Heat-sensitive serum masking cofactor(s) of antiphospholipid antibody (aPL) in normal human sera (NHS) are specifically inactivated at 56 degrees C. The degree of binding in ELISA by unmasked aPL in NHS was equivalent to that in non-heated, aPL-reactive autoimmune SLE sera. Previously "negative" SLE sera also reacted equally strongly in the aPL ELISA when similarly heat-inactivated. Isotype studies by ELISA of the heat-potentiated aPL in 36 NHS revealed the presence of specific IgG (34/36), IgM (11/36) and IgA (24/36) aPL antibodies. 11/36 (31%) NHS had all three aPL isotypes while 13/36 (36%) had both IgG and IgA antibodies to phospholipid.
We investigated the association of the HLA genes in Malaysian patients with systemic lupus erythematosus (SLE) and their associations with the clinical manifestations in 160 SLE patients (99 Chinese and 61 Malays) and 107 healthy control individuals (58 Chinese and 49 Malays) were studied. Sequence specific primer amplification (PCR-SSP) phototyping techniques were used to analyse 25 HLA-A allele groups, 31 HLA-DR allele groups and 9 HLA-DQ allele groups. Appreciable increases in allele frequencies of HLA-A*11, DRB1*0701, DRB1*1601-1606, DRB5*01-02 and DQB1*05, and decrease in HLA-DRB1*1101-1121, 1411, DRB1*1201-3, DRB1*1301-22, DRB3*0101, 0201, 0202, 0203, 0301 and DQB1*0301, 1304 in SLE patients compared with healthy control individuals. However, after Bonferroni correction (p(c)<0.05) only HLA-A*1101, 1102, DRB5*01-02, DQB1*05, DRB1*1201-3, DRB3*0101, 0201, 0202, 0203, 0301 and DQB1*0301, 0304 remained significant. Allele frequencies of DRB1*0701 and DRB4*0101101, 0102, 0103, DQB1*05, DRB1*1301-22, DRB3*0101, 0201, 0202, 0203, 0301 and DQB1*0301, 0304 were significantly increased in Malay SLE patients compared with healthy control individuals. In contrast, Chinese SLE patients had increased allele frequencies of DRB1*1601-1606, DQB1*05, DRB1*1201-3, DRB3*0101, 0201, 0202, 0203, 0301, DRB3*0101, 0201, 0202, 0203, 0301 and DQB1*0301, 0304 compared with healthy control individuals. HLA-A*6801-02 and DRB1*1601-1606 frequencies appeared elevated in a subset of patients with serositis and DRB1* 0401-1122 frequency was elevated in those displaying neurologic disorder. However, unequivocal evidence of these associations would require investigation of substantially larger cohorts. On the whole, our findings suggest that HLA allele associations with SLE are race specific in Malays and Chinese.
Study site: SLE clinic, University of Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
BACKGROUND: In Malaysia, patients have a choice of attending a public (fully subsidised bygovernment) hospital (PUBH) or a private (fee-paying) hospital (PRIH) for their healthcare.The aim of this study was to, firstly, provide an overview of the characteristics of MalaysianSLE patients attending rheumatology clinics, and secondly, to ascertain if there were any dif-ferences between patients attending PUBH and PRIH.
METHODS:A standardised questionnaire was administered to all SLE patients attendingrheumatology clinics in a PRIH in Selangor state and a PUBH in Negeri Sembilan state dur-ing the months of September to December 2009.
