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Hyperacute renal failure is rarely the initial presentation of systemic lupus erythematosus (SLE). Pregnancy can predispose untreated lupus nephritis to acute renal failure. Collapsing glomerulopathy (CG) type of renal failure is not a new clinicopathological entity. There have been documented cases prior to 1979. It is thought that detection bias coupled with the predilection for HIV has caused this form of glomerulopathy to be incorrectly named or diagnosed as 'malignant focal segmental glomerulosclerosis (FSGS)'. This is a case of CG described in lupus nephritis. We present a case of untreated lupus in a female in whom pregnancy triggered the exacerbation of lupus nephritis that presented as collapsing glomerulopathy.

Systemic lupus erythematosus (SLE) is a chronic multifactorial inflammatory autoimmune disease with heterogeneous clinical manifestations. Among different manifestations, lupus nephritis (LN) remains a major cause of morbidity and mortality. There are few FDA approved treatments for LN. In general, they are non-selective and lead to global immunosuppression with significant side effects including an increased risk of infection. In the past 60 years, only one new drug, belimumab was approved for lupus disease with modest efficacy in clinic and not approved for patients suffering for nephritis. Therefore, it is urgent to develop new treatments to replace or reduce the use of current ones. Histone deacetylase 6 (HDAC6) plays a variety of biologic functions in a number of important molecular pathways in diverse immune cells. Both innate and adaptive immune cells contribute to pathogenesis of lupus. Among those cells, B cells play a central role in pathogenesis of lupus nephritis in an anti-body dependent manner through differentiation into plasma cells (PCs). As a result, HDAC6 inhibitors represent an entirely new class of agents that could have potent effects in SLE. Importantly, the available toxicity profile suggests that HDAC6 inhibitors could be advanced into SLE safely. We have demonstrated previously that histone deacetylase (HDAC6) expression is increased in animal models of systemic lupus erythematosus (SLE) and that inhibition of HDAC6 decreased disease. ACY-738 is a hydroxamic acid HDAC6 inhibitor that is highly selective for HDAC6. In our current studies, we tested if an orally selective HDAC6 inhibitor, ACY-738, would decrease disease pathogenesis in a lupus mouse model with established early disease. Moreover, we sought to delineate the cellular and molecular mechanism(s) of action of a selective HDAC6 inhibitor in SLE. In order to define the mechanism by which HDAC6 inhibition decreases disease pathogenesis in NZB/W mice by using RNAseq to evaluate the transcriptomic signatures of splenocytes from treated and untreated mice coupled with applied computational cellular and pathway analysis. In addition, we sought to bridge between the transcriptomic data obtained from the HDAC6 treated mice and human gene expression information to determine the relevance to this target in possibly controlling human lupus. We treated 20-week-old (early-disease) NZB/W F1 female mice with two different doses of the selective HDAC6 inhibitor (ACY-738) for 4~5 weeks. As the mice aged, we determined autoantibody production and cytokine levels by ELISA, and renal function by measuring proteinuria. At the termination of the study, we performed a comprehensive analysis on B cells, T cells, and innate immune cells using flow cytometry and examined renal tissue for immune-mediated pathogenesis using immunohistochemistry and immunofluorescence. We then used RNAseq to determine the genomic signatures of splenocytes from treated and untreated mice and applied computational cellular and pathway analysis to reveal multiple signaling events associated with B cell activation and differentiation in SLE that were modulated by HDAC6 inhibition. Our results showed a reduced germinal center B cell response, decreased T follicular helper cells and diminished interferon (IFN)-γ production from T helper cells in splenic tissue. Additionally, we found the IFN-α-producing ability of plasmacytoid dendritic cells was decreased along with immunoglobulin isotype switching and the generation of pathogenic autoantibodies. Renal tissue showed decreased immunoglobulin deposition and reduced inflammation as judged by glomerular and interstitial inflammation. The molecular pathways by which B cells become pathogenic PC secreting autoantibodies in SLE are incompletely characterized. RNA sequence data showed that PC development was abrogated and germinal center (GC) formation was greatly reduced. When the HDAC6 inhibitor-treated lupus mouse gene signatures were compared to human lupus patient gene signatures, the results showed numerous immune and inflammatory pathways increased in active human lupus were significantly decreased in the HDAC6 inhibitor treated animals. Pathway analysis suggested alterations in cellular metabolism might contribute to the normalization of lupus mouse spleen genomic signatures, and this was confirmed by direct measurement of the impact of the HDAC6 inhibitor on metabolic activities of murine spleen cells. Taken together, these studies show selective HDAC6 inhibition decreased several parameters of disease pathogenesis in lupus-prone mice. The decrease was in part due to inhibition of B cell development and response. RNA sequence data analysis show HDAC6 inhibition decreases B cell activation signaling pathways and reduces PC differentiation in SLE and suggests that a critical event might be modulation of cellular metabolism. / Doctor of Philosophy / Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease by which immune cells mistakenly attacks healthy self-cells in different organs. Kidney inflammation occurs in nearly 50% of patients with lupus resulting in kidney damage leading to end stage renal disease. Lupus nephritis (LN) is major cause of morbidity and mortality associated with SLE. Current treatments for LN consist primarily of immunosuppressants that block the immune response and leave the patients with unwanted side effects including an increased risk of infection. To circumvent the unwanted side effects, we explored a novel mechanism to target the immune response. My project was to determine whether histone deacetylase 6 (HDAC6) inhibition would suppress the autoimmune inflammatory response in lupus. We found that inhibition of HDAC6 was effective at attenuating early LN, probably by down-regulating innate immune response, which suppressed subsequent adaptive immune responses downstream. HDAC6 inhibition affected the innate immune response by inhibiting type I interferon production by plasmacytoid dendritic cells. HDAC6 inhibition affected the cell mediated immune response by decreasing T helper cell and B cell activation. To determine the mechanism by which HDAC6 inhibits immune cells activation, we used RNAseq to reveal HDAC6 inhibition on multiple signaling events associated with the induction of lupus disease. These results suggest that HDAC6 could be a potential therapeutic target in the early stage of LN.

