Systemic lupus erythematosus pathophysiology: Difference between revisions

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{{Systemic lupus erythematosus}}
{{Systemic lupus erythematosus}}


{{CMG}}; {{AE}} {{MIR}} {{CZ}} {{RT}}
{{CMG}}; {{AE}} {{MIR}}, {{CZ}}, {{RT}}


==Overview==
==Overview==
The pathophysiology of systemic lupus erythematosus involves the [[immune system]]. There are other factors like [[genetic]] factors, [[hormonal]] abnormalities, and environmental factors that play some roles as well. The most prominent events involving [[immune]] abnormalities are related to persistent activation of [[B cells]] and [[Plasma cell|plasma cells]] that make [[Autoantibody|auto-antibodies]] during disease progression. The most prominent events involving [[hormonal]] abnormalities are due to [[prolactin]] and [[estrogen]]. The most important environmental factors related to disease progression are [[ultraviolet]] (UV) light and some [[infections]]. On microscopic [[histopathological]] analysis, [[apoptotic]] [[Keratinocyte|keratinocytes]], [[vacuolization]] of the [[basement membrane]], and [[dermal]] [[mucin]] deposition are characteristic findings of SLE [[dermatitis]], and active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]] are characteristic findings of SLE nephritis.
The pathophysiology of systemic lupus erythematosus involves the [[immune system]]. Other factors such as [[genetic]] factors, [[hormonal]] abnormalities, and environmental factors also play a role. The most important environmental factors involved in the [[pathogenesis]] of SLE include [[ultraviolet]] (UV) light and some [[infections]]. The most important [[Gene|genes]] involved in the [[pathogenesis]] of SLE include [[HLA-DR2]], [[HLA-DR3]], [[HLA]] class 3, C1q, and [[IRF5|interferon (IFN) regulatory factor 5]]. The most prominent events involving [[immune]] abnormalities are related to persistent activation of [[B cells]] and [[Plasma cell|plasma cells]] that make [[Autoantibody|auto-antibodies]] during disease progression. The disease developmental process begins with the release of microparticles and [[proinflammatory]] [[cytokines]] from the cells that are undergoing [[apoptosis]]. Due to excess amount of [[apoptosis]], the body is unable to clear these microparticles entirely, and these microparticles are presented to [[dendritic cells]] as [[antigens]]. [[Dendritic cells]] process these microparticles and mature, and present these as [[antigens]] to [[T-cells]]. [[T-cells]], microparticles, and [[proinflammatory]] [[cytokines]] themselves trigger [[B-cell]] activation and [[autoantibody]] production. As a result, body tissues lose their self-tolerance. The most prominent events involving [[hormonal]] abnormalities are due to [[prolactin]] and [[estrogen]]. On microscopic [[histopathological]] analysis, [[apoptotic]] [[Keratinocyte|keratinocytes]], [[vacuolization]] of the [[basement membrane]], and [[dermal]] [[mucin]] deposition are characteristic findings of SLE [[dermatitis]], and active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]] are characteristic findings of [[lupus nephritis]].
==Pathogenesis==
==Pathogenesis==
The progression of systemic lupus erythematosus (SLE) involves the [[immune system]]. Nearly all of the [[pathological]] manifestation of SLE are due to [[antibody]] formation and the creation and deposition of [[immune complexes]] in different organs of the body. When the [[immune complexes]] are formed, they will deposit in different body tissues and [[vessels]], which may lead to [[complement]] activation and more organ damage. There are other factors like [[genetic]] factors, hormonal abnormalities, and environmental factors that play some roles in the pathogenesis of SLE as well.
The progression of systemic lupus erythematosus (SLE) involves the [[immune system]]. Nearly all of the [[pathological]] manifestations of SLE occur due to [[antibody]] formation and the creation and deposition of [[immune complexes]] in different organs of the body. When the [[immune complexes]] are formed, they deposit on different body tissues and [[vessels]], which may lead to [[complement]] activation and more organ damage. There are other factors such as [[genetic]] factors, hormonal abnormalities, and environmental factors that also play a role in the pathogenesis of SLE.
[[File:Lupus final.jpg|left|size:800×591 pixels]]
[[File:Lupus2.jpg|left|size:800×591 pixels]]
 
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=== Environmental factors ===
=== Environmental factors ===
The environmental factors and genetic factors are the most important risk factors of developing SLE, as by their effect, disinhibited cellular apoptosis chain may start. This apoptosis step is known as the first step in the lupus pathogenesis.
The environmental factors and genetic factors are the most important risk factors for developing SLE because they may jump-start the disinhibited cellular [[apoptosis]] chain. This [[apoptosis]] step is the first step in the pathogenesis of lupus.
* Infections
* Infections
** May stimulate some [[antigen]] specific cells and increase apoptosis
** May stimulate some [[antigen]] specific cells and increase [[apoptosis]]
** May induce anti-DNA [[antibodies]]  
** May induce anti-DNA [[antibodies]]  
** May mimic lupus-like symptoms
** May mimic lupus-like symptoms
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*** [[Epstein Barr virus|Epstein-Barr virus (EBV)]]
*** [[Epstein Barr virus|Epstein-Barr virus (EBV)]]
*** [[Trypanosomiasis]]
*** [[Trypanosomiasis]]
*** [[mycobacterial]] infections
*** [[Mycobacterial]] infections
*** SLE flares may follow [[bacterial infections]]
*** SLE flares may follow [[bacterial infections]]
* [[Ultraviolet|Ultraviolet (UV)]] light:  
* [[Ultraviolet|Ultraviolet (UV)]] light:  
** Can stimulate [[B-cells]] to produce more [[antibodies]]  
** Can stimulate [[B-cells]] to produce more [[antibodies]]  
** May activate [[macrophages]], interfere with [[antigen processing]], and hence increase the degree of [[autoimmunity]]
** May activate [[macrophages]], interfere with [[antigen processing]], and therefore increase the degree of [[autoimmunity]]


=== Immune abnormalities ===
=== Immune abnormalities ===
Development of systemic lupus erythematosus (SLE) is the due to activation of different mechanisms that may result in [[auto-immune|auto-immunity]]. The disease developmental process began with the release of microparticles and [[proinflammatory]] [[cytokines]] from the cells that are undergoing [[apoptosis]]. Due to excess amount of [[apoptosis]], the body is unable to clear these microparticles entirely, and these microparticles are presented to [[dendritic cells]] as [[antigens]]. [[Dendritic cells]] process these microparticles and get matured, and present these as [[antigens]] to [[T-cells]]. [[T-cells]], microparticles, and [[proinflammatory]] [[cytokines]] themselves, trigger [[B-cell]] activation and [[autoantibody]] production. As a result, body tissues lose their self-tolerance. Affected patients are no longer entirely tolerant to all of their [[Antigens|self-antigens]], consequently progress to an [[Autoimmunity|autoimmune]] disease and develop [[autoantibodies]] as a response. During disease progression, [[B cell|B cells]] and [[Plasma cell|plasma cells]] that make [[Autoantibody|autoantibodies]] are more persistently activated due to signaling abnormalities and thus make more [[Autoantibody|autoantibodies]]. These [[autoantibodies]] are targeted predominantly to [[intracellular]] [[nucleoprotein]] particles.<ref name="pmid8519610">{{cite journal |vauthors=Elkon K |title=Autoantibodies in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=7 |issue=5 |pages=384–8 |year=1995 |pmid=8519610 |doi= |url=}}</ref><ref name="pmid25449682">{{cite journal |vauthors=Yaniv G, Twig G, Shor DB, Furer A, Sherer Y, Mozes O, Komisar O, Slonimsky E, Klang E, Lotan E, Welt M, Marai I, Shina A, Amital H, Shoenfeld Y |title=A volcanic explosion of autoantibodies in systemic lupus erythematosus: a diversity of 180 different antibodies found in SLE patients |journal=Autoimmun Rev |volume=14 |issue=1 |pages=75–9 |year=2015 |pmid=25449682 |doi=10.1016/j.autrev.2014.10.003 |url=}}</ref> This increase in [[autoantibody]] production and persistence is supposed to be [[Downregulate|downregulated]] by anti-idiotypic [[antibodies]] or regulatory immune cells, but the massive [[Immunology|immunologic]] response in SLE prevents this [[downregulation]] to take place. The most important [[immune]] abnormalities that are related to SLE development and progression are: 
The development of systemic lupus erythematosus (SLE) is due to the activation of different mechanisms that may result in [[auto-immune|auto-immunity]]. The disease developmental process begins with the release of microparticles and [[proinflammatory]] [[cytokines]] from the cells that are undergoing [[apoptosis]]. Due to excess amount of [[apoptosis]], the body is unable to clear these microparticles entirely, and these microparticles are presented to [[dendritic cells]] as [[antigens]]. [[Dendritic cells]] process these microparticles and mature, and present these as [[antigens]] to [[T-cells]]. [[T-cells]], microparticles, and [[proinflammatory]] [[cytokines]] themselves trigger [[B-cell]] activation and [[autoantibody]] production. As a result, body tissues lose their self-tolerance. Affected patients are no longer entirely tolerant to all of their [[Antigens|self-antigens]], leading to development of an [[Autoimmunity|autoimmune]] disease and producing [[autoantibodies]] as a response. During disease progression, [[B cell|B cells]] and [[Plasma cell|plasma cells]] that make [[Autoantibody|autoantibodies]] are more persistently activated due to signaling abnormalities, causing them to make more [[Autoantibody|autoantibodies]]. These [[autoantibodies]] are targeted predominantly to [[intracellular]] [[nucleoprotein]] particles.<ref name="pmid8519610">{{cite journal |vauthors=Elkon K |title=Autoantibodies in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=7 |issue=5 |pages=384–8 |year=1995 |pmid=8519610 |doi= |url=}}</ref><ref name="pmid25449682">{{cite journal |vauthors=Yaniv G, Twig G, Shor DB, Furer A, Sherer Y, Mozes O, Komisar O, Slonimsky E, Klang E, Lotan E, Welt M, Marai I, Shina A, Amital H, Shoenfeld Y |title=A volcanic explosion of autoantibodies in systemic lupus erythematosus: a diversity of 180 different antibodies found in SLE patients |journal=Autoimmun Rev |volume=14 |issue=1 |pages=75–9 |year=2015 |pmid=25449682 |doi=10.1016/j.autrev.2014.10.003 |url=}}</ref> This increase in [[autoantibody]] production and persistence is supposed to be [[Downregulate|downregulated]] by anti-idiotypic [[antibodies]] or regulatory [[immune cells]], but the massive [[Immunology|immunologic]] response in SLE prevents this [[downregulation]] from taking place. After formation of [[immune complexes]], the [[classical complement pathway]] is activated, which leads to the deposition of [[immune complexes]] in different organs and is responsible for flare ups and long term complications. The most important [[immune]] abnormalities that are related to SLE development and progression are: 


