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Lundtoft C, Sjöwall C, Rantapää‐Dahlqvist S, Bengtsson AA, Jönsen A, Pucholt P, Wu YL, Lundström E, Eloranta M, Gunnarsson I, Baecklund E, Jonsson R, Hammenfors D, Forsblad‐d'Elia H, Eriksson P, Mandl T, Bucher S, Norheim KB, Auglaend Johnsen SJ, Omdal R, Kvarnström M, Wahren‐Herlenius M, Truedsson L, Nilsson B, Kozyrev SV, Bianchi M, Lindblad‐Toh K, Yu C, Nordmark G, Sandling JK, Svenungsson E, Leonard D, Rönnblom L, Rönnblom L. Strong Association of Combined Genetic Deficiencies in the Classical Complement Pathway With Risk of Systemic Lupus Erythematosus and Primary Sjögren's Syndrome. Arthritis Rheumatol 2022; 74:1842-1850. [PMID: 35729719 PMCID: PMC9828039 DOI: 10.1002/art.42270] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/17/2022] [Revised: 05/17/2022] [Accepted: 06/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Complete genetic deficiency of the complement component C2 is a strong risk factor for monogenic systemic lupus erythematosus (SLE), but whether heterozygous C2 deficiency adds to the risk of SLE or primary Sjögren's syndrome (SS) has not been studied systematically. This study was undertaken to investigate potential associations of heterozygous C2 deficiency and C4 copy number variation with clinical manifestations in patients with SLE and patients with primary SS. METHODS The presence of the common 28-bp C2 deletion rs9332736 and C4 copy number variation was examined in Scandinavian patients who had received a diagnosis of SLE (n = 958) or primary SS (n = 911) and in 2,262 healthy controls through the use of DNA sequencing. The concentration of complement proteins in plasma and classical complement function were analyzed in a subgroup of SLE patients. RESULTS Heterozygous C2 deficiency-when present in combination with a low C4A copy number-substantially increased the risk of SLE (odds ratio [OR] 10.2 [95% confidence interval (95% CI) 3.5-37.0]) and the risk of primary SS (OR 13.0 [95% CI 4.5-48.4]) when compared to individuals with 2 C4A copies and normal C2. For patients heterozygous for rs9332736 with 1 C4A copy, the median age at diagnosis was 7 years earlier in patients with SLE and 12 years earlier in patients with primary SS when compared to patients with normal C2. Reduced C2 levels in plasma (P = 2 × 10-9 ) and impaired function of the classical complement pathway (P = 0.03) were detected in SLE patients with heterozygous C2 deficiency. Finally, in a primary SS patient homozygous for C2 deficiency, we observed low levels of anti-Scl-70, which suggests a risk of developing systemic sclerosis or potential overlap between primary SS and other systemic autoimmune diseases. CONCLUSION We demonstrate that a genetic pattern involving partial deficiencies of C2 and C4A in the classical complement pathway is a strong risk factor for SLE and for primary SS. Our results emphasize the central role of the complement system in the pathogenesis of both SLE and primary SS.
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Affiliation(s)
- Christian Lundtoft
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden,Present address:
Olink Proteomics
| | - Christopher Sjöwall
- Division of Inflammation and Infection, Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | | | - Anders A. Bengtsson
- Department of Clinical Sciences Lund, Rheumatology, Lund University, and Skåne University HospitalLundSweden
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, and Skåne University HospitalLundSweden
| | - Pascal Pucholt
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden
| | - Yee Ling Wu
- Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, and the Department of Microbiology and ImmunologyLoyola UniversityChicagoIllinois
| | - Emeli Lundström
- Division of Rheumatology, Department of Medicine SolnaKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | | | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine SolnaKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | - Eva Baecklund
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden
| | - Roland Jonsson
- Broegelmann Research Laboratory, Department of Clinical ScienceUniversity of BergenBergenNorway
| | | | - Helena Forsblad‐d'Elia
- Department of Rheumatology and Inflammation ResearchSahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Per Eriksson
- Division of Inflammation and Infection, Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Thomas Mandl
- Division of Rheumatology, Department of Clinical Sciences MalmöLund University, and NovartisMalmöSweden
| | - Sara Bucher
- Department of Rheumatology, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Katrine B. Norheim
- Department of Rheumatology, Stavanger University Hospital, Stavanger, Norway, and the Institute of Clinical Science, University of BergenBergenNorway
| | | | - Roald Omdal
- Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway, and the Department of RheumatologyStavanger University HospitalStavangerNorway
| | - Marika Kvarnström
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden, and the Academic Specialist Center, Center for Rheumatology, Stockholm Health ServicesStockholmSweden
| | - Marie Wahren‐Herlenius
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden, and Broegelmann Research Laboratory, Department of Clinical Science, University of BergenBergenNorway
| | - Lennart Truedsson
- Department of Microbiology, Immunology, and GlycobiologyLund University HospitalLundSweden
| | - Bo Nilsson
- Department of Immunology, Genetics, and PathologyUppsala UniversityUppsalaSweden
| | - Sergey V. Kozyrev
