O lúpus eritematoso sistêmico (LES) é uma doença autoimune com forte componente genético, caracterizada por inflamação crônica e produção de autoanticorpos. O objetivo deste trabalho foi determinar o perfil de variação no número de cópias (CNVs) e de regiões de perda de heterozigose (LOH) na patogênese do LES. A detecção de CNVs e LOH foi feita pela metodologia Cytoscan HD array em pacientes com LES (n = 23) e indivíduos saudáveis (n = 110). Devido à formação tri-híbrida da população brasileira, foi desenvolvido e validado um painel de 345 marcadores informativos de ancestralidade, a partir dados provenientes do próprio array, para estimar as proporções de ancestralidade individual e, em última instância, inseri-las nos modelos de regressão logística como variável de controle nas análises de distribuição de CNVs e LOH. O perfil de CNVs evidenciou que o número e o tamanho de duplicações são maiores nos indivíduos saudáveis do que nos pacientes com LES. Duplicações nos genes FCGR3B e ADAM3A foram descritas como fator de proteção ao LES, quando tais genes foram avaliados por PCR quantitativa em maior grupo amostral de pacientes (n = 135) e controles (n = 200). Além disso, mostrou-se o efeito sinérgico da presença da deleção em ambos os loci FCGR3B e ADAM3A no aumento do risco para desenvolver a doença. Deleções em pacientes com LES envolvendo os genes CFHR4, CFHR5 e HLA-DPB2, previamente descritos em associação com o LES na literatura, foram identificadas por array e confirmadas por PCR digital. O protocolo desenvolvido para identificação de variantes raras, resultou em um conjunto de 21 CNVs raras em pacientes com LES. Em relação às regiões de perda de heterozigose, não foram encontradas evidências de que o número médio e a extensão dos segmentos LOH seja diferente entre pacientes e indivíduos saudáveis. No entanto, os cromossomos 6 e 12 em pacientes exibem regiões de perda de heterozigose em maior quantidade e tamanho do que os de indivíduos saudáveis, além de apresentarem 17 segmentos LOH restritos ao grupo de pacientes com LES. Os resultados aqui descritos evidenciam que novos loci de susceptibilidade ao LES podem ser encontrados quando a distribuição de CNVs é analisada em todo o genoma, em que a investigação de sua relação com a patogênese pode contribuir para a compreensão da base genética da doença. / Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong genetic background characterized by chronic inflammation and autoantibody production. The purpose of this study was to determine the copy number variation (CNV) and loss of heterozygosity (LOH) profiles in the susceptibility to SLE. The detection of CNVs and LOH was performed by the Cytoscan HD array methodology in SLE patients (n = 23) and healthy subjects (n = 110). Due to the tri-hybrid composition of the Brazilian population, a panel of 345 ancestral informative markers was developed and validated, based on data from the array itself, to estimate the proportions of individual ancestry and, ultimately, to insert them into the logistic regression models as a control variable in the analysis of CNV and LOH distribution. The CNVs profile showed that the burden and the size of duplications are higher in healthy individuals than in SLE patients. Duplications in FCGR3B and ADAM3A genes were described as a protective factor for SLE, when these genes were evaluated by quantitative PCR in a larger SLE (n = 135) and control (n = 200) groups. In addition, the synergistic effect of the presence of deletion in both FCGR3B and ADAM3A loci increase the risk of developing the disease. Deletions in SLE patients encompassing the CFHR4, CFHR5 and HLA-DPB2 genes, previously described in the literature in association to SLE, were identified by the array and confirmed by droplet digital PCR. The pipeline developed here for the identification of rare variants resulted in a set of 21 rare CNVs in SLE patients. Regarding the loss of heterozygosity regions, no evidence was found that the mean number and extent of LOH segments is different between patients and healthy individuals. However, the chromosomes 6 and 12 in SLE patients exhibit greater quantity and size of LOH than those of healthy individuals, besides showing 17 LOH segments restricted to the group of SLE. The results described here show that novel susceptibility loci to SLE can be found once the distribution of variants is analyzed throughout the genome, in which the investigation of its relation to the pathogenesis may contribute to the understanding of the genetic basis of the disease.

