Objetivo General: Identificar el perfil clínico y de laboratorio al momento del diagnóstico del lupus eritematoso sistémico (LES) en pacientes del Hospital Nacional Arzobispo Loayza (HNAL) del 2009-2013. Metodología: Estudio descriptivo, observacional, transversal. La población estudiada fueron pacientes del HNAL con el diagnóstico de LES del 2009-2013. Se registró información de las historias clínicas mediante una ficha de recolección de datos validada mediante juicio de expertos. Los resultados fueron analizados utilizando el paquete estadístico SPSS 20, y presentados mediante medias, medianas y rango intercuartilar (RIC). Resultados: 67 pacientes con edad promedio de 34±13 años al momento del diagnóstico. Las medianas del tiempo de enfermedad previo al diagnóstico y de demora al diagnóstico fueron 3 (RIC 1-6) y 0 (RIC 0-1) meses, respectivamente. Todos los pacientes presentaron síndrome general. Las manifestaciones clínicas más frecuentes fueron artritis/sinovitis (65,7%), alopecia sin cicatrices (25,4%) y fotosensibilidad (22,4%). Las manifestaciones de laboratorio más frecuentes fueron anticuerpo antinuclear positivo (83,6%) linfopenia e hipocomplementemia (ambos con 62,7%). La distribución del cumplimiento de criterios del American College of Rheumatology (ACR) y Systemic Lupus International Collaborating Clinics (SLICC) fue del 67,2% y 80,6%, respectivamente. La mediana del número de criterios ACR y SLICC al diagnóstico fue 4 (RIC 3-5) y 5 (RIC 4-6), respectivamente; 31,3% presentaron exclusivamente criterio médico para el diagnóstico. Conclusiones: Las principales manifestaciones implican alteraciones sistémicas y órgano-específicas, como hematológicas, articulares e inmunológicas. Se resalta la importancia del criterio médico para el diagnóstico de LES en la práctica clínica. / General Objective: To identify clinical and laboratory characteristics at diagnosis of systemic lupus erythematosus (SLE) at Hospital Nacional Arzobispo Loayza (HNAL) since 2009 to 2013. Methodology: Descriptive, observational and cross-type study. Population studied were patients with the diagnosis of SLE in the register of the Department of Statistics of the Hospital National Arzobispo Loayza among 2009 to 2013. Information from medical records was recorded by a data collection sheet validated by expert judgment, analyzing with SPSS 20.0 Results: 67 patients with an average age of 34±13 years were included. Median time to disease prior to diagnosis and delay to diagnosis were 3 (IQR 1-6) and 0 (IQR 0-1) months, respectively. All the patients had general syndrome. The most common clinical manifestations were arthritis/synovitis (65.7%), photosensitivity (22.4%) and alopecia unscarred (25.4%). The most frequent manifestations of laboratory features were title positive for antinuclear antibody (83.6%), lymphopenia and hypocomplementemia (bother with 62.7%). The compliance of criteria of the American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) was 67.2% and 80.6%, respectively. The median of criteria at diagnosis for ACR and SLICC was 4 (IQR 3-5) and 5 (IQR 4-6), respectively. On the other hand, 31.3% of the patients were diagnosis purely by medical criteria for the diagnosis of SLE. Conclusions: The main manifestations involve systemic and specific alterations, as hematological, joint and immune. Furthermore, it is relevant the importance of the medical criteria for diagnosis of SLE at the clinical practice. Keywords: systemic lupus erythematosus, half-blood, diagnosis. / Tesis

Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

[pt] O presente trabalho tem como objetivo de analisar de que forma o lúpus interfere na experiência de gravidez dessas mulheres. O mesmo é classificado como uma doença crônica multissistêmica de natureza autoimune conhecida pela sua imprevisibilidade, apresentando períodos de remissões e recaídas. A gestação para mulheres com lúpus é considerada como de alto risco e necessitam de um planejamento sistemático, pois estas podem apresentar recorrentes abortos e a ativação da doença durante o período gestacional. Ao discutirmos sobre gestantes com lúpus, iremos dar ênfase as suas experiências em relação à patologia, a saúde sexual e reprodutiva, e a maternidade, onde estas são perpassadas pelas relações familiares. Nessa perspectiva configuram-se como objetivos específicos deste trabalho: 1) Discutir os sentidos da maternidade para mulheres gestantes com doença autoimune convivendo com lúpus; 2) Verificar como as relações familiares se expressam no que se refere ao cuidado e apoio de mulheres com lúpus; 3) Discutir como as gestantes com lúpus convivem com sua patologia. O percurso metodológico deste trabalho buscou compreender sob essas perspectivas o cotidiano de cinco mulheres na vivência desse cenário. Como procedimentos