Made available in DSpace on 2019-03-30T00:18:27Z (GMT). No. of bitstreams: 0 Previous issue date: 2017-11-24 / Introduction: Systemic lupus erythematosus (SLE) is an autoimmune, multisystemic disease, characterized by the production of autoantibodies, deposition of immunocomplexes, systemic inflammation, and tissue damage. About 37% to 45% of SLE patients develop lupus nephritis (NL) at some point in the course of the disease. A proportion of 10 to 30% of patients with NL evolve to chronic kidney disease (CKD), within 15 years after diagnosis, even with aggressive treatment. Objective: To analyze the sociodemographic, clinical and laboratory profile of patients with NL undergoing renal transplantation in a public tertiary hospital. To detect the relapse of SLE and the time of survival of the renal graft and the patient. To identify the score of the index of damage through the criteria of Systemic Lupus International Collaborating Clinics (SLICC) in patients with SLE. To compare the renal survival of the patients under study with other Brazilian research with similar clinical profile. Methods: We analyzed all the records of patients submitted to renal transplantation from July 1996 to May 2016 at the General Hospital of Fortaleza (HGF), a reference center in the North Northeast for transplants. Of these, patients with a diagnosis of NL were selected as the cause of terminal CKD (n = 35), which met the criteria of the American College of Rheumatology (ACR). RESULTS: Of a total of 1.861 renal transplantations, 38 (1.8%) of them were performed in 35 patients with LN, 3 of which underwent more than one transplantation. The mean age of the patients in the diagnosis of SLE was 33.0 ± 11.1 years. The majority were female (94.7%) and non-Caucasian (68.4%). 57.9% underwent renal biopsy before transplantation. The mean of the SLICC was 4.7 ± 1.2. Most donors (71.1%) were deceased. The mean time from diagnosis of SLE to renal transplantation was 10.3 ± 6.4 years. The mean pre-transplantation dialysis time was 3.9 ± 3.7 years. The acute rejection rate in the first year was identified in 7.9% of the patients. The graft and patient surges were, respectively, 97.1% and 100% at six months; 84.9% and 96.9%, in the first year, and 73.3% and 92.5%, in the fifth year. 2.6% had recurrence of SLE. Comparing patients who evolved with graft loss and those who maintained good graft function, we observed a higher prevalence of thrombosis (p = 0.017) and antiphospholipid syndrome (p = 0.036) in the first group. Conclusion: The study demonstrated that patients with NL undergoing renal transplantation had a good survival over a 5-year follow-up period and that the presence of thrombosis and antiphospholipid syndrome were important factors for graft loss. Keywords: Kidney transplantation; Lupus nephritis; Systemic lupus erythematosus. / Introdução: O lúpus eritematoso sistêmico (LES) é uma doença autoimune, multissistêmica, caracterizada pela produção de autoanticorpos, deposição de imunocomplexos, inflamação sistêmica, além de dano tecidual. Cerca de 37% a 45% dos pacientes com LES, desenvolvem nefrite lúpica (NL) em algum momento do curso da doença. Uma proporção de 10 a 30% dos pacientes com NL evoluem para doença renal crônica (DRC), em um prazo de 15 anos após o diagnóstico, mesmo com o tratamento agressivo. Objetivo: Analisar o perfil sociodemográfico, clínico e laboratorial de pacientes com NL submetidos a transplante renal de um hospital público terciário. Detectar a recidiva do LES e o tempo de sobrevidas do enxerto renal e do paciente. Identificar o escore do índice de dano através dos critérios do Systemic Lupus International Collaborating Clinics (SLICC) em pacientes com LES. Comparar a sobrevida renal dos pacientes em estudo com outra pesquisa brasileira com o perfil clínico semelhante. Métodos: Foram analisados todos os registros de pacientes submetidos a transplante renal do período de Julho de 1996 a maio de 2016 no Hospital Geral de Fortaleza (HGF), centro de referência Norte Nordeste em transplantes. Destes, foram selecionados os de pacientes com diagnóstico de NL como causa de DRC terminal (n=35), que preenchiam critérios do Colégio Americano de Reumatologia (ACR). Resultados: De um total de 1.861 transplantes renais, 38 (1.8%) foram realizados em 35 pacientes com NL, 3 dos quais foram submetidos a mais de um transplante. A média de idade dos pacientes no diagnóstico do LES foi de 33,0 ± 11,1 anos. A maioria era do sexo feminino (94,7%) e não-caucasianos (68,4%). 