The Anti-DNA Antibodies: Their Specificities for Unique DNA Structures and Their Unresolved Clinical Impact—A System Criticism and a Hypothesis

Systemic lupus erythematosus (SLE) is diagnosed and classified by criteria, or by experience, intuition and traditions, and not by scientifically well-defined etiology(ies) or pathogenicity(ies). One central criterion and diagnostic factor is founded on theoretical and analytical approaches based on our imperfect definition of the term “The anti-dsDNA antibody”. “The anti-dsDNA antibody” holds an archaic position in SLE as a unique classification criterium and pathogenic factor. In a wider sense, antibodies to unique transcriptionally active or silent DNA structures and chromatin components may have individual and profound nephritogenic impact although not considered yet – not in theoretical nor in descriptive or experimental contexts. This hypothesis is contemplated here. In this analysis, our state-of-the-art conception of these antibodies is probed and found too deficient with respect to their origin, structural DNA specificities and clinical/pathogenic impact. Discoveries of DNA structures and functions started with Miescher’s Nuclein (1871), via Chargaff, Franklin, Watson and Crick, and continues today. The discoveries have left us with a DNA helix that presents distinct structures expressing unique operations of DNA. All structures are proven immunogenic! Unique autoimmune antibodies are described against e.g. ssDNA, elongated B DNA, bent B DNA, Z DNA, cruciform DNA, or individual components of chromatin. In light of the massive scientific interest in anti-DNA antibodies over decades, it is an unexpected observation that the spectrum of DNA structures has been known for decades without being implemented in clinical immunology. This leads consequently to a critical analysis of historical and contemporary evidence-based data and of ignored and one-dimensional contexts and hypotheses: i.e. “one antibody - one disease”. In this study radical viewpoints on the impact of DNA and chromatin immunity/autoimmunity are considered and discussed in context of the pathogenesis of lupus nephritis.

Hematological malignancies in systemic lupus erythematosus: clinical characteristics, risk factors, and prognosis—a case-control study

Background Systemic lupus erythematosus (SLE) is a chronic and complex multi-system autoimmune disorder. Higher risks of hematological malignancies (HM) were observed in SLE patients, which was associated with higher mortality. The mechanism and risk factors of HM oncogenesis in SLE patients are still under investigation. The aim of this study was to explore clinical characteristics, risk factors, and prognosis of SLE patients with or without HM in the Chinese population. Methods A retrospective, case-controlled study was conducted in 72 SLE patients between January 2013 and December 2020. Clinical and laboratory data were collected and compared between the two groups of patients with HM and those without HM. Logistic regression analysis was performed to determine risk factors of HM oncogenesis. The survival rate was estimated by Kaplan-Meier methods and Cox proportional hazards regression analysis. Results Among 72 SLE patients in this study, fifteen complicated with HM and 57 without HM were identified. The incidence rate of HM was approximately 0.24% with elevated standardized incidence ratios of lymphoma and leukemia (27.559 and 12.708, respectively). Patients with HM were older when diagnosed with SLE, with a higher frequency of infection and splenomegaly, lower levels of hemoglobin and high-density lipoprotein compared with those without HM. Fewer patients with HM expressed positive anti-dsDNA antibody (26.7% vs 66.7%, P = 0.005) or received hydroxychloroquine treatment (40.0% vs 86.0%, P = 0.001). Older age at SLE diagnosis (OR=1.122, 95% CI: 1.037–1.214) was regarded as an independent risk factor of HM oncogenesis. Female (RR= 0.219, 95% CI: 0.070–0.681) and hydroxychloroquine (RR= 0.281, 95% CI: 0.094–0.845) were protective factors of mortality in SLE patients. Conclusions SLE patients with an older age are at an increased risk of HM carcinogenesis. The prognosis of male patients with SLE tends to be poorer whether complicated with HM. The association of antinuclear antibody spectrum, medication, and HM oncogenesis in SLE needs further investigation.