de investigação, utilizamos entrevistas semiestruturadas que foram realizadas individualmente por meio de plataforma virtual. Os resultados apontam para a importância das relações familiares quando dissertamos sobre gestantes e lúpus. Ademais, pensarmos o medo existente em relação aos desdobramentos da gestação e a maternidade, e também a relevância das associações e grupos de mulheres que convivem com lúpus para a convivência com a patologia. Destacamos a imprescindibilidade do planejamento e execução de políticas públicas e a ampliação dos estudos sobre o lúpus. / [en] The present work aims to analyze how lupus interferes in the pregnancy experience of these women. It is classified as a chronic multisystem disease of an autoimmune nature known for its unpredictability, periods of remissions and relapses. Pregnancy for women with lupus is considered to be at high risk and elements of systematic planning, as they may present with recurrent abortions and the activation of the disease during the gestational period. When discussing pregnant women with lupus, we will emphasize how their experiences in relation to pathology, sexual and reproductive health, and motherhood, where these are permeated by family relationships. In this perspective, the specific objectives of this work are configured: 1) Discuss the meanings of motherhood for pregnant women with autoimmune disease living with lupus; 2) Check how family relationships are expressed in terms of the care and support of women with lupus; 3) Discuss how pregnant women with lupus live with their pathology. The methodological path of this work sought to understand these perspectives in the daily lives of five women in the experience of this scenario. As investigation procedures, we use semistructured changes that were carried out through a virtual platform. The results point to the importance of family relationships when we talk about pregnant women and lupus. In addition, we think about the existing fear in relation to the consequences of pregnancy and motherhood, and also the descent of women and groups of women who live with lupus to live with the pathology. We highlight the indispensability of planning and implementing public policies and the expansion of studies on lupus.

Les mitochondries sont des organelles intracellulaires impliquées dans de nombreuses voies biologiques. Suite à la mort ou l’activation de certains types cellulaires, elles peuvent être relarguées dans le milieu extracellulaire où, elles sont reconnues comme des signaux de danger (DAMPS), générant une réponse pro-inflammatoire par le système immunitaire inné. Les interactions entre les mitochondries et l’immunité adaptative sont encore méconnues. Neuf classes d’anticorps anti mitochondriaux (AMA M1 à M9) ont été décrits différentes pathologies telles que la syphilis, la cirrhose biliaire primitive (CBP), le lupus érythémateux disséminé (LED) ou le syndrome des anti phospholipides (APS), sans que leur association avec l’expression clinique de ces maladies n’ait jamais été étudiée. Dans la présente étude, nous avons développé des méthodes de détection des AMA et anti-ADN mitochondrial (AMtDNA) puis étudié des corrélations entre la présence de ces anticorps et les caractéristiques de la maladie exprimées par des patients lupiques. Nous avons mis en évidence une association protectrice des AMA envers les évènements thrombotiques ainsi qu’une corrélation entre les niveaux d’AMtDNA et une élévation de l’index d’activité de la maladie (SLEDAI) en lien avec un accroissement des anticorps ciblant l’ADN double-brins (DsDNA). / Mitochondria are intracellular organelles that are involved in a vast number of biological pathways. They may be released in the extracellular milieu upon cell death or the activation of several types of cells where they will be recognized as danger signals (DAMPs), eliciting a pro-inflammatory response by the innate immune system. To this day, interplays between mitochondria and the adaptive branch of the immunity are poorly defined. Nine classes of anti mitochondrial antibodies (AMA M1 to M9) were reported in diseases such as syphilis, primary biliary cirrhosis (PBS), systemic lupus erythematosus (SLE) or the anti-phospholipid syndrome (APS) but their association to the clinical manifestations of these diseases have never been studied. In the present study, we developed methods for the detection of AMA and anti-mitochondrial DNA antibodies (AMtDNA) then studied correlations between the presence of these antibodies and clinical features expressed by lupus patients. We found a protective association of AMA towards thrombotic events and that AMtDNA levels correlates with an increase of the SLE disease activity index (SLEDAI) linked to an increase of the antibodies targeting double-stranded DNA (DsDNA).