57,9% foram submetidos à biópsia renal antes do transplante. A média do SLICC foi de 4,7 ± 1,2. A maioria dos doadores (71,1%) eram falecidos. A média do tempo do diagnóstico do LES até o transplante renal foi de 10,3 ± 6,4 anos. O tempo médio de diálise prévio ao transplante foi 3,9 ± 3,7 anos. A taxa de rejeição aguda, no primeiro ano, foi identificada em 7,9% dos pacientes. As sobrevidas do enxerto e do paciente foram respectivamente, 97,1% e 100% aos seis meses; 84,9% e 96,9%, no primeiro ano, e 73,3% e 92,5%, no quinto ano. 2,6% apresentou recidiva do LES. Comparando os pacientes que evoluíram com perda do enxerto e os que mantiveram boa função do enxerto, observamos uma maior prevalência de trombose (p=0,017) e síndrome antifosfolípide (p=0,036) no primeiro grupo. Conclusão: O estudo demonstrou que pacientes com NL submetidos a transplante renal apresentam uma boa sobrevida em um período de seguimento de 5 anos e que a presença de trombose e síndrome antifosfolípide foram fatores importantes para a perda do enxerto. Palavras-chave: Transplante de rim; Nefrite lúpica; Lúpus eritematoso sistêmico.

BACKGROUND Inducible costimulator (ICOS) and its ligand (ICOSL) are a pair of costimulatory molecules that co-localize in germinal centers (GC). This interaction is critical for the maturation of GC B cells to affinity-matured memory B cells and long-lived plasma cells. Both ICOS and ICOSL are implicated in systemic lupus erythematosus (SLE). It is known that ICOSL sheds from the cell membrane and that the soluble form of ICOSL (sICOSL) is elevated in SLE; though the function of sICOSL is poorly understood. While it is known that binding of ICOSL on antigen-presenting cells (APC) to ICOS on T cells leads to cell signaling resulting in T cell activation and differentiation, there is also some preliminary evidence that reverse signaling may also occur through ICOSL in APCs. The binding interaction between ICOS and sICOSL has not been fully characterized and is important to understand if either molecule is to be targeted therapeutically. The hypothesis evaluated in this study was that the ICOS: ICOSL interaction is a potent and critical mediator of proinflammatory signaling and immune activation that functions both via activated T cell-mediated forward signaling and APC-mediated reverse signaling mechanisms and that ectodomain shedding of ICOSL is a protective mechanism that leads to down-regulation of the proinflammatorysignaling cascade initiated by this interaction. The aim of this thesis is to characterize the binding interaction between ICOS and ICOSL and to provide a review of the literature and discuss future work that would enhance the biological understanding of this interaction and its role in lupus and other autoimmune diseases. METHODS The binding interaction between ICOS and ICOSL was characterized using both soluble proteins and cells with expressed recombinant proteins. Purified soluble ICOSL (sICOSL) was characterized using size-exclusion chromatography multiangle light scattering (SEC-MALS). Surface plasmon resonance (SPR) was used to measure the binding affinity between sICOSL and human ICOS fused to the fragment crystallizable (Fc) portion of an immunoglobulin molecule (hICOS.Fc). The binding interaction was further characterized to account for avidity between hICOS.Fc and sICOSL and between hICOS.Fc and ICOSL expressed recombinant on the cell surface using a solution-based binding method. RESULTS Expressed recombinant and purified sICOSL dimerized over time and with increasing temperatures. The sICOSL: hICOS.Fc interaction did not follow a typical 1:1 binding interaction. In-solution binding experiments resulted in a tighter equilibrium dissociation binding constant (KD) than the surface-based results obtained by SPR. The KD for hICOS.Fc binding to human ICOSL(hICOSL) expressed on cells agreed well with the KD for hICOS.Fc to the soluble protein, indicating that the in-solution binding measurement may measure binding avidity rather than affinity and that this may be the more physiologically relevant interaction. CONCLUSIONS I show in the experimental part of this study that the interaction between ICOS and ICOSL is quite potent and that much of the binding strength is due to avidity, or the combined strength of multiple parts of the molecules interacting with one another, rather than the affinity alone. As this interaction is implicated in SLE pathogenesis, it would be useful to develop a clearer understanding of the most relevant physiological form of these molecules (soluble or transmembrane) and of the biological signaling events that are initiated via this interaction in order to determine whether targeting ICOS or ICOSL may be therapeutically viable approaches.

