Systemic lupus erythematosus. Disease outcome in patients with a disease duration of at least 10 years: second evaluation.

Data related to the disease course of patients with systemic lupus erythematosus (SLE) with special attention to the persistence of disease activity in the long term are scarce. At this moment reliable figures are only known about the survival rate as a measure of outcome. The aim of this multicenter study was to describe the outcome of SLE patients with a disease duration of greater than 10 y. Outcome parameters were two disease activity-scoring systems (SLEDAI and ECLAM), the end organ damage (SLICC/ACR damage index) and treatment. Our results are derived from 187 SLE patients followed at 10 different centres in Europe over a period of 1 y. Serious clinical signs or exacerbations, defined by the occurrence or detoriation of already existing symptoms of renal and cerebral nervous systems were observed in 2-11% of the patients, seizures and psychosis in 3%, proteinuria in 11% and an increase in serum creatinine in 5% of the patients. No change took place in the overall damage index. Yet, the disease course in most patients was characterized by periods of tiredness (42-60%), arthritis (20-25%), skin involvement such as malar rash (32-40%), migraine (15-20%), anaemia (15%) and leucopenia (17-19%). Summarizing these results it is shown that patients, still under care after such a long time of having this disease, do have a disease that is far from extinguished.

Systemic lupus erythematosus: clinical features in patients with a disease duration of over 10 years, first evaluation.

OBJECTIVE: Most information available about the disease course of patients with systemic lupus erythematosus (SLE) is restricted to the first 5 yr after disease onset. Data about the disease course 10 yr after disease onset are rare. The aim of this multicentre study was to describe the outcome of SLE patients with a disease duration of >10 yr. METHODS: Outcome parameters were the SLE Disease Activity Index (SLEDAI), the European Consensus Lupus Activity Measure (ECLAM), the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index (SLICC/ACR), a global damage index (DI) and required treatment. In 10 different European rheumatology centres, all SLE patients who were evaluated in the last 3 months of 1994, and who had been diagnosed with SLE at least 10 yr ago, were included in the study. RESULTS: It should be stressed that our results are confined to a patient cohort, defined by a disease duration of at least 10 yr, and who are still under clinical care at the different centres in Europe. These SLE patients still showed some disease activity, related to symptoms of the skin and musculoskeletal systems, next to the presence of renal involvement. A total of 72% of the patients needed treatment with prednisolone (

Cytokine production in whole blood cell cultures of patients with rheumatoid arthritis.

OBJECTIVE: The measurement of cytokine production of activated lymphocytes and monocytes in the whole blood cell (WBC) culture system may provide a sensitive tool for evaluating the actual ongoing immune response of patients with rheumatoid arthritis (RA). METHODS: Lipopolysaccharide (LPS) up to 250 pg/ml was used for the stimulation of monocytes for measuring the production of tumour necrosis factor alpha (TNF alpha), interleukin 6 (IL6) and IL12, while the anti-CD3 (1 microgram/ml) and anti-CD28 (5 micrograms/ml) combination was used for T cell stimulation with the measuring of IL4 and interferon gamma (INF gamma) production. Twenty seven patients with RA and 23 healthy controls were studied. RESULTS: The results showed a decreased IL6 (LPS stimulus 4-6 pg/ml) and IL-12 (LPS stimulus 16-62 pg/ml) production in the RA patients. The maximal production of both cytokines was comparable with the normal controls. T cell stimulation showed a significant decreased INF gamma production in the RA patients. CONCLUSIONS: These findings obtained in the WBC culture system are highly suggestive for a decreased TH-1 derived cytokine production by a diminished IL12 production in RA patients. Another possibility is that both IL12 and INF gamma production in WBCs are inhibited by eventual circulating serum factors.

Common variable immunodeficiency in a patient with systemic lupus erythematosus.

This report describes a young girl who developed systemic lupus erythematosus at the age of 11. In the years thereafter a conversion took place from hypergammaglobulinemia to hypogammaglobulinemia with the absence of circulating and bone marrow B-cells. Some aspects of the aetiopathogenesis of common variable immunodeficiency are discussed.

Cytokine production (IL-6 and TNF alpha) in whole blood cell cultures of patients with systemic lupus erythematosus.

Whole blood cell culture has great advantage over isolated peripheral blood mononuclear cell culture, because it needs only small amounts of blood and is fast to perform. The current report focuses on the measurement of IL-6 and TNF alpha produced by peripheral blood monocytes of patients with systemic lupus erythematosus (SLE) in the whole blood cell culture system. After an initial triggering with lipopolysaccharide (LPS), a specific stimulus for monocytes, a decreased production of IL-6 relative to the controls was observed. Dividing our SLE patients according to treatment with corticosteroids, overall the IL-6 production was decreased in the patients treated with corticosteroids. TNF alpha production was comparable with normals, with the exception of an increased spontaneous production and using LPS stimulus of 4 pg/ml. In the patients treated with corticosteroids a decreased TNF production was observed, in contrast to the non-treated patients in which an increased TNF production was found compared with the controls using LPS doses higher than 62 pg/ml. The impaired acute phase reaction (APR) that has been described in the literature, might be explained by our observation of a decreased production of mainly IL-6. However, also this study showed that treatment has a strong impact on ex vivo IL-6 and TNF production.