==== Microparticles ====
==== Microparticles ====
*Increased level of microparticles (MPs):
Increased level of microparticles (MPs):<ref name="pmid23672591">{{cite journal |vauthors=Dye JR, Ullal AJ, Pisetsky DS |title=The role of microparticles in the pathogenesis of rheumatoid arthritis and systemic lupus erythematosus |journal=Scand. J. Immunol. |volume=78 |issue=2 |pages=140–8 |year=2013 |pmid=23672591 |doi=10.1111/sji.12068 |url=}}</ref>
**Microparticles are small, membrane-bound vesicles enclose [[DNA]], [[RNA]], [[nuclear]] proteins, [[cell adhesion molecule]]<nowiki/>s, [[Growth factor|growth factors]], and [[Cytokine|cytokines]]
*Microparticles are small, membrane-bound vesicles enclosing [[DNA]], [[RNA]], [[nuclear]] proteins, [[cell adhesion molecule]]<nowiki/>s, [[Growth factor|growth factors]], and [[Cytokine|cytokines]]
**They are shed from cells during [[apoptosis]] or activation
*They are shed from cells during [[apoptosis]] or activation
**Microparticles can drive [[inflammation]] and [[autoimmunity]] by their derivatives<ref name="pmid23672591">{{cite journal |vauthors=Dye JR, Ullal AJ, Pisetsky DS |title=The role of microparticles in the pathogenesis of rheumatoid arthritis and systemic lupus erythematosus |journal=Scand. J. Immunol. |volume=78 |issue=2 |pages=140–8 |year=2013 |pmid=23672591 |doi=10.1111/sji.12068 |url=}}</ref>
*Microparticles can drive [[inflammation]] and [[autoimmunity]] by their derivatives
==== Pro-inflammatory cytokines ====
==== Pro-inflammatory cytokines ====
*Increased expression of specific [[Genetic|genetic factors]] that may be associated with promoting [[autoimmunity]]
Increased expression of specific [[Genetic|genetic factors]] may be associated with promoting [[autoimmunity]]. The most important cytokine changes include:<ref name="pmid15593221">{{cite journal |vauthors=Kirou KA, Lee C, George S, Louca K, Papagiannis IG, Peterson MG, Ly N, Woodward RN, Fry KE, Lau AY, Prentice JG, Wohlgemuth JG, Crow MK |title=Coordinate overexpression of interferon-alpha-induced genes in systemic lupus erythematosus |journal=Arthritis Rheum. |volume=50 |issue=12 |pages=3958–67 |year=2004 |pmid=15593221 |doi=10.1002/art.20798 |url=}}</ref><ref name="pmid23672591" />
*Increased expression of [[interferon alpha]] (IFN-α) inducible [[RNA]] transcripts by [[Mononuclear cells|mononuclear]] cells<ref name="pmid15593221">{{cite journal |vauthors=Kirou KA, Lee C, George S, Louca K, Papagiannis IG, Peterson MG, Ly N, Woodward RN, Fry KE, Lau AY, Prentice JG, Wohlgemuth JG, Crow MK |title=Coordinate overexpression of interferon-alpha-induced genes in systemic lupus erythematosus |journal=Arthritis Rheum. |volume=50 |issue=12 |pages=3958–67 |year=2004 |pmid=15593221 |doi=10.1002/art.20798 |url=}}</ref> 
*Increased expression of [[interferon alpha]] (IFN-α) inducible [[RNA]] transcripts by [[Mononuclear cells|mononuclear]] cells 
*Increased [[Interferon type I|IFN-I]] production due to increased availability of stimulatory [[nucleic acids]]
*Increased [[Interferon type I|IFN-I]] production due to increased availability of stimulatory [[nucleic acids]]
**May be responsible for SLE chronic characteristics
**May be responsible for SLE chronic characteristics
*Elevated levels of circulating [[TNF-alpha]] correlate with active disease, and [[TNF]] is expressed in [[Kidney|renal tissue]] in [[lupus nephritis]]
*Elevated levels of circulating [[TNF-alpha]] (expressed by [[Kidney|renal tissue]] in [[lupus nephritis]]) correlate with active disease


==== Signaling abnormalities ====
==== Signaling abnormalities ====
[[Protein kinase|Protein kinases]] are responsible for [[intracellular]] [[cytokine]] signal. Intracellular signaling is leading to various types of cell response, such as:
[[Protein kinase|Protein kinases]] are responsible for [[intracellular]] [[cytokine]] signals. [[Intracellular signaling]] leads to various types of cell response, such as:
* Cell migration
* [[Cell migration]]
* Cell proliferation
* [[Cell proliferation]]
* Inflammatory response
* [[Inflammatory response]]
Cell signaling abnormalities will lead to:
[[Cell signaling]] abnormalities leads to:
* T and B [[Lymphocyte|lymphocytes]] cellular hyperactivity
* T and B [[Lymphocyte|lymphocytes]] cellular hyperactivity
* T and B [[Lymphocyte|lymphocytes]] hyper responsiveness
* T and B [[Lymphocyte|lymphocytes]] hyper responsiveness
* Persistence of autoreactive [[T cell|T cells]] that would otherwise have been deleted
* Persistence of auto-reactive [[T cell|T cells]] that would otherwise have been deleted
Signaling abnormalities of T and B [[Lymphocyte|lymphocytes]], may be due to:
Signaling abnormalities of T and B [[Lymphocyte|lymphocytes]], may be due to:
* Increased [[calcium]] responses to [[antigen]] stimulation
* Abnormal [[Potassium channels|voltage-gated potassium channels]], these channels facilitate excessive [[calcium]] entry into [[T cells]] and lead to increased [[calcium]] responses to [[antigen]] stimulation
* [[Hyperphosphorylation]] of [[cytosolic]] [[protein]] substrates
* [[Hyperphosphorylation]] of [[cytosolic]] [[protein]] substrates
* Decreased nuclear factor kB
* Decreased nuclear factor kB
* Abnormal [[Potassium channels|voltage-gated potassium channels]], these channels facilitate excessive [[calcium]] entry into [[T cells]]
==== B-Cell role ====
==== B-Cell role ====
* Increase in circulating [[plasma cells]] and [[Memory B cell|memory B cells]] that is associated with SLE activity
* Increase in circulating [[plasma cells]] and [[Memory B cell|memory B cells]] that are associated with SLE activity
* [[Polyclonal antibody|Polyclonal]] activation of [[B cell|B cells]] and abnormal [[B-cell receptor]] signaling
* [[Polyclonal antibody|Polyclonal]] activation of [[B cell|B cells]] and abnormal [[B-cell receptor]] signaling
* Increase in [[B cell|B cells]] life span
* Increase in [[B cell|B cells']] life span
==== T-Cell role ====
==== T-Cell role ====
* Decrease in [[cytotoxic T cells]], decrease in [[suppressor T cells|suppressor T cell]]'s function, and impaired generation of [[T-cell|polyclonal T-cell]] cytolytic activity
* Decrease in [[cytotoxic T cells]], decrease in [[suppressor T cells|suppressor T cell]] function, and impaired generation of [[T-cell|polyclonal T-cell]] [[cytolytic]] activity
* Increased number and activity of [[T helper cell|helper T cells]]
* Increased number and activity of [[T helper cell|helper T cells]]
* As an example of immune abnormalities and their complications, nervous system involvement in SLE is due to:
===== Neutrophil role =====
**Small to moderate sized [[vessels]] [[Vasculopathies|vasculopathy]] with [[Perivascular cell|perivascular]] accumulation of [[mononuclear cells]], without destruction of the [[blood vessel]]
**[[Antiphospholipid antibodies]]
*These changes promote the production of [[antinuclear antibodies]]
===== Neutrophil =====
*Increased number of circulating [[neutrophils]] undergoing NETosis (NET=[[neutrophil extracellular traps]]), a form of [[apoptosis]] specific for [[Neutrophil|neutrophils]], releases [[DNA]] bound to [[protein]] in protein nets, which stimulates anti-DNA and [[Interferon-alpha|IFN-alpha]] production
*Increased number of circulating [[neutrophils]] undergoing NETosis (NET=[[neutrophil extracellular traps]]), a form of [[apoptosis]] specific for [[Neutrophil|neutrophils]], releases [[DNA]] bound to [[protein]] in protein nets, which stimulates anti-DNA and [[Interferon-alpha|IFN-alpha]] production
*Increased [[neutrophil]] extracellular trap leads to: <ref name="pmid26658004">{{cite journal |vauthors=Barnado A, Crofford LJ, Oates JC |title=At the Bedside: Neutrophil extracellular traps (NETs) as targets for biomarkers and therapies in autoimmune diseases |journal=J. Leukoc. Biol. |volume=99 |issue=2 |pages=265–78 |year=2016 |pmid=26658004 |doi=10.1189/jlb.5BT0615-234R |url=}}</ref>
*Increased [[neutrophil]] extracellular trap leads to: <ref name="pmid26658004">{{cite journal |vauthors=Barnado A, Crofford LJ, Oates JC |title=At the Bedside: Neutrophil extracellular traps (NETs) as targets for biomarkers and therapies in autoimmune diseases |journal=J. Leukoc. Biol. |volume=99 |issue=2 |pages=265–78 |year=2016 |pmid=26658004 |doi=10.1189/jlb.5BT0615-234R |url=}}</ref>
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=== Hormonal abnormalities ===
=== Hormonal abnormalities ===
The following evidence is suggestive of the [[Hormone|hormonal]] predisposition to SLE:
The following evidence is suggestive of the [[Hormone|hormonal]] predisposition to SLE:
* Sexual predilection for females, shows the relationship of female hormones and the onset of SL
* Predilection of the disease for females shows the relationship between female hormones and the onset of SLE
* Significantly increased risk for SLE in:<ref name="pmid17393454">{{cite journal |vauthors=Costenbader KH, Feskanich D, Stampfer MJ, Karlson EW |title=Reproductive and menopausal factors and risk of systemic lupus erythematosus in women |journal=Arthritis Rheum. |volume=56 |issue=4 |pages=1251–62 |year=2007 |pmid=17393454 |doi=10.1002/art.22510 |url=}}</ref>
* Significantly increased risk for SLE in:<ref name="pmid17393454">{{cite journal |vauthors=Costenbader KH, Feskanich D, Stampfer MJ, Karlson EW |title=Reproductive and menopausal factors and risk of systemic lupus erythematosus in women |journal=Arthritis Rheum. |volume=56 |issue=4 |pages=1251–62 |year=2007 |pmid=17393454 |doi=10.1002/art.22510 |url=}}</ref>
** Early age of [[menarche]]
** Early age of [[menarche]]
** Early age at [[menopause]] or surgical [[menopause]]
** Early age at [[menopause]] or surgical [[menopause]]
** Women that are treated with [[estrogen]]-containing regimens such as [[oral contraceptives]] or [[postmenopausal]] [[Hormone replacement therapy|hormone replacement therapies]]
** Women that are treated with [[estrogen]]-containing regimens such as [[oral contraceptives]] or [[postmenopausal]] [[Hormone replacement therapy|hormone replacement therapies]]
Hormones that are related to disease progression:<ref name="pmid10503654">{{cite journal |vauthors=Lahita RG |title=The role of sex hormones in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=11 |issue=5 |pages=352–6 |year=1999 |pmid=10503654 |doi= |url=}}</ref>
Hormones that are related to disease progression include:<ref name="pmid10503654">{{cite journal |vauthors=Lahita RG |title=The role of sex hormones in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=11 |issue=5 |pages=352–6 |year=1999 |pmid=10503654 |doi= |url=}}</ref>
==== Prolactin: ====
==== Prolactin: ====
*Stimulates the [[immune system]] and is elevated in SLE
*Stimulates the [[immune system]] and is elevated in SLE