Introdução: lúpus eritematoso é uma doença crônica auto-imune que afeta o tecido conjuntivo e múltiplos órgãos. Manifestações orais são pouco freqüentes, caracterizadas por lesões de aspectos variados. Diagnósticos diferenciais incluem líquen plano, leucoplasia, eritema polimorfo e pênfigo vulgar. Métodos: O objetivo deste trabalho foi estudar as lesões orais de 46 doentes com LE do ambulatório de Colagenoses e de Estomatologia do HC-FMUSP, enfocando os aspectos clínicos, histológicos, a proliferação e maturação epitelial (expressão de citoqueratinas, p-53 e ki-67), as proteínas da membrana basal (colágeno IV, fibronectina e laminina) e a constituição do infiltrado inflamatório (anticorpos CD3, CD4, CD8, CD 20, CD 68 e CD1A). Resultados: Quarenta e seis doentes (34 mulheres e 12 homens) apresentaram lesões orais, todos com alterações histológicas de mucosite de interface, infiltrado inflamatório superficial e profundo e depósitos subepiteliais PAS positivos. Positividade para IgM ao longo da membrana basal do epitélio foi observada pelo exame de IFD na maioria dos doentes. A avaliação das citoqueratinas mostrou um epitélio hiperproliferativo com expressão de CK 5/6 e CK 14 em todas as camadas, além da marcação do p-53 e ki-67 na camada basal. Os linfócitos T subtipo CD4 predominaram no infiltrado inflamatório, sendo mais rara a presença de linfócitos B e macrófagos. Células de Langerhans foram ausentes. Colágeno IV mostrou intensa expressão na membrana basal, a expressão da fibronectina foi mais difusa na lâmina própria e não se observou a presença de laminina. Conclusão: as lesões orais do LE predominam no sexo feminino e exibem aspectos clínicos variados. A mucosa jugal e lábios foram mais afetados. O aspecto histológico foi o de mucosite de interface associada a infiltrado inflamatório superficial e profundo com predomínio de linfócitos T CD4+, As citoqueratinas mostraram alteração no padrão de distribuição, caracterizando um epitélio hiperproliferativo. Na matriz extracelular predominou o colágeno IV na membrana basal. / Background: Lupus erythematosus (LE) is a multifactorial autoimmune disease of unknown cause. It may affect the oral mucosa in either its acute, subacute and chronic forms, with varied prevalence. Reports evaluate that mucosal involvement ranges from 9-45% in patients with systemic disease and from 3-20% in patients with chronic cutaneous involvement. Methods: Forty-six patients with confirmed diagnosis of LE, presenting oral lesions were included in the study. Oral mucosal lesions were analyzed clinically and their histopathological features were investigated. Additionally, using immunohistochemistry, the status of epithelial maturation proliferation and apoptosis of the biopsied lesions was assessed through the expression of cytokeratins, ki-67 and Fas. The inflammatory infiltrate constitution was also assessed using immunohistochemistry against the following clusters of differentiation: CD3, CD4, CD8, CD20, CD68 and CD1A. Finally, the components of extracellular matrix were analyzed trough the expression of collagen, laminin and fibronectina. Results: From 46 (15,45%) patients with specific LE oral lesions 34 were females (25) with cutaneous LE and 9 with systemic LE) and 12 were males (11 with cutaneous LE and 1 with systemic LE) out of 298 patients examined with lupus erithematosus. Clinical aspects of lesions varied, and lips and buccal mucosa were the most affected sites. Histologically, lesions revealed lichenoid mucositis with perivascular infiltrate and thickening of basement membrane. Cytokeratins profile showed hyperproliferative epithelium, with expression of CK5/6 and CK14 on all epithelial layers, CK16 on all suprabasal layers. CK10 was verified on the prickle cell layer only. Ki-67 and p53 were sparsely positive and Fas was present both in the basal layer of the epithelium and in the inflammatory infiltrate. Inflammatory infiltrate was predominantly composed by T lymphocytes of the CD4 subtype, with a minor prevalence of Blymphocytes, isolated macrophages and rare Langerhans cells. Matrix proteins collagen IV and laminin were present mainly in the basement membranes of the epithelium and blood vessels, whilst fibronectina was not detected. Conclusions: Oral lesions of lupus erythematosus show a variety of clinical aspects and histologically consist of a lichenoid mucositis with deep inflammatory infiltrate. Patterns of cytokeratins expression are of a hyperproliferative epithelium and the inflammatory infiltrate is composed predominantly of T-lymphocytes positive lymphocytes. This panel must analyzed in relation to the inflammatory cytokines for a better understanding of the mechanisms of the disease.