Serum levels of soluble forms of T cell activation antigens CD27 and CD25 in systemic lupus erythematosus in relation with lymphocytes count and disease course.

Systemic lupus erythematosus (SLE) patients are characterized by a low lymphocyte count, which is considered a specific disease marker and is related to disease activity. The membrane bound molecules CD25 and CD27 are expressed and released in a soluble CD25 (sCD25) and soluble CD27 (sCD27) form by activation of predominantly T cells. In previous studies it was claimed that sCD25 as well sCD27 might be used as parameters for activation of the immune system; a correlation between the sCD25 profile with the disease course in SLE patients was also shown. To assess the relationship between lymphocyte count and these T cell activation markers, we performed a cross-sectional and a longitudinal study. In the longitudinal study three SLE patients who were known for a long time at our outpatient clinic were studied. Both T cell markers strongly correlated with each other and formed a reflection of the disease course. In all 7 periods of exacerbation, which we observed in the 3 investigated patients, both levels increased preceding this period; however, no correlation was found with the lymphocyte count. In the cross sectional study of 69 patients with SLE, sCD25 and sCD27 levels were correlated with defined disease manifestations; sCD25 was elevated in all periods of increased disease activity. The same holds true for sCD27, with the exception of patients with nephritis in which the highest levels were observed. Both profiles of sCD25 and sCD27 were strongly correlated during the whole disease course. Our data prove that in the pathogenesis of SLE an active recruitement of unprimed and primed T cells takes place.

Antibodies to a 15 kD nuclear antigen in patients with juvenile chronic arthritis and uveitis.

Young girls with a pauciarticular onset of juvenile chronic arthritis and circulating antinuclear antibodies are at risk for chronic uveitis. The actual nuclear antigen for these antinuclear antibodies has not been defined. Conventional laboratory techniques, such as counter immunoelectrophoresis, have shown that antibodies to well defined "extractable nuclear antigens" (eg, RNP, Sm, SS-A, and SS-B) are not present in patients with juvenile chronic arthritis. Therefore, other, previously unknown nuclear antigens may be involved. Sera of 64 patients with juvenile chronic arthritis, including 22 patients with chronic anterior uveitis, were studied using the immunoblotting technique to characterize the nuclear antigens. Antinuclear antibodies were present in 12 (55%) of the 22 patients with uveitis, and only in six (14%) of the 42 patients without chronic anterior uveitis. With the immunoblotting technique, antibodies to a 15 kD nuclear antigen were found in 10 (45%) of the 22 patients with chronic anterior uveitis, whereas only two (5%) of the 42 patients without chronic anterior uveitis showed these antibodies (P less than 0.001). Only clearly visible and reproducible lines in the immunoblotting patterns were studied. This may provide a diagnostic tool for the early detection of uveitis and means for further pathogenetic studies.

Anti-dsDNA: choice of assay in relation to clinical value.

Antibodies to DNA are quite specific for systemic lupus erythematosus (SLE) and occur in the majority of SLE patients. Therefore, their detection is an important diagnostic aid to the clinician. Detection of anti-dsDNA may precede the diagnosis of SLE by more than a year. Fluctuations in the level of anti-dsDNA in an individual patient may give important information on the clinical status of the patient. Four of the most important methods developed for the measurement of anti-dsDNA antibodies will be discussed in this paper: the Farr assay, the PEG assay, the indirect immunofluorescence test on Crithidia luciliae and the ELISA. They will also be compared with one commercially available (Farr) assay, the Amersham anti-dsDNA kit. Each method, detects a part of the spectrum of anti-dsDNA antibodies produced by a patient. The Farr assay is the most specific for SLE; however, milder forms of the disease in which patients have only low avidity anti-dsDNA may easily be missed by this technique. Clinically, high avidity anti-dsDNA is related more frequently to the occurrence of nephritis, whereas low avidity anti-dsDNA antibodies are found more often in patients with central nervous system involvement. Traditionally, SLE is considered an immune-complex disease, in which inflammatory processes are initiated by local deposition of DNA/anti-dsDNA complexes. More recently, a major role was thought to be played by crossreactions of anti-dsDNA with tissue constituents. Our current view, however, is that such a crossreactivity plays only a minor role; we postulate that binding to glomerular constituents is caused by anti-dsDNA antibodies complexed with DNA and histones.