Orientadores: Simone Appenzeller, Lilian Tereza Lavras Costallat / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T13:51:27Z (GMT). No. of bitstreams: 1 Peres_FernandoAugusto_M.pdf: 1437476 bytes, checksum: a879071e9da761defaf00fb710eaf9b4 (MD5) Previous issue date: 2014 / Resumo: Lúpus Eritematoso Sistêmico (LES) é uma doença autoimune, crônica e mutissistêmica, caracterizada por períodos de atividade e remissão. Manifestações neuropsiquiátricas ocorrem em 12-95% dos pacientes, dependendo dos critérios diagnósticos aplicados e estão associadas a uma elevada morbi-mortalidade. Vários anticorpos têm sido relacionados com manifestações neuropsiquiátricas no LES, os mais frequentemente associados são anticorpo antifosfolípides, um subtipo de dupla-fita DNA e anticorpo anti-P ribossomal. Estudos recentes têm demonstrado a alta especificidade do anti-P ribossomal para o LES podendo ser também um marcador para atividade de doença. Anti-P ribossomal são capazes de se ligar em células neuronais em áreas relacionadas com o sistema límbico que são associadas ao olfato. Os objetivos deste trabalho foram analisar a prevalência de distúrbio olfatório no LES, correlacionar essas alterações olfatórias a alterações de humor, ansiedade, presença de manifestações neuropsiquiátricas e atividade e dano da doença e associar os níveis de anti-P ribossomal com distúrbios olfatórios, presença de manifestações neuropsiquiátricas e atividade da doença. Foram selecionados pacientes com diagnóstico de LES, seguidos no ambulatório de reumatologia do HC-UNICAMP, no período de março de 2011 a dezembro de 2013. O grupo controle foi constituído por voluntários sadios com idade e gênero semelhantes aos do grupo de pacientes com LES, que não apresentavam histórico de doenças autoimunes ou alérgicas, sem alterações de vias aéreas superiores e sem histórico de uso de drogas inalantes. Foram incluídos 120 pacientes com LES, e 135 voluntários sadios. Ansiedade foi encontrada em 67,5% dos pacientes e em 39,2% dos controles e depressão foi identificada em 46,6% dos pacientes e em 28,8% dos controles. Alteração olfatória foi observada em 51,6% dos pacientes e em 29,6% dos controles. O anti-P ribossomal foi identificado exclusivamente em pacientes e estava presente em 13 (10,8%) deles. Alteração olfatória foi associada com LES; pacientes tiveram médias significativamente menores nas três fases da avaliação olfatória e, consequentemente, no somatório total do teste (LDI). A alteração olfatória ainda se associou inversamente com ansiedade (p=0,004; R= -0,18), depressão (p=0,01; R= -0,232), dano da doença (p=0,002; R=-0,282) e maior idade (p<0,001; R= -0.353). Não encontramos associação entre alteração olfatória, sexo ou atividade da doença (p=0,891 e p=0,914, respectivamente). O LDI se correlacionou com histórico de manifestações NP, sendo que pacientes com manifestações NP tinham média de LDI de 28,35 (DP±5,30) pontos, enquanto que pacientes sem manifestações NP tinham média de LDI de 30,8 (DP±4,51) pontos (p<0,05). O Anti-P ribossomal não foi associado com a presença de manifestações NP (p=0,730), porém quando analisamos os subitens classificatórios de manifestações NP separadamente, observamos associação entre anti-P ribossomal positivo e psicose (p<0,05). Observamos ainda associação do anti-P ribossomal com atividade da doença. Não observamos outras associações com anti-P ribossomal. Concluímos que pacientes apresentam uma significativa diminuição do olfato quando comparados a controles sadios, que se associa com histórico de manifestações neuropsiquiátricas, ansiedade, depressão, dano da doença e maior idade. Os anticorpos anti-P ribossomais estavam presentes exclusivamente em pacientes e se associou com psicose e atividade da doença / Abstract: Systemic lupus erythematosus (SLE) is an autoimmune, chronic, multisystemic disorder characterized by periods of activity and remission. Neuropsychiatric manifestations occur in 12-95 % of SLE patients, depending on the diagnostic criteria applied and are associated with a high morbidity and mortality. Several antibodies have been associated with neuropsychiatric manifestations in SLE. These antibodies are more often associated with antiphospholipid antibody, a subtype of double-stranded DNA and antiribosomal P antibodies. Recent studies have demonstrated the high specificity of antiribosomal P antibodies for SLE, suggesting that antiribosomal P antibodies may be a biomarker for disease activity. Antiribosomal P antibodies are able to bind to neuronal cells in areas of the limbic system which are responsible to the olfactory. The objectives of this study were to analyze the prevalence of olfactory disorder in SLE, to correlate olfactory changes to mood disorders, anxiety, presence of neuropsychiatric manifestations, disease activity and damage, and also to associate of the presence of antiribosomal P antibodies with olfactory disorders, presence of neuropsychiatric manifestations and disease activity. One hundred and twenty SLE patients included in the study were followed at the outpatient rheumatology UNICAMP, from March 2011 to December 2013. The control group was consisted of 135 healthy volunteers matched by age and sex. They had no history of autoimmune or allergic diseases, with no changes in upper airway and no history of use of inhalant drugs. Anxiety was observed in 67.5 % SLE patients and in 39.2% controls. Depression was identified in 46.6 % SLE patients and in 28.8% controls. Olfactory changes were observed in 51.6 % SLE patients and in 29.6 % controls. Anti-ribosomal P antibodies were identified exclusively in SLE patients and were present in 13 (10.8%) of them. Olfactory changes had significantly lower averages in all three phases of the olfactory evaluation and, consequently, in the total sum test (LDI). The olfactory also inversely associated with anxiety (p = 0.004, R = -0.18), depression (p = 0.01, R = -0.232), cumulative damage (p = 0.002 R = -0.282) and age (p <0.001 , R = -0.353). We did not observe an association between olfactory changes and gender or disease activity (p = 0.891 and p = 0,914), respectively. The TDI was correlated with a CNS involvement, and patients with NPC [mean of 28.35 (SD ± 5.30] points, whereas patients without CNS involvement had a mean TDI of 30.8 (SD ± 4.51) points (p < 0.05). Antiribosomal P antibodies were not associated with the presence of CNS involvemnt (p = 0.730), but when we analyzed each subitem of CNS involvement separately, we observed an association between the presence of antiribosomal P antibodies and psychosis (p < 0.05). We also observed an association between antiribosomal P antibodies and disease activity (p < 0.05). We concluded that SLE patients show a significant decrease of smell when compared to healthy controls. Olfactory changes are associated with a history of neuropsychiatric symptoms, anxiety, depression, cumulative damage, and older age. Antiribosomal P antibodies were exclusively observed in SLE patients compared to healthy controls and were associated with psychosis and disease activity / Mestrado / Clinica Medica / Mestre em Clinica Medica

