A vacina contra hepatite B tem sido implicada como um desencadeador de doenças auto-imunes, mas ainda não existem estudos prospectivos no lúpus. Assim, avaliamos prospectivamente a segurança e eficácia da imunização com a vacina recombinante contra hepatite B (Euvax B® - LG) em pacientes com diagnóstico de lúpus. Foram selecionadas 28 pacientes com a doença inativa (SLEDAI<4), com idade entre 18 e 50 anos e sorologia negativa para o vírus da hepatite B (VHB). Os critérios de exclusão foram o uso de prednisona >=20 mg/dia e drogas imunossupressoras, anti-dsDNA e anticardiolipina negativos. Os dados clínicos e laboratoriais foram coletados na entrada do estudo e um mês após cada dose da vacina. Além disso, obtivemos dados do ano anterior usando o prontuário eletrônico padronizado. A média de idade foi de 34 ± 7,7 anos e a média da duração da doença foi de 10,4 ± 6,7 anos. Soroconversão adequada foi atingida no final do estudo (93%), embora tenhamos observado uma baixa freqüência após a primeira dose (4%) e após a segunda dose (54%). Nenhuma alteração significativa na média de SLEDAI foi detectada após cada dose durante o estudo (0,14 ± 0,52 vs. 0 vs. 0,61 ± 1,66 vs. 0,36 ± 1,34, p=0,11). Reforçando estes achados, os 11% de atividade de doença durante o período de vacinação foi semelhante aos 21% observados no ano anterior (p=0,46). Além disso, a média da dose de prednisona na entrada foi comparável à dose do final do estudo (2,86 ± 3,06 vs. 4,64 ± 8,25 mg/d, p=0,32). A freqüência do uso de terapia imunossupressora no período da vacinação (11%) foi semelhante aos 14% observados no ano anterior (p=0,66). A vacinação contra hepatite B apresentou uma resposta de anticorpos protetores adequada e foi segura nos pacientes com lúpus inativo. / Hepatitis B vaccination has been implicated as a potential trigger for autoimmune diseases but there are no prospective studies in lupus. We therefore assessed prospectively the safety and efficacy of immunization with recombinant DNA hepatitis B vaccine (Euvax B® - LG) in SLE patients. Twenty-eight consecutive inactive SLE patients (SLEDAI<4), age between 18-50 years and negative serology for hepatitis B virus (HBV) were selected. Exclusion criteria were prednisone > 20mg/day and immunosuppressive drugs. Clinical and laboratorial assessments were obtained at study entry and one month after the three doses. In addition, a previous one year evaluation was performed using a standard electronic protocol. The mean age was 34 ± 7.7 years and disease duration was 10.4 ± 6.7 years. An adequate seroconversion was achieved at the end of the study (93%), although a lower frequency after the first (4%) and second dose (54%) was observed. No significant change in mean SLEDAI score was detected after each dose throughout the study (0.14 ± 0.52 vs. 0 vs. 0.61 ± 1.66 vs. 0.36 ± 1.34, p=0.11). Reinforcing these findings, the 11% flares during vaccination was similar to the 21% observed in the previous year (p=0.46). Furthermore, the mean prednisone dose at study entry was comparable to the end of the study (2.86 ± 3.06 vs. 4.64 ± 8.25 mg/d, p=0.32). In addition, the frequency of immunosuppressive therapy during the vaccination period (11%) was alike to the 14% observed in the previous year before entry (p=0.66). Hepatitis B vaccination was safe in inactive SLE patients with an adequate vaccine response rate.