High Systemic Type I Interferon Activity is Associated with Active Class III/IV Lupus Nephritis

Objective Previous studies suggest a link between high serum type I interferon (IFN) and lupus nephritis (LN). We determined whether serum IFN activity is associated with subtypes of LN and studied renal tissues and cells to understand the impact of IFN in LN. Methods 221 systemic lupus erythematosus (SLE) patients were studied. Serum IFN activity was measured by WISH bioassay. mRNA in-situ hybridization was used in renal tissue to measure expression of the representative IFN-induced gene, interferon-induced protein with tetratricopeptide repeats-1 (IFIT1), and the plasmacytoid dendritic cell (pDC) marker gene C-type lectin domain family-4 member C (CLEC4C or BDCA2). Podocyte cell line gene expression was measured by real-time PCR. Results Class III/IV LN prevalence was significantly increased in patients with high serum IFN compared with those with low IFN (OR=5.48, p=4.0x10-7). In multivariate regression models, type I IFN was a stronger predictor of class III/IV LN than complement C3 or anti-dsDNA antibody, and could account for the association of these variables with LN. IFIT1 expression was increased in all classes of LN, but most in the glomerular areas of active class III/IV LN kidneys. IFIT1 expression was not closely co-localized with pDCs. IFN directly activated podocyte cell lines to induce chemokines and proapoptotic molecules. Conclusion Systemic high IFN is involved in the pathogenesis of severe LN. We do not find co-localization of pDCs with IFN signature in renal tissue, and instead observe the greatest intensity of IFN signature in glomerular areas, which could suggest a blood source of IFN.

Anti-TNF-alpha-induced lupus in patients with non-infectious uveitis

Purpose Anti-TNF-α-induced lupus (ATIL) is a rare condition considered as a drug-induced lupus (DIL) in patients under anti-TNF-α therapies. Nowadays it is still unclear if ATIL is a classical DIL or represent a distinct syndrome. Some characteristics of DIL have been described specifically associated with patients with lupus-like syndrome receiving anti-TNF-α therapy: the severity of the disease, incidence/prevalence of dsDNA antibodies (anti-dsDNA) and hypocomplementaemia. The objective of this study is to describe the development of ATIL in patients with non-infectious uveitis in a single tertiary center. Methods Retrospective description of a case series. Results We describe three patients with noninfectious uveitis (NIU) of different etiologies who developed antinuclear antibody (ANA) and anti-dsDNA antibody positivity, arthritis and, in one case, skin lesions under adalimumab treatment. The condition resolved in all of them after adalimumab withdrawal. Corticosteroids were required in one patient, non-steroidal anti-inflammatory drugs in two patients, and hydroxychloroquine in one of them. None required another immunosuppressive drug. A subsequent control of the NIU could continue to be carried out without anti-TNF-α therapy in two patients and in the remaining a switch was made to another anti-TNF-α (golimumab). Conclusion The current report describes three cases of ATIL in patients with different types of NIU which share some common features: ANA positivity, articular symptoms, and a temporal relationship between symptoms onset and anti-TNF-α treatment. A review of the literature and comparison with the few previous reported ATIL cases was conducted as well.

RENAL VEIN THROMBOSIS WITH INFRAHEPATIC INFERIOR VENA CAVA EXTENSION IN A CASE OF ANTI dsDNA ANTIBODY NEGATIVE LUPUS NEPHRITIS

Systemic Lupus Erythematosis (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. Anti dsDNA antibody has been considered as a marker of renal disease. Hence elevated levels are expected in patients with Lupus Nephritis (LN). But in a subset of these patients anti dsDNA antibody is negative and this heralds the development of burned out LN (stage 5 LN) which predisposes patients to thrombosis. Prophylactic anticoagulation plays an important role in the management of such patients. We describe a case of a 19 year old female with lupus nephritis and renal vein thrombosis that had extended into the inferior vena cava. Her serology was strikingly signicant for the absence of anti dsDNA antibody. The factors that predispose to the development of venous thrombosis in patients with Lupus Nephritis are discussed. In conclusion, negative anti dsDNA antibodies heralds the development of stage ve Lupus Nephritis which predisposes to thrombosis. Guidelines for prophylactic anticoagulation as per serum albumin levels are also discussed.

miR-20a Overexpression in Adipose-Derived Mesenchymal Stem Cells Promotes Therapeutic Efficacy in Murine Lupus Nephritis by Regulating Autophagy