Orientadores: Lilian Tereza Lavras Costallat, Simone Appenzeller / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T07:49:05Z (GMT). No. of bitstreams: 1 Ferrari_AnaLuisaVanalle_M.pdf: 849343 bytes, checksum: f0c264713a909a78bdd04a6d3e6f65da (MD5) Previous issue date: 2013 / Resumo: Introdução: Perda auditiva neurosensorial é conhecida como uma manifestação incomum do Lúpus Eritematoso Sistêmico(LES), podendo ocorrer como primeira manifestação de doença, já tendo sido associada com Síndrome do Anticorpo Antifosfolípide (SAF) e doença cardiovascular. Objetivo: Determinar a frequência de perda auditiva em um grupo de pacientes com lúpus eritematoso sistêmico e avaliar a associação entre a perda auditiva e idade, tempo de doença, atividade de doença e dano, anticorpos antifosfolípides e fatores de risco para doença cardiovascular. Método: Foi realizado um estudo transversal que incluiu pacientes com LES do sexo feminino acompanhadas no ambulatório de Reumatologia da Unicamp de forma consecutiva. Em todas as pacientes foram realizadas avaliação clínica, laboratorial e audiometria. Análise Estatística: Foi realizada análise de componentes principais (PCA), correlação de Speaman e regressão logística. Resultados: Foram estudadas 89 pacientes, todas do sexo feminino e com média de idade de 38,98 (±7,77) anos. A média de duração de doença foi 10,29 (± 9,19). Perda auditiva neurosensorial avaliada por audiometria e avaliação clínica foi encontrada em 14 pacientes, o que corresponde a 16%. Não se observou associação entre a perda auditiva e idade, tempo de doença, atividade de doença (SLEDAI), dano de doença (SLICC) e anticorpos antifosfolípides. Quanto aos fatores de risco para doença cardiovascular observou-se associação entre perda auditiva e níveis elevados de LDL (p=0,008), corroborando a associação entre perda auditiva e dislipidemia. Não foram observadas associações com outros fatores de risco cardiovasculares estudados como triglicérides, HDL, hipertensão arterial, glicemia de jejum e índice de massa corporal (IMC). Conclusões: Apesar de considerada incomum, perda auditiva foi observada em 16% dos nossos pacientes. Não se observou associação entre a perda auditiva e idade, tempo de doença, atividade de doença, dano e anticorpos antifosfolípides. Foi encontrada associação com níveis elevados de LDL, apontando que a presença de dislipidemia pode ser responsável por estas alterações no LES / Abstract: Introduction: Sensorioneural hearing loss (SHL) is a uncommon condition in systemic lupus erythematosus (SLE) but it can occur as the first manifestation of disease. Some authors have associated this manifestation with Antiphospholipid Syndrome (APS), and cardiovascular disease. Objective: To determine the frequency of neurosensorial hearing loss in a group of SLE patients and the association between SHL and age, years of disease, activity and damage of SLE, antiphospholipid antibodies profile and cardiovascular comorbidities. Methods: We conducted a cross-sectional study including patients with SLE followed at the Rheumatic Clinic in UNICAMP in a consecutive way. We performed in all patients audiometry, clinical and laboratorial evaluation. Statistical Analysis: Our data were submitted to logistic regression. We also used principal component analysis (PCA) and Spearman correlation. Results: The study included 89 patients. They were all women with mean age 38,98 (± 7,77) years and mean disease's duration of 10,29 (± 9,19) years. We found neurosensorial hearing loss evaluated using audiometry test and clinical evaluation in 14 patients, representing 16%. It was not observed any association between hering loss and age, time of disease, disease activity (SLEDAI), and damage (SLICC), APS and antiphospholipid antibodies. Considering cardiovascular risk factors, significant association between hearing loss and LDL level (p=0,008) was found, corroborating the association of hearing loss and dyslipidemia as a predictor of vascular disease. Other risk factors were not associated, as HDL, triglycerides, hypertension and body mass index (BMI). Conclusion: Although uncommon, we found hearing loss in 16% of cases studied. Also, we found a positive association with LDL level, pointing that cardiovascular disease (not only immune) can be responsible for these alterations. It was not observed any association between hearing loss and age, time of disease, disease's activity, damage, APS and antiphospholipid antibodies. Our study indicates an important risk factor for neurosensorial hearing loss in SLE patients / Mestrado / Clinica Medica / Mestra em Clínica Médica

Le Lupus Erythémateux Systémique (LES) est une maladie autoimmune sévère dont laquelle les lymphocytes B (LB) jouent un rôle central. Afin de rechercher des anomalies génétiques propre à ces cellules, notre laboratoire a étudié l’expression des gènes dans les LB de patients atteints d’un LES, par rapport à des sujets témoins. Ce projet a pour but d’étudier un de ces gènes (FKBP11), surexprimé dans les LB au cours du LES. Pour cela nous avons créé, à l’aide de lentivirus, des souris transgéniques reproduisant de manière ubiquitaire la surexpression de ce gène. Ces souris développent une hyperplasie des organes lymphoïdes, une hyper gamma globulinémie de type IgG3, et présentent une réponse humorale augmentée après immunisation avec un antigène T-indépendant. Notre étude met en évidence que la surexpression de FKBP11 favorise le développement des plasmocytes dans leur phase initiale dépendante de l’expression de Pax5, après induction de la différenciation plasmocytaire in vitro. Enfin, les souris développent des autoanticorps variés. De plus, le rôle d’une surexpression de FKBP11 dans la rupture de tolérance B a été montré chez des souris transgéniques anti-ADN 56R, croisées avec notre modèle lentigénique, qui voient leur production d’autoanticorps augmentée. La surexpression de FKBP11 dans le modèle C57BL/6lpr/lpr accentue le caractère lymphoprolifératif et l’hyper gamma globulinémie présents dans ces souris. Au cours de ce projet de thèse, j’ai également initié l’étude de deux autres gènes surexprimés dans les LB de patients lupiques (PRDX4, TRIB1), par le développement de modèles transgéniques murins. / Systemic Lupus Erythematosus (SLE) is a severe autoimmune disease where B cells play a central role and carry intrinsic genetic