- Science for Life Laboratory, Department of Medical Biochemistry and MicrobiologyUppsala UniversityUppsalaSweden
| | - Matteo Bianchi
- Science for Life Laboratory, Department of Medical Biochemistry and MicrobiologyUppsala UniversityUppsalaSweden
| | - Kerstin Lindblad‐Toh
- Science for Life Laboratory, Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden, and Broad Institute of MIT and HarvardCambridgeMassachusetts
| | | | - Chack‐Yung Yu
- Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's HospitalColumbusOhio
| | - Gunnel Nordmark
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden
| | | | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine SolnaKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | - Dag Leonard
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden
| | - Lars Rönnblom
- Department of Medical Sciences, RheumatologyUppsala UniversityUppsalaSweden
| | - Lars Rönnblom
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
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Lundtoft C, Pucholt P, Martin M, Bianchi M, Lundström E, Eloranta ML, Sandling JK, Sjöwall C, Jönsen A, Gunnarsson I, Rantapää-Dahlqvist S, Bengtsson AA, Leonard D, Baecklund E, Jonsson R, Hammenfors D, Forsblad-d'Elia H, Eriksson P, Mandl T, Magnusson Bucher S, Norheim KB, Auglaend Johnsen SJ, Omdal R, Kvarnström M, Wahren-Herlenius M, Notarnicola A, Andersson H, Molberg Ø, Diederichsen LP, Almlöf J, Syvänen AC, Kozyrev SV, Lindblad-Toh K, Nilsson B, Blom AM, Lundberg IE, Nordmark G, Diaz-Gallo LM, Svenungsson E, Rönnblom L. Complement C4 Copy Number Variation is Linked to SSA/Ro and SSB/La Autoantibodies in Systemic Inflammatory Autoimmune Diseases. Arthritis Rheumatol 2022; 74:1440-1450. [PMID: 35315244 PMCID: PMC9543510 DOI: 10.1002/art.42122] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Copy number variation of the C4 complement components, C4A and C4B, has been associated with systemic inflammatory autoimmune diseases. This study was undertaken to investigate whether C4 copy number variation is connected to the autoimmune repertoire in systemic lupus erythematosus (SLE), primary Sjögren's syndrome (SS), or myositis. METHODS Using targeted DNA sequencing, we determined the copy number and genetic variants of C4 in 2,290 well-characterized Scandinavian patients with SLE, primary SS, or myositis and 1,251 healthy controls. RESULTS A prominent relationship was observed between C4A copy number and the presence of SSA/SSB autoantibodies, which was shared between the 3 diseases. The strongest association was detected in patients with autoantibodies against both SSA and SSB and 0 C4A copies when compared to healthy controls (odds ratio [OR] 18.0 [95% confidence interval (95% CI) 10.2-33.3]), whereas a weaker association was seen in patients without SSA/SSB autoantibodies (OR 3.1 [95% CI 1.7-5.5]). The copy number of C4 correlated positively with C4 plasma levels. Further, a common loss-of-function variant in C4A leading to reduced plasma C4 was more prevalent in SLE patients with a low copy number of C4A. Functionally, we showed that absence of C4A reduced the individuals' capacity to deposit C4b on immune complexes. CONCLUSION We show that a low C4A copy number is more strongly associated with the autoantibody repertoire than with the clinically defined disease entities. These findings may have implications for understanding the etiopathogenetic mechanisms of systemic inflammatory autoimmune diseases and for patient stratification when taking the genetic profile into account.
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Affiliation(s)
| | | | | | - Matteo Bianchi
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | - Emeli Lundström
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Andreas Jönsen
- Lund University and Skåne University Hospital, Lund, Sweden
| | - Iva Gunnarsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | | | | | | | | | - Roald Omdal
- Stavanger University Hospital, Stavanger, Norway
| | - Marika Kvarnström
- Karolinska Institutet, Karolinska University Hospital, and Stockholm Health Services, Region Stockholm, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Karolinska Institutet and Karolinska University Hospital Stockholm, Sweden, and University of Bergen, Bergen, Norway
| | | | | | | | - Louise Pyndt Diederichsen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, and Odense University Hospital, Odense, Denmark
| | - Jonas Almlöf
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | | | - Sergey V Kozyrev
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden
| | - Kerstin Lindblad-Toh
- Science for Life Laboratory and Uppsala University, Uppsala, Sweden, and Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | | | | | | | | | - Ingrid E Lundberg
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Abstract
The antiphospholipid syndrome (APS) comprises the association between vascular thrombosis, including microthrombosis, pregnancy morbidity and the coexistence of anti-phospholipid antibodies. Thrombotic microangiopathy (TMA) can be one of the manifestations of the APS and may involve any organ. This feature of the APS is probably less recognized by clinical doctors than venous thrombosis and recurrent abortions. This case report presents a patient who developed a widespread TMA with renal failure, gastric mucosa ulceration, urinary bladder ulcerations and a finger necrosis as part of the APS.
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Affiliation(s)
- S J A Johnsen
- Clinical Immunology Unit, Department of Internal Medicine, Stavanger University Hospital, Norway.
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