RESULTS:One hundred and thirty patients were included in the study. There were 55(42.3%) patients from PRIH and 75 (57.7%) from PUBH. 93.8% were female. 61.5% wereChinese, 29.2% Malay and 7.7% Indians. The majority of patients completed secondaryschooling (46.9%) with significantly less PUBH patients going onto higher education(P = 0.001). 53.8% were in fulltime employment with 37.7% housewives/unemployed.There were significantly more unemployed patients in PUBH (45.3%) versus PRIH (27.2%)(P = 0.05). 33.8% of patients were single, 60.8% married and 3.8% divorced. Average ageat SLE diagnosis was 29.8510.17 years. At diagnosis, the most common presenting symp-tom was related to the mucocutaneous system 70.8%, followed by joints 55.3%, haemato-logical 46.9% and renal 23.1%. Significantly more patients had renal involvement atdiagnosis in PUBH (33.3%) versus PRIH (9.1%) (P = 0.001). At the time of survey, therewere 12 (9.2%) patients in remission. Of those still symptomatic, 48.5% related to themucocutaneous system, 32.3% joints, 27.7% haematological, 22.3% renal, with significantlymore current renal disease in PUBH (30.7%) versus PRIH (10.9%) (P = 0.008). The mostfrequently prescribed drug was prednisolone in 83.1% of patients, followed by hydroxychlo-roquine 68.5% and azathioprine 23.1%. Only 64.8% of patients on prednisolone were onbone protective agents. More patients in PRIH were on prednisolone (90.9%) versus PUBH(77.3%) (P = 0.04), but more patients were on activated vitamin D in PUBH (72%) versusPRIH (29.1%) (P < 0.001).
CONCLUSION:The demographics and clinical characteristics of SLE patients attending PUBHand PRIH are significantly different. This has important implications when considering edu-cational and treatment strategies
Objective: SLE is an autoimmune disease which affects multiple organ system. Clinical and immunological expression of the disease have been widely studied and variations occur in different ethnic groups. Here in this study, we have analyzed the clinical manifestations and immunological features of Malaysian patients with Systemic lupus erythematosus (SLE) and compared them with SLE population from some of the Asian countries. Study design: A total of 134 Malaysian patients attending the SLE Clinic of The National University Hospital of Malaysia, Kuala Lumpur and who satisfy the revised ACR (American College of Rheumatology) criteria for the classification of SLE were enrolled into the study. Data on the demography, clinical and immunological features were obtained from medical records. Materials and Methods: The female to male ratio in the study cohort was 10:1 and consisted of the Malay, Chinese and Indian races. Past clinical and immunological features were entered into a prepared questionnaire. At study entry patients were seen by a rheumatologist for assessment of present clinical condition and blood obtained for immunological tests (Antinuclear, antids DNA, antiSm, antiU1RNP, antiSSA(Ro), antiSSB(La), anticardiolipin (IgG and IgM) antibodies and complements C3 and C4). Chi-square, Fisher's exact test and Mann Whitney U Test were used to analyze data. Results: Clinical features expressed at disease presentation in order of frequency was mucocutaneous (72%), followed by musculoskeletal (58%) and renal involvement (45%) which was also similar during the course of the disease (90%, 72% and 64% respectively). A high prevalence of antiSSB (La) antibodies was found (48%). Conclusion: This study provides the literature on the clinical and immunological features of Malaysian SLE patients and further shows the different spectrum of disease profile when compared to other ethnic groups. The roles of racial and genetic factors are suggested.
Objective: The frequency of the HLA class II antigens (HLA DR, DQ and DP) were determined among Malay patients with systemic lupus erythematosus (SLE) to ascertain the role they play in disease susceptibility. Study design: Fifty-six Malay SLE patients on follow-up at the SLE Clinic of the National University of Malaysia Hospital, Kuala Lumpur were enrolled into the study. Controls were taken from healthy unrelated individuals, ethnically-matched. Materials and Methods: Five ml of anticoagulated blood was taken from each patient and control and DNA extracted. The HLADR, DQ and DP antigen/allele frequencies were determined by the technique of modified PCR-RFLP and statistical analysis done by Chi-square and Fischers exact test. Relative risk was determined by the odds ratio and significant p values were corrected for the number of antigens/alleles tested. Results: We found that the DR2 antigen was significantly increased among the patients (85.7%) as compared to controls (61%)(p corr=0.03, RR=3.83). As for HLA-DQA1, the allele most commonly found among the patients was *0102 (57 vs 49.2%). HLA-DQA1* 0601 was slightly decreased among the patients but this finding was insignificant. Both HLA-DQB1*0501 and 0601 were found to be increased among the patients even after correction of multiple comparisons made (p=0.0036, RR=4.56 and p=0.0048, RR=6.0, respectively). However, HLA-DQB1*0503 and 0301 was slightly decreased in the sle patients though not statistically significant. The frequency of HLA-DQB1*0201 was insignificantly increased among the patients. Limited studies on the DPB1 locus shows the uncertain role of this antigen in contributing to disease susceptibility. However, our analysis of the HLA-DPB1*0901 showed a slight increase among the patients as compared to controls but failed to remain significant after being corrected with number of comparisons made. All other HLA-DPB1 alleles exhibited similar frequencies between sle patients and controls. Conclusion: From this study we suggest that HLA DR2, DQB1*0501 and *0601 may be important genetic factors in conferring disease susceptibility in the Malay SLE population of Malaysia.