==== Exogenous estrogen ====
==== Exogenous estrogen ====
* including [[oral contraceptive]] use and [[postmenopausal]] [[hormone replacement therapy]]: <ref name="pmid10503654">{{cite journal |vauthors=Lahita RG |title=The role of sex hormones in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=11 |issue=5 |pages=352–6 |year=1999 |pmid=10503654 |doi= |url=}}</ref><ref name="pmid25155581">{{cite journal |vauthors=Hughes GC, Choubey D |title=Modulation of autoimmune rheumatic diseases by oestrogen and progesterone |journal=Nat Rev Rheumatol |volume=10 |issue=12 |pages=740–51 |year=2014 |pmid=25155581 |doi=10.1038/nrrheum.2014.144 |url=}}</ref>
* Including [[oral contraceptive]] use and [[postmenopausal]] [[hormone replacement therapy]]: <ref name="pmid10503654">{{cite journal |vauthors=Lahita RG |title=The role of sex hormones in systemic lupus erythematosus |journal=Curr Opin Rheumatol |volume=11 |issue=5 |pages=352–6 |year=1999 |pmid=10503654 |doi= |url=}}</ref><ref name="pmid25155581">{{cite journal |vauthors=Hughes GC, Choubey D |title=Modulation of autoimmune rheumatic diseases by oestrogen and progesterone |journal=Nat Rev Rheumatol |volume=10 |issue=12 |pages=740–51 |year=2014 |pmid=25155581 |doi=10.1038/nrrheum.2014.144 |url=}}</ref>
** Stimulates the type 1 [[IFN]] pathway
** Stimulates the type 1 [[IFN]] pathway
** Stimulates [[thymocytes]], [[CD8]]+ and [[CD4]]+ [[T cell|T cells]], [[B cell|B cells]], [[Macrophage|macrophages]], and causes the release of certain [[cytokines]] (eg, [[IL-1]])
** Stimulates [[thymocytes]], [[CD8]]+ and [[CD4]]+ [[T cell|T cells]], [[B cell|B cells]], [[Macrophage|macrophages]], and causes the release of certain [[cytokines]] (eg, [[IL-1]])
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** Enhanced adhesion of peripheral [[mononuclear cells]] to [[endothelium]]
** Enhanced adhesion of peripheral [[mononuclear cells]] to [[endothelium]]
==== Progesterone: ====
==== Progesterone: ====
** May inhibit the type 1 [[interferon]] pathway, suggesting that a balance between [[estrogen]] and [[progesterone]] may be critical for the body to remain healthy
*May inhibit the type 1 [[interferon]] pathway, suggesting that a balance between [[estrogen]] and [[progesterone]] may be critical for the body to remain healthy
** Down-regulates [[T cell|T-cell]] proliferation and increases the number of [[CD8 cytotoxic lymphocyte|CD8 cells]]
** Down-regulates [[T cell|T-cell]] proliferation and increases the number of [[CD8 cytotoxic lymphocyte|CD8 cells]]
* Both [[progesterone]] and high levels of [[estrogen]] promote a [[Th2]] response, which favors [[autoantibody]] production
** Act mainly as a protective agent
=== Lupus nephritis ===
* Both [[progesterone]] and high levels of [[estrogen]] promote a [[Th2]] response, which favors [[autoantibody|auto-antibody]] production
In the initial phase of the disease, the immune deposits and/or autoantibodies induce cytokine production in renal resident cells, leading to further inflammatory cytokine/chemokine expression and leukocyte infiltration and activation. Then, infiltrate leukocytes, such as macrophages (M''φ'') and dendritic cells (DCs), secrete a variety of cytokines and activate naïve T cells, leading the cytokine profile towards T helper (Th)1, Th2, and/or Th17.
The current paradigm is that LN results from immune complex deposition in the renal glomeruli leading to complement activation, chronic inflammation and renal insufficiency defined by histopathology and the presence of proteinuria and cellular casts.<div style="-webkit-user-select: none;">