Proteinúria é a principal manifestação da nefrite lúpica (NL) e reflete lesão no podócito. Análise dos biomarcadores do podócito foi realizada com o objetivo de identificar se o fenótipo podocitário é distinto na NL membranosa pura e proliferativa. Expressão de sinaptopodina, proteína 1 do tumor de Wilms (Wilms tumor protein 1 - WT1), proteína epitelial glomerular 1 (glomerular epitelial protein 1 - GLEPP1) e nefrina foi avaliada em 52 biópsias de NL por imunohistoquímica. Expressão preservada de sinaptopodina foi observada em apenas 10 (19,2%) de todas as biópsias enquanto que 42 (80,8%) apresentavam expressão reduzida. Ambos os grupos tinham proteinúria semelhante no momento da biópsia (p = 0,22), porém, no seguimento médio de quatro anos houve uma tendência para menores níveis médios de proteinúria nos pacientes com marcação preservada de sinaptopodina (0,26 ± 0,23 vs 0,84 ± 0,90 g/24 h, p = 0,05) do que naqueles com expressão reduzida. Trinta e nove (75%) biópsias foram classificadas como proliferativa e treze (25%) como membranosa pura. Comparação dos biomarcadores do podócito demonstrou predomíno de marcação preservada de sinaptopodina (69,2%), WT1 (69,2%), GLEPP1 (53,9%) e nefrina (60%) no grupo membranosa pura enquanto apenas < 10% das proliferativas apresentaram expressão preservada. Nossos dados sugerem que nas classes proliferativas parece haver lesão estrutural do podócito, enquanto que na membranosa pura o padrão predominantemente preservado sugere uma lesão funcional do podócito que pode ser responsável pelo melhor prognóstico a longo prazo do desfecho da proteinúria / Proteinuria is a major feature of lupus nephritis (LN) and reflects podocyte injury. Analysis of podocyte biomarkers was performed attempting to identify if podocyte phenotype is distinct in pure membranous and proliferative LN. Expression of synaptopodin, Wilms tumor protein 1 (WT1), glomerular epithelial protein 1 (GLEPP1) and nephrin was evaluated in 52 LN biopsies by immunohistochemistry. Preserved synaptopodin expression was observed in only 10 (19,2%) of all biopsies while 42 (80,8%) had a reduced expression. Both groups had comparable proteinuria at the time of biopsy (p=0,22), however, in the mean follow-up of four years there was a tendency to lower mean levels of proteinuria in patients with preserved synaptopodin staining (0,26 ± 0,23 vs. 0,84 ± 0,90 g/24 h, p=0,05) than those with diminished expression. Thirty-nine (75%) biopsies were classified as proliferative and thirteen (25%) as pure membranous. Comparison of podocyte biomarkers demonstrated a predominance of preserved staining of synaptopodin (69,2%), WT1 (69,2%), GLEPP1 (53,9%) and nephrin (60%) in the pure membranous group whereas only < 10% of the proliferative showed preserved expression. Our data suggest that in proliferative forms there seems to occur structural podocyte damage, whereas in the pure membranous the predominant preserved pattern suggests a dysfunctional podocyte lesion that may account for the better long-term prognosis of proteinuria outcome

Introdução: Os anticorpos antiproteína P ribossomal (anti-P) são considerados marcadores sorológicos específicos do Lúpus Eritematoso Sistêmico (LES) e estão associados a acometimento hepático nesta doença. As semelhanças entre a hepatite autoimune (HAI) e a hepatite associada ao LES levou ao questionamento se o anticorpo anti-P também estaria presente na HAI. Objetivo: Avaliar a frequência e significância clínica do anticorpo anti-P em uma grande coorte de pacientes com HAI. Métodos: Foram analisados os soros de 96 pacientes com HAI, coletados no diagnóstico e comparados com 82 soros de indivíduos saudáveis. Todos os soros foram testados para a presença do anticorpo anti-P pelo método de ELISA, do anticorpo anti-DNA de dupla fita pelo método de imunofluorescência indireta usando Crithidia luciliae e do anticorpo anti-Sm pelo método de ELISA. Os critérios de exclusão adotados foram a presença de outros anticorpos específicos de LES como o anti-DNA de dupla fita (n=1) e o anti-Sm (n=2) ou se o paciente apresentasse o diagnóstico de LES definido pelo Colégio Americano de Reumatologia (n=0). Os prontuários médicos foram revisados para dados demográficos, clínicos e resultados de exames laboratoriais relacionados a hepatopatia