Fine specificities of anti-nuclear antibodies in murine models of graft-versus-host disease.

Two models of murine graft-versus-host disease (GVHD) were studied with respect to autoantibody production and development of systemic lupus erythematosus (SLE) like disease. One model was induced by injection of (B10.A(4R) x B10.A(2R]F1 mice with parental (B10.A(4R] spleen and lymph node cells (groups I GVHD), the other by injection of (DBA/2 x C57/B16)F1 mice with DBA/2 cells (group II GVHD). Group I GVHD mice remained in a seemingly healthy condition and did not show any proteinuria, in spite of high titres of anti-nuclear antibodies including antibodies to dsDNA, anti-Sm and anti-ribosomal P protein antibodies. Measured levels of these autoantibodies as well as their isotypes were comparable with those found in MRL/lpr and NZB/W mice. Group II GVHD mice developed SLE-like disease signs, including severe proteinuria. At 4 months after induction of the GVHD, almost 50% of these mice had died. At the time nephritis was present, group II mice also produced anti-dsDNA and anti-nuclear antibodies of other (unknown) specificities, but no anti-Sm or anti-P. Furthermore, the incidence of these antibodies was lower than observed in group I GVHD, MRL/lpr or NZB/W mice. It is concluded that (high avidity) anti-dsDNA as well as anti-Sm and anti-P may be present in the circulation without giving rise to the development of nephritis.

Technical problems concerning the use of immunoblots for the detection of antinuclear antibodies.

When the immunoblotting technique is used as a diagnostic tool, the reproducibility of the results is a major problem. When purified radiolabelled proteins were applied onto SDS gels, the recovery of radioactivity on the blot after electrophoresis, blotting and incubation ranged from 10 to 65%, depending on the protein. Although the addition of SDS was subsequently shown to improve protein transfer from gel to blot, it is not recommended because immunological recognition of proteins is diminished after this transfer step. We suggest that during the incubation of protein blots detergents are necessary not only to diminish non-specific background, but also to renature proteins. However, since these detergents also elute protein from nitrocellulose and other blotting matrices, they are in part responsible for the lack of reproducibility in immunoblotting results.

Cross-reactive binding patterns of monoclonal antibodies to DNA are often caused by DNA/anti-DNA immune complexes.

Recently, the role of antibodies to DNA in the pathogenesis of systemic lupus erythematosus (SLE) has been reevaluated, since observed cross-reactive binding of anti-DNA to tissue-related antigens might substantially contribute to the inflammatory process of the disease. Evidence of this cross-reactivity has, in part, been obtained from studies with monoclonal anti-DNA. However, we now report that the presence of DNA/anti-DNA immune complexes in monoclonal antibody preparations may be the cause of the observed cross-reactive binding patterns. Studying a panel of anti-DNA producing hybridomas (n = 63), we detected such immune complexes in 76% of the obtained culture supernatants by using an anti-protamine sulphate (PS) ELISA; complexes formed with 1 microgram/ml DNA or more were traced in this assay. In cultures of anti-DNA-producing hybridomas, complexes were detected from day 3 on. Treatment of supernatants with DNase reduced the anti-PS reactivity to an average of only 20% of the original reactivity. Contaminating DNA/anti-DNA immune complexes were found to play no role in the cross-reactivity of anti-DNA antibodies with cardiolipin, a minor role in cross-reactivity with dextran sulphate, but a substantial role in the cross-reactivity with heparan sulphate, histones and other nuclear or cytoplasmic antigens. Our results clearly demonstrate that exclusion of the presence of immune complexes in antibody preparations is a prerequisite when cross-reactivity patterns of anti-DNA antibodies are studied.

Reaction patterns of monoclonal antibodies to DNA.

Starting with spleen cells from MRL/lpr, NZB/W, and graft-vs-host-diseased mice, we prepared a total of 57 hybridomas that produce antibodies to DNA. Using various approaches, we studied the avidity of these monoclonals in relation to their behavior in four anti-DNA assays. From the results obtained, we postulate that on the basis of anti-DNA avidity the anti-DNA ELISA, the polyethylene glycol assay, the indirect immunofluorescence test on Crithidia luciliae, and the Farr assay (in this order) detect a decreasing amount of anti-dsDNA, the Farr assay being strictly selective for high avidity anti-dsDNA. mAb selected by the anti-DNA ELISA generally were of a low avidity toward DNA. Using cardiolipin and dextran sulfate, a polyanion that bears a resemblance in charge to DNA, we studied the cross-reactivity of the monoclonals. A total of 6 of the 57 monoclonals were found to cross-react with cardiolipin, and 26 with dextran sulfate. We observed an inverse relationship between anti-DNA avidity and cross-reactivity: the lower the avidity of the antibody, the more cross-reactive it is. Based on these findings, we postulate that it is at least questionable whether low avidity, cross-reactive (monoclonal) anti-DNA is representative for the anti-DNA found in patients with SLE.