Background: Systemic lupus erythematosus (SLE) is a chronic disease of autoimmune nature. Genetic pre-disposition has been known to play a role. With a number of genes already named, the IL-RA is no exception. Polymorphism in the human cytokine gene, an uncommon allele of a variable repeat polymorphism in intron 2 of the IL1-RA gene has been found to be associated with SLE. Objective: The aim of this present study was to study the polymorphism of the IL-1RA gene in Malay and Chinese SLE patients and to investigate the possible contribution of the IL-RA gene polymorphism in disease susceptibility. Materials and Methods: We thus investigated the allele frequencies of the IL-RA gene polymorphism in 87 Malay and 100 Chinese SLE population at the Hospital of National University of Malaysia, Kuala Lumpur by PCR and direct analysis by electrophoresis on agarose gel. Unrelated healthy ethnically-matched individuals were taken as controls. Results: Allelic frequencies of the IL1-RN*4 were most dominant in all groups (patients and controls) but there was no significant differences among them. We found an increased allelic frequency and carriage rate of the IL1-RN*2 repeat in both the Malay and Chinese SLE cases compared to controls. However they were not statistically significant. Conclusion: Thus from this finding we postulate that the polymorphism of the IL-1RA gene (both alleles 2 and 4) does not influence susceptibility to SLE.
Objectives: To evaluate the frequency of HLA Class II antigens in Malays with SLE in order to determine their role in disease susceptibility and association with clinical manifestations.
Design: Cross-sectional study
Methods: Fifty-four SLE patients from Malay ethnic attending Physician Clinic at Hospital Universiti Sains Malaysia were enrolled into the study. Demographic and clinical findings were obtained from medical records. HLA typing of class II antigens were carried out using MicroSSP Class II generic (DRB/ DQB) from One Lambda Inc. Controls were from ethnically matched healthy individuals.
Results: A univariate analysis confirmed the association between HLA-DR15 with SLE compared to healthy control group; and was maintained using multiple logistic regression model (P corr = 0.002, adjusted OR = 5.513). There was a weak decrease of HLA-DR4 which was not significant after corrections for multiple comparisons made. DR7 was found to be significantly increased in patients with malar rash. There was positive association of DR15 with arthritis in patients compare to those without.
Conclusion: Our data support the role of HLA Class II genes in conferring SLE susceptibility.
Study site: Physician Clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
We conducted a prospective longitudinal study to determine the nature and prevalence of cardiac abnormalities in systemic lupus erythematosus and to study their natural history and relationship with disease activity. Forty consecutive inpatients with systemic lupus erythematosus were studied during their admission and subsequently 6 to 12 months later. On each occasion a clinical cardiovascular examination was carried out, disease activity was scored using the "Lupus Activity Criteria Count" and a Doppler echocardiographic examination was carried out. 72.5% of patients had an abnormal echocardiogram in the first study while 51.7% were abnormal during the follow-up study. Valvar disease occurred in 37.5% of patients. The mitral valve was most commonly affected. Libman-Sacks endocarditis was rare (2.5%). Pericardial effusions were seen in 36.2% of echocardiograms. The majority (76.0%) of these were associated with hypoalbuminaemia. 80.0% of patients had active disease during the first examination and 41.4% at follow-up. There was no correlation between activity of disease and prevalence of cardiac abnormalities at either examination. We conclude that cardiac disease is common in systemic lupus erythematosus. Prevalence of cardiac abnormality did not correlate with disease activity.