abnormalities.Today, only a few SLE genes have been validated in humans. Looking for these intrinsic B cell abnormalities in SLE, we have performed a microarray analysis of the human transcriptoma in B cells from quiescent SLE patients, in comparison to normal subjects. The project proposes to explore the consequences of overexpression of one of these genes: FKBP11. For this purpose, a lentiviral construct allowing the ubiquitous overexpression of FKBP11 was produced, and has been used to generate lentigenic mice. These mice develop a hyperplasia of lymphoid organs, an IgG3 hypergammaglobulinemia and an increase of humoral immune response after immunisation with a T-independent antigen. Our study points out that the overexpression of FKBP11 promotes the plasmocyte development, at the initial stage which is dependent on Pax5 expression, after in vitro induction of the plasmacytic differentiation. Finally, these mice produce various autoantibodies. The role of FKBP11 overexpression in B cell central tolerance breakdown has been demonstrated in anti-DNA 56R transgenic mice crossed with our lentigenic model. These mice have an increase of autoantibody production. The FKBP11 overexpression in C57BL/6lpr/lpr model increases the lymphoproliferative syndrome and the hypergammaglobulinemia in this model. During this thesis, I have also initiated the study of two others genes which were found overexpressed in B cells of lupus patients (PRDX4, TRIB1), by the development of transgenic murine models.

Le lupus érythémateux disséminé (LES) est une maladie systémique auto-immune chronique dont le retentissement sur la vie des patients est très lourd. Au cours de la décennie écoulée, des échelles de qualité de vie spécifique du lupus systémique ont été développées pour compléter les données obtenues avec les questionnaires génériques. Dans une première partie de ce travail, nous exposons la définition du concept de qualité de vie et les différentes manières de la mesurer. Nous présentons ensuite l’état des connaissances sur les facteurs influençant la qualité de vie au cours du LES. Dans une seconde partie, nous exposons les résultats obtenus sur une cohorte de 182 patients atteints de LES (étude FRESHQOLA) ayant pour but de valider la version française du questionnaire spécifique LupusQoL. La validité et la fiabilité du questionnaire étaient satisfaisantes. Dans une seconde partie, nous présentons les résultats de la sensibilité au changement du même questionnaire, et nous montrons que le LupusQoL permet de capter un changement dans l’état de santé des patients, et qu’il serait plus sensible au changement que le questionnaire générique SF-36 pour mesurer une amélioration de leur état de santé. Dans une troisième partie, nous présentons les résultats de l’étude EQUAL sur 330 patients ayant pour objectif la validation du questionnaire SLEQOL. Outre la fiabilité et la validité du questionnaire, nous avons réalisé une analyse de fonctionnement différentiel d’item entre les patients de notre cohorte et un échantillon de patients issus de la cohorte de développement de l’échantillon à Singapour. Le SLEQOL était fiable et valide malgré 4 items montrant un fonctionnement différentiel modéré. Dans une quatrième partie, nous présentons l’analyse des facteurs associés à la qualité de vie mesurée par les questionnaires spécifiques LupusQoL, SLEQOL et les questionnaires génériques SF-36 et WHOQOL dans cette même cohorte de 330 patients. La qualité de vie dans les domaines physique, mental et social était fortement associée aux facteurs socio-économiques et en particulier la précarité sociale, telle que mesurée par le score EPICES. Les femmes avaient une altération de la qualité de vie spécifique, tandis que le surpoids et le tabagisme influençaient les questionnaires génériques mais pas les questionnaires spécifiques, suggérant que dans ces situations, les patients n’attribuent pas la gêne à leur lupus. Enfin, l’atteinte articulaire était la manifestation clinique de la maladie la plus fortement associée à une diminution de la qualité de vie. Ces résultats ouvrent donc des perspectives dans la compréhension du retentissement du lupus systémique sur le quotidien des patients et nous permettront de mieux comprendre les résultats des essais cliniques et études épidémiologiques à venir. / Systemic Lupus Erythematosus (SLE) is a chronic systemic auto-immune disease that considerably impairs patients’ daily living. During the past 10 years, disease-specific health related quality of life questionnaires have been developed in order to complete the information obtained using generic questionnaires in SLE patients. In the first part of our work, we present the definition of the concept of quality of life and the different way to measure it. In the second part, we present the results of a cohort study of 182 SLE patients that aimed to validate the French version of the SLE-specific questionnaire LupusQoL. Validity and reliability of the questionnaire were found to be satisfactory. In the second part, we present the results concerning responsiveness of the same questionnaire. We showed that LupusQol was able to capture a change in patients’ health state, and that it could be more responsive than the generic SF-36 questionnaire in patients with improving symptoms. In the third part, we present the results of a study involving 330 patients that aimed to validate the SLEQOL questionnaire. Besides determining the validity and reliability of the questionnaire, we conducted a differential item functioning analysis between patients of our cohort and patients from the development cohort of the SLEQOL in Singapore. The SLEQOL was found to be reliable and valid despite 4 items showing a moderate differential item functioning. In the fourth part, we present the results of the analysis of factors associated with quality of life in SLE patients, as measured by SLEQOL and LupusQoL specific questionnaires, and WHOQOL and SF-36 generic questionnaires in the same cohort of 330 patients. Quality of life in physical, mental and social domains was strongly associated with socio-economic factors, especially the social precariousness, as measured by the EPICES score. Women had a lower generic quality of life, whereas overweight and smoking influenced the generic questionnaires but not the specific ones, suggesting that in those situation, patients did not attribute their problem to lupus. Finally, articular involvement of the disease was the clinical symptom with the strongest association with quality of life impairment. This study opens up new areas of research that will lead to better understanding of SLE burden and improve the interpretation of results from future clinical trials and epidemiological studies.