Conjugated linoleic acid (CLA) has been shown to reduce inflammation via Peroxisome Proliferator-Activated Receptor (PPAR)-γ in inflammatory disorders such as Crohn's Disease and Inflammatory Bowel Disease. We sought to determine whether CLA isomers would reduce inflammation via PPAR-γ in cultured mesangial cells, and in murine models of anti-glomerular basement membrane (anti-GBM) glomerulonephritis and Systemic Lupus Erythematosus (SLE). SV40-transformed mouse mesangial cells (MES13) were cultured with pure CLA isomers (c9,t11 or t10,c12-CLA or a 50:50 mixture prior to immune stimulation with lipopolysaccharide and interferon-γ. Next, cultured mesangial cells were transfected with small interfering RNA (siRNA) targeting PPAR-γ and treated with CLA isomers prior to immune stimulation. ELISA, qPCR, Western blot, and Griess reaction were performed to measure cytokine production, mRNA expression, induced nitric oxide synthase (iNOS) and nitrite production, respectively. Next, myeloid-specific (LysM creR2+) PPAR-γ knockout mice were treated with CLA prior to the induction of anti-GBM glomerulonephritis and evaluated for disease. Finally, NZM2410/J mice (a natural model of SLE) were treated with c9,t11-CLA and evaluated for disease progression. Treatment with CLA reduced IL-6 production in cultured mesangial cells, but not in siRNA-treated mesangial cells, supporting a PPAR-γ-mediated mechanism. CLA treatment increased both Transforming Growth Factor (TGF-β) and Interleukin-1 Receptor Antagonist (IL-1RA) mRNA expression independent of PPAR--γ. While CLA treatment reduced nitrite production and iNOS production to some degree, this was an inconsistent finding. Conversely, in the induced anti-GBM mouse model, CLA treatment increased mesangial cell IL-6 mRNA expression, reduced TGF-β expression, and had no effect on IL-1RA. Moreover, NZM2410/J mice that were fed a c9,t11-CLA-supplemented diet had reduced survival times, increased renal inflammation and increased serum IgG2a relative to controls. Taken together, these studies indicate that the in vitro MES13 cell line does not translate to the in vivo mouse model of anti-GBM induced glomerulonephritis. Furthermore, while CLA may have beneficial effects in other mouse models, it worsens disease in NZM2410/J mice. Findings from these models should be interpreted with caution. / Ph. D.