e anticorpos específicos de HAI. Resultado: Títulos moderados ou alto (> 40 U) de anti-P foram encontrados em 9,7% (9/93) dos pacientes com HAI e em nenhum dos controles (p = 0,003). No diagnóstico, os pacientes com anti-P positivo ou negativo apresentavam características demográficas/clínicas semelhantes, como a frequência de cirrose (44,4% vs 28,5%, p = 0,44) e exames laboratoriais relacionados a hepatite (p > 0,05). Entretanto, ao final do seguimento destes pacientes (média de 10,2 ± 4,9 anos), os pacientes positivos para anticorpos anti-P apresentaram uma maior frequência de cirrose quando comparados a pacientes negativos para anti-P (100% vs 60%, p = 0,04). Conclusão: a demonstração da presença do anticorpo anti-P em pacientes com HAI sem evidência de LES sugere um mecanismo comum de acometimento hepático nestas duas doenças. Além disso, a presença deste anticorpo parece predizer um pior prognóstico nos pacientes com HAI / Background: Autoantibodies to ribosomal P proteins (anti-rib P) are specific serological markers for systemic lupus erythematosus (SLE) and are associated with liver involvement in this disease. The similarity in autoimmune background between autoimmune hepatitis (AIH) and SLE- associated hepatitis raises the possibility that anti-rib P antibodies might also have relevance in AIH. Aims: To evaluate the frequency and clinical significance of anti-rib P antibodies in a large AIH cohort. Methods: Sera obtained at diagnosis of 96 AIH patients and of 82 healthy controls were tested for IgG anti-ribosomal P protein by ELISA. All of the sera were also screened for other lupus-specific autoantibodies, three patients with the presence of anti-dsDNA (n=1) and anti-Sm (n = 2) were excluded. Results: Moderate to high titers (> 40 U) of anti-rib P antibody were found in 9.7% (9/93) of the AIH patients and none of the controls (P = 0.003). At presentation, AIH patients with and without anti-rib P antibodies had similar demographic/clinical features, including the frequency of cirrhosis (44.4% vs. 28.5%, P = 0.44), hepatic laboratorial findings (p > 0.05). Importantly, at the final observation (follow-up period 10.2 ± 4.9 years), the AIH patients with anti-rib P had a significantly higher frequency of cirrhosis compared to the negative group (100% vs. 60%, P = 0.04). Conclusion: The novel demonstration of anti-rib P in AIH patients without clinical or laboratory evidence of SLE suggests a common underlying mechanism targeting the liver in these two diseases. In addition, this antibody appears to predict the patients with worse AIH prognoses

A vacina contra hepatite B tem sido implicada como um desencadeador de doenças auto-imunes, mas ainda não existem estudos prospectivos no lúpus. Assim, avaliamos prospectivamente a segurança e eficácia da imunização com a vacina recombinante contra hepatite B (Euvax B® - LG) em pacientes com diagnóstico de lúpus. Foram selecionadas 28 pacientes com a doença inativa (SLEDAI<4), com idade entre 18 e 50 anos e sorologia negativa para o vírus da hepatite B (VHB). Os critérios de exclusão foram o uso de prednisona >=20 mg/dia e drogas imunossupressoras, anti-dsDNA e anticardiolipina negativos. Os dados clínicos e laboratoriais foram coletados na entrada do estudo e um mês após cada dose da vacina. Além disso, obtivemos dados do ano anterior usando o prontuário eletrônico padronizado. A média de idade foi de 34 ± 7,7 anos e a média da duração da doença foi de 10,4 ± 6,7 anos. Soroconversão adequada foi atingida no final do estudo (93%), embora tenhamos observado uma baixa freqüência após a primeira dose (4%) e após a segunda dose (54%). Nenhuma alteração significativa na média de SLEDAI foi detectada após cada dose durante o estudo (0,14 ± 0,52 vs. 0 vs. 0,61 ± 1,66 vs. 0,36 ± 1,34, p=0,11). Reforçando estes achados, os 11% de atividade de doença durante o período de vacinação foi semelhante aos 21% observados no ano anterior (p=0,46). Além disso, a média da dose de prednisona na entrada foi comparável à dose do final do estudo (2,86 ± 3,06 vs. 4,64 ± 8,25 mg/d, p=0,32). A freqüência do uso de terapia imunossupressora no período da vacinação (11%) foi semelhante aos 14% observados no ano anterior (p=0,66). A vacinação contra hepatite B apresentou uma resposta de anticorpos protetores