Patients with chronic inflammatory conditions such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) experience premature cardiovascular mortality and morbidity compared with the general population. The increased risk of cardiovascular disease (CVD) may in part, result from an interaction between traditional and non-traditional risk factors, modulated by chronic inflammation. The aim of this project was to look at lipid associated biomarkers in patients with SLE/RA and the association between these markers and cardiovascular disease outcomes. We also aimed to study the effect of inflammation reduction on vascular biomarkers. In the first study we examined 168 SLE patients median (IQR) age was 53 (46-61) years and median disease duration 13 (7, 23) years and 56 healthy controls median age 50 (39-60) years. We demonstrated elevated level of oxidised-LDLin SLE patients compared with healthy controls (76 (57, 99) U/l vs 56 (42, 88)U/l P= 0.02). We further explored the association between oxidant stress and premature atherosclerosis as measured by carotid intima media thickness (cIMT) and plaque. In addition to age and systolic blood pressure, oxidised-LDL and urinary 8-isoprostane were significantly and independently associated with cIMTin SLE patients _ coefficient 95%CI [0.00007 (5.29−6, 0.0001) and 0.003 (0.0008,0.004)], respectively. In healthy controls, age was the only independent variable. In the Norfolk Arthritis Register, 1266 patients with early inflammatory polyarthritis (IP) were studied. A linear regression analysis revealed a significant negative association between CRP and lipid profile namely TC, LDL, TG and ApoA-1. During a median (IQR) follow up = 5.5 (3.7-7.7) years 100 (7%) patients died (all causes) of which 33% (33) deaths were attributed to CVD. Forward stepwise regression analysis demonstrated that a low total cholesterol was independently associated with all cause mortality HR (95%CI) 0.75 (0.61, 0.91) and CVD mortality HR (95%CI) 0.49 (0.29, 0.85). In a small cohort 27 SLE patients and 15 healthy controls. We measured endothelial function using flow mediated dilatation of the brachial artery. At baseline we found a significant increase in TG level [1.36 (0.9, 1.87) mmol/l vs0.88 (0.64, 1) mmol/l P= 0.009] and a significant impaired endothelial function in SLE patients compared to the healthy controls [2.86 (0.6, 5.3) vs 6.81 (3.46,8.57), P= 0.03]. After treatment, there was a trend towards reduced TG level and improved endothelial function. Oxidised-LDL did not change significantly. In conclusion, oxidant stress is increased in SLE patients and relates to some measures of subclinical atherosclerosis. Control of inflammation may not be sufficient to completely control this in routine practice. In early RA, active inflammationmay mask any tendency to hyperlipidemia in this population. Low total cholesterol may be the best biomarker of the overall metabolic and inflammatory status of the patients as well as indicating a group with increased risk of future mortality.

INTRODUÇÃO: O Lúpus Eritematoso Sistêmico (LES) é uma doença inflamatória crônica que pode acometer qualquer órgão ou sistema. O acometimento do coração pode ocorrer em até 50% dos casos e não existem estudos de prevalência de eventos arrítmicos (EA) em pacientes com LES, nem de correlações laboratoriais preditoras de sua ocorrência. OBJETIVOS: Estabelecer a taxa de ocorrência de EA e identificar variáveis laboratoriais preditoras de sua ocorrência em pacientes com LES em seguimento em ambulatório de hospital terciário; estabelecer a associação entre o uso de cloroquina com a ocorrência de EA e óbitos (tipo, número e tempo de seguimento). MÉTODOS: Foi realizado um estudo clínico descritivo, observacional e aberto com pacientes em seguimento ambulatorial no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo que foram submetidos a avaliação clínica, exames laboratoriais, ECG de repouso e Holter de 24h. A associação entre as variáveis e os EA foi avaliada por meio dos testes qui-quadrado, razão de verossimilhança, teste exato de Fisher, teste t-Student, teste não-paramétrico de Mann-Whitney, regressão logística múltipla e curva ROC. RESULTADOS: Entre agosto/2005 e agosto/2006 foram estudados 325 pacientes consecutivos, sendo 8 excluídos. A idade média foi de 40,25 anos, 91% mulheres. O tempo médio do diagnóstico de LES foi de 11,36 anos e apenas 6 pacientes apresentaram critérios para atividade do LES (escore SLEDAI). Duzentos e vinte e um pacientes estavam em uso de cloroquina. Alterações ao ECG ocorreram em 66 pacientes (20,82%): 5 bloqueios atrioventriculares de 1º grau; 4 