==Genetics==
==Genetics==
Systemic lupus erythematosus is transmitted in [[polygenic inheritance]] pattern. [[Genes]] involved in the [[pathogenesis]] of systemic lupus erythematosus include [[HLA]] class 2 especially DR2 nd DR3, HLA class 3 especially complement genes include C2 and C4 genes, IFNRF5 gene, and other genes related to [[Immune systems|immunologic system]] as well.
Systemic lupus erythematosus is transmitted in a [[polygenic inheritance]] pattern. [[Genes]] involved in the [[pathogenesis]] of systemic lupus erythematosus include [[HLA]] class 2 (especially DR2 and DR3), [[HLA]] class 3 (especially complement genes including C2 and C4 genes), IFNRF5 gene, and other genes related to the [[Immune systems|immunologic system]].
The following evidence is also suggestive of the [[genetic predisposition]] of SLE:<ref name="pmid10768211">{{cite journal |vauthors=Sullivan KE |title=Genetics of systemic lupus erythematosus. Clinical implications |journal=Rheum. Dis. Clin. North Am. |volume=26 |issue=2 |pages=229–56, v–vi |year=2000 |pmid=10768211 |doi= |url=}}</ref>
The following evidence is also suggestive of the [[genetic predisposition]] of SLE:<ref name="pmid10768211">{{cite journal |vauthors=Sullivan KE |title=Genetics of systemic lupus erythematosus. Clinical implications |journal=Rheum. Dis. Clin. North Am. |volume=26 |issue=2 |pages=229–56, v–vi |year=2000 |pmid=10768211 |doi= |url=}}</ref>
* Increase of disease occurrence in [[identical twins]]
* Increase occurrence of disease in [[identical twins]]
* Increased disease frequency among first degree relatives
* Increased disease frequency among first degree relatives
* The increased risk of developing the disease in siblings of SLE patients
* The increased occurrence of the disease in siblings of SLE patients
{| class="wikitable"  
{| class="wikitable"  
! align="center" style="background: #4479BA; color: #FFFFFF; " |Class
! style="background: #4479BA; color: #FFFFFF; " align="center" |Class
! align="center" style="background: #4479BA; color: #FFFFFF; " |Gene subtype
! style="background: #4479BA; color: #FFFFFF; " align="center" |Gene subtype
! colspan="1" rowspan="1" align="center" style="background: #4479BA; color: #FFFFFF; " |Function
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; " align="center" |Function
! align="center" style="background: #4479BA; color: #FFFFFF; " |Pathological effect and Molecular mechanisms
! style="background: #4479BA; color: #FFFFFF; " align="center" |Pathological effect and Molecular mechanisms
|-
|-
! style="background:#DCDCDC;" |Autoantigen presentation  
! style="background:#DCDCDC;" |Autoantigen presentation  
| align="center" style="background:#DCDCDC;" |HLA class 2<ref name="pmid12867584">{{cite journal |vauthors=Lee HS, Chung YH, Kim TG, Kim TH, Jun JB, Jung S, Bae SC, Yoo DH |title=Independent association of HLA-DR and FCgamma receptor polymorphisms in Korean patients with systemic lupus erythematosus |journal=Rheumatology (Oxford) |volume=42 |issue=12 |pages=1501–7 |year=2003 |pmid=12867584 |doi=10.1093/rheumatology/keg404 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[HLA]] class 2<ref name="pmid12867584">{{cite journal |vauthors=Lee HS, Chung YH, Kim TG, Kim TH, Jun JB, Jung S, Bae SC, Yoo DH |title=Independent association of HLA-DR and FCgamma receptor polymorphisms in Korean patients with systemic lupus erythematosus |journal=Rheumatology (Oxford) |volume=42 |issue=12 |pages=1501–7 |year=2003 |pmid=12867584 |doi=10.1093/rheumatology/keg404 |url=}}</ref>
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |
* Contains [[genes]] encoding [[glycoproteins]] that process and present [[peptides]] for recognition by [[T cells]] ([[Antigen-presenting cell|antigen presenting cells]])
* Contains [[genes]] encoding [[glycoproteins]] that process and present [[peptides]] for recognition by [[T cells]] ([[Antigen-presenting cell|antigen presenting cells]])
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** [[HLA-DR3]]  
** [[HLA-DR3]]  
|
|
* Associated with an overall 2 to 3 fold increase in the risk of SLE  
* Associated with an overall 2- to 3-fold increase in the risk of SLE  
* More in European and Asian
* More common in European and Asian people
* [[HLA-DQ]] and [[HLA-DR]] alleles:
* [[HLA-DQ]] and [[HLA-DR]] alleles:
** Strong association with SLE [[autoantibodies]]
** Strong association with SLE [[autoantibodies]]
|-
|-
! rowspan="2" style="background:#DCDCDC;" |Immune complex dependent response
! rowspan="2" style="background:#DCDCDC;" |Immune complex dependent response
| align="center" style="background:#DCDCDC;" |HLA class 3<ref name="pmid11079100">{{cite journal |vauthors=Pickering MC, Botto M, Taylor PR, Lachmann PJ, Walport MJ |title=Systemic lupus erythematosus, complement deficiency, and apoptosis |journal=Adv. Immunol. |volume=76 |issue= |pages=227–324 |year=2000 |pmid=11079100 |doi= |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[HLA]] class 3<ref name="pmid11079100">{{cite journal |vauthors=Pickering MC, Botto M, Taylor PR, Lachmann PJ, Walport MJ |title=Systemic lupus erythematosus, complement deficiency, and apoptosis |journal=Adv. Immunol. |volume=76 |issue= |pages=227–324 |year=2000 |pmid=11079100 |doi= |url=}}</ref>
|
|
* Contains important [[Gene|immune genes]] including:
* Contains important [[Gene|immune genes]] including:
Line 169: Line 134:
** C4 [[gene]]
** C4 [[gene]]
** Encode [[Complement|complement proteins]]
** Encode [[Complement|complement proteins]]
* The [[complement system]] act through [[opsonization]]:
* The [[complement system]] acts through [[opsonization]]:
** Facilitates the clearance of [[Apoptosis|apoptotic debris]] and cellular fragments
** Facilitates the clearance of [[Apoptosis|apoptotic debris]] and cellular fragments
** The fragments may contain nuclear antigens, which are targets for SLE-associated [[autoantibodies]]
** The fragments may contain nuclear antigens, which are targets for SLE-associated [[autoantibodies]]
Line 181: Line 146:
* Circulating complement C4 proteins deficiency will promote [[autoimmunity]]
* Circulating complement C4 proteins deficiency will promote [[autoimmunity]]
|-
|-
| align="center" style="background:#DCDCDC;" |C1q genes<ref name="pmid11079100">{{cite journal |vauthors=Pickering MC, Botto M, Taylor PR, Lachmann PJ, Walport MJ |title=Systemic lupus erythematosus, complement deficiency, and apoptosis |journal=Adv. Immunol. |volume=76 |issue= |pages=227–324 |year=2000 |pmid=11079100 |doi= |url=}}</ref>
| style="background:#DCDCDC;" align="center" |C1q genes<ref name="pmid11079100">{{cite journal |vauthors=Pickering MC, Botto M, Taylor PR, Lachmann PJ, Walport MJ |title=Systemic lupus erythematosus, complement deficiency, and apoptosis |journal=Adv. Immunol. |volume=76 |issue= |pages=227–324 |year=2000 |pmid=11079100 |doi= |url=}}</ref>
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |
* The [[complement system]] act through [[opsonization]]:
* The [[complement system]] acts through [[opsonization]]:
** Facilitates the clearance of [[Apoptosis|apoptotic debris]] and cellular fragments
** Facilitates the clearance of [[Apoptosis|apoptotic debris]] and cellular fragments
** The fragments may contain nuclear antigens, which are targets for SLE-associated [[autoantibodies]]
** The fragments may contain nuclear antigens, which are targets for SLE-associated [[autoantibodies]]
|
|
* [[Homozygous]] deficiency of ''C1q''
* [[Homozygous]] deficiency of ''C1q:''
** Rare
** Rare
** Develop a severe and early onset form of SLE
** Develop a severe and early onset form of SLE
Line 193: Line 158:
|-  
|-  
! rowspan="4" style="background:#DCDCDC;" |Innate response   
! rowspan="4" style="background:#DCDCDC;" |Innate response   
| align="center" style="background:#DCDCDC;" |[[IRF5|Interferon (IFN) regulatory factor 5]]<ref name="pmid20080916">{{cite journal |vauthors=Löfgren SE, Yin H, Delgado-Vega AM, Sanchez E, Lewén S, Pons-Estel BA, Witte T, D'Alfonso S, Ortego-Centeno N, Martin J, Alarcón-Riquelme ME, Kozyrev SV |title=Promoter insertion/deletion in the IRF5 gene is highly associated with susceptibility to systemic lupus erythematosus in distinct populations, but exerts a modest effect on gene expression in peripheral blood mononuclear cells |journal=J. Rheumatol. |volume=37 |issue=3 |pages=574–8 |year=2010 |pmid=20080916 |doi=10.3899/jrheum.090440 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[IRF5|Interferon (IFN) regulatory factor 5]]<ref name="pmid20080916">{{cite journal |vauthors=Löfgren SE, Yin H, Delgado-Vega AM, Sanchez E, Lewén S, Pons-Estel BA, Witte T, D'Alfonso S, Ortego-Centeno N, Martin J, Alarcón-Riquelme ME, Kozyrev SV |title=Promoter insertion/deletion in the IRF5 gene is highly associated with susceptibility to systemic lupus erythematosus in distinct populations, but exerts a modest effect on gene expression in peripheral blood mononuclear cells |journal=J. Rheumatol. |volume=37 |issue=3 |pages=574–8 |year=2010 |pmid=20080916 |doi=10.3899/jrheum.090440 |url=}}</ref>
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |
* Code a [[transcription factor]] in the type 1 [[interferon]] pathway
* Codes a [[transcription factor]] in the type 1 [[interferon]] pathway
* Regulates:
* Regulates:
** Expression of [[IFN]]-dependent [[genes]]
** Expression of [[IFN]]-dependent [[genes]]
Line 205: Line 170:
* Specific combinations of several [[polymorphisms]] in the [[IRF5]] region interact to increase disease risk
* Specific combinations of several [[polymorphisms]] in the [[IRF5]] region interact to increase disease risk
|-
|-
| align="center" style="background:#DCDCDC;" |[[STAT4]]<ref name="pmid18579578">{{cite journal |vauthors=Sigurdsson S, Nordmark G, Garnier S, Grundberg E, Kwan T, Nilsson O, Eloranta ML, Gunnarsson I, Svenungsson E, Sturfelt G, Bengtsson AA, Jönsen A, Truedsson L, Rantapää-Dahlqvist S, Eriksson C, Alm G, Göring HH, Pastinen T, Syvänen AC, Rönnblom L |title=A risk haplotype of STAT4 for systemic lupus erythematosus is over-expressed, correlates with anti-dsDNA and shows additive effects with two risk alleles of IRF5 |journal=Hum. Mol. Genet. |volume=17 |issue=18 |pages=2868–76 |year=2008 |pmid=18579578 |pmc=2525501 |doi=10.1093/hmg/ddn184 |url=}}</ref><ref name="pmid19109131">{{cite journal |vauthors=Kariuki SN, Kirou KA, MacDermott EJ, Barillas-Arias L, Crow MK, Niewold TB |title=Cutting edge: autoimmune disease risk variant of STAT4 confers increased sensitivity to IFN-alpha in lupus patients in vivo |journal=J. Immunol. |volume=182 |issue=1 |pages=34–8 |year=2009 |pmid=19109131 |pmc=2716754 |doi= |url=}}</ref><ref name="pmid18516230">{{cite journal |vauthors=Taylor KE, Remmers EF, Lee AT, Ortmann WA, Plenge RM, Tian C, Chung SA, Nititham J, Hom G, Kao AH, Demirci FY, Kamboh MI, Petri M, Manzi S, Kastner DL, Seldin MF, Gregersen PK, Behrens TW, Criswell LA |title=Specificity of the STAT4 genetic association for severe disease manifestations of systemic lupus erythematosus |journal=PLoS Genet. |volume=4 |issue=5 |pages=e1000084 |year=2008 |pmid=18516230 |pmc=2377340 |doi=10.1371/journal.pgen.1000084 |url=}}</ref><ref name="pmid18803832">{{cite journal |vauthors=Kawasaki A, Ito I, Hikami K, Ohashi J, Hayashi T, Goto D, Matsumoto I, Ito S, Tsutsumi A, Koga M, Arinami T, Graham RR, Hom G, Takasaki Y, Hashimoto H, Behrens TW, Sumida T, Tsuchiya N |title=Role of STAT4 polymorphisms in systemic lupus erythematosus in a Japanese population: a case-control association study of the STAT1-STAT4 region |journal=Arthritis Res. Ther. |volume=10 |issue=5 |pages=R113 |year=2008 |pmid=18803832 |pmc=2592800 |doi=10.1186/ar2516 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[STAT4]]<ref name="pmid18579578">{{cite journal |vauthors=Sigurdsson S, Nordmark G, Garnier S, Grundberg E, Kwan T, Nilsson O, Eloranta ML, Gunnarsson I, Svenungsson E, Sturfelt G, Bengtsson AA, Jönsen A, Truedsson L, Rantapää-Dahlqvist S, Eriksson C, Alm G, Göring HH, Pastinen T, Syvänen AC, Rönnblom L |title=A risk haplotype of STAT4 for systemic lupus erythematosus is over-expressed, correlates with anti-dsDNA and shows additive effects with two risk alleles of IRF5 |journal=Hum. Mol. Genet. |volume=17 |issue=18 |pages=2868–76 |year=2008 |pmid=18579578 |pmc=2525501 |doi=10.1093/hmg/ddn184 |url=}}</ref><ref name="pmid19109131">{{cite journal |vauthors=Kariuki SN, Kirou KA, MacDermott EJ, Barillas-Arias L, Crow MK, Niewold TB |title=Cutting edge: autoimmune disease risk variant of STAT4 confers increased sensitivity to IFN-alpha in lupus patients in vivo |journal=J. Immunol. |volume=182 |issue=1 |pages=34–8 |year=2009 |pmid=19109131 |pmc=2716754 |doi= |url=}}</ref><ref name="pmid18516230">{{cite journal |vauthors=Taylor KE, Remmers EF, Lee AT, Ortmann WA, Plenge RM, Tian C, Chung SA, Nititham J, Hom G, Kao AH, Demirci FY, Kamboh MI, Petri M, Manzi S, Kastner DL, Seldin MF, Gregersen PK, Behrens TW, Criswell LA |title=Specificity of the STAT4 genetic association for severe disease manifestations of systemic lupus erythematosus |journal=PLoS Genet. |volume=4 |issue=5 |pages=e1000084 |year=2008 |pmid=18516230 |pmc=2377340 |doi=10.1371/journal.pgen.1000084 |url=}}</ref><ref name="pmid18803832">{{cite journal |vauthors=Kawasaki A, Ito I, Hikami K, Ohashi J, Hayashi T, Goto D, Matsumoto I, Ito S, Tsutsumi A, Koga M, Arinami T, Graham RR, Hom G, Takasaki Y, Hashimoto H, Behrens TW, Sumida T, Tsuchiya N |title=Role of STAT4 polymorphisms in systemic lupus erythematosus in a Japanese population: a case-control association study of the STAT1-STAT4 region |journal=Arthritis Res. Ther. |volume=10 |issue=5 |pages=R113 |year=2008 |pmid=18803832 |pmc=2592800 |doi=10.1186/ar2516 |url=}}</ref>
|
|
* Encodes the signal transducer and activator of transcription 4 protein
* Encodes the signal transducer and activator of transcription 4 protein
Line 215: Line 180:
* [[Mutation]] lead to an increased [[sensitivity]] to [[Interferon-alpha|IFN-α]] signaling in peripheral blood [[mononuclear cells]]
* [[Mutation]] lead to an increased [[sensitivity]] to [[Interferon-alpha|IFN-α]] signaling in peripheral blood [[mononuclear cells]]
|-
|-
| align="center" style="background:#DCDCDC;" |The ''[[IRAK1]]-[[MECP2]]'' region
| style="background:#DCDCDC;" align="center" |The ''[[IRAK1]]-[[MECP2]]'' region
|
|
* Encode a [[protein kinase]]:
* Encodes a [[protein kinase]]:
** Regulates multiple pathways in both [[Innate immune system|innate]] and [[Adaptive immune response|adaptive immune responses]] by linking several immune-receptor-complexes to [[TNF]] receptor-associated factor 6
** Regulates multiple pathways in both [[Innate immune system|innate]] and [[Adaptive immune response|adaptive immune responses]] by linking several immune-receptor-complexes to [[TNF]] receptor-associated factor 6
** Critical role in the [[Transcriptional regulation|transcriptional suppression]] of [[methylation]]-sensitive genes
** Critical role in the [[Transcriptional regulation|transcriptional suppression]] of [[methylation]]-sensitive genes
Line 223: Line 188:
* The exact [[Pathogenicity|pathogenetics]] is not completely known
* The exact [[Pathogenicity|pathogenetics]] is not completely known
|-
|-
| align="center" style="background:#DCDCDC;" |[[Fc region|FcγR genes]]<ref name="pmid10413210">{{cite journal |vauthors=Yap SN, Phipps ME, Manivasagar M, Tan SY, Bosco JJ |title=Human Fc gamma receptor IIA (FcgammaRIIA) genotyping and association with systemic lupus erythematosus (SLE) in Chinese and Malays in Malaysia |journal=Lupus |volume=8 |issue=4 |pages=305–10 |year=1999 |pmid=10413210 |doi=10.1191/096120399678847876 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[Fc region|FcγR genes]]<ref name="pmid10413210">{{cite journal |vauthors=Yap SN, Phipps ME, Manivasagar M, Tan SY, Bosco JJ |title=Human Fc gamma receptor IIA (FcgammaRIIA) genotyping and association with systemic lupus erythematosus (SLE) in Chinese and Malays in Malaysia |journal=Lupus |volume=8 |issue=4 |pages=305–10 |year=1999 |pmid=10413210 |doi=10.1191/096120399678847876 |url=}}</ref>
|
|
* Encode [[proteins]] that :
* Encode [[proteins]] that:
** Recognize [[immune complexes]]
** Recognize [[immune complexes]]
** Involved in [[Antibody-dependent cellular cytotoxicity|antibody-dependent]] responses
** Are involved in [[Antibody-dependent cellular cytotoxicity|antibody-dependent]] responses
|
|
* [[Mutation]] associated with:
* [[Mutation]] associated with:
Line 234: Line 199:
|-
|-
! rowspan="2" style="background:#DCDCDC;" |Cell apoptosis regulators
! rowspan="2" style="background:#DCDCDC;" |Cell apoptosis regulators
| align="center" style="background:#DCDCDC;" |[[TREX1]]
| style="background:#DCDCDC;" align="center" |[[TREX1]]
|
|
* Encodes a major [[exonuclease]]:
* Encodes a major [[exonuclease]]:
Line 247: Line 212:
*# Systemic [[autoimmunity]]
*# Systemic [[autoimmunity]]
|-
|-
! style="background:#DCDCDC;" |[[Interleukin 10|IL-10]]
| style="background:#DCDCDC;" align="center" |[[Interleukin 10|IL-10]]
|
|
* Encodes [[IL-10]]
* Encodes [[IL-10]]
Line 255: Line 220:
|-
|-
! rowspan="2" style="background:#DCDCDC;" |IFNα regulators
! rowspan="2" style="background:#DCDCDC;" |IFNα regulators
| align="center" style="background:#DCDCDC;" |[[TNFAIP3]] and [[TNIP1]]
| style="background:#DCDCDC;" align="center" |[[TNFAIP3]] and [[TNIP1]]
|
|
* Encodes key regulators of the [[NFκB]] signaling pathway
* Encode key regulators of the [[NFκB]] signaling pathway
* Modulate cell activation, [[cytokine]] signaling and [[apoptosis]]
* Modulate cell activation, [[cytokine]] signaling and [[apoptosis]]
|
|
* The exact [[Pathogenicity|pathogenetics]] is not completely known
* The exact [[Pathogenicity|pathogenetics]] is not completely known
|-
|-
| align="center" style="background:#DCDCDC;" |PHRF1
| style="background:#DCDCDC;" align="center" |PHRF1
|
|
* Encodes an [[elongation factor]]
* Encodes an [[elongation factor]]
Line 269: Line 234:
|-
|-
! rowspan="7" style="background:#DCDCDC;" |Regulators of Lymphocytes
! rowspan="7" style="background:#DCDCDC;" |Regulators of Lymphocytes
| align="center" style="background:#DCDCDC;" |TNFSF4
| style="background:#DCDCDC;" align="center" |TNFSF4
|
|
* The [[genes]] in this loci produce interaction induces the production of co-stimulatory signals to activate [[T cells]]
* The [[genes]] in this loci produce interaction induces the production of co-stimulatory signals to activate [[T cells]]
Line 280: Line 245:
** Influencing the functional consequences of [[T cell|T-cell activation]]
** Influencing the functional consequences of [[T cell|T-cell activation]]
|-
|-
| align="center" style="background:#DCDCDC;" |[[BLK (gene)|BLK]]<ref name="pmid19180478">{{cite journal |vauthors=Ito I, Kawasaki A, Ito S, Hayashi T, Goto D, Matsumoto I, Tsutsumi A, Hom G, Graham RR, Takasaki Y, Hashimoto H, Ohashi J, Behrens TW, Sumida T, Tsuchiya N |title=Replication of the association between the C8orf13-BLK region and systemic lupus erythematosus in a Japanese population |journal=Arthritis Rheum. |volume=60 |issue=2 |pages=553–8 |year=2009 |pmid=19180478 |doi=10.1002/art.24246 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[BLK (gene)|BLK]]<ref name="pmid19180478">{{cite journal |vauthors=Ito I, Kawasaki A, Ito S, Hayashi T, Goto D, Matsumoto I, Tsutsumi A, Hom G, Graham RR, Takasaki Y, Hashimoto H, Ohashi J, Behrens TW, Sumida T, Tsuchiya N |title=Replication of the association between the C8orf13-BLK region and systemic lupus erythematosus in a Japanese population |journal=Arthritis Rheum. |volume=60 |issue=2 |pages=553–8 |year=2009 |pmid=19180478 |doi=10.1002/art.24246 |url=}}</ref>
|
|
* Encodes a [[protein kinase]]:
* Encodes a [[protein kinase]]:
** Mediates [[intracellular signaling]]
** Mediates [[intracellular signaling]]
** Influences [[B cells]] proliferation and differentiation
** Influences [[B cells]] proliferation and differentiation
** Influence tolerance of [[B cells]]
** Influences tolerance of [[B cells]]
|
|
* More common in Chinese and Japanese populations
* More common in Chinese and Japanese populations
|-
|-
| align="center" style="background:#DCDCDC;" |[[PTPN22]]<ref name="pmid19302045">{{cite journal |vauthors=Gregersen PK, Olsson LM |title=Recent advances in the genetics of autoimmune disease |journal=Annu. Rev. Immunol. |volume=27 |issue= |pages=363–91 |year=2009 |pmid=19302045 |pmc=2992886 |doi=10.1146/annurev.immunol.021908.132653 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[PTPN22]]<ref name="pmid19302045">{{cite journal |vauthors=Gregersen PK, Olsson LM |title=Recent advances in the genetics of autoimmune disease |journal=Annu. Rev. Immunol. |volume=27 |issue= |pages=363–91 |year=2009 |pmid=19302045 |pmc=2992886 |doi=10.1146/annurev.immunol.021908.132653 |url=}}</ref>
|
|
* Encodes a [[lymphoid]]-specific [[Phosphatases|phosphatase]] that inhibits [[T cell|T-cell]] activation
* Encodes a [[lymphoid]]-specific [[Phosphatases|phosphatase]] that inhibits [[T cell|T-cell]] activation
Line 296: Line 261:
* More seen in European populations
* More seen in European populations
* [[Mutation]] increases the intrinsic [[lymphoid]]-specific [[Phosphatases|phosphatase]] activity that lead to:
* [[Mutation]] increases the intrinsic [[lymphoid]]-specific [[Phosphatases|phosphatase]] activity that lead to:
** Reduced [[T cell receptor|T-cell receptor (TCR)]] signaling threshold
** Reduction of [[T cell receptor|T-cell receptor (TCR)]] signaling threshold
** Promotes [[autoimmunity]]
** Promotion of [[autoimmunity]]
|-
|-
| align="center" style="background:#DCDCDC;" |BANK1<ref name="pmid11782428">{{cite journal |vauthors=Yokoyama K, Su Ih IH, Tezuka T, Yasuda T, Mikoshiba K, Tarakhovsky A, Yamamoto T |title=BANK regulates BCR-induced calcium mobilization by promoting tyrosine phosphorylation of IP(3) receptor |journal=EMBO J. |volume=21 |issue=1-2 |pages=83–92 |year=2002 |pmid=11782428 |pmc=125810 |doi=10.1093/emboj/21.1.83 |url=}}</ref><ref name="pmid18204447">{{cite journal |vauthors=Kozyrev SV, Abelson AK, Wojcik J, Zaghlool A, Linga Reddy MV, Sanchez E, Gunnarsson I, Svenungsson E, Sturfelt G, Jönsen A, Truedsson L, Pons-Estel BA, Witte T, D'Alfonso S, Barizzone N, Barrizzone N, Danieli MG, Gutierrez C, Suarez A, Junker P, Laustrup H, González-Escribano MF, Martin J, Abderrahim H, Alarcón-Riquelme ME |title=Functional variants in the B-cell gene BANK1 are associated with systemic lupus erythematosus |journal=Nat. Genet. |volume=40 |issue=2 |pages=211–6 |year=2008 |pmid=18204447 |doi=10.1038/ng.79 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |BANK1<ref name="pmid11782428">{{cite journal |vauthors=Yokoyama K, Su Ih IH, Tezuka T, Yasuda T, Mikoshiba K, Tarakhovsky A, Yamamoto T |title=BANK regulates BCR-induced calcium mobilization by promoting tyrosine phosphorylation of IP(3) receptor |journal=EMBO J. |volume=21 |issue=1-2 |pages=83–92 |year=2002 |pmid=11782428 |pmc=125810 |doi=10.1093/emboj/21.1.83 |url=}}</ref><ref name="pmid18204447">{{cite journal |vauthors=Kozyrev SV, Abelson AK, Wojcik J, Zaghlool A, Linga Reddy MV, Sanchez E, Gunnarsson I, Svenungsson E, Sturfelt G, Jönsen A, Truedsson L, Pons-Estel BA, Witte T, D'Alfonso S, Barizzone N, Barrizzone N, Danieli MG, Gutierrez C, Suarez A, Junker P, Laustrup H, González-Escribano MF, Martin J, Abderrahim H, Alarcón-Riquelme ME |title=Functional variants in the B-cell gene BANK1 are associated with systemic lupus erythematosus |journal=Nat. Genet. |volume=40 |issue=2 |pages=211–6 |year=2008 |pmid=18204447 |doi=10.1038/ng.79 |url=}}</ref>
|
|
* Encodes a [[B cell|B-cell]] adaptor protein
* Encodes a [[B cell|B-cell]] adaptor protein
* Facilitates the release of [[intracellular]] [[calcium]]
* Facilitates the release of [[intracellular]] [[calcium]]
* Alter the [[B-cell]] activation threshold
* Alters the [[B-cell]] activation threshold
| rowspan="2" |
| rowspan="2" |
* Mutations lead to hyperctivation of [[B-cell receptor|B-cell receptors]] and the subsequent [[B-cell]] hyperactivity that is commonly observed in SLE
* Mutations lead to hyperctivation of [[B-cell receptor|B-cell receptors]] and the subsequent [[B-cell]] hyperactivity that is commonly observed in SLE
|-
|-
| align="center" style="background:#DCDCDC;" |LYN<ref name="pmid18204446">{{cite journal |vauthors=Harley JB, Alarcón-Riquelme ME, Criswell LA, Jacob CO, Kimberly RP, Moser KL, Tsao BP, Vyse TJ, Langefeld CD, Nath SK, Guthridge JM, Cobb BL, Mirel DB, Marion MC, Williams AH, Divers J, Wang W, Frank SG, Namjou B, Gabriel SB, Lee AT, Gregersen PK, Behrens TW, Taylor KE, Fernando M, Zidovetzki R, Gaffney PM, Edberg JC, Rioux JD, Ojwang JO, James JA, Merrill JT, Gilkeson GS, Seldin MF, Yin H, Baechler EC, Li QZ, Wakeland EK, Bruner GR, Kaufman KM, Kelly JA |title=Genome-wide association scan in women with systemic lupus erythematosus identifies susceptibility variants in ITGAM, PXK, KIAA1542 and other loci |journal=Nat. Genet. |volume=40 |issue=2 |pages=204–10 |year=2008 |pmid=18204446 |pmc=3712260 |doi=10.1038/ng.81 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |LYN<ref name="pmid18204446">{{cite journal |vauthors=Harley JB, Alarcón-Riquelme ME, Criswell LA, Jacob CO, Kimberly RP, Moser KL, Tsao BP, Vyse TJ, Langefeld CD, Nath SK, Guthridge JM, Cobb BL, Mirel DB, Marion MC, Williams AH, Divers J, Wang W, Frank SG, Namjou B, Gabriel SB, Lee AT, Gregersen PK, Behrens TW, Taylor KE, Fernando M, Zidovetzki R, Gaffney PM, Edberg JC, Rioux JD, Ojwang JO, James JA, Merrill JT, Gilkeson GS, Seldin MF, Yin H, Baechler EC, Li QZ, Wakeland EK, Bruner GR, Kaufman KM, Kelly JA |title=Genome-wide association scan in women with systemic lupus erythematosus identifies susceptibility variants in ITGAM, PXK, KIAA1542 and other loci |journal=Nat. Genet. |volume=40 |issue=2 |pages=204–10 |year=2008 |pmid=18204446 |pmc=3712260 |doi=10.1038/ng.81 |url=}}</ref>
|
|
* Mediates [[B-cell]] activation
* Mediates [[B-cell]] activation
* Mediates [[B-cell]] inhibition
* Mediates [[B-cell]] inhibition
|-
|-
| align="center" style="background:#DCDCDC;" |ETS1<ref name="pmid17967903">{{cite journal |vauthors=Moisan J, Grenningloh R, Bettelli E, Oukka M, Ho IC |title=Ets-1 is a negative regulator of Th17 differentiation |journal=J. Exp. Med. |volume=204 |issue=12 |pages=2825–35 |year=2007 |pmid=17967903 |pmc=2118518 |doi=10.1084/jem.20070994 |url=}}</ref><ref name="pmid19838195">{{cite journal |vauthors=Gateva V, Sandling JK, Hom G, Taylor KE, Chung SA, Sun X, Ortmann W, Kosoy R, Ferreira RC, Nordmark G, Gunnarsson I, Svenungsson E, Padyukov L, Sturfelt G, Jönsen A, Bengtsson AA, Rantapää-Dahlqvist S, Baechler EC, Brown EE, Alarcón GS, Edberg JC, Ramsey-Goldman R, McGwin G, Reveille JD, Vilá LM, Kimberly RP, Manzi S, Petri MA, Lee A, Gregersen PK, Seldin MF, Rönnblom L, Criswell LA, Syvänen AC, Behrens TW, Graham RR |title=A large-scale replication study identifies TNIP1, PRDM1, JAZF1, UHRF1BP1 and IL10 as risk loci for systemic lupus erythematosus |journal=Nat. Genet. |volume=41 |issue=11 |pages=1228–33 |year=2009 |pmid=19838195 |pmc=2925843 |doi=10.1038/ng.468 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |ETS1<ref name="pmid17967903">{{cite journal |vauthors=Moisan J, Grenningloh R, Bettelli E, Oukka M, Ho IC |title=Ets-1 is a negative regulator of Th17 differentiation |journal=J. Exp. Med. |volume=204 |issue=12 |pages=2825–35 |year=2007 |pmid=17967903 |pmc=2118518 |doi=10.1084/jem.20070994 |url=}}</ref><ref name="pmid19838195">{{cite journal |vauthors=Gateva V, Sandling JK, Hom G, Taylor KE, Chung SA, Sun X, Ortmann W, Kosoy R, Ferreira RC, Nordmark G, Gunnarsson I, Svenungsson E, Padyukov L, Sturfelt G, Jönsen A, Bengtsson AA, Rantapää-Dahlqvist S, Baechler EC, Brown EE, Alarcón GS, Edberg JC, Ramsey-Goldman R, McGwin G, Reveille JD, Vilá LM, Kimberly RP, Manzi S, Petri MA, Lee A, Gregersen PK, Seldin MF, Rönnblom L, Criswell LA, Syvänen AC, Behrens TW, Graham RR |title=A large-scale replication study identifies TNIP1, PRDM1, JAZF1, UHRF1BP1 and IL10 as risk loci for systemic lupus erythematosus |journal=Nat. Genet. |volume=41 |issue=11 |pages=1228–33 |year=2009 |pmid=19838195 |pmc=2925843 |doi=10.1038/ng.468 |url=}}</ref>
|
|
* Negatively regulates the differentiation of [[B cells]] and type 17 [[T-helper cells]]
* Negatively regulates the differentiation of [[B cells]] and type 17 [[T-helper cells]]
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* The exact [[Pathogenicity|pathogenetics]] is not completely known
* The exact [[Pathogenicity|pathogenetics]] is not completely known
|-
|-
| align="center" style="background:#DCDCDC;" |[[IKZF1]]<ref name="pmid17357110">{{cite journal |vauthors=Wojcik H, Griffiths E, Staggs S, Hagman J, Winandy S |title=Expression of a non-DNA-binding Ikaros isoform exclusively in B cells leads to autoimmunity but not leukemogenesis |journal=Eur. J. Immunol. |volume=37 |issue=4 |pages=1022–32 |year=2007 |pmid=17357110 |doi=10.1002/eji.200637026 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |[[IKZF1]]<ref name="pmid17357110">{{cite journal |vauthors=Wojcik H, Griffiths E, Staggs S, Hagman J, Winandy S |title=Expression of a non-DNA-binding Ikaros isoform exclusively in B cells leads to autoimmunity but not leukemogenesis |journal=Eur. J. Immunol. |volume=37 |issue=4 |pages=1022–32 |year=2007 |pmid=17357110 |doi=10.1002/eji.200637026 |url=}}</ref>
|
|
* Encode a [[lymphoid]]-restricted [[transcription factor]]
* Encodes a [[lymphoid]]-restricted [[transcription factor]]
* Regulates:
* Regulates:
** [[Lymphocyte]] differentiation and proliferation
** [[Lymphocyte]] differentiation and proliferation
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|-
|-
! style="background:#DCDCDC;" |Genes involved in immune complex clearance
! style="background:#DCDCDC;" |Genes involved in immune complex clearance
| align="center" style="background:#DCDCDC;" |ITGAM<ref name="pmid19838195">{{cite journal |vauthors=Gateva V, Sandling JK, Hom G, Taylor KE, Chung SA, Sun X, Ortmann W, Kosoy R, Ferreira RC, Nordmark G, Gunnarsson I, Svenungsson E, Padyukov L, Sturfelt G, Jönsen A, Bengtsson AA, Rantapää-Dahlqvist S, Baechler EC, Brown EE, Alarcón GS, Edberg JC, Ramsey-Goldman R, McGwin G, Reveille JD, Vilá LM, Kimberly RP, Manzi S, Petri MA, Lee A, Gregersen PK, Seldin MF, Rönnblom L, Criswell LA, Syvänen AC, Behrens TW, Graham RR |title=A large-scale replication study identifies TNIP1, PRDM1, JAZF1, UHRF1BP1 and IL10 as risk loci for systemic lupus erythematosus |journal=Nat. Genet. |volume=41 |issue=11 |pages=1228–33 |year=2009 |pmid=19838195 |pmc=2925843 |doi=10.1038/ng.468 |url=}}</ref>
| style="background:#DCDCDC;" align="center" |ITGAM<ref name="pmid19838195">{{cite journal |vauthors=Gateva V, Sandling JK, Hom G, Taylor KE, Chung SA, Sun X, Ortmann W, Kosoy R, Ferreira RC, Nordmark G, Gunnarsson I, Svenungsson E, Padyukov L, Sturfelt G, Jönsen A, Bengtsson AA, Rantapää-Dahlqvist S, Baechler EC, Brown EE, Alarcón GS, Edberg JC, Ramsey-Goldman R, McGwin G, Reveille JD, Vilá LM, Kimberly RP, Manzi S, Petri MA, Lee A, Gregersen PK, Seldin MF, Rönnblom L, Criswell LA, Syvänen AC, Behrens TW, Graham RR |title=A large-scale replication study identifies TNIP1, PRDM1, JAZF1, UHRF1BP1 and IL10 as risk loci for systemic lupus erythematosus |journal=Nat. Genet. |volume=41 |issue=11 |pages=1228–33 |year=2009 |pmid=19838195 |pmc=2925843 |doi=10.1038/ng.468 |url=}}</ref>
|
|
* Encode a [[protein]] that binds the [[complement]] cleavage fragment of [[C3b]]
* Encodes a [[protein]] that binds the [[complement]] cleavage fragment of [[C3b]]
|
|
* Contributed to SLE susceptibility
* Contributes to SLE susceptibility
|}
|}