Objective. Lupus nephritis is the most common and severe complication of systemic lupus erythematosus. The aim of our study was to investigate the efficacy of miR-20a overexpressing adipose-derived stem cell (ADSC) transplantation in murine lupus nephritis (LN) and explore potential molecular mechanisms. Methods. Mouse ADSCs were transfected with a miR-20a lentiviral vector to obtain miR-20a overexpression ADSCs (miR-20a-ADSCs). We first observed the influence of miR-20a on ADSC viability and apoptosis in vitro. B6.MRL/lpr mice were administered ADSC/miR-20a-ADSC intravenously every week from age 30 to 33 weeks, and the lupus and normal control groups received PBS on the same schedule. Results. miR-20a expression increased in miR-20a-ADSC-derived exosomes, and miR-20a overexpression promoted ADSC proliferation and inhibited apoptosis. Compared with ADSCs, miR-20a-ADSC treatment significantly improved serologic and histologic abnormalities, as evidenced by reduced serum creatinine, anti-dsDNA antibody, 24 h urine protein levels, nephritis scores, and C3/IgG deposits. Furthermore, miR-20a-ADSC treatment resulted in downregulated Akt, mTOR, and p62 expression and upregulated miR-20a, Beclin 1, and LC3 II/I expression compared with ADSC treatment. After treatment with miR-20a-ADSC, a significant increase in the number of autophagosomes within podocytes was observed, along with upregulated expression of podocin and nephrin, compared with the ADSC group. Conclusions. miR-20a-ADSC transplantation prevents the development of lupus nephritis and significantly ameliorates already-established disease, and its mechanism is related to autophagy by targeting the miR-20a-regulated mTOR pathway.

Comparisons of Anti-dsDNA Antibody Detection Methods by Chemiluminescent Immunoassay and Enzyme-Linked Immunosorbent Assay in Systemic Lupus Erythematosus

This study aimed to compare the test results of anti-double-stranded DNA (anti-dsDNA) antibodies obtained using chemiluminescent immunoassay (CIA) and enzyme-linked immunosorbent assay (ELISA), and investigate predictors of inconsistent results. This retrospective study included 502 patients who underwent CIA and ELISA to determine their anti-dsDNA antibody values within a year. We compared the diagnostic power for SLE, disease activity, and predictive power for lupus nephritis (LN). A multivariate analysis was performed to determine the predictors of inconsistencies. CIA and ELISA were moderately correlated in terms of their consistency (Cronbach’s α = 0.571), and yielded comparably favorable results in terms of SLE diagnostic power and SLE disease activity. However, if the patient had LN, CIA displayed higher predictive power than ELISA (0.620 vs. 0.555, p = 0.026). Compared with the CIA/ELISA double-positive group, the inconsistent group had lower anti-C1q circulating immune complexes (CIC) antibody values (OR: 0.42, 95% CI: 0.18–0.94, p = 0.036), and lower SLEDAI scores (≥4) (OR: 0.33, 95% CI: 0.14–0.79, p = 0.013). Anti-dsDNA antibody detection with CIA exhibited higher predictability for diagnosing LN than did ELISA. In the event of inconsistencies between anti-dsDNA methods, SLE disease activity and CIC test values should be considered simultaneously.

Clinical study of factors associated with pregnancy outcomes in pregnant women with systemic lupus erythematosus in the southern China