bradicardias sinusais; 4 taquicardias sinusais e 1 supraventricular; 6 bloqueios do ramo direito (BRD); 2 bloqueios do ramo esquerdo (BRE); 45 QT prolongados. Ao Holter foram identificados 4 pacientes com pausas > 2,0 segundos; 45 com FC mínima < 50bpm; 90 com extrassístoles supraventriculares (ESV); 26 com taquiarritmias supraventriculares (FA/TA); 65 com extrassístoles ventriculares (EV). Foram registrados 7 óbitos (2,47%). Idade acima de 40 anos foi preditora da ocorrência de EA (p=0,002; OR=2,523; IC 95%= 1,389-5,583). A presença do anticorpo anticardiolipina foi preditora da ocorrência de BRD/BRE (p = 0,005; OR 3,989; IC 95% = 1,615-9,852). Títulos de C3 abaixo de 105mg% foram preditores de menor probabilidade de ocorrência de FC mínima < 50bpm (p=0,016; OR=1,018; IC 95%=1,003-1,033). Os preditores para a ocorrência de EV foram a idade (p=0,002; OR=1,051; IC95%=1,018-1,085) e a duração do QRS (p=0,005; OR=1,061; IC95%=1,018-1,106); quanto mais avançada a idade e quanto mais largo o QRS, maior a probabilidade de ocorrência de EV. Para a ocorrência de TA/FA, os preditores foram a idade (p<0,001; OR=1,100; IC95%=1,050-1,154) e o tempo de uso cloroquina (p=0,035; OR=0,921; IC95%=0,853-0,994); quanto mais avançada a idade e quanto menor o tempo de uso de cloroquina, maior a probabilidade de ocorrência de TA/FA. Pacientes com mais de 50 anos e tempo de uso de cloroquina inferior a 8 anos tiveram mais TA/FA. CONCLUSÕES: Neste estudo, que avaliou pacientes com LES em seguimento ambulatorial em hospital terciário, a taxa de ocorrência de EA foi elevada; a sua correlação com variáveis laboratoriais identificou como preditores de maior ocorrência: idade acima de 40 anos, título de C3 abaixo de 105mg% e presença de anticorpo anticardiolipina. A cloroquina demonstrou efeito protetor cardíaco sobre a evolução da doença. / INTRODUCTION: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory illness that can affect any organ and system. Up to 50% of patients have their heart affected and there are no prevalence studies of arrhythmic events (AE) in SLE patients and laboratory predictors are also unknown. OBJECTIVES: To establish the rate of occurrence of AE and to identify laboratory predictors in outpatients with SLE; to establish the association between chloroquine use and the occurrence of AE and death (type, number and time of follow-up). METHODS: A descriptive, observational and opened clinical study was carried out with SLE oupatients selected from the Rheumatology clinic of São Paulo University Medical School, Brazil. They were submitted to clinical evaluation, laboratory exams, resting-ECG and 24-hour Holter monitoring. Statistics: The association between the variables and the occurrence of AE was assessed by chi-square, likelihood ratio, Fishers test, t-Student, Mann-Whitney, ROC curve and logistic regressions. RESULTS: Between august/05-august/06, 325 consecutive patients were studied. Resting-ECG abnormalities were found in 66 patients, rate of 20.82%. The average age was 40.25yo, 91% female. The average time of SLE diagnosis was of 11.36y and only 6 presented criteria for diseases activity (SLEDAI score). There were 221 patients using chloroquine. ECG disturbances found: 5 1st degree AV-block; 4 sinus bradycardia; 4 sinus tachycardia and 1 supraventricular tachycardia; 6 RBBB; 2 LBBB; 45 long QT. At Holter monitoring: 4 pauses>2.0s; 45 HR<50bpm; 90 atrial ectopies; 26 atrial tachyarrhythmia; 65 ventricular ectopies. Seven death were registered (2.47%). Age above 40yo was predictor of AE (p=0.002; OR=2.5; 95%IC=1.4-5.6). Presence of anticardiolipine antibody was predictor of QRS>120ms occurrence (p = 0.005; OR 3.989; IC 95% = 1.615-9.852). C3 level bellow 105mg% was predictor of non-occurrence of HR<50bpm (p=0.02; OR=1.02;95% IC=1.003-1.03). The predictor for ventricular ectopies (VE) occurrence were age (p=0,002; OR=1,051; IC95%=1,018-1,085) and QRS duration (p=0,005; OR=1,061; IC95%=1,018-1,106); advanced age and longer QRS predicted greater probability of VE. For supraventricular tachyarrhythmia (AT/AF) the predictors were age (p<0,001; OR=1,100; IC95%=1,050-1,154) and time of Chloroquine use (p=0,035; OR=0,921; IC95%=0,853-0,994); advanced age and short time of Chloroquine use are related to greater probability of AT/AF. Patients older than 50y and using chloroquine for less than 8y had more AT/AF. CONCLUSIONS: The rate of AE occurrence was high (20%) and the correlation with laboratory variables identified predictors of occurrence of AE: age above 40 years, C3 level below 105mg% and anticardiolipin antibody. Chloroquine demonstrated cardiac protection effect.