==Associated Conditions==
==Associated Conditions==
* [[Homozygous]] deficiencies of the components of [[complement]] especially C1q are associated with developing immunologic diseases especially SLE or a lupus-like disease.<ref name="pmid11564823">{{cite journal |vauthors=Petry F, Botto M, Holtappels R, Walport MJ, Loos M |title=Reconstitution of the complement function in C1q-deficient (C1qa-/-) mice with wild-type bone marrow cells |journal=J. Immunol. |volume=167 |issue=7 |pages=4033–7 |year=2001 |pmid=11564823 |doi= |url=}}</ref>
* [[Homozygous]] deficiencies of the components of [[complement]], especially C1q, are associated with developing immunologic diseases, particularly SLE or a lupus-like disease.<ref name="pmid11564823">{{cite journal |vauthors=Petry F, Botto M, Holtappels R, Walport MJ, Loos M |title=Reconstitution of the complement function in C1q-deficient (C1qa-/-) mice with wild-type bone marrow cells |journal=J. Immunol. |volume=167 |issue=7 |pages=4033–7 |year=2001 |pmid=11564823 |doi= |url=}}</ref>
* The FcγRIIA [[polymorphism]] has been associated with [[nephritis]] in African Americans, Koreans, and Hispanics. Both FcgammaRIIa and FcgammaRIIIa have low binding [[alleles]] that confer risk for SLE and may act in the [[pathogenesis]] of disease. <ref name="pmid24997134">{{cite journal |vauthors=Li R, Peng H, Chen GM, Feng CC, Zhang YJ, Wen PF, Qiu LJ, Leng RX, Pan HF, Ye DQ |title=Association of FCGR2A-R/H131 polymorphism with susceptibility to systemic lupus erythematosus among Asian population: a meta-analysis of 20 studies |journal=Arch. Dermatol. Res. |volume=306 |issue=9 |pages=781–91 |year=2014 |pmid=24997134 |doi=10.1007/s00403-014-1483-5 |url=}}</ref>
* The FcγRIIA [[polymorphism]] has been associated with [[nephritis]] in African Americans, Koreans, and Hispanics. Both FcgammaRIIa and FcgammaRIIIa have low binding [[alleles]] that confer risk for SLE and may act in the [[pathogenesis]] of disease. <ref name="pmid24997134">{{cite journal |vauthors=Li R, Peng H, Chen GM, Feng CC, Zhang YJ, Wen PF, Qiu LJ, Leng RX, Pan HF, Ye DQ |title=Association of FCGR2A-R/H131 polymorphism with susceptibility to systemic lupus erythematosus among Asian population: a meta-analysis of 20 studies |journal=Arch. Dermatol. Res. |volume=306 |issue=9 |pages=781–91 |year=2014 |pmid=24997134 |doi=10.1007/s00403-014-1483-5 |url=}}</ref>
* Women treated with [[estrogen]]-containing regimens such as oral [[contraceptives]] or [[HRT|postmenopausal hormone replacement therapies]] are more predisposed to SLE.
* Women treated with [[estrogen]]-containing regimens such as oral [[contraceptives]] or [[HRT|postmenopausal hormone replacement therapies]] are more predisposed to SLE.
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* Anti-Ro, anti-La, anti sm, and anti RNP [[antibodies]] have been associated with [[mucocutaneous]] involvement and less severe [[nephropathy]].
* Anti-Ro, anti-La, anti sm, and anti RNP [[antibodies]] have been associated with [[mucocutaneous]] involvement and less severe [[nephropathy]].
== Gross Pathology ==
== Gross Pathology ==
On gross pathology of [[kidney]], bilateral [[pallor]], and [[Hypertrophy (medical)|hypertrophy]] of [[kidneys]] are characteristic findings of systemic lupus erythematosus.
On gross pathology the most important characteristic findings are:
 