Objectives: This study aims to estimate predicted factors for maternal and fetal outcomes in Hakka pregnant women with systemic lupus erythematosus (SLE) in the Southern China. Patients and methods: Between June 2014 and February 2020, we retrospectively analyzed the data of a total of 123 singleton pregnant women with SLE (mean age: 27.1±4.1 years; range, 19 to 39 years) who were referred to our rheumatology clinic. Demographic, clinical, and laboratory data of the patients were recorded. Adverse pregnancy outcomes (APOs) were assessed. Results: Multivariate logistic regression analysis revealed that preeclampsia was associated with the increased odds of APOs (odds ratios [OR]=9.538, 95% confidence interval [CI]: 2.055-44.271, p=0.004), premature birth (OR=14.289, 95% CI: 3.596-56.777, p<0.001) and low birth weight (OR=8.275, 95% CI: 2.117-32.345, p=0.002). Anti-double-stranded deoxyribonucleic acid (anti-dsDNA) antibody positivity was the predictor of APOs (OR=2.165, 95% CI: 1.034-4.532, p=0.040), premature birth (OR=2.849, 95% CI: 1.220-6.657, p=0.016) and pregnancy loss (OR=3.004, 95% CI: 1.086-8.305, p=0.034). The use of hydroxychloroquine and prednisone was associated with the decreased odds of APOs (OR=0.412, 95% CI: 0.198-0.860, p=0.018) and pregnancy loss (OR=0.304, 95% CI: 0.111-0.831, p=0.020). Conclusion: Our study results indicate that preeclampsia, anti-dsDNA antibody positivity, and the use of hydroxychloroquine and prednisone are independent predictors of pregnancy outcomes.

Induction of Systemic Lupus Erythematosus-like Syndrome in BALB/c Mice Leads to Disturbance in Splenic T Cell Subpopulations

Mechanisms underlying the systemic lupus erythematosus (SLE) have not yet been elucidated. In this study, we evaluated the balance of T cell subsets in BALB/c mice model of SLE induced; using Con A and polyamines as DNA immunogenicity modifiers. BALB/c mice were immunized subcutaneously with 50 µg extracted DNA from cells cultured in different conditions: splenocytes+ polyamines (group P), splenocytes+ Con A (group A), splenocytes+ polyamines+ Con A (group PA) and splenocytes only (control). Anti-double-stranded DNA –(ds-DNA) antibodies, proteinuria, and antinuclear autoantibodies were assessed by enzyme-linked immunosorbent assay, Bradford method, and immunofluorescence respectively. Transcription factors of different T helper subsets were examined by real-time polymerase chain reaction. The serum level of the anti-dsDNA antibody in group PA was higher than that in the other groups (p>0.05). Antinuclear antibody (ANA) titer increased in groups A and PA. Proteinuria level in group PA was significantly higher than that in the control group (p<0.001). Expression of Foxp3 was decreased in group A (p=0.001). Additionally, the ratios of T-bet/GATA3 and T-bet/Foxp3 were also increased in group A. (p>0.05). Our results revealed an increased ratio of Th1 to Th2 and decreased expression of Foxp3 in group A, but group PA manifested more obvious signs of the disease. These results suggest that other mechanisms rather than disturbance in T cells' balance may involve the development of disease symptoms.

Glucocorticoid Discontinuation in Patients With Systemic Lupus Erythematosus With Prior Severe Organ Involvement: a Single-center Retrospective Analysis

Background:Long-term glucocorticoid use in systemic lupus erythematosus (SLE) may have significant side effects; however, glucocorticoid discontinuation is occasionally associated with disease flare-ups. Therefore, we evaluated the risk factors for disease flares and the flare rate upon glucocorticoid tapering in patients with prior severe organ involvement.Methods:Patients with SLE with glucocorticoid tapering at our institution were retrospectively analyzed. We divided the patients according to the presence of prior severe organ involvement and compared flare rates and time to first flare after glucocorticoid discontinuation. Furthermore, we determined risk and protective factors for flares after glucocorticoid discontinuation.Results:A total of 309 patients with SLE were screened; 298 had prednisolone tapered to less than 7.5 mg/day and 75 had glucocorticoid discontinuation. Overall, 73 patients met the inclusion criteria; 49 were classified as SLE with prior severe organ involvement. No statistical differences were noted in the 52-week flare rate and time to first flare after glucocorticoid discontinuation between patients with and without prior severe organ involvement (52-week flare rate: 16.7% vs. 18.2%, p = 1.0; time to first flare: 322 [280, 1169] vs. 385 [304, 2345] days, p = 0.33). Hypocomplementemia, elevated anti-dsDNA antibody titers of more than twice the upper limit of the laboratory reference range, and positive anti-Smith/anti-ribonucleoprotein antibody were negatively associated with flare-free remission.Conclusion:Glucocorticoid discontinuation can often be achieved in patients with SLE without increasing flare risk in most patients with prior severe organ involvement, especially when the disease is clinically and serologically stable.