Tumour necrosis factor superfamily 4 (TNFSF4) gene has been reported to be associated with systemic lupus erythematosus (SLE) susceptibility due to its encoding for OX40L protein that can increase autoantibody production and cause imbalance of T-cell proliferation. The purpose of this study was to investigate the association of TNFSF4 rs2205960, rs1234315, rs8446748 and rs704840 with SLE in the Malaysian population. A total of 476 patients with SLE and 509 healthy controls were recruited. Real-time polymerase chain reaction (PCR) was applied to genotype the selected single nucleotide polymorphisms (SNPs). Allelic and genotypic frequencies of each SNP were calculated for each ethnic group, and association test was performed using logistic regression. The overall association of each SNP in Malaysian patients with SLE was determined with meta-analysis. The frequency of minor T allele of TNFSF4 rs2205960 was significant in Chinese and Indian patients with SLE, with P values of 0.05 (OR = 1.27, 95% CI: 1.00-1.61) and 0.004 (OR = 3.16, 95% CI: 1.41-7.05), respectively. Significant association of minor G allele of rs704840 with SLE was also observed in Chinese (P = 0.03, OR = 1.26, 95% CI: 1.02-1.56). However, after Bonferroni correction, only T allele of rs2205960 remained significantly associated with Indian cohort. Overall, minor G allele of rs704840 showed significant association with SLE in the Malaysian population with P values of 0.05 (OR = 1.20, 95% CI: 1.00-1.43). We suggested TNFSF4 rs704840 could be the potential SLE risk factors in the Malaysian population.
The programmed cell death 1 (PDCD1) gene encodes for the PD-1 (programmed death 1) molecule, which negatively regulates self-reactive T- and B-cells in the maintenance of peripheral tolerance. A previous report had shown the development of lupus-like phenotypes in PD-1-deficient C57BL/6 mice, was suggestive to the role of PDCD1 in predisposing to systemic lupus erythematosus (SLE). Hence, we aimed to investigate the association between PDCD1 and SLE susceptibility in the Malaysian population. A TaqMan-based real-time PCR was employed to screen for PD1.1, PD1.3, PD1.5 and PD1.6 in both SLE and healthy control groups of 200 samples each. The observed frequency for PD1.5C/C genotype was significantly higher in Indian SLE patients and Malay controls (p < 0.01). On the other hand, the PD1.5C/T genotype might predispose the Malays to SLE, but confer a protective effect among the Indians (p < 0.01). The PD1.1, PD1.3 and PD1.6 were, however, not correlated to genetic predisposition of SLE in our Malaysian population. In conclusion, PD1.5 variant was significantly associated to SLE susceptibility in our Malaysian cohort. Our failure in replicating the association between other investigated PDCD1 variants and risk of getting SLE might due to ethnic and geographic variations in the distribution of these genetic variants.
OBJECTIVE:
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease and glucocorticoid is the mainstay of treatment in SLE. The reported incidence of steroid-induced diabetes mellitus (SDM) ranged between 1-53%. We sought to investigate the prevalence and associated factors of SDM in patients with SLE.
METHODOLOGY:
A total of 100 SLE patients attending the Nephrology/SLE and Rheumatology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) who received corticosteroid treatment were recruited. The diagnosis of diabetes mellitus was based on the 2010 American Diabetes Association's criteria. Prevalent cases of SDM were also included. Statistical analysis was performed to determine the factors associated with SDM.
RESULTS:
Thirteen of them (13%) developed SDM, with the median onset of diagnosis from commencement of glucocorticoid treatment being 8 years (range 0.5-21 years). Although only seven Indians were recruited into the study, three of them (42.9%) had SDM compared to Malays (9.3%) and Chinese (12.8%) (P ≤ 0.05). Univariate and multivariate analysis showed that higher numbers of system or organ involvement in SLE, abdominal obesity, hypertriglyceridemia and daily prednisolone of ≥ 1 mg/kg/day were the important associated factors of SDM (P ≤ 0.05). Meanwhile, hydroxychloroquine (HCQ) use was associated with reduced SDM prevalence (P < 0.05).
