-1, suggesting that Ets-1 may be an important factor in the cytokine-mediated inflammatory and destructive cascade characteristic of RA.
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Stummvoll GH, Aringer M, Smolen JS, Köller M, Kiener HP, Steiner CW, Bohle B, Knobler R, Graninger WB. Derangement of apoptosis-related lymphocyte homeostasis in systemic sclerosis. Rheumatology (Oxford) 2000; 39:1341-50. [PMID: 11136877 DOI: 10.1093/rheumatology/39.12.1341] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Both increased and decreased apoptosis may be involved in generating autoimmunity. This study addressed the question of whether apoptosis and apoptosis-regulating proteins are altered in systemic sclerosis (SSc). Patients and methods. Peripheral lymphocytes of 39 SSc patients and 47 healthy control persons were studied for apoptosis, Bcl-2 and Bax levels, expression of Fas (CD95) and activation markers (CD25, HLA-DR) as determined by fluorocytometry. Serum Fas and Fas ligand were measured by ELISA. RESULTS SSc lymphocytes (mainly CD4(+)) expressed increased amounts of Bcl-2, while Bax was not elevated. Apoptosis rates of SSc lymphocytes were increased in unsupplemented medium, but returned to normal in the presence of autologous plasma. SSc patients had increased percentages of activated and CD95(+) lymphocytes and elevated soluble Fas and soluble FasL levels in serum. Activating anti-CD95 antibodies further increased the apoptosis rate. CONCLUSIONS Increased in vitro apoptosis, elevated lymphocytic Bcl-2 content and the increased number of Fas-positive T cells are not specific for peripheral blood from SSc patients, but indicate deregulation of lymphocyte homeostasis in this disease.
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Affiliation(s)
- G H Stummvoll
- Department of Rheumatology, Internal Medicine III, University of Vienna, Vienna, Austria
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