adequada e foi segura nos pacientes com lúpus inativo. / Hepatitis B vaccination has been implicated as a potential trigger for autoimmune diseases but there are no prospective studies in lupus. We therefore assessed prospectively the safety and efficacy of immunization with recombinant DNA hepatitis B vaccine (Euvax B® - LG) in SLE patients. Twenty-eight consecutive inactive SLE patients (SLEDAI<4), age between 18-50 years and negative serology for hepatitis B virus (HBV) were selected. Exclusion criteria were prednisone > 20mg/day and immunosuppressive drugs. Clinical and laboratorial assessments were obtained at study entry and one month after the three doses. In addition, a previous one year evaluation was performed using a standard electronic protocol. The mean age was 34 ± 7.7 years and disease duration was 10.4 ± 6.7 years. An adequate seroconversion was achieved at the end of the study (93%), although a lower frequency after the first (4%) and second dose (54%) was observed. No significant change in mean SLEDAI score was detected after each dose throughout the study (0.14 ± 0.52 vs. 0 vs. 0.61 ± 1.66 vs. 0.36 ± 1.34, p=0.11). Reinforcing these findings, the 11% flares during vaccination was similar to the 21% observed in the previous year (p=0.46). Furthermore, the mean prednisone dose at study entry was comparable to the end of the study (2.86 ± 3.06 vs. 4.64 ± 8.25 mg/d, p=0.32). In addition, the frequency of immunosuppressive therapy during the vaccination period (11%) was alike to the 14% observed in the previous year before entry (p=0.66). Hepatitis B vaccination was safe in inactive SLE patients with an adequate vaccine response rate.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease affecting 20 to 250 individuals per 100,000 worldwide. Symptomology includes dermatological manifestations such as discoid lesions, acute cutaneous rashes, and oral and nasal ulcers, along with musculoskeletal, pulmonary, and renal complications. Abnormal T and B lymphocyte function and apoptosis, immune complex clearance, complement function, and nucleosome processing are typical of disease pathophysiology. SLE is the result of both environmental and genetic factors, which together create the conditions leading to disease onset and progression. Of these environmental factors, Epstein-Barr virus (EBV) infection is known to cause the genesis of cross-reactive antibodies in SLE prone individuals that can initiate disease activity. Viral infection and modulation of cellular genes is important in understanding the microenvironment that could lead to immune mis-regulation and the inception of lupus in those individuals at risk. During disease development, a variety of variables assist and detract from disease progression and the quality of life experienced by SLE patients. Research into EBV-infected naïve B lymphocytes revealed that EBV modulates the chemotactic receptor EBI2 during viral infection via the BRRF1 viral gene product Na. This likely changes B lymphocyte chemotaxis in secondary tissue in virally infected B cells. Current literature suggests this results in sequestration of cells to peripheral areas of the tissue and mis-regulation of the immune response. It is not uncommon for SLE patients to have neuropsychiatric disorders due to lupus disease activity. With SLE patients being up to 6 times more at risk for depression, recognition and treatment of depression and anxiety have been shown to improve quality of life, pain, and treatment outcomes. Two studies investigate both clinical laboratory and psychosocial assessment variables that we suspect to be correlated with depression in patients with SLE. Univariate and multivariate analysis from our first study identified an array of variables that show strong associations with depression, including: Body Mass Index, Pain, Total Complement, fatigue assessments, and SF-36 scores. The second study found similar associations, but further found that serum IL-10 levels demonstrated a strong correlation with depression in SLE patients. In this final study SLE patients are compared alongside healthy, clinically depressed, and rheumatoid arthritis patients to provide evidence that increased depression in SLE patients is due more to disease pathology than a result of chronic inflammation.