* [[Kidney]]: Bilateral [[pallor]] and [[Hypertrophy (medical)|hypertrophy]]  
On gross pathology of [[brain]], [[infarct]] regions and [[hemorrhages]] are characteristic findings of systemic lupus erythematosus.
* [[Brain]]: [[Infarct]] regions and [[hemorrhages]]
 
* [[Heart]]: [[Cardiomegaly]] and [[valvular]] vegetation
On gross pathology of [[Cardiac valve|cardiac valves]], [[cardiomegaly]] and [[valvular]] vegetation are characteristic findings of systemic lupus erythematosus.
* [[Pleura|Lung]]: [[Pleural fibrosis|Peural fibrosis]] and [[pleural effusion]]
 
On gross pathology of [[pleura]], [[pleuritis]] and [[pleural fibrosis]] are characteristic findings of systemic lupus erythematosus.


== Microscopic Pathology ==
== Microscopic Pathology ==
One of the most important special cells that can be found in lupus patients is Lupus erythematosus cell, abbreviated LE cell. LE cell is a [[neutrophil]] that has engulfed an intact nucleus. It is also known as a LE body.
On microscopic histopathological analysis, lupus erythematosus (LE) cells can be seen in SLE. LE cells are [[neutrophils]] that have engulfed an intact nucleus. LE cells are also known as LE bodies.


On microscopic [[histopathological]] analysis, [[apoptotic]] [[keratinocytes]], [[vacuolization]] of the [[basement membrane]], and dermal mucin [[Deposition (chemistry)|deposition]] are characteristic findings of SLE [[dermatitis]], and active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]] are characteristic findings of [[Lupus nephritis|SLE nephritis]]. [[Microscopic]] findings in systemic lupus erythematosus based on organ system involvement include:
On microscopic [[histopathological]] analysis, [[apoptotic]] [[keratinocytes]], [[vacuolization]] of the [[basement membrane]], and dermal mucin deposition are characteristic findings of SLE [[dermatitis]], and active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]] are characteristic findings of [[Lupus nephritis|SLE nephritis]]. [[Microscopic]] findings in systemic lupus erythematosus are based on the involved organ system.