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production and deposition of nuclear self-antigen-containing immune complexes. Epigenetic factors, including altered microRNA (miRNA) expression, may contribute to aberrant immune cell function in SLE. miRNAs are small, noncoding RNAs that bind to the 3’ untranslated region of target mRNAs resulting in post-transcriptional gene modulation. IL-6, an inflammatory cytokine overproduced by mesangial cells in SLE, contains a potential binding site for miR-let-7a. In order to examine if alterations in miR-let-7a expression can influence inflammatory mediator production in SLE, we isolated mesangial cell miRNAs from 8 and 32- week-old female New Zealand Black/White (NZB/W) mice. We found miR-let-7a expression was significantly increased in the mesangial cells of pre-diseased and actively diseased NZB/W mice compared to age-matched female New Zealand White (NZW) controls. Overexpression of miR-let-7a in vitro increased IL-6 production in LPS/IFN-γ-stimulated mesangial cells compared to the stimulated control. Due to the crucial role of miR-let-7a in cell division and inflammation, we investigated miR-let-7a-mediated proliferation and NFκB activation in J774A.1 macrophages and MES 13 mesangial cells in vitro. Cell proliferation, retinoblastoma protein (Rb) phosphorylation, and NFκB activation were increased in cells transfected with miR-let-7a and stimulated with LPS/IFN-γ. Expression and production of the cell cycle inhibitor E2F5 was decreased in stimulated cells overexpressing miR-let-7a. We found that the cell cycle promoter E2F2 and NFκB target the miR-let-7a promoter. Next we sought to determine alterations in iii specific disease-associated miRNAs in female NZB/W mice treated with hydroxychloroquine (HCQ) or prednisone (PRED) for 12 weeks beginning at 20 weeks-of-age. We found that treatment with HCQ or PRED induced unique changes to miRNA expression in multiple tissues. In order to identify specific miRNAs as disease-modifying agents and not merely disease correlates, further in vitro analyses confirmed HCQ or PRED-mediated inhibition of miRNAs is critical to alter the inflammatory response. Taken together, our results suggest that overexpression of miR-let-7a may contribute to hyperplasia and the proinflammatory response in SLE. Our studies indicate that lupus therapeutics may work, in part, by altering the expression of disease-associated miRNAs in immune cells and the urine. / Ph. D.

Thesis (Ph. D.)--University of Virginia, 2008. / Includes bibliographical references. Also available online through Digital Dissertations.

O Lúpus Eritematoso Sistêmico (LES) é uma doença autoimune inflamatória crônica que possui uma etiopatogênese complexa. Diversos fatores participam da patogênese da doença, dentre eles alterações no balanço de citocinas e quimiocinas. As quimiocinas e seus receptores são fundamentais na regulação da migração de leucócitos durante a inflamação e acredita-se que elas possam ter um papel importante na patogênese de doenças autoimunes, inclusive no LES. Diversos estudos abordaram o papel de quimiocinas e seus receptores no LES, porém, principalmente se tratando dos receptores de quimiocinas CCR5 e CCR2, não existe um consenso. Devido à falta de consenso em relação ao papel dos receptores de quimiocinas na patogênese do LES e considerando a necessidade de mais estudos nesta área, o presente trabalho tem por objetivo investigar o possível papel de polimorfismos na região promotora do CCR5 no desenvolvimento do LES, comparando as frequências dos genótipos e haplótipos entre pacientes e controles, e analisar o possível envolvimento destes polimorfismos nas manifestações clínicas/laboratoriais da doença. O estudo incluiu 382 pacientes com LES (289 Euro-descendentes e 93 Afro-descendentes) e 375 controles (243 Euro-descendentes e 132 Afro-descendentes) genotipados para os polimorfismos CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) e CCR5-59653 C>T (rs1800024) através de PCR-RFLP e sequenciamento, respectivamente. Dados prévios de nosso grupo em relação ao CCR5delta32 foram incluídos no estudo para a inferência dos haplótipos e como um possível fator de confusão na regressão binária logística. Os resultados obtidos indicam que, em pacientes Euro-descendentes, as frequências reduzidas o polimorfismo CCR5delta32 e o haplótipo HHG*2 observadas em pacientes quando