Systemic lupus erythematosus (SLE) is an autoimmune disease involving the inflammatory damages of multiple organs. Lupus nephritis (LN) as the manifestation in the kidney occurs in more than 50% of SLE patients and is a major cause of morbidity and mortality. Current treatments consist of immunosuppressants that always lead to compromised immune responses with increased risks of infections as the major side effect. To minimize this side effect, it is crucial to develop new treatments that are more natural and specific. Vitamin A, particularly in the form of its functional metabolite, retinoic acid, has shown some beneficial effects against LN in both lupus-prone mouse models and clinical cases. However, a more systemic evaluation of vitamin A treatment in lupus had not been investigated. In our study, we found paradoxical effects of all-trans-retinoic acid (tRA) on lupus-like disease in MRL/lpr lupus-prone mice. Starting at 6 weeks old when the inflammatory environment had been established in MRL/lpr mice, tRA administration reduced immune cell numbers in the secondary lymphoid organs and improved glomerulonephritis. However, circulating autoantibodies and inflammation in renal tubulointerstitium and other organs were increased. The detrimental effects of tRA were not present in MRL control mice, which didn't have an established inflammatory environment at 6 weeks old as shown in MRL/lpr mice, suggesting that the pro-inflammatory effects of tRA are dependent on the pre-existing inflammatory environment. Therefore, to successfully apply vitamin A-based treatment, it is important to avoid the detrimental effects of tRA on lupus by identifying and then specifically eliminating the critical pro-inflammatory immune cell types in lupus. As treatments usually start after the onset of apparent symptoms in patients at the effector stage of autoimmune responses, targeting the inflammatory contributors at this stage appears to be more practical and critical. Among different types of leukocytes, we chose to focus on dendritic cells (DCs), because they are highly diverse and critical in the immune responses as a bridge between the innate and adaptive immune systems. Plasmacytoid DCs (pDCs) as a candidate target have been demonstrated to be crucial for the initiation of lupus development by producing IFNα. However, we demonstrated that although pDCs produced a large amount of IFNα during disease initiation, those from late-stage lupus mice were found to be defective in producing IFNα, suggesting that pDC-targeted treatments should be performed at the initiation stage. This will depend on the progress in early diagnosis in the future. Besides pDCs, we identified a CD11c+ cell population absent at the early-stage but gradually accumulating at the late-stage in the kidneys of lupus mice. These cells have a phenotype of mature monocyte-derived DCs, with particularly high CX3CR1 expression on the surface. Consistent with their pathogenic cytokine profile, in vivo administration of anti-CX3CR1-saporin conjugates to dysfunction these cells in MRL/lpr mice significantly reduced proteinuria scores. Ex vivo activation of renal-infiltrating CD4+ T cells showed increased survival rate, proliferation and IFN-γ production of activated CD4+ T cells when they were cultured with these renal-infiltrating CD11c+ cells. These results suggest that the renal-infiltrating CD11c+ cells are pathogenic and promote inflammation in the kidney at the later effector stage of lupus by interacting with renal-infiltrating CD4+ T cells. In conclusion, although vitamin A showed anti-inflammatory effects on reducing glomerulonephritis, its use in lupus treatment should be guarded due to the other potential pro-inflammatory effects induced by the pre-existing inflammatory environment. IFNα-producing pDCs and CX3CR1highCD11c+ monocyte-derived DCs could be specific therapeutic targets to reduce the established inflammation at the early stage and late stage of LN, respectively. Therefore, it is worthwhile to further investigate the comprehensive effects of combination therapy on lupus, with vitamin A administration and pDCs-specific depletion at the early stage, and CX3CR1highCD11c+ monocyte-derived DCs-specific depletion at the late stage. / Ph. D.