=== Skin involvement histopathology ===
=== Skin histopathology ===
Common shared [[histopathologic]] features among all different subtypes of cutaneous lupus include:
Common shared [[histopathologic]] features among all different subtypes of cutaneous lupus include:
* [[Hyperkeratosis]]
* [[Hyperkeratosis]]
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* [[Superficial]], [[Perivascular cell|perivascular]], and perifollicular areas (due to [[Mononuclear cells|mononuclear cell]] inflammatory infiltrate)
* [[Superficial]], [[Perivascular cell|perivascular]], and perifollicular areas (due to [[Mononuclear cells|mononuclear cell]] inflammatory infiltrate)
{| class="wikitable"
{| class="wikitable"
! align="center" style="background: #4479BA; color: #FFFFFF; " |SLE dermatitis subtype
! style="background: #4479BA; color: #FFFFFF; " align="center" |SLE dermatitis subtype
! align="center" style="background: #4479BA; color: #FFFFFF; " |Specific microscopic findings
! style="background: #4479BA; color: #FFFFFF; " align="center" |Specific microscopic findings
! style="background: #4479BA; color: #FFFFFF; " align="center" |Preview
|-
|-
! align="center" style="background:#DCDCDC;" |Acute cutaneous lupus erythematosus
! style="background:#DCDCDC;" align="center" |Acute cutaneous lupus erythematosus
|
|
* Lymphohistiocytic infiltrate in the [[superficial]] dermis <ref name="pmid20482683">{{cite journal |vauthors=Sepehr A, Wenson S, Tahan SR |title=Histopathologic manifestations of systemic diseases: the example of cutaneous lupus erythematosus |journal=J. Cutan. Pathol. |volume=37 Suppl 1 |issue= |pages=112–24 |year=2010 |pmid=20482683 |doi=10.1111/j.1600-0560.2010.01510.x |url=}}</ref>
* Lymphohistiocytic infiltrate in the [[superficial]] dermis <ref name="pmid20482683">{{cite journal |vauthors=Sepehr A, Wenson S, Tahan SR |title=Histopathologic manifestations of systemic diseases: the example of cutaneous lupus erythematosus |journal=J. Cutan. Pathol. |volume=37 Suppl 1 |issue= |pages=112–24 |year=2010 |pmid=20482683 |doi=10.1111/j.1600-0560.2010.01510.x |url=}}</ref>
| rowspan="3" |[[File:Vacuolar interface dermatitis - high mag.jpg|thumb|300px|<SMALL><SMALL>''[https://librepathology.org/wiki/Main_Page/ Adapted from Librepathology]''</SMALL></SMALL>]]
|-
|-
! align="center" style="background:#DCDCDC;" |Subacute cutaneous lupus erythematosus
! style="background:#DCDCDC;" align="center" |Subacute cutaneous lupus erythematosus
|
|
* Less [[Follicular cell|follicular]] plugging and [[hyperkeratosis]] in comparison with dischoid lupus erythematosus
* Less [[Follicular cell|follicular]] plugging and [[hyperkeratosis]] in comparison with dischoid lupus erythematosus
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* Absence or minimal change of [[basement membrane]] thickening
* Absence or minimal change of [[basement membrane]] thickening
|-
|-
! align="center" style="background:#DCDCDC;" |Chronic cutaneous lupus erythematosus
! style="background:#DCDCDC;" align="center" |Chronic cutaneous lupus erythematosus
|
|
* [[Discoid lupus erythematosus]] :
* [[Discoid lupus erythematosus]] :
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** [[Mononuclear cell]] infiltration near the dermal-epidermal junction, [[Blood vessels|dermal blood vessel]]<nowiki/>s, and appendages
** [[Mononuclear cell]] infiltration near the dermal-epidermal junction, [[Blood vessels|dermal blood vessel]]<nowiki/>s, and appendages
* Lupus erythematosus tumidus:  
* Lupus erythematosus tumidus:  
** Consisting of predominately CD3+/CD4+ [[lymphocytes]]
** Consists of predominately [[CD3|CD3+]]/[[CD4+]] [[lymphocytes]]
** Focal interface changes
** Focal interface changes
* Lupus profundus (lupus panniculitis) :
* Lupus profundus (lupus panniculitis):
** [[Perivascular cell|Perivascular]] infiltrates of [[mononuclear cells]] plus [[panniculitis]]
** [[Perivascular cell|Perivascular]] infiltrates of [[mononuclear cells]] plus [[panniculitis]]
** [[Hyaline]] fat necrosis
** [[Hyaline]] fat necrosis
** Direct [[immunofluorescence]]: Immune deposits in the dermal-epidermal junction
** Direct [[immunofluorescence]]: immune deposits in the dermal-epidermal junction
|}
|}


=== Glomerulonephritis histopathology ===
=== Glomerulonephritis histopathology ===
{| class="wikitable"
{| class="wikitable"
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small>Class<small>
! style="background: #4479BA; color: #FFFFFF; " align="center" |<small>Class<small>
! align="center" style="background: #4479BA; color: #FFFFFF; " |SLE nephritis subtype
! style="background: #4479BA; color: #FFFFFF; " align="center" |SLE nephritis subtype
! align="center" style="background: #4479BA; color: #FFFFFF; " |Light microscopy findings
! style="background: #4479BA; color: #FFFFFF; " align="center" |Light microscopy findings
! align="center" style="background: #4479BA; color: #FFFFFF; " |Electron microscopy/Immunofluorescence findings
! style="background: #4479BA; color: #FFFFFF; " align="center" |Light microscopy previews
! style="background: #4479BA; color: #FFFFFF; " align="center" |Electron microscopy/Immunofluorescence findings
|-
|-
| align="center" |'''I'''
! align="center" |'''I'''
| style="background:#DCDCDC;" |Minimal mesangial lupus nephritis
| style="background:#DCDCDC;" |Minimal mesangial lupus nephritis
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
|
|
* Mesangial [[immune]] deposits
* Mesangial [[immune]] deposits
|-
|-
| align="center" |'''II'''
! align="center" |'''II'''
| style="background:#DCDCDC;" |Mesangial proliferative lupus nephritis  
| style="background:#DCDCDC;" |Mesangial proliferative lupus nephritis  
|
|
* [[Mesangial proliferative glomerulonephritis|Mesangial hyper cellularity]] (of any degree)
* [[Mesangial proliferative glomerulonephritis|Mesangial hyper cellularity]] (of any degree)
* [[Mesangial cells|Mesangial]] matrix expansion
* [[Mesangial cells|Mesangial]] matrix expansion
|[[File:Membranous nephropathy - mpas - very high mag.jpg|thumb|300px|<SMALL><SMALL>''[https://librepathology.org/wiki/Main_Page/ Adapted from Librepathology]''</SMALL></SMALL>]]
|
|
* Isolated [[Subepithelial connective tissue graft|subepithelial]] or subendothelial deposits
* Isolated [[Subepithelial connective tissue graft|subepithelial]] or subendothelial deposits
|-
|-
| align="center" |'''III'''
! align="center" |'''III'''
| style="background:#DCDCDC;" |Focal lupus nephritis
| style="background:#DCDCDC;" |Focal lupus nephritis
|
|
* Active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]]  
* Active or inactive [[Endocapillary proliferative glomerulonephritis|endocapillary]] or extracapillary segmental [[glomerulonephritis]]  
* Involvement of glomeruli < 50%
* Involvement of glomeruli < 50%
|[[File:1599px-Focal segmental glomerulosclerosis - high mag.jpg|thumb|300px|<SMALL><SMALL>''[https://librepathology.org/wiki/Main_Page/ Adapted from Librepathology]''</SMALL></SMALL>]]
|
|
* Immune deposits in the subendothelial space of the [[Glomerular capillaries|glomerular capillary]] and [[mesangium]]
* Immune deposits in the subendothelial space of the [[Glomerular capillaries|glomerular capillary]] and [[mesangium]]
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* [[Tubulointerstitial diseases of the kidney|Tubulointerstitial]] or vascular abnormalities
* [[Tubulointerstitial diseases of the kidney|Tubulointerstitial]] or vascular abnormalities
|-
|-
| align="center" |'''IV'''
! align="center" |'''IV'''
| style="background:#DCDCDC;" |Diffuse lupus nephritis
| style="background:#DCDCDC;" |Diffuse lupus nephritis
|
|
Line 433: Line 402:
* [[Mesangial proliferative glomerulonephritis|Mesangial abnormalities]]
* [[Mesangial proliferative glomerulonephritis|Mesangial abnormalities]]
* Involvement of glomeruli > 50%
* Involvement of glomeruli > 50%
| rowspan="2" |[[File:Membranoproliferative glomerulonephritis - very high mag.jpg|thumb|300px|<SMALL><SMALL>''[https://librepathology.org/wiki/Main_Page/ Adapted from Librepathology]''</SMALL></SMALL>]]
|
|
* Subendothelial deposits specially during the active phase
* Subendothelial deposits specially during the active phase
* Diffuse wire loop deposits with little or no glomerular proliferation
* Diffuse wire loop deposits with little or no glomerular proliferation
|-
|-
| align="center" |'''V'''
! align="center" |'''V'''
| style="background:#DCDCDC;" |Lupus membranous nephropathy
| style="background:#DCDCDC;" |Lupus membranous nephropathy
|
|
Line 445: Line 415:
* Global or segmental [[Subepithelial connective tissue graft|subepithelial]] immune deposits
* Global or segmental [[Subepithelial connective tissue graft|subepithelial]] immune deposits
|-
|-
| align="center" |'''VI'''
! align="center" |'''VI'''
| style="background:#DCDCDC;" |Advanced sclerosing lupus nephritis
| style="background:#DCDCDC;" |Advanced sclerosing lupus nephritis
|
|
* Global [[sclerosis]]
* Global [[sclerosis]]
* Involvement of [[glomeruli]] > 90%
* Involvement of [[glomeruli]] > 90%
|[[File:Crescentic glomerulonephritis (2).jpg|thumb|300px|<SMALL><SMALL>''[https://librepathology.org/wiki/Main_Page/ Adapted from Librepathology]''</SMALL></SMALL>]]
|
|
* Global or segmental [[Subepithelial connective tissue graft|subepithelial]] immune deposits
* Global or segmental [[Subepithelial connective tissue graft|subepithelial]] immune deposits
|}
|}


=== Synovial involvement histopathology ===
=== Synovial histopathology ===
* Nonspecific histopathologic findings
* Nonspecific histopathologic findings
* Superficial [[fibrin]]-like material
* Superficial [[fibrin]]-like material
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** [[Thrombi]]
** [[Thrombi]]


=== Mucosal involvement histopathology ===
=== Mucosal histopathology ===
* [[Hyperkeratosis]]
* [[Hyperkeratosis]]
* [[Atrophy]] of rete processes
* [[Atrophy]] of rete processes
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====Videos====
=====Lupus nephritis histopathology=====
{{#ev:youtube|Tw07BFaDEo0}}
{{#ev:youtube|Tw07BFaDEo0}}


Latest revision as of 18:29, 23 August 2017

Title
https://https://www.youtube.com/watch?v=0junqD4BLH4%7C350}}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2], Cafer Zorkun, M.D., Ph.D. [3], Raviteja Guddeti, M.B.B.S. [4]

Overview

The pathophysiology of systemic lupus erythematosus involves the immune system. Other factors such as genetic factors, hormonal abnormalities, and environmental factors also play a role. The most important environmental factors involved in the pathogenesis of SLE include ultraviolet (UV) light and some infections. The most important genes involved in the pathogenesis of SLE include HLA-DR2, HLA-DR3, HLA class 3, C1q, and interferon (IFN) regulatory factor 5. The most prominent events involving immune abnormalities are related to persistent activation of B cells and plasma cells that make auto-antibodies during disease progression. The disease developmental process begins with the release of microparticles and proinflammatory cytokines from the cells that are undergoing apoptosis. Due to excess amount of apoptosis, the body is unable to clear these microparticles entirely, and these microparticles are presented to dendritic cells as antigens. Dendritic cells process these microparticles and mature, and present these as antigens to T-cells. T-cells, microparticles, and proinflammatory cytokines themselves trigger B-cell activation and autoantibody production. As a result, body tissues lose their self-tolerance. The most prominent events involving hormonal abnormalities are due to prolactin and estrogen. On microscopic histopathological analysis, apoptotic keratinocytes, vacuolization of the basement membrane, and dermal mucin deposition are characteristic findings of SLE dermatitis, and active or inactive endocapillary or extracapillary segmental glomerulonephritis are characteristic findings of lupus nephritis.