Routine testing for antinuclear antibodies: a comparison of immunofluorescence, counterimmunoelectrophoresis and immunoblotting.

We compared the classical immunofluorescence test (IFT) and counterimmunoelectrophoresis method (CIE) with the new immunoblotting technique (IBT) for the detection of antinuclear antibodies (ANA). Sera from 200 patients were tested in all three assays. Patients were classified as having either rheumatic disease including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), primary Raynaud's phenomenon or nonrheumatic disease. Within these broad categories, we observed that IFT and IBT showed a more or less comparable sensitivity and specificity (IFT: 0.54 and 0.82, respectively; IBT: 0.39 and 0.79, respectively). The CIE method combines a high specificity (0.99) with an extremely low sensitivity (0.08). By combining positive results obtained by IFT and IBT, a higher specificity (0.97) but a diminished sensitivity (0.24) is obtained. As IBT allows simultaneous discrimination between ANA of different specificities, we also tested for a correlation between the presence of anti-Sm, anti-RNP and anti-SS-B and the disease category. Only anti-SS-B discriminated significantly between rheumatic- and nonrheumatic disease. Anti-RNP was found in 50% of the SLE patients and in 50% of the MCTD patients; anti-Sm in 17% of the SLE patients and 25% of the MCTD patients. Anti-SS-B was found in 33% of the SLE patients. However, predictive rates of these ANA were low: 0.37 (anti-RNP), 0.67 (anti-Sm) and 0.43 (anti-SS-B). We conclude that from a practical point of view IFT is the preferable assay to screen for the presence of ANA. To characterize ANA specificities, however, the IBT is far superior to the CIE technique.

Antinuclear antibodies in patients with systemic lupus erythematosus: a comparison of counterimmunoelectrophoresis and immunoblotting.

Traditionally, the method used mostly to identify antinuclear antibody (ANA) specificities is the counterimmunoelectrophoresis technique (CIE), in which a salt extract of rabbit thymus powder (so-called extractable nuclear antigen or ENA) serves as the source of antigen. Recently, the immunoblotting technique (IBT) has been introduced in the serology of antinuclear antibodies. A nuclear extract of HeLa cells is generally used as antigen in this method. In this paper, we compared both methods using sera of patients with active systemic lupus erythematosus (SLE). Only anti-Sm, anti-RNP, and Anti-SSB were taken into consideration, as the former technique only allowed the identification of these specificities. Within these restrictions, we found that, of 77 patients with SLE, 21 had CIE-detectable antibodies in their circulation and 29 IBT-detectable antibodies. Anti-RNP and anti-SSB were detected more frequently with the CIE than with the IBT; anti-Sm, on the other hand, was detected more frequently with the IBT than with the CIE. Several significant correlations were found between incidences of measured antibody specificities and disease features. The presence of anti-RNP (both if measured with the IBT or with the CIE) was found to be negatively correlated with nephritis. If measured with the IBT, the presence of anti-Sm correlated negatively with hematological disorders, and the presence of anti-SSB correlated positively with renal involvement.(ABSTRACT TRUNCATED AT 250 WORDS)

An improved incubation apparatus for Western blots used for the detection of antinuclear antibodies.

To facilitate the use of Western blots for the detection of antibodies, we have developed an incubation apparatus. The use of this apparatus simplifies the incubation of blots with antisera, permits the testing of large numbers of sera and eliminates artefacts caused by the use of loose strips. The introduction of a pressure bag in the lower lid of the apparatus secures a steady pressure over the entire blot, a feature lacking in currently available commercial equipment. The detection of antinuclear antibodies is presented as an example of the use of this incubator.

T cell function in systemic lupus erythematosus: normal production of and responsiveness to interleukin 2.

To investigate the role of interleukin 2 (IL-2) in systemic lupus erythematosus (SLE) mononuclear cells (MNC) of 68 SLE patients were tested for their ability to produce and also to respond to IL-2. Cells were collected monthly over an one year period. IL-2 production by MNC was measured under various conditions after optimal and suboptimal stimulation. Although we found a large variation in IL-2 production by individual MNC preparations no statistical significant differences were found between normal and SLE cells. To study IL-2 responsiveness, proliferation of MNC was studied under conditions where endogenous IL-2 production is limiting. Addition of IL-2 resulted in a four- to eight-fold enhancement of proliferative responses. However also in this respect no differences were found between SLE patients and healthy controls. Thus, in this group of SLE patients no abnormalities in IL-2 production or response could be demonstrated.