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease with no known cure. Despite years of study, the etiology of SLE is still unclear. Both genetic and environmental factors have been implicated in the disease mechanisms. Gut microbiota as an environmental factor and the immune system interact to maintain tissue homeostasis, but whether this interaction is involved in the pathogenesis of SLE is unclear. In a classical model of lupus nephritis, MRL/lpr, we found decrease of Lactobacillales but increase of Lachnospiraceae in the gut microbiota. Increasing Lactobacillales in the gut by suppling a mixture of 5 Lactobacillus strains improved renal function of these mice and prolonged their survival. Further studies revealed that MRL/lpr mice possessed a "leaky" gut, which was reversed by increased Lactobacillus colonization. Inside the kidney, oral Lactobacillus treatment also skewed the Treg-Th17 balance towards a Treg phenotype. To remove Lachnospiraceae that was higher in lupus-prone mice than controls, we administered vancomycin orally to MRL/lpr mice after disease onset from 9 to 15 weeks of age. Vancomycin functions by removing Gram-positive bacteria such as Lachnospiraceae but sparing Lactobacillus spp. The treatment during active lupus reshaped the gut microbiota and significantly ameliorated systemic autoimmunity and kidney histopathology at 15 weeks of age. However, when vancomycin treatment was initiated from a very early age, the beneficial effect was not observed. Strikingly, mice given vancomycin only at the young age exhibited an even worse disease outcome. Indeed, regulatory B (Breg) cells were found to be reduced after the vancomycin treatment at young age. Importantly, adoptive transfer of Breg cells at 6-7 weeks of age rescued the beneficial effect, which indicates that Breg cells, inducible by vancomycin-sensitive gut microbiota, plays an important role in suppressing lupus disease initiation and progression. Finally, we demonstrated that bacterial DNA from the gut microbiota might be the inducer of Breg cells, as bacterial DNA administration at young age reproduced the beneficial effect seen in the Breg adoptive transfer experiment. Future studies are required to examine the clinical efficacy of targeting gut microbiota as a novel treatment against SLE. / Ph. D.

Introdução: A nefrite lúpica (NL) é o maior preditor de morbidade e mortalidade em pacientes portadores de lupus eritematoso sistêmico. Recentes estudos mostram que a proteína quimiotática de monócitos (MCP-1) está implicada na ativação de células inflamatórias, afetando a progressão e a severidade da NL, e que a excreção urinária do MCP-1 (uMCP-1) está aumentada em pacientes com NL em atividade. Na literatura os dados sobre o polimorfismo do gene MCP-1 A(-2518)G e do seu receptor CCR2 V(-64)I sobre a susceptibilidade para nefrite lúpica ainda estão em discussão. Objetivos: Avaliar a associação entre o polimorfismo do gene MCP-1 e do seu receptor CCR2 em pacientes com NL e indivíduos saudáveis, além da associação de ambos os polimorfismos com parâmetros clínicos e histológicos nos pacientes portadores de NL. Além disso, avaliar a associação entre a excreção urinária do MCP-1 em pacientes portadores de nefrite lúpica em atividade com parâmetros clínicos e histológicos. Pacientes e Métodos: As genotipagens do MCP-1 e do CCR2 foram realizadas em 197 pacientes com nefrite lúpica através da extração do DNA genômico, seguido da técnica de reação em cadeia da polimerase, utilizando-se primers específicos. A dosagem urinária do MCP-1 foi realizada em 34 pacientes com nefrite lúpica em atividade através da técnica de ELISA. Resultados: Foram estudados 197 pacientes portadores de nefrite lúpica, do sexo feminino, com idade média de 28±9,8 anos, sendo 65,5% de etnia branca e 34,5% não-branca, acompanhados em nosso ambulatório durante o período de 69±37,1 meses. Como grupo controle, utilizou-se um grupo de 220 indivíduos saudáveis do sexo feminino, pareados de acordo com idade e etnia. Quanto à distribuição do genótipo do MCP-1, evidenciou-se que a freqüência do genótipo GG foi significativamente maior nos pacientes portadores de nefrite lúpica quando comparado ao grupo controle (12,7%x5,0%) (p=0,019), enquanto que o genótipo AA apresentou maior freqüência no grupo controle, porém sem significância estatística (48,7%x56,8%). Com relação aos alelos, a freqüência do alelo A foi significativamente maior no grupo controle (75,9%x68%) (p=0,007) quando comparada aos pacientes com NL. Já em relação ao polimorfismo do CCR2, não foi observada nenhuma diferença na freqüência do genótipo entre os dois grupos, porém foi observada maior freqüência do alelo V no grupo controle (89,8%x86,3%) (p=0,046). Não houve associação entre o genótipo e alelos do MCP-1 e do CCR2 com a função renal no início e no final do estudo, marcadores imunológicos, manifestações clínicas (SLEDAI) e a classe histológica. Porém, observou-se um predomínio significante dos flares moderado e grave nos pacientes portadores dos genótipos AA e AG (p< 0,05) em relação ao genótipo GG, enquanto que, em relação à distribuição alélica do MCP-1 e ao CCR2, não se notou diferença estatística. Não se evidenciou diferença estatística entre as curvas de sobrevida renal funcional dos pacientes portadores de nefrite lúpica e os genótipos do MCP-1 e CCR2 e seus respectivos alelos. Notou-se diferença estatística na variação da creatinina sérica ao longo do seguimento (p<0,001). Foram também estudados 34 pacientes portadores de