comparados com controles foram associadas com a doença (p=0,001; OR 3,5; 95%CI 1,6-7,5 e 2,0% vs. 7,2%; presidual=2,9E-5; respectivamente). Em pacientes Afrodescendentes, as frequências dos haplótipos HHA/HHB, HHC e HHG*2 foram diferentes em pacientes e controles (10% vs. 20,5%, presidual = 0,003; 29,4% vs. 17,4%; presidual=0,003 e 3,9% vs. 0,8%; presidual=0,023; respectivamente). Em relação às manifestações clínicas da doença, a presença do CCR5delta32 foi confirmada como um fator de susceptibilidade para nefrite classe IV em pacientes Afro-descendentes e no grupo de pacientes como um todo (pcorrigido=0,012; OR 3,0; 95%CI 3,0-333,3 e pcorrigido=0,0006; OR 6,8; 95%CI 1,9-2,48; respectivamente). Em conclusão, o presente estudo indica que polimorfismos na região promotora do CCR5 podem atuar como modificadores no LES. Os resultados observados reforçam o papel do polimorfismo CCR5delta32 como um fator de proteção para o desenvolvimento do LES em Euro-descendentes e como um fator de susceptibilidade à nefrite classe IV em pacientes Afro-descendentes. Além disto, também foram descritos a redução da frequência dos haplótipos HHA/HHB e o aumento da frequência dos haplótipos HHC e HHG*2 em pacientes Afro-descendentes, que possivelmente podem estar associados com uma maior expressão do CCR5 em subtipos específicos celulares e com uma menor expressão deste receptor de maneira geral. / Systemic Lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease, characterized by a complex etiopathogenesis. Many factors are known to participate in the pathogenesis of SLE, including alterations in the cytokines or chemokines balance. Chemokines and their receptors are central players in the regulation of leucocytes chemotaxis in inflammation and they are thought to have an important role in the pathogenesis of autoimmune diseases, including SLE. Several studies have addressed the role of chemokines and their receptors in SLE, however there is no consensus regarding their involvement on the pathogenesis of the disease. Given the lack of consensus considering the role of chemokine receptors in SLE pathogenesis and the need for more studies in this area, the present work aims to investigate a possible role of the CCR5 promoter region polymorphisms in the development of SLE comparing the frequencies of the genotypes and haplotypes with ethnically matched controls and analyze if there is a possible involvement of the polymorphisms in the clinical outcome of the disease. This study included 388 SLE patients (289 classified as Europeanderived and 93 as African-derived) and 375 controls (243 European-derived and 132 African-derived) genotyped for the CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) and CCR5-59653 C>T (rs1800024) polymorphisms though PCRRFLP and direct sequencing, respectively. Previous data from CCR5delta32 were included in the study to infer the haplotypes and also as a possible confounding factor in the binary logistic regression. Our results indicated that, in Europeanderived patients, CCR5delta32 and the HHG*2 haplotype reduced frequencies in patients when compared to controls were associated with the disease (p=0.001; OR 3.5; 95%CI 1.6-7.5 and 2.0%, vs. 7.2% residual p= 2.9E-5, respectively). In African-derived patients, the HHA/HHB, HHC and HHG*2 haplotype frequencies differed between patients and controls (10% vs. 20.5%, residual p= 0.003; 29.4% vs. 17.4%, residual p=0.003 and 3.9% vs. 0.8%, residual p=0.023; respectively). Considering the clinical manifestations of the disease, CCR5delta32 presence was confirmed as a susceptibility factor to class IV nephritis in the African-derived group and when patients were considered together (pcorrected=0.012; OR 3.0; 95%CI 3.0-333.3 and pcorrected= 0.0006; OR 6.8; 95%CI 1.9-2.48, respectively). In conclusion, this study indicates that CCR5 promoter polymorphisms are important disease modifiers in SLE. Present data reinforces CCR5delta32 polymorphism as a protective factor for the development of the disease in European-derived patients and as a susceptibility factor for class IV nephritis in African-derived patients. Furthermore, we also describe a reduced frequency of HHA/HHB and an enhanced frequency of HHC and HHG*2 haplotypes in our African-derived patients, which potentially could reflect in a higher expression of CCR5 in specific cell subsets and in a lower expression of CCR5 overall.