Diese Arbeit untersucht die Wirksamkeit des monoklonalen Antikörpers Belimumab bei Patient*innen mit systemischem Lupus erythematodes in einer monozentrischen Routinekohorte. Besonderes Augenmerk lag auf der Betrachtung des Ansprechens einzelner Organmanifestationen. Es sollten Subgruppen mit hoher oder niedriger Wahrscheinlichkeit für ein Ansprechen identifiziert werden. Es erfolgte eine retrospektive Auswertung von regelmäßig und standardisiert erhobenen Patient*innendaten. Betrachtet wurden dokumentierte Symptome, Laborparameter und daraus abgeleitete klinische Scores. Betrachtet wurden 4 Zeitpunkte in den ersten 12 Monaten der Therapie und ein weiterer Last visit-Zeitpunkt zur Evaluation des Langzeiterfolges. Bei Patient*innen, deren Therapie vorzeitig beendet wurde, wurden die Werte der letzten Beobachtung unter Therapie übernommen. Es erfolgte eine Auswertung in Untergruppen, abhängig vom Nachweis von Organmanifestationen zu Therapiebeginn. Untersucht wurde ein aussagekräftiges Studienkollektiv mit eher niedriger Krankheitsaktivität. Die Therapie mit Belimumab am UKD wurde für die meisten Patient*innen als erfolgreich bewertet; von 27 Therapien wurden 21 (78 %) von den behandelnden Ärzt*innen als erfolgreich eingeschätzt, was auf eine gute Wirksamkeit in der Population hinweist. Die Zahl symptomfreier Personen stieg innerhalb von 12 Monaten von 1 auf 7 und im weiteren Therapieverlauf auf 10. Es zeigten sich signifikante Änderungen von klinischen Scores und Komplementproteinen; so fiel der mediane SLEDAI von 6 auf 4 Punkte und das mediane C4 stieg von 0,09 g/l innerhalb von 12 Monaten auf normwertige 0,10 g/l sowie im weiteren Verlauf auf 0,16 g/l. Die mittlere Prednisolondosierung wurde innerhalb von 12 Monaten von 5,8 mg/d auf 5,0 mg/d und langfristig auf 3,3 mg/d gesenkt. Belimumab zeigte sich bei 6 von 6 Patient*innen mit Exanthem und 4 von 6 Patient*innen mit Arthritis mit fast vollständigem Symptomrückgang sehr gut wirksam. Von 10 Patient*innen mit einem initialem Prednisolonbedarf von ≥ 7,5mg/d konnten 6 ihre Prednisolondosis um mindestens 25 % senken. Das Symptom Fatigue wurde bei 6 von 18 Patient*innen nach 12 Monaten nicht mehr dokumentiert. Von 11 Patient*innen mit Raynaud-Symptomatik wurde ebendiese nach 12 Monaten nur noch von 7 dokumentiert. Es zeigten sich keine Hinweise auf eine Wirksamkeit auf Leuko- oder Thrombopenie. In weiteren Studien könnte die Wirksamkeit von Belimumab bei Patient*innen mit Lupusnephritis, Raynaud-Symptomatik, Fatigue, hämatologischer Beteiligung und niedriger Krankheitsaktivität weiter untersucht werden.:INHALTSVERZEICHNIS III ABKÜRZUNGSVERZEICHNIS VIII 1 EINLEITUNG 10 1.1 Systemischer Lupus erythematodes (SLE) 10 1.1.1 Geschichte 10 1.1.2 Epidemiologie 11 1.1.3 Ätiologie und Pathogenese 11 1.1.4 Symptome 12 1.1.4.1 Konstitutionell 14 1.1.4.2 Hämatologisch 14 1.1.4.3 Neuropsychiatrisch 14 1.1.4.4 Mukokutan 14 1.1.4.5 Serositis 15 1.1.4.6 Muskuloskelettal 15 1.1.4.7 Renal 15 1.1.4.8 weitere Symptome 15 1.1.5 Diagnostik 16 1.1.5.1 Anamnese 16 1.1.5.2 Klinische Untersuchung 16 1.1.5.3 Labordiagnostik 16 1.1.6 Aktivitätsmessung 17 1.1.7 Letalität 17 1.1.8 Sozioökonomische Belastung und QOL-Einschränkung 18 1.1.9 Klassifikationskriterien 19 1.1.10 Aktivitätsscores 20 1.1.11 Therapie 20 1.1.11.1 Basismaßnahmen 21 1.1.11.2 Glukokortikoide 21 1.1.11.3 DMARDs (disease-modifying anti-rheumatic drugs) 21 1.1.11.4 Cyclophosphamid 22 1.2 Belimumab 23 1.2.1 Wirkmechanismus 23 1.2.2 Zulassungsstudien 23 1.2.2.1 Studienpopulation 24 1.2.2.2 nachgewiesene Effekte 24 Unerwünschte Arzneimittelwirkungen (UAW) in den Zulassungsstudien 25 1.2.2.3 Zulassung 26 1.2.3 Belimumab in der klinischen Anwendung 26 2 FRAGESTELLUNG 27 3 MATERIAL UND METHODEN 28 3.1 Studienkollektiv 28 3.2 Ethik 28 3.3 Erhobene Daten 28 3.3.1 Charakterisierung des Studienkollektivs 29 3.3.2 Datumsangaben 29 3.3.3 Zeitpunkte 29 3.3.4 Zeitpunktabhängige Parameter 30 3.3.5 Erhobene, nicht aussagekräftige Daten 32 3.3.6 Organmanifestationen 32 3.4 Quellen 33 3.4.1 Patient*innenakte 34 3.4.2 Ärztliche Verlaufsdokumentation 34 3.4.3 Medikamente 35 3.4.4 SLE-Bogen 35 3.4.5 Laborwerte 36 3.4.6 Berechnung von klinischen Scores 37 3.4.7 Therapieerfolg 37 3.4.8 Dokumentationsungenauigkeiten 37 3.5 Statistische Verfahren 38 3.5.1 Normalverteilung 38 3.5.2 Signifikanztests 39 4 ERGEBNISSE 41 4.1 Studienkollektiv 41 4.1.1 Allgemeine Zusammensetzung 41 4.1.2 Erfüllung der EULAR/ACR2019-Kriterien 43 4.1.3 Antikörperstatus 44 4.1.4 Charakterisierung der einzelnen Patient*innen 45 4.2 Zeitpunktübergreifende Ergebnisse 49 4.2.1 Auswertungszeitraum 49 4.2.2 Therapiedauer 50 4.2.3 Zeitpunkte und beendete Therapien 