nefrite lúpica em atividade, do sexo feminino, com idade média de 28,4 ± 9,9 anos, sendo 26,5% pacientes de etnia branca e 73,5% de etnia não-branca. A dosagem do MCP-1 urinário foi realizada no início do quadro e após 3 e 6 meses de seguimento. Em relação ao uMCP-1, houve um aumento significante do mesmo no início do quadro renal quando comparado com 3 e 6 meses de tratamento (p<0,05). Evidenciou-se um aumento do uMCP-1 nos pacientes que apresentavam creatinina plasmática inicial > 1,2mg/dl (p<0,05), porém não houve associação entre uMCP-1 e a creatinina após 6 meses de tratamento. Não se observou associação entre os níveis de uMCP-1 com as manifestações clínicas (SLEDAI), classe histológica e marcadores imunológicos, exceto quanto ao anticorpo antifosfolípide, pois houve excreção aumentada do uMCP-1 em pacientes com anticorpo antifosfolípide positivo no início do quadro (p<0,05). Notou-se valores elevados do uMCP-1 nos pacientes que apresentaram flares grave e moderado em relação ao flare leve (p<0,05). Quanto à distribuição genotípica do MCP-1 em relação ao uMCP-1, foi observado uma associação do uMCP-1 em pacientes portadores dos genótipos AG e AA quando comparados ao genótipo GG (p<0,05). Já em relação à distribuição genotípica e alélica do CCR2, não se notou nenhuma diferença na freqüência dos mesmos e a dosagem de uMCP-1. Conclusões: Houve uma significante associação do genótipo GG do polimorfismo do MCP-1 em pacientes portadoras de NL na população estudada, além de uma associação entre os níveis do uMCP-1 com a severidade do flare renal e a função renal nas pacientes portadoras de NL. / Introduction: Lupus Nephritis (LN) contributes substantially to morbidity and mortality in patients with systemic lupus erythematosus. Literature data show monocyte chemoattractant protein (MCP-1) is implicated in the activation of inflamatory cells and has been suggested to affect the progression and severity of lupus nephritis and urinary MCP-1 levels (uMCP-1) are increased in LN patients during active renal disease. Literature data about genotype polymorphism of MCP-1 A(-2518)G and of its receptor CCR2 V(-64)I and susceptibility to LN is still open to discussion. Objectives: The aim of our protocol was to study association of the genotype polymorphism of MCP-1 and CCR2 with LN compared to a healthy matched population and study association these polymorphisms with clinical and histological parameters in LN patients. Moreover, investigate the relationship of uMCP-1 on the onset, severity and resolution of LN flare. Patients and Methods: Genomic DNA was extracted from peripheral leukocytes from 197 LN patients and MCP-1 and CCR2 genomic variants were detected by polymerase chain reaction followed by restriction enzyme-fragment analysis. uMCP-1 levels were mesured by enzyme-linked immunosorbent assay from 34 LN flare patients. Results: One hundred and ninety seven (197) female patients with histological diagnosis de LN undergoing follow up in our institution and 220 ethnically matched healthy controls were enrolled in this study. Epidemiological characteristics of the LN group were: age 28±9.8 years, race 65.5% of caucasians and 34.5% of Brazilian afro-south-latins. Baseline values were collected at the onset of LN and final values in their last follow up (69±37.1 months). There was a significant association of the GG genotype polymorphism of MCP-1 with LN patients compared to controls (12.7%x5.0%) (p=0.019), while the allele A distribuition was associated with healthy controls (75.9%x68%) (p=0.007). Considering CCR2 -64 V/I polymorphism genotype there was a association of the allele V with the control group compared to LN (89.8%x86.3%) (p=0.046). Analyzing genotype polymorphism of MCP-1 and CCR2 there werent correlation with renal function, immunological markers, clinical manifestations (SLEDAI) or histological classes of LN. There was a significant association of the AA and AG genotypes polymorphism of MCP-1 with moderate and severe renal flares compared to GG genotype polymorphism of MCP-1 (p< 0.05). Kaplan-Meier analysis of the renal survival curves with respect to the studied genotypes did not show any influence in the progression of renal disease. There was a significant association of the creatinine onset and on follow up (p<0.001). Thrity four (34) female patients with criteria for active LN and histological diagnosis were enrolled and treated for six months. Each patient was evaluated once a month and uMCP-1 bimonthly. Epidemiological characteristics of the group showed: age 28.4±9.9 years and race 26.5% caucasians and 73.5% Brazilian afro-south-latins. uMCP-1 excretion at onset (T0) of LN was significantly increased when compared to uMCP-1 measured on the third (T3) and sixth months (T6) (p<0.05). Analyzing uMCP-1 values on T0 there was a correlation with creatinine (p<0,05), but not with, clinical manifestations histological classes of LN or immunological markers, except in patients with positive antiphospholipid autoantibodies demonstrated increased of uMCP-1 (p<0.05). Otherwise, uMCP-1 levels were associated with seriousness of nephritis flares, severe and moderate over mild (p<0.05). Considering MCP-1 polymorphism genotype there was association of the AA and AG genotypes with increased uMCP-1 in patients with active renal disease (p<0.05). Conclusions: There is a significant association of the GG genotype of MCP-1 -2518 A/G polymorphism with LN in our population. uMCP-1 levels in LN is associated with flare seriousness and renal function.