The Association of Cancer Development in Patients with Systemic Lupus Erythematosus by Rose Michelle Coley MPH, Walden University, 2011 BS, University of Mount Olive, 2008 Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Public Health Walden University March 2016 Both cancer and autoimmune diseases have been associated with numerous factors that may independently lead to the development of either disease. When these factors overlap the difficulty in assessing association is compounded. The numerous factors that are thought to cause systemic lupus erythematosus (SLE), which leads to the development of cancer, makes the study of an association between the 2 diseases challenging. The purpose of this study was to examine whether the risk of cancer development increased in SLE patients compared to the risk in non-SLE patients. Researchers have not shown consistent relationships of cancer development in patients with SLE; however, consideration of the various factors that contribute to the diseases is necessary to measure an association between the 2 diseases. This study used the Clinical Practice Research database (CPRD), a large, population-based database to test the relationship between SLE and cancer. A matched retrospective cohort study among SLE (n=3025) and non-SLE (n=180555) patients was conducted using the propensity score methodology to help balance the differences between the comparison groups. The propensity score methodology created a similar distribution of observed baseline covariates between the 2 groups. With adjustment for age, the predictor variable of SLE indicates that a patient with SLE is still 2.7 times more likely to develop cancer than is a non-SLE patient. The study outcomes could promote positive social change by reinforcing current recommendations for cancer screenings in persons with SLE, which could enhance the ability to detect cancer early enough to decrease mortality because of cancer in persons with SLE.

<p>Linkage in the 2q37 region was evaluated using microsatellite markers in multi-case families from Sweden, Iceland and Norway. Both the two-point and the multipoint linkage analysis show highly significant LOD scores (Z=4.51 and 6.03, respectively). Linkage disequilibrium mapping indicates that some association exists in this region. The <i>PDCD1</i> gene was suggested as a candidate gene within the 2q37 locus due to its importance in immune regulation. Indeed, one haplotype, described by the presence of allele A of the PD1.3 SNP located within intron 4 of this gene, shows linkage to SLE in the Nordic families. The PD1.3A allele is also found to be strongly associated in familiar and sporadic cases of SLE in Europeans and Mexicans. Functional studies further support PD1.3A to be a susceptibility allele for SLE.</p><p>The 1q23 region, containing the genes for the low affinity Fcγ receptors, was fine mapped using single- and multi- case families of various origins. Genetic variants of those genes were analysed and association is found to both the risk alleles of <i>Fc</i>γ<i>RIIA</i> and <i>Fc</i>γ<i>RIIIA</i> in all families. In these families, a single haplotype carrying both risk alleles is predominantly transmitted to patients with SLE, suggesting a presence of linkage disequilibrium between those two genes. <i>Fc</i>γ<i>RIIA</i> and <i>Fc</i>γ<i>RIIIA</i> are also found to be associated to SLE and lupus nephritis in a case-control cohort from Sweden. In the same cohort, the PD1.3A allele shows strong association to lupus nephritis. We suggest that there may be an additive effect between <i>Fc</i>γ<i>RIIA</i> and <i>PDCD1</i>, since having the disease-associated genotypes at both loci gives an increased risk for developing lupus nephritis.</p><p>Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disorder with a complex multifactorial aetiology. Genetic studies suggest that several genes are involved in disease pathogenesis and that extended genetic heterogeneity is present.</p>

<p>The aim with this thesis has been to identify genes involved in the pathogenesis of Systemic Lupus Erythematosus (SLE). SLE is a systemic autoimmune disorder, most likely caused by both several genetic and environmental factors. </p><p>In order to identify susceptibility loci for the disease we performed linkage analyses on data from 70 families of various ethnic origins. Significant linkage was found in two regions. One region (chromosome 17p12-q11) was linked to SLE in a set of Argentine families. Since the same region had been previously identified in several linkage studies on Multiple Sclerosis patients, we propose that this locus may contain a genetic variant that affects not only SLE, but also autoimmunity in general. The second locus is located on chromosome 4p14-13 and has only been identified in a set of Icelandic families. We suggest that this locus contains a mutation that has been enriched in the Icelandic population due to its population history.