Com o objetivo de determinar a freqüência dos auto-anticorpos antinucleares e suas associações com manifestações clínico-laboratoriais e entre si, no Lúpus Eritematoso Sistêmico (LES), foi elaborado o presente estudo numa população de 120 pacientes do Rio Grande do Sul. / In arder to determine the frequency of antinuclear autoantibodies, their relationships between themselves and with different clinical and laboratory features, 120 patients with Systemic Lupus Rrytbematosus (SLE) from the state of Rio Grande do Sul were studied.

Con el objetivo de evaluar las características clínico﷓epidemiológicas de la Tuberculosis (TB) en pacientes con Lupus Eritematoso Sistémico (LES), diseñamos un estudio caso﷓control en el Servicio de Reumatología del Hospital Nacional Guillermo Almenara frigoven. Para tal fin, evaluamos los registros clínicos de 387 pacientes con LES atendidos entre los años 1990 y 2002. Durante este lapso encontramos 14 casos de Tuberculosis (TB) apareados con 28 controles con LES sin TB según sexo y edad. Los pacientes con TB tuvieron un mayor tiempo de enfermedad y recibieron una mayor dosis acumulada de corticoides. No encontramos diferencias entre la presentación clínica de LES entre ambos grupos. Siete casos (50%) correspondieron a pacientes con TB extrapulmonar. Respectivamente fueron 1 caso de TB osteoarticular, meníngea, pleural, endobronquial, renal, pericárdica y cutánea. Los pacientes con TB pulmonar tuvieron un mayor tiempo de LES y los pacientes con TB extrapulmonar una mayor frecuencia de antecedentes de TB. El diagnóstico de TB fue hecho por la búsqueda de bacilos ácido﷓alcohol resistentes (BAAR) en 617 casos de TB pulmonar y 417 casos de TB extrapulmonar. Conclusión: Encontramos 14 casos (3.61%) de TB en pacientes con LES. 50% correspondieron a formas extrapulmonares. Los pacientes con TB tuvieron un mayor tiempo de LES y recibieron una mayor dosis de corticoides. Recomendamos el diagnóstico precoz de TB en pacientes con LES ofreciendo profilaxis antituberculosa con Isoniazida a todos los pacientes. / To evaluate the clinical and epidemiological characteristics of TB in patients with SLE, we design a case﷓control study in the Rheumatology service of the Hospital Nacional Guillermo Almenara. For this purpose, we reviewed the clinical charts of 387 patients with SLE who were hospitalized between 1990 and 2002. During this time we found 14 cases of TB matched wíth 28 patients with LES but without TB according to sex and age. Patients with TB had a higher time of SLE and received a higher accumulate dosis of steroidá. We did not found differences between the clinical presentation of SLE of thís groups. Seven cases (50%) correspond to patients with extrapulmonary TB. Respectively were included cases of osteoarticular, meningeal, pleural, endobronchíal, renal, pericardical and cutaneous TB. People with pulmonary TB had a higher time of SLE and patients with extrapulmonary TB had a higher frequency of TB history. The diagnoses of TB were made by study of acid fast bacilli in 617 cases of pulmonary TB and 417 cases of extrapulmonary TB. Conclusion: We found 14 cases (3.61 %) of TB in SLE patients. 50% correspond to extrapulmonary forms. Patients with TB had a higher time of SLE and received a higher dosage of steroids. We recommend strategies for an early diagnoses of TB in SLE patients and Isoniazid usage in all of them. / Tesis

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with a strong and complex genetic basis. To dissect the function of the lupus susceptibility loci on New Zealand black (NZB) mouse chromosome 1, the lab had previously generated congenic mice with an introgressed homozygous NZB chromosome 1 intervals extending from ~35 or ~82 to 106 cM on the C57BL/6 background. Although both mouse strains made IgG anti-nuclear antibodies (ANAs), ANA titres and cellular activation were significantly higher in mice with the longer interval. These studies suggest the presence of two susceptibility genes. In this