O desencadeamento do Lúpus Eritematoso Sistêmico (LES) está relacionado às situações estressantes e traumáticas da vida dos pacientes, o que sugere o fator psicológico como deflagrador da doença. A Nefrite Lúpica (NL) pode ser a primeira manifestação do LES e constitui fator de maior morbidade e mortalidade, por levar à insuficiência renal, com necessidade de hemodiálise, e colocar o sujeito diante de mudanças da rotina de vida, da autoimagem, o que faz da própria doença um evento traumático para o paciente. Dentro desse contexto, os objetivos desta pesquisa foram: (i) verificar a existência de eventos de vida associados ao deflagramento do LES nos relatos dos pacientes com NL e a forma como esses pacientes compreendem o seu adoecimento; e (ii) analisar correlações entre eventos de vida, estado de atividade do LES e perfil socioeconômico. Para a pesquisa empírica, adotou-se uma abordagem quali-quantitativa, por meio da aplicação dos seguintes instrumentos: entrevista semiestruturada (psicológica), entrevista para eventos de vida recentes (psiquiátrica) e instrumental de classificação socioeconômica. A amostra foi composta por 43 sujeitos internados no Serviço de Nefrologia do Hospital das Clínicas de São Paulo, sendo 22 pacientes do grupo caso, com NL e 21 pacientes do grupo controle, com doença glomerular primária. Os dados clínicos e laboratoriais foram coletados por meio do SLEDAI e por consulta ao prontuário. Os principais resultados obtidos demonstram que a ocorrência de eventos de vida não apresentou correlação à atividade do LES. Evidencia-se uma associação entre eventos de vida negativos e o deflagramento da doença nos dois grupos estudados, o que demonstra que eventos negativos também antecedem e podem estar associados ao início de outras patologias. Quanto à maneira como os pacientes com NL compreendem o seu adoecimento, observou-se que eles compreendem parcialmente sua doença, atribuindo um significado negativo e associam uma situação emocional ao início do adoecimento. São pacientes que percebem os problemas de suas vidas e possuem necessidade de lidar com o adoecimento implicando-se ao tratamento. Há sofrimento quanto ao adoecimento pelas mudanças e limitações que a doença impõe, principalmente em relação à autoestima, por isto, sofrem emocionalmente e possuem necessidade de serem escutados e amparados. Portanto, conclui-se que os eventos de vida negativos e/ou traumáticos estão relacionados ao deflagramento do LES tanto de forma objetiva como um acontecimento que envolve mudanças no ambiente social externo, sem considerar a subjetividade do sujeito quanto de forma subjetiva como um evento de vida singular, relatado pelos próprios pacientes como um evento traumático. Essas evidências sugerem que os pacientes com NL possuem fatores psicológicos particulares que atuam tanto no curso da doença, quanto em seu deflagramento / The onset of Systemic Lupus Erythematosus (SLE) is related to stressful and traumatic situations in patient lives, which suggests the psychological factor to trigger the disease. The Lupus Nephritis (LN) may be the first manifestation of SLE and is a major factor of morbidity and mortality, because it leads to kidney failure, requiring hemodialysis. Furthermore, the LN changes the routine of life and selfimage of patients, which makes the disease itself a traumatic event. Within this context, this study aims to: (i) verify the existence of life events associated with the outbreak of SLE, and how these patients understand their illness, and (ii) evaluate correlations between life events, status of SLE activity and socioeconomic profile. For the empirical research, we used a qualitative and quantitative approach, applying the following instruments: a semi-structured psychological interview; a psychiatric interview for recent life events and an instrumental for socioeconomic status. The sample was consisted of 43 subjects admitted to the Nephrology Department, at Hospital das Clinicas in Sao Paulo: 22 patients formed the case group, with LN and 21 formed the control group, with primary glomerular disease. The clinical and laboratory data were collected using the SLEDAI. The main results show that the occurrence of life events had no correlation with SLE activity. There was an association between negative life events and the outbreak of the disease in both groups, showing that negative events also precede and may be associated with the onset of other pathologies. Regarding the manner LN patients understand their illness, we see that they partially understand their disease, giving a negative meaning and associating an emotional situation at the beginning of illness. These are patients who perceive problems in their lives and need to deal with the disease giving importance to the treatment. The illness process causes suffering due to the changes and limitations the disease imposes, especially related to self-esteem, therefore, patients suffer emotionally and demand to be heard and supported. Thus, we conclude that the negative life events and/or trauma are related to the triggering of SLE both in an objective way as an event that involves changes in the external social environment, without taking into account the subjectivity of the subject as in a subjective singular life event, reported by the patient as a traumatic event. Based on this analysis, we suggest that patients with LN have particular psychological factors that operate both in the course of the disease, and in its triggering