Pathogenesis

The progression of systemic lupus erythematosus (SLE) involves the immune system. Nearly all of the pathological manifestations of SLE occur due to antibody formation and the creation and deposition of immune complexes in different organs of the body. When the immune complexes are formed, they deposit on different body tissues and vessels, which may lead to complement activation and more organ damage. There are other factors such as genetic factors, hormonal abnormalities, and environmental factors that also play a role in the pathogenesis of SLE.

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Environmental factors

The environmental factors and genetic factors are the most important risk factors for developing SLE because they may jump-start the disinhibited cellular apoptosis chain. This apoptosis step is the first step in the pathogenesis of lupus.

Immune abnormalities

The development of systemic lupus erythematosus (SLE) is due to the activation of different mechanisms that may result in auto-immunity. The disease developmental process begins with the release of microparticles and proinflammatory cytokines from the cells that are undergoing apoptosis. Due to excess amount of apoptosis, the body is unable to clear these microparticles entirely, and these microparticles are presented to dendritic cells as antigens. Dendritic cells process these microparticles and mature, and present these as antigens to T-cells. T-cells, microparticles, and proinflammatory cytokines themselves trigger B-cell activation and autoantibody production. As a result, body tissues lose their self-tolerance. Affected patients are no longer entirely tolerant to all of their self-antigens, leading to development of an autoimmune disease and producing autoantibodies as a response. During disease progression, B cells and plasma cells that make autoantibodies are more persistently activated due to signaling abnormalities, causing them to make more autoantibodies. These autoantibodies are targeted predominantly to intracellular nucleoprotein particles.[1][2] This increase in autoantibody production and persistence is supposed to be downregulated by anti-idiotypic antibodies or regulatory immune cells, but the massive immunologic response in SLE prevents this downregulation from taking place. After formation of immune complexes, the classical complement pathway is activated, which leads to the deposition of immune complexes in different organs and is responsible for flare ups and long term complications. The most important immune abnormalities that are related to SLE development and progression are: 

Microparticles

Increased level of microparticles (MPs):[3]

Pro-inflammatory cytokines

Increased expression of specific genetic factors may be associated with promoting autoimmunity. The most important cytokine changes include:[4][3]

Signaling abnormalities

Protein kinases are responsible for intracellular cytokine signals. Intracellular signaling leads to various types of cell response, such as:

Cell signaling abnormalities leads to:

  • T and B lymphocytes cellular hyperactivity
  • T and B lymphocytes hyper responsiveness
  • Persistence of auto-reactive T cells that would otherwise have been deleted

Signaling abnormalities of T and B lymphocytes, may be due to:

B-Cell role

T-Cell role

Neutrophil role

Hormonal abnormalities

The following evidence is suggestive of the hormonal predisposition to SLE:

Hormones that are related to disease progression include:[7]

Prolactin:

Exogenous estrogen

Progesterone:

Genetics

Systemic lupus erythematosus is transmitted in a polygenic inheritance pattern. Genes involved in the pathogenesis of systemic lupus erythematosus include HLA class 2 (especially DR2 and DR3), HLA class 3 (especially complement genes including C2 and C4 genes), IFNRF5 gene, and other genes related to the immunologic system. The following evidence is also suggestive of the genetic predisposition of SLE:[10]

  • Increase occurrence of disease in identical twins
  • Increased disease frequency among first degree relatives
  • The increased occurrence of the disease in siblings of SLE patients
Class Gene subtype Function Pathological effect and Molecular mechanisms
Autoantigen presentation HLA class 2[11]
  • Associated with an overall 2- to 3-fold increase in the risk of SLE
  • More common in European and Asian people
  • HLA-DQ and HLA-DR alleles:
Immune complex dependent response HLA class 3[12]
  • Complete C2 and C4 deficiencies:
    • Rare
    • Associated with a mild form of SLE that affects mostly the joints and skin
  • Stronger genetic evidence for an association with SLE in C4A than C4-B
  • Circulating complement C4 proteins deficiency will promote autoimmunity
C1q genes[12]
Innate response Interferon (IFN) regulatory factor 5[13]
STAT4[14][15][16][17]
  • Encodes the signal transducer and activator of transcription 4 protein
The IRAK1-MECP2 region
FcγR genes[18]
Cell apoptosis regulators TREX1
IL-10
  • Increased IL-10 production by B cells and monocytes from patients with SLE is known to correlate with disease activity
IFNα regulators TNFAIP3 and TNIP1
  • Encode key regulators of the NFκB signaling pathway
  • Modulate cell activation, cytokine signaling and apoptosis
PHRF1
Regulators of Lymphocytes TNFSF4
  • The genes in this loci produce interaction induces the production of co-stimulatory signals to activate T cells
BLK[19]
  • More common in Chinese and Japanese populations
PTPN22[20]
BANK1[21][22]
  • Mutations lead to hyperctivation of B-cell receptors and the subsequent B-cell hyperactivity that is commonly observed in SLE
LYN[23]
ETS1[24][25]
IKZF1[26]
  • A novel SLE susceptibility locus in a Chinese population
  • A strong candidate locus in European-derived populations
Genes involved in immune complex clearance ITGAM[25]
  • Contributes to SLE susceptibility

Associated Conditions

Gross Pathology

On gross pathology the most important characteristic findings are:

Microscopic Pathology

On microscopic histopathological analysis, lupus erythematosus (LE) cells can be seen in SLE. LE cells are neutrophils that have engulfed an intact nucleus. LE cells are also known as LE bodies.

On microscopic histopathological analysis, apoptotic keratinocytes, vacuolization of the basement membrane, and dermal mucin deposition are characteristic findings of SLE dermatitis, and active or inactive endocapillary or extracapillary segmental glomerulonephritis are characteristic findings of SLE nephritis. Microscopic findings in systemic lupus erythematosus are based on the involved organ system.

Skin histopathology

Common shared histopathologic features among all different subtypes of cutaneous lupus include:

SLE dermatitis subtype Specific microscopic findings Preview
Acute cutaneous lupus erythematosus
Adapted from Librepathology
Subacute cutaneous lupus erythematosus
Chronic cutaneous lupus erythematosus

Glomerulonephritis histopathology

Class SLE nephritis subtype Light microscopy findings Light microscopy previews Electron microscopy/Immunofluorescence findings
I Minimal mesangial lupus nephritis -
II Mesangial proliferative lupus nephritis
Adapted from Librepathology
III Focal lupus nephritis
Adapted from Librepathology
IV Diffuse lupus nephritis
Adapted from Librepathology
  • Subendothelial deposits specially during the active phase
  • Diffuse wire loop deposits with little or no glomerular proliferation
V Lupus membranous nephropathy
VI Advanced sclerosing lupus nephritis
Adapted from Librepathology

Synovial histopathology

Mucosal histopathology


Lupus nephritis histopathology

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References

  1. ↑ Elkon K (1995). "Autoantibodies in systemic lupus erythematosus". Curr Opin Rheumatol. 7 (5): 384–8. PMID 8519610.
  2. ↑ Yaniv G, Twig G, Shor DB, Furer A, Sherer Y, Mozes O, Komisar O, Slonimsky E, Klang E, Lotan E, Welt M, Marai I, Shina A, Amital H, Shoenfeld Y (2015). "A volcanic explosion of autoantibodies in systemic lupus erythematosus: a diversity of 180 different antibodies found in SLE patients". Autoimmun Rev. 14 (1): 75–9. doi:10.1016/j.autrev.2014.10.003. PMID 25449682.
  3. ↑ 3.0 3.1 Dye JR, Ullal AJ, Pisetsky DS (2013). "The role of microparticles in the pathogenesis of rheumatoid arthritis and systemic lupus erythematosus". Scand. J. Immunol. 78 (2): 140–8. doi:10.1111/sji.12068. PMID 23672591.
  4. ↑ Kirou KA, Lee C, George S, Louca K, Papagiannis IG, Peterson MG, Ly N, Woodward RN, Fry KE, Lau AY, Prentice JG, Wohlgemuth JG, Crow MK (2004). "Coordinate overexpression of interferon-alpha-induced genes in systemic lupus erythematosus". Arthritis Rheum. 50 (12): 3958–67. doi:10.1002/art.20798. PMID 15593221.
  5. ↑ Barnado A, Crofford LJ, Oates JC (2016). "At the Bedside: Neutrophil extracellular traps (NETs) as targets for biomarkers and therapies in autoimmune diseases". J. Leukoc. Biol. 99 (2): 265–78. doi:10.1189/jlb.5BT0615-234R. PMID 26658004.
  6. ↑ Costenbader KH, Feskanich D, Stampfer MJ, Karlson EW (2007). "Reproductive and menopausal factors and risk of systemic lupus erythematosus in women". Arthritis Rheum. 56 (4): 1251–62. doi:10.1002/art.22510. PMID 17393454.
  7. ↑ 7.0 7.1 Lahita RG (1999). "The role of sex hormones in systemic lupus erythematosus". Curr Opin Rheumatol. 11 (5): 352–6. PMID 10503654.
  8. ↑ Hughes GC, Choubey D (2014). "Modulation of autoimmune rheumatic diseases by oestrogen and progesterone". Nat Rev Rheumatol. 10 (12): 740–51. doi:10.1038/nrrheum.2014.144. PMID 25155581.
  9. ↑ Cohen-Solal JF, Jeganathan V, Grimaldi CM, Peeva E, Diamond B (2006). "Sex hormones and SLE: influencing the fate of autoreactive B cells". Curr. Top. Microbiol. Immunol. 305: 67–88. PMID 16724801.
  10. ↑ Sullivan KE (2000). "Genetics of systemic lupus erythematosus. Clinical implications". Rheum. Dis. Clin. North Am. 26 (2): 229–56, v–vi. PMID 10768211.
  11. ↑ Lee HS, Chung YH, Kim TG, Kim TH, Jun JB, Jung S, Bae SC, Yoo DH (2003). "Independent association of HLA-DR and FCgamma receptor polymorphisms in Korean patients with systemic lupus erythematosus". Rheumatology (Oxford). 42 (12): 1501–7. doi:10.1093/rheumatology/keg404. PMID 12867584.
  12. ↑ 12.0 12.1 Pickering MC, Botto M, Taylor PR, Lachmann PJ, Walport MJ (2000). "Systemic lupus erythematosus, complement deficiency, and apoptosis". Adv. Immunol. 76: 227–324. PMID 11079100.
  13. ↑ Löfgren SE, Yin H, Delgado-Vega AM, Sanchez E, Lewén S, Pons-Estel BA, Witte T, D'