thesis I have sought to further characterize the cellular abnormalities and underlying genetic polymorphisms that produce them in these mice. Using mixed hematopoietic chimeric mice, with a mixture of tagged-B6 and congenic bone marrow I demonstrate that there are intrinsic B and T cell functional defects in chromosome 1 congenic mice. I further show that an intrinsic B cell defect is required for efficient recruitment of B cells into the spontaneous germinal centres and differentiation of autoantibody producing cells in these mice. To more precisely localize the susceptibility loci, I produced and characterized a number of additional subcongenic mouse strains. This revealed surprising genetic complexity with the presence of at least four lupus susceptibility loci and a suppressor locus on chromosome 1, several of which appeared to impact on T cell function. Finally, I generated bicongenic mice carrying both NZB chromosome 1 and 13 intervals, hypothesizing that since these were two of the major intervals associated with autoimmune disease in NZB mice they would fully recapitulate the autoimmune phenotypes. Although this hypothesis was incorrect, several novel phenotypes developed including marked expansion of the plasmacytoid and myeloid dendritic cell compartments and increased BAFF and IgA autoantibody production. Although this expansion was associated with TLR hyper-responsiveness, disease severity remained mild, possibly due to the lack of IFN- production, which appeared to be inhibited in these mice. Thus, lupus arises from immune defects affecting several cellular populations, which are the product of multiple genetic polymorphisms that interact in a complex fashion to produce the autoimmune phenotype.

Objective: To examine the workplace challenges of lupus patients. Methods: A cross sectional study surveyed lupus patients seen at the Toronto Lupus Clinic in the last 2 years. We included questions on health, work context and psychosocial perceptions. Descriptive statistics described the sociodemographic and clinical characteristics of the sample; multivariable analysis examined factors associated with workplace activity limitations, job strain, and job accommodations. Results: 362 respondents completed the questionnaire (60% response). 49.7% were currently employed. Participants who recently left work had higher disease activity and workplace activity limitations. Employed participants had low to moderate job strain. Seventy percent of employed participants used job accommodations. Health, work context, and psychological factors were significantly associated with workplace activity limitations, job strain and job accommodations. Conclusion: Persons living with lupus are faced by different challenges at the workplace. Workplace difficulties and needs of individuals with lupus should be assessed by health professionals.

Objective: To examine the workplace challenges of lupus patients. Methods: A cross sectional study surveyed lupus patients seen at the Toronto Lupus Clinic in the last 2 years. We included questions on health, work context and psychosocial perceptions. Descriptive statistics described the sociodemographic and clinical characteristics of the sample; multivariable analysis examined factors associated with workplace activity limitations, job strain, and job accommodations. Results: 362 respondents completed the questionnaire (60% response). 49.7% were currently employed. Participants who recently left work had higher disease activity and workplace activity limitations. Employed participants had low to moderate job strain. Seventy percent of employed participants used job accommodations. Health, work context, and psychological factors were significantly associated with workplace activity limitations, job strain and job accommodations. Conclusion: Persons living with lupus are faced by different challenges at the workplace. Workplace difficulties and needs of individuals with lupus should be assessed by health professionals.