Thesis (Ph.D. in Human Medical Genetics) -- University of Colorado at Denver and Health Sciences Center, 2005. / Typescript. Includes bibliographical references (leaves 104-138). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

Introdução: A nefrite lúpica (NL) é o maior preditor de morbidade e mortalidade em pacientes portadores de lupus eritematoso sistêmico. Recentes estudos mostram que a proteína quimiotática de monócitos (MCP-1) está implicada na ativação de células inflamatórias, afetando a progressão e a severidade da NL, e que a excreção urinária do MCP-1 (uMCP-1) está aumentada em pacientes com NL em atividade. Na literatura os dados sobre o polimorfismo do gene MCP-1 A(-2518)G e do seu receptor CCR2 V(-64)I sobre a susceptibilidade para nefrite lúpica ainda estão em discussão. Objetivos: Avaliar a associação entre o polimorfismo do gene MCP-1 e do seu receptor CCR2 em pacientes com NL e indivíduos saudáveis, além da associação de ambos os polimorfismos com parâmetros clínicos e histológicos nos pacientes portadores de NL. Além disso, avaliar a associação entre a excreção urinária do MCP-1 em pacientes portadores de nefrite lúpica em atividade com parâmetros clínicos e histológicos. Pacientes e Métodos: As genotipagens do MCP-1 e do CCR2 foram realizadas em 197 pacientes com nefrite lúpica através da extração do DNA genômico, seguido da técnica de reação em cadeia da polimerase, utilizando-se primers específicos. A dosagem urinária do MCP-1 foi realizada em 34 pacientes com nefrite lúpica em atividade através da técnica de ELISA. Resultados: Foram estudados 197 pacientes portadores de nefrite lúpica, do sexo feminino, com idade média de 28±9,8 anos, sendo 65,5% de etnia branca e 34,5% não-branca, acompanhados em nosso ambulatório durante o período de 69±37,1 meses. Como grupo controle, utilizou-se um grupo de 220 indivíduos saudáveis do sexo feminino, pareados de acordo com idade e etnia. Quanto à distribuição do genótipo do MCP-1, evidenciou-se que a freqüência do genótipo GG foi significativamente maior nos pacientes portadores de nefrite lúpica quando comparado ao grupo controle (12,7%x5,0%) (p=0,019), enquanto que o genótipo AA apresentou maior freqüência no grupo controle, porém sem significância estatística (48,7%x56,8%). Com relação aos alelos, a freqüência do alelo A foi significativamente maior no grupo controle (75,9%x68%) (p=0,007) quando comparada aos pacientes com NL. Já em relação ao polimorfismo do CCR2, não foi observada nenhuma diferença na freqüência do genótipo entre os dois grupos, porém foi observada maior freqüência do alelo V no grupo controle (89,8%x86,3%) (p=0,046). Não houve associação entre o genótipo e alelos do MCP-1 e do CCR2 com a função renal no início e no final do estudo, marcadores imunológicos, manifestações clínicas (SLEDAI) e a classe histológica. Porém, observou-se um predomínio significante dos flares moderado e grave nos pacientes portadores dos genótipos AA e AG (p< 0,05) em relação ao genótipo GG, enquanto que, em relação à distribuição alélica do MCP-1 e ao CCR2, não se notou diferença estatística. Não se evidenciou diferença estatística entre as curvas de sobrevida renal funcional dos pacientes portadores de nefrite lúpica e os genótipos do MCP-1 e CCR2 e seus respectivos alelos. Notou-se diferença estatística na variação da creatinina sérica ao longo do seguimento (p<0,001). Foram também estudados 34 pacientes portadores de nefrite lúpica em atividade, do sexo feminino, com idade média de 28,4 ± 9,9 anos, sendo 26,5% pacientes de etnia branca e 73,5% de etnia não-branca. A dosagem do MCP-1 urinário foi realizada no início do quadro e após 3 e 6 meses de seguimento. Em relação ao uMCP-1, houve um aumento significante do mesmo no início do quadro renal quando comparado com 3 e 6 meses de tratamento (p<0,05). Evidenciou-se um aumento do uMCP-1 nos pacientes que apresentavam creatinina plasmática inicial > 1,2mg/dl (p<0,05), porém não houve associação entre uMCP-1 e a creatinina após 6 meses de tratamento. Não se observou associação entre os níveis de uMCP-1 com as manifestações clínicas (SLEDAI), classe histológica e marcadores