</p><p>The <i>BCL2 </i>gene has been suggested as a candidate gene for SLE. Three markers in this gene were investigated for association with the disease in two different populations. However, no association could be found with any of the markers or when these markers were analysed together as a haplotype. We conclude that the <i>BCL2</i> gene is not associated with SLE in our material. This result contradicts previously published results of an association between <i>BCL2</i> and SLE. </p><p>We suggest that the PD-1 pathway (involved in inhibition of T- and B-cell responses) is an important component in SLE pathogenesis. A regulatory variant in the <i>PD-1</i> gene had previously been associated with SLE and here we show strong association (p<0.0001) to a haplotype containing SNPs in both <i>PD-L1</i> and <i>PD-L2</i>. </p><p>Our results indicate that SLE is a disease caused by several genetic variations that differ between families and populations.</p>

Systemic lupus erythematosus (SLE) is a chronic and complex autoimmune disorder characterized by a failure in the mechanism of self-tolerance and production of autoantibodies, potentially affecting any organ in the body. The genetic factors behind the disease have been extensively studied in the past years and to date a list of more than 30 loci have been associated with SLE. However, very little is known about the functional significance of the risk variants. In this thesis, we focused on the analysis of SLE-associated variants in three genes: interferon regulatory factor 5 (IRF5), CD226 and the microRNA 146a. In paper I, we analyzed four polymorphisms in the IRF5 gene in a large set of individuals from different populations. We replicated a strong association of a promoter indel in our meta-analysis, but expression analysis indicated that it is rather another variant, SNP rs10954213 in the poly(A) signal of the gene that is in fact the major contributor to the altered gene expression in leukocytes. In manuscript II, we further characterized the regulation of IRF5 expression, showing that this gene can be up-regulated by estrogen in PBMCs and monocytes, regardless of the genotype, which could to some extent, explain the sex-bias of SLE. In paper III, we investigated the association of CD226 with SLE and the potential functional effect of the associated variants. The genetic analysis showed an association of a three-SNP-haplotype located at the 3’UTR region of the gene. The risk haplotype correlated with lower CD226 protein expression on the surface of cytotoxic and helper T cells, as well as in NK T cells. Reporter assays pointed to rs727088 in the 3’UTR as the main responsible variant for altered gene expression. In paper IV, we described the association of a variant in microRNA miR-146a, involved in the interferon pathway, with SLE in Europeans, which could in addition be correlated with decreased expression of both mature and primary miR-146a in leukocytes. In summary, we have investigated the genetic association of three genes with SLE in a large cohort of individuals and identified variants responsible for functional alterations of these genes, providing further insight into the pathogenesis of SLE.

Linkage in the 2q37 region was evaluated using microsatellite markers in multi-case families from Sweden, Iceland and Norway. Both the two-point and the multipoint linkage analysis show highly significant LOD scores (Z=4.51 and 6.03, respectively). Linkage disequilibrium mapping indicates that some association exists in this region. The PDCD1 gene was suggested as a candidate gene within the 2q37 locus due to its importance in immune regulation. Indeed, one haplotype, described by the presence of allele A of the PD1.3 SNP located within intron 4 of this gene, shows linkage to SLE in the Nordic families. The PD1.3A allele is also found to be strongly associated in familiar and sporadic cases of SLE in Europeans and Mexicans. Functional studies further support PD1.3A to be a susceptibility allele for SLE. The 1q23 region, containing the genes for the low affinity Fcγ receptors, was fine mapped using single- and multi- case families of various origins. Genetic variants of those genes were analysed and association is found to both the risk alleles of FcγRIIA and FcγRIIIA in all families. In these families, a single haplotype carrying both risk alleles is predominantly transmitted to patients with SLE, suggesting a presence of linkage disequilibrium between those two genes. FcγRIIA and FcγRIIIA are also found to be associated to SLE and lupus nephritis in a case-control cohort from Sweden. In the same cohort, the PD1.3A allele shows strong association to lupus nephritis. We suggest that there may be an additive effect between FcγRIIA and PDCD1, since having the disease-associated genotypes at both loci gives an increased risk for developing lupus nephritis. Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disorder with a complex multifactorial aetiology. Genetic studies suggest that several genes are involved in disease pathogenesis and that extended genetic heterogeneity is present.