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with a strong and complex genetic basis. To dissect the function of the lupus susceptibility loci on New Zealand black (NZB) mouse chromosome 1, the lab had previously generated congenic mice with an introgressed homozygous NZB chromosome 1 intervals extending from ~35 or ~82 to 106 cM on the C57BL/6 background. Although both mouse strains made IgG anti-nuclear antibodies (ANAs), ANA titres and cellular activation were significantly higher in mice with the longer interval. These studies suggest the presence of two susceptibility genes. In this thesis I have sought to further characterize the cellular abnormalities and underlying genetic polymorphisms that produce them in these mice. Using mixed hematopoietic chimeric mice, with a mixture of tagged-B6 and congenic bone marrow I demonstrate that there are intrinsic B and T cell functional defects in chromosome 1 congenic mice. I further show that an intrinsic B cell defect is required for efficient recruitment of B cells into the spontaneous germinal centres and differentiation of autoantibody producing cells in these mice. To more precisely localize the susceptibility loci, I produced and characterized a number of additional subcongenic mouse strains. This revealed surprising genetic complexity with the presence of at least four lupus susceptibility loci and a suppressor locus on chromosome 1, several of which appeared to impact on T cell function. Finally, I generated bicongenic mice carrying both NZB chromosome 1 and 13 intervals, hypothesizing that since these were two of the major intervals associated with autoimmune disease in NZB mice they would fully recapitulate the autoimmune phenotypes. Although this hypothesis was incorrect, several novel phenotypes developed including marked expansion of the plasmacytoid and myeloid dendritic cell compartments and increased BAFF and IgA autoantibody production. Although this expansion was associated with TLR hyper-responsiveness, disease severity remained mild, possibly due to the lack of IFN- production, which appeared to be inhibited in these mice. Thus, lupus arises from immune defects affecting several cellular populations, which are the product of multiple genetic polymorphisms that interact in a complex fashion to produce the autoimmune phenotype.

Con el objetivo de evaluar las características clínico﷓epidemiológicas de la Tuberculosis (TB) en pacientes con Lupus Eritematoso Sistémico (LES), diseñamos un estudio caso﷓control en el Servicio de Reumatología del Hospital Nacional Guillermo Almenara frigoven. Para tal fin, evaluamos los registros clínicos de 387 pacientes con LES atendidos entre los años 1990 y 2002. Durante este lapso encontramos 14 casos de Tuberculosis (TB) apareados con 28 controles con LES sin TB según sexo y edad. Los pacientes con TB tuvieron un mayor tiempo de enfermedad y recibieron una mayor dosis acumulada de corticoides. No encontramos diferencias entre la presentación clínica de LES entre ambos grupos. Siete casos (50%) correspondieron a pacientes con TB extrapulmonar. Respectivamente fueron 1 caso de TB osteoarticular, meníngea, pleural, endobronquial, renal, pericárdica y cutánea. Los pacientes con TB pulmonar tuvieron un mayor tiempo de LES y los pacientes con TB extrapulmonar una mayor frecuencia de antecedentes de TB. El diagnóstico de TB fue hecho por la búsqueda de bacilos ácido﷓alcohol resistentes (BAAR) en 617 casos de TB pulmonar y 417 casos de TB extrapulmonar. Conclusión: Encontramos 14 casos (3.61%) de TB en pacientes con LES. 50% correspondieron a formas extrapulmonares. Los pacientes con TB tuvieron un mayor tiempo de LES y recibieron una mayor dosis de corticoides. Recomendamos el diagnóstico precoz de TB en pacientes con LES ofreciendo profilaxis antituberculosa con Isoniazida a todos los pacientes. / To evaluate the clinical and epidemiological characteristics of TB in patients with SLE, we design a case﷓control study in the Rheumatology service of the Hospital Nacional Guillermo Almenara. For this purpose, we reviewed the clinical charts of 387 patients with SLE who were hospitalized between 1990 and 2002. During this time we found 14 cases of TB matched wíth 28 patients with LES but without TB according to sex and age. Patients with TB had a higher time of SLE and received a higher accumulate dosis of steroidá. We did not found differences between the clinical presentation of SLE of thís groups. Seven cases (50%) correspond to patients with extrapulmonary TB. Respectively were included cases of osteoarticular, meningeal, pleural, endobronchíal, renal, pericardical and cutaneous TB. People with pulmonary TB had a higher time of SLE and patients with extrapulmonary TB had a higher frequency of TB history. The diagnoses of TB were made by study of acid fast bacilli in 617 cases of pulmonary TB and 417 cases of extrapulmonary TB. Conclusion: We found 14 cases (3.61 %) of TB in SLE patients. 50% correspond to extrapulmonary forms. Patients with TB had a higher time of SLE and received a higher dosage of steroids. We recommend strategies for an early diagnoses of TB in SLE patients and Isoniazid usage in all of them.