imunológicos, exceto quanto ao anticorpo antifosfolípide, pois houve excreção aumentada do uMCP-1 em pacientes com anticorpo antifosfolípide positivo no início do quadro (p<0,05). Notou-se valores elevados do uMCP-1 nos pacientes que apresentaram flares grave e moderado em relação ao flare leve (p<0,05). Quanto à distribuição genotípica do MCP-1 em relação ao uMCP-1, foi observado uma associação do uMCP-1 em pacientes portadores dos genótipos AG e AA quando comparados ao genótipo GG (p<0,05). Já em relação à distribuição genotípica e alélica do CCR2, não se notou nenhuma diferença na freqüência dos mesmos e a dosagem de uMCP-1. Conclusões: Houve uma significante associação do genótipo GG do polimorfismo do MCP-1 em pacientes portadoras de NL na população estudada, além de uma associação entre os níveis do uMCP-1 com a severidade do flare renal e a função renal nas pacientes portadoras de NL. / Introduction: Lupus Nephritis (LN) contributes substantially to morbidity and mortality in patients with systemic lupus erythematosus. Literature data show monocyte chemoattractant protein (MCP-1) is implicated in the activation of inflamatory cells and has been suggested to affect the progression and severity of lupus nephritis and urinary MCP-1 levels (uMCP-1) are increased in LN patients during active renal disease. Literature data about genotype polymorphism of MCP-1 A(-2518)G and of its receptor CCR2 V(-64)I and susceptibility to LN is still open to discussion. Objectives: The aim of our protocol was to study association of the genotype polymorphism of MCP-1 and CCR2 with LN compared to a healthy matched population and study association these polymorphisms with clinical and histological parameters in LN patients. Moreover, investigate the relationship of uMCP-1 on the onset, severity and resolution of LN flare. Patients and Methods: Genomic DNA was extracted from peripheral leukocytes from 197 LN patients and MCP-1 and CCR2 genomic variants were detected by polymerase chain reaction followed by restriction enzyme-fragment analysis. uMCP-1 levels were mesured by enzyme-linked immunosorbent assay from 34 LN flare patients. Results: One hundred and ninety seven (197) female patients with histological diagnosis de LN undergoing follow up in our institution and 220 ethnically matched healthy controls were enrolled in this study. Epidemiological characteristics of the LN group were: age 28±9.8 years, race 65.5% of caucasians and 34.5% of Brazilian afro-south-latins. Baseline values were collected at the onset of LN and final values in their last follow up (69±37.1 months). There was a significant association of the GG genotype polymorphism of MCP-1 with LN patients compared to controls (12.7%x5.0%) (p=0.019), while the allele A distribuition was associated with healthy controls (75.9%x68%) (p=0.007). Considering CCR2 -64 V/I polymorphism genotype there was a association of the allele V with the control group compared to LN (89.8%x86.3%) (p=0.046). Analyzing genotype polymorphism of MCP-1 and CCR2 there werent correlation with renal function, immunological markers, clinical manifestations (SLEDAI) or histological classes of LN. There was a significant association of the AA and AG genotypes polymorphism of MCP-1 with moderate and severe renal flares compared to GG genotype polymorphism of MCP-1 (p< 0.05). Kaplan-Meier analysis of the renal survival curves with respect to the studied genotypes did not show any influence in the progression of renal disease. There was a significant association of the creatinine onset and on follow up (p<0.001). Thrity four (34) female patients with criteria for active LN and histological diagnosis were enrolled and treated for six months. Each patient was evaluated once a month and uMCP-1 bimonthly. Epidemiological characteristics of the group showed: age 28.4±9.9 years and race 26.5% caucasians and 73.5% Brazilian afro-south-latins. uMCP-1 excretion at onset (T0) of LN was significantly increased when compared to uMCP-1 measured on the third (T3) and sixth months (T6) (p<0.05). Analyzing uMCP-1 values on T0 there was a correlation with creatinine (p<0,05), but not with, clinical manifestations histological classes of LN or immunological markers, except in patients with positive antiphospholipid autoantibodies demonstrated increased of uMCP-1 (p<0.05). Otherwise, uMCP-1 levels were associated with seriousness of nephritis flares, severe and moderate over mild (p<0.05). Considering MCP-1 polymorphism genotype there was association of the AA and AG genotypes with increased uMCP-1 in patients with active renal disease (p<0.05). Conclusions: There is a significant association of the GG genotype of MCP-1 -2518 A/G polymorphism with LN in our population. uMCP-1 levels in LN is associated with flare seriousness and renal function.