50 4.2.4 Therapieerfolg 51 4.2.5 Krankheitsschübe und Prednisolonstoßtherapien 52 4.2.6 weitere Medikamente 53 4.2.7 Unerwünschte Arzneimittelwirkungen 53 4.3 Zeitpunktabhängige Ergebnisse 55 4.3.1 Datumsdifferenzen 55 4.3.2 Prednisolonbasistherapie 56 4.3.3 Symptome 56 4.3.4 Paraklinik 58 4.3.5 Scores 58 4.3.6 Angaben auf der visuellen Analogskala 59 4.4 Auswertung nach Patient*innengruppen 61 4.4.1 Indikationsrelevante Organbeteiligungen 61 4.4.2 Patient*innen mit Arthritis 62 4.4.3 Patient*innen mit Fatigue 64 4.4.4 Patient*innen mit Exanthem 67 4.4.5 Patient*innen mit Raynaud-Symptomatik 68 4.4.6 Patient*innen mit hämatologischer Beteiligung 70 4.4.7 Patient*innen mit hohem Prednisolonbedarf 74 4.4.8 Patient*innen mit aktiver Lupusnephritis 76 5 DISKUSSION 78 5.1 Stärken und Schwächen der Studie 78 5.1.1 Anzahl der Patient*innen 78 5.1.2 Definition des Therapieerfolgs 78 5.1.3 Schubförmiger Verlauf der Erkrankung 79 5.1.4 Systematischer Fehler der Scores 79 5.1.5 Fortführung der letzten Beobachtung bei Patient*innen mit beendeter Therapie 80 5.1.6 Last visit-Zeitpunkt 80 5.1.7 Auswertung nach Patient*innengruppen 80 5.2 Studienkollektiv 82 5.2.1 Allgemeine Zusammensetzung 82 5.2.2 Erfüllung der EULAR/ACR2019-Kriterien 84 5.2.3 Antikörperstatus 86 5.3 Zeitpunktübergreifende Ergebnisse 87 5.3.1 Therapieerfolg 87 5.3.2 Krankheitsschübe und Prednisolonstoßtherapien 87 5.3.3 weitere Medikamente 87 5.3.4 Unerwünschte Arzneimittelwirkungen 87 5.4 Zeitpunktabhängige Ergebnisse 89 5.4.1 Datumsdifferenzen 89 5.4.2 Prednisolonbasistherapie 89 5.4.3 Symptome 89 5.4.4 Paraklinik 89 5.4.5 Scores 90 5.4.6 Angaben auf der visuellen Analogskala 91 5.5 Auswertung nach Patient*innengruppen 92 5.5.1 Indikationsrelevante Organbeteiligungen 92 5.5.2 Patient*innen mit Arthritis 93 5.5.3 Patient*innen mit Fatigue 93 5.5.4 Patient*innen mit Exanthem 93 5.5.5 Patient*innen mit Raynaud-Symptomatik 94 5.5.6 Patient*innen mit hämatologischer Beteiligung 94 5.5.7 Patient*innen mit hohem Prednisolonbedarf 94 5.5.8 Patient*innen mit aktiver Lupusnephritis 95 5.6 Relevanteste Ergebnisse 96 5.7 Ausblick 97 6 ZUSAMMENFASSUNG 98 7 SUMMARY 99 LITERATURVERZEICHNIS 106 ANHANG 123 DANKSAGUNG 124 ANLAGE 1: ERKLÄRUNG ZUR ERÖFFNUNG DES PROMOTIONSVERFAHRENS 125 ANLAGE 2: ERKLÄRUNG ZUR EINHALTUNG AKTUELLER GESETZLICHER VORGABEN 126

Patients with connective tissue diseases (CTD) such as systemic lupus erythematosus (SLE) have an increased risk for infections. This study investigated the outcome and characteristics of CTD patients under intensive care unit (ICU) treatment for sepsis

Background: The prevalence of herpes zoster (HZ) is high in patients with rheumatic diseases. Systemic lupus erythematosus (SLE) doubles the risk for developing HZ. However, little is known about natural humoral immunity against varicella zoster virus (VZV) in patients with SLE. Hence, we compared VZV IgG antibody concentrations in a group of SLE patients with healthy controls and patients with rheumatoid arthritis (RA). Methods: n = 56 patients with SLE, n = 54 patients with RA, and n = 56 healthy controls were included in this study. The VZV IgG antibody concentration was measured using an enzyme-linked immunosorbent assay (ELISA). The antibody concentrations were compared between the groups. Results: Overall IgG antibody titers for VZV in SLE patients were comparable to healthy controls but higher when compared to patients with rheumatoid arthritis (p = 0.0012). In consequence, antibody levels in controls were higher than in RA patients (p = 0.0097). Stratification by age revealed highest titers among SLE patients in the fourth life decade (p = 0.03 for controls, p = 0.0008 for RA patients) whereas RA patients in their sixth decade had the lowest antibody concentration (p = 0.03 for controls, p = 0.04 for SLE patients). Regarding the individual HZ history, antibody levels of SLE patients with a positive history exceeded all other groups. Conclusions: Although humoral VZV immunity in SLE patients is comparable to healthy controls it seems to be pronounced in young SLE patients between 30 and 39. The lowest VZV IgG levels were found in RA patients. HZ seems to induce antibody production, particularly in patients with SLE. Immunological processes might contribute to VZV antibody levels in SLE patients, but further investigations are needed to substantiate this hypothesis. Even though the increased HZ prevalence seems to be independent of humoral immunity in SLE patients, reduced humoral immunity might contribute to HZ in RA patients. The available HZ subunit vaccination might be an appropriate way to reduce the HZ risk in patients with rheumatic diseases.