CONCLUSION:
The prevalence of SDM among SLE patients was 13% and Indians were more prone to develop SDM compared to other races. Higher numbers of system involvement, abdominal obesity, hypertriglyceridemia and the use of oral prednisolone of ≥ 1 mg/kg/day were associated with SDM, while HCQ use potentially protects against SDM.
We report a 29-year-old Malay man who had pulmonary manifestations as an initial presentation for systemic lupus erythematosus. He had prolonged hospitalization and was treated with intensive care therapy with immunosuppressants.
Mycophenolate is an immunosuppressive agent which has been used in systemic lupus erythematosus (SLE) patients who have failed conventional therapy. However, the use of mycophenolate sodium in extra-renal SLE involvement has yet to be established. This study aimed to assess the efficacy of mycophenolate sodium in extra-renal SLE.
BACKGROUND: The ethiopathogenesis of increased apoptosis of lymphocytes in systemic lupus erythematosus (SLE) is still incompletely understood but anti-C1q autoantibodies have been shown to induce apoptosis in lymphocytes from healthy donors and certain cell lines.
AIM: This study was undertaken to investigate the relationship between peripheral lymphocyte apoptosis and serum levels of anti-C1q autoantibodies in SLE patients.
METHODS: The sera of 124 patients with SLE involving 62 active SLE and 62 inactive SLE, fulfilling America College of Rheumatology (ACR) classification criteria for SLE (1997) were incubated with peripheral blood lymphocytes of healthy donors. The results were compared with 124 sex- and age-matched normal controls. Apoptotic lymphocytes (AL) were detected by flow cytometry using annexin V and propidium iodide binding. Anti-C1q autoantibodies were detected by an enzyme-linked immunoassay kit for all SLE patients.
RESULTS: Results demonstrated that the percentage of AL in the peripheral blood of active SLE patients was significantly higher (n = 62, 34.95 ± 12.78%) than that of the inactive SLE patients (n = 62, 30.69 ± 10.13%, P = 0.042, 95%CI = 0.16-8.36) and normal controls (n = 124, 27.92 ± 10.22%, P = 0.001, 95%CI = 3.33-10.73). The percentage of AL significantly correlated with serum levels of anti-C1q autoantibodies in the active SLE patients (r = 0.263, P = 0.039) but not in the inactive SLE patients (r = 0.170, P = 0.185).
CONCLUSION: The results of this study suggest that increased serum levels of anti-C1q autoantibodies are responsible for apoptosis and may play a pathogenic role in SLE patients, especially in active disease.
KEYWORDS: anti-C1q; apoptosis; flowcytometry; systemic lupus erythematosus
Study site: Medical outpatient clinic and medical wards, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
AIM: To determine if baseline vitamin D levels would influence the gain in bone mineral density (BMD) in female systemic lupus erythematosus (SLE) patients on corticosteroids (CS) taking bone-active medication.
METHOD: Premenopausal SLE patients participating in a trial assessing the efficacy of calcium alone, calcitriol and calcium, and alendronate and calcium, on BMD in patients on CS, were studied. Patients were randomly allocated to the treatment groups at the start of the study and followed up for 2 years. Serum 25-hydroxy vitamin D [25(OH)D] was measured at baseline.
RESULTS: Thirty-eight patients were studied. One (2%) patient had osteoporosis, nine (24%) had osteopenia and all others had normal BMD. The mean baseline 25(OH)D levels were 21.6 ± 4.6 ng/mL (± 1 SD). Twelve (32%) patients had vitamin D deficiency [25(OH)D < 20 ng/mL]. There was a significant negative correlation between SLEDAI scores and 25(OH)D levels, that is, patients with high SLEDAI scores had significantly lower 25(OH)D levels (P = 0.033). Left femoral neck BMD was significantly lower in the deficient compared to insufficient group (P = 0.042). There was a trend toward better BMD gain at 2 years in the vitamin D insufficient compared to the deficient group, which did not reach statistical significance.
CONCLUSION: This study showed that in female SLE patients, low vitamin D levels are associated with higher disease activity and suggests that patients who have higher vitamin D levels have a better BMD response during treatment with bone-active agents.