O desencadeamento do Lúpus Eritematoso Sistêmico (LES) está relacionado às situações estressantes e traumáticas da vida dos pacientes, o que sugere o fator psicológico como deflagrador da doença. A Nefrite Lúpica (NL) pode ser a primeira manifestação do LES e constitui fator de maior morbidade e mortalidade, por levar à insuficiência renal, com necessidade de hemodiálise, e colocar o sujeito diante de mudanças da rotina de vida, da autoimagem, o que faz da própria doença um evento traumático para o paciente. Dentro desse contexto, os objetivos desta pesquisa foram: (i) verificar a existência de eventos de vida associados ao deflagramento do LES nos relatos dos pacientes com NL e a forma como esses pacientes compreendem o seu adoecimento; e (ii) analisar correlações entre eventos de vida, estado de atividade do LES e perfil socioeconômico. Para a pesquisa empírica, adotou-se uma abordagem quali-quantitativa, por meio da aplicação dos seguintes instrumentos: entrevista semiestruturada (psicológica), entrevista para eventos de vida recentes (psiquiátrica) e instrumental de classificação socioeconômica. A amostra foi composta por 43 sujeitos internados no Serviço de Nefrologia do Hospital das Clínicas de São Paulo, sendo 22 pacientes do grupo caso, com NL e 21 pacientes do grupo controle, com doença glomerular primária. Os dados clínicos e laboratoriais foram coletados por meio do SLEDAI e por consulta ao prontuário. Os principais resultados obtidos demonstram que a ocorrência de eventos de vida não apresentou correlação à atividade do LES. Evidencia-se uma associação entre eventos de vida negativos e o deflagramento da doença nos dois grupos estudados, o que demonstra que eventos negativos também antecedem e podem estar associados ao início de outras patologias. Quanto à maneira como os pacientes com NL compreendem o seu adoecimento, observou-se que eles compreendem parcialmente sua doença, atribuindo um significado negativo e associam uma situação emocional ao início do adoecimento. São pacientes que percebem os problemas de suas vidas e possuem necessidade de lidar com o adoecimento implicando-se ao tratamento. Há sofrimento quanto ao adoecimento pelas mudanças e limitações que a doença impõe, principalmente em relação à autoestima, por isto, sofrem emocionalmente e possuem necessidade de serem escutados e amparados. Portanto, conclui-se que os eventos de vida negativos e/ou traumáticos estão relacionados ao deflagramento do LES tanto de forma objetiva como um acontecimento que envolve mudanças no ambiente social externo, sem considerar a subjetividade do sujeito quanto de forma subjetiva como um evento de vida singular, relatado pelos próprios pacientes como um evento traumático. Essas evidências sugerem que os pacientes com NL possuem fatores psicológicos particulares que atuam tanto no curso da doença, quanto em seu deflagramento / The onset of Systemic Lupus Erythematosus (SLE) is related to stressful and traumatic situations in patient lives, which suggests the psychological factor to trigger the disease. The Lupus Nephritis (LN) may be the first manifestation of SLE and is a major factor of morbidity and mortality, because it leads to kidney failure, requiring hemodialysis. Furthermore, the LN changes the routine of life and selfimage of patients, which makes the disease itself a traumatic event. Within this context, this study aims to: (i) verify the existence of life events associated with the outbreak of SLE, and how these patients understand their illness, and (ii) evaluate correlations between life events, status of SLE activity and socioeconomic profile. For the empirical research, we used a qualitative and quantitative approach, applying the following instruments: a semi-structured psychological interview; a psychiatric interview for recent life events and an instrumental for socioeconomic status. The sample was consisted of 43 subjects admitted to the Nephrology Department, at Hospital das Clinicas in Sao Paulo: 22 patients formed the case group, with LN and 21 formed the control group, with primary glomerular disease. The clinical and laboratory data were collected using the SLEDAI. The main results show that the occurrence of life events had no correlation with SLE activity. There was an association between negative life events and the outbreak of the disease in both groups, showing that negative events also precede and may be associated with the onset of other pathologies. Regarding the manner LN patients understand their illness, we see that they partially understand their disease, giving a negative meaning and associating an emotional situation at the beginning of illness. These are patients who perceive problems in their lives and need to deal with the disease giving importance to the treatment. The illness process causes suffering due to the changes and limitations the disease imposes, especially related to self-esteem, therefore, patients suffer emotionally and demand to be heard and supported. Thus, we conclude that the negative life events and/or trauma are related to the triggering of SLE both in an objective way as an event that involves changes in the external social environment, without taking into account the subjectivity of the subject as in a subjective singular life event, reported by the patient as a traumatic event. Based on this analysis, we suggest that patients with LN have particular psychological factors that operate both in the course of the disease, and in its triggering