O Lúpus Eritematoso Sistêmico (LES) é uma doença autoimune inflamatória crônica que possui uma etiopatogênese complexa. Diversos fatores participam da patogênese da doença, dentre eles alterações no balanço de citocinas e quimiocinas. As quimiocinas e seus receptores são fundamentais na regulação da migração de leucócitos durante a inflamação e acredita-se que elas possam ter um papel importante na patogênese de doenças autoimunes, inclusive no LES. Diversos estudos abordaram o papel de quimiocinas e seus receptores no LES, porém, principalmente se tratando dos receptores de quimiocinas CCR5 e CCR2, não existe um consenso. Devido à falta de consenso em relação ao papel dos receptores de quimiocinas na patogênese do LES e considerando a necessidade de mais estudos nesta área, o presente trabalho tem por objetivo investigar o possível papel de polimorfismos na região promotora do CCR5 no desenvolvimento do LES, comparando as frequências dos genótipos e haplótipos entre pacientes e controles, e analisar o possível envolvimento destes polimorfismos nas manifestações clínicas/laboratoriais da doença. O estudo incluiu 382 pacientes com LES (289 Euro-descendentes e 93 Afro-descendentes) e 375 controles (243 Euro-descendentes e 132 Afro-descendentes) genotipados para os polimorfismos CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) e CCR5-59653 C>T (rs1800024) através de PCR-RFLP e sequenciamento, respectivamente. Dados prévios de nosso grupo em relação ao CCR5delta32 foram incluídos no estudo para a inferência dos haplótipos e como um possível fator de confusão na regressão binária logística. Os resultados obtidos indicam que, em pacientes Euro-descendentes, as frequências reduzidas o polimorfismo CCR5delta32 e o haplótipo HHG*2 observadas em pacientes quando comparados com controles foram associadas com a doença (p=0,001; OR 3,5; 95%CI 1,6-7,5 e 2,0% vs. 7,2%; presidual=2,9E-5; respectivamente). Em pacientes Afrodescendentes, as frequências dos haplótipos HHA/HHB, HHC e HHG*2 foram diferentes em pacientes e controles (10% vs. 20,5%, presidual = 0,003; 29,4% vs. 17,4%; presidual=0,003 e 3,9% vs. 0,8%; presidual=0,023; respectivamente). Em relação às manifestações clínicas da doença, a presença do CCR5delta32 foi confirmada como um fator de susceptibilidade para nefrite classe IV em pacientes Afro-descendentes e no grupo de pacientes como um todo (pcorrigido=0,012; OR 3,0; 95%CI 3,0-333,3 e pcorrigido=0,0006; OR 6,8; 95%CI 1,9-2,48; respectivamente). Em conclusão, o presente estudo indica que polimorfismos na região promotora do CCR5 podem atuar como modificadores no LES. Os resultados observados reforçam o papel do polimorfismo CCR5delta32 como um fator de proteção para o desenvolvimento do LES em Euro-descendentes e como um fator de susceptibilidade à nefrite classe IV em pacientes Afro-descendentes. Além disto, também foram descritos a redução da frequência dos haplótipos HHA/HHB e o aumento da frequência dos haplótipos HHC e HHG*2 em pacientes Afro-descendentes, que possivelmente podem estar associados com uma maior expressão do CCR5 em subtipos específicos celulares e com uma menor expressão deste receptor de maneira geral. / Systemic Lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease, characterized by a complex etiopathogenesis. Many factors are known to participate in the pathogenesis of SLE, including alterations in the cytokines or chemokines balance. Chemokines and their receptors are central players in the regulation of leucocytes chemotaxis in inflammation and they are thought to have an important role in the pathogenesis of autoimmune diseases, including SLE. Several studies have addressed the role of chemokines and their receptors in SLE, however there is no consensus regarding their involvement on the pathogenesis of the disease. Given the lack of consensus considering the role of chemokine receptors in SLE pathogenesis and the need for more studies in this area, the present work aims to investigate a possible role of the CCR5 promoter region polymorphisms in the development of SLE comparing the frequencies of the genotypes and haplotypes with ethnically matched controls and analyze if there is a possible involvement of the polymorphisms in the clinical outcome of the disease. This study included 388 SLE patients (289 classified as Europeanderived and 93 as African-derived) and 375 controls (243 European-derived and 132 African-derived) genotyped for the CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) and CCR5-59653 C>T (rs1800024) polymorphisms though PCRRFLP and direct sequencing, respectively. Previous data from CCR5delta32 were included in the study to infer the haplotypes and also as a possible confounding factor in the binary logistic regression. Our results indicated that, in Europeanderived patients, CCR5delta32 and the HHG*2 haplotype reduced frequencies in patients when compared to controls were associated with the disease (p=0.001; OR 3.5; 95%CI 1.6-7.5 and 2.0%, vs. 7.2% residual p= 2.9E-5, respectively). In African-derived patients, the HHA/HHB, HHC and HHG*2 haplotype frequencies differed between patients and controls (10% vs. 20.5%, residual p= 0.003; 29.4% vs. 17.4%, residual p=0.003 and 3.9% vs. 0.8%, residual p=0.023; respectively). Considering the clinical manifestations of the disease, CCR5delta32 presence was confirmed as a susceptibility factor to class IV nephritis in the African-derived group and when patients were considered together (pcorrected=0.012; OR 3.0; 95%CI 3.0-333.3 and pcorrected= 0.0006; OR 6.8; 95%CI 1.9-2.48, respectively). In conclusion, this study indicates that CCR5 promoter polymorphisms are important disease modifiers in SLE. Present data reinforces CCR5delta32 polymorphism as a protective factor for the development of the disease in European-derived patients and as a susceptibility factor for class IV nephritis in African-derived patients. Furthermore, we also describe a reduced frequency of HHA/HHB and an enhanced frequency of HHC and HHG*2 haplotypes in our African-derived patients, which potentially could reflect in a higher expression of CCR5 in specific cell subsets and in a lower expression of CCR5 overall.

O Lúpus Eritematoso Sistêmico (LES) é uma doença autoimune inflamatória crônica que possui uma etiopatogênese complexa. Diversos fatores participam da patogênese da doença, dentre eles alterações no balanço de citocinas e quimiocinas. As quimiocinas e seus receptores são fundamentais na regulação da migração de leucócitos durante a inflamação e acredita-se que elas possam ter um papel importante na patogênese de doenças autoimunes, inclusive no LES. Diversos estudos abordaram o papel de quimiocinas e seus receptores no LES, porém, principalmente se tratando dos receptores de quimiocinas CCR5 e CCR2, não existe um consenso. Devido à falta de consenso em relação ao papel dos receptores de quimiocinas na patogênese do LES e considerando a necessidade de mais estudos nesta área, o presente trabalho tem por objetivo investigar o possível papel de polimorfismos na região promotora do CCR5 no desenvolvimento do LES, comparando as frequências dos genótipos e haplótipos entre pacientes e controles, e analisar o possível envolvimento destes polimorfismos nas manifestações clínicas/laboratoriais da doença. O estudo incluiu 382 pacientes com LES (289 Euro-descendentes e 93 Afro-descendentes) e 375 controles (243 Euro-descendentes e 132 Afro-descendentes) genotipados para os polimorfismos CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) e CCR5-59653 C>T (rs1800024) através de PCR-RFLP e sequenciamento, respectivamente. Dados prévios de nosso grupo em relação ao CCR5delta32 foram incluídos no estudo para a inferência dos haplótipos e como um possível fator de confusão na regressão binária logística. Os resultados obtidos indicam que, em pacientes Euro-descendentes, as frequências reduzidas o polimorfismo CCR5delta32 e o haplótipo HHG*2 observadas em pacientes quando comparados com controles foram associadas com a doença (p=0,001; OR 3,5; 95%CI 1,6-7,5 e 2,0% vs. 7,2%; presidual=2,9E-5; respectivamente). Em pacientes Afrodescendentes, as frequências dos haplótipos HHA/HHB, HHC e HHG*2 foram diferentes em pacientes e controles (10% vs. 20,5%, presidual = 0,003; 29,4% vs. 17,4%; presidual=0,003 e 3,9% vs. 0,8%; presidual=0,023; respectivamente). Em relação às manifestações clínicas da doença, a presença do CCR5delta32 foi confirmada como um fator de susceptibilidade para nefrite classe IV em pacientes Afro-descendentes e no grupo de pacientes como um todo (pcorrigido=0,012; OR 3,0; 95%CI 3,0-333,3 e pcorrigido=0,0006; OR 6,8; 95%CI 1,9-2,48; respectivamente). Em conclusão, o presente estudo indica que polimorfismos na região promotora do CCR5 podem atuar como modificadores no LES. Os resultados observados reforçam o papel do polimorfismo CCR5delta32 como um fator de proteção para o desenvolvimento do LES em Euro-descendentes e como um fator de susceptibilidade à nefrite classe IV em pacientes Afro-descendentes. Além disto, também foram descritos a redução da frequência dos haplótipos HHA/HHB e o aumento da frequência dos haplótipos HHC e HHG*2 em pacientes Afro-descendentes, que possivelmente podem estar associados com uma maior expressão do CCR5 em subtipos específicos celulares e com uma menor expressão deste receptor de maneira geral. / Systemic Lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease, characterized by a complex etiopathogenesis. Many factors are known to participate in the pathogenesis of SLE, including alterations in the cytokines or chemokines balance. Chemokines and their receptors are central players in the regulation of leucocytes chemotaxis in inflammation and they are thought to have an important role in the pathogenesis of autoimmune diseases, including SLE. Several studies have addressed the role of chemokines and their receptors in SLE, however there is no consensus regarding their involvement on the pathogenesis of the disease. Given the lack of consensus considering the role of chemokine receptors in SLE pathogenesis and the need for more studies in this area, the present work aims to investigate a possible role of the CCR5 promoter region polymorphisms in the development of SLE comparing the frequencies of the genotypes and haplotypes with ethnically matched controls and analyze if there is a possible involvement of the polymorphisms in the clinical outcome of the disease. This study included 388 SLE patients (289 classified as Europeanderived and 93 as African-derived) and 375 controls (243 European-derived and 132 African-derived) genotyped for the CCR2-64I G>A (rs1799864), CCR5-59353 C>T (rs1799988), CCR5-59356 C>T (rs41469351), CCR5-59402 A>G (rs1800023) and CCR5-59653 C>T (rs1800024) polymorphisms though PCRRFLP and direct sequencing, respectively. Previous data from CCR5delta32 were included in the study to infer the haplotypes and also as a possible confounding factor in the binary logistic regression. Our results indicated that, in Europeanderived patients, CCR5delta32 and the HHG*2 haplotype reduced frequencies in patients when compared to controls were associated with the disease (p=0.001; OR 3.5; 95%CI 1.6-7.5 and 2.0%, vs. 7.2% residual p= 2.9E-5, respectively). In African-derived patients, the HHA/HHB, HHC and HHG*2 haplotype frequencies differed between patients and controls (10% vs. 20.5%, residual p= 0.003; 29.4% vs. 17.4%, residual p=0.003 and 3.9% vs. 0.8%, residual p=0.023; respectively). Considering the clinical manifestations of the disease, CCR5delta32 presence was confirmed as a susceptibility factor to class IV nephritis in the African-derived group and when patients were considered together (pcorrected=0.012; OR 3.0; 95%CI 3.0-333.3 and pcorrected= 0.0006; OR 6.8; 95%CI 1.9-2.48, respectively). In conclusion, this study indicates that CCR5 promoter polymorphisms are important disease modifiers in SLE. Present data reinforces CCR5delta32 polymorphism as a protective factor for the development of the disease in European-derived patients and as a susceptibility factor for class IV nephritis in African-derived patients. Furthermore, we also describe a reduced frequency of HHA/HHB and an enhanced frequency of HHC and HHG*2 haplotypes in our African-derived patients, which potentially could reflect in a higher expression of CCR5 in specific cell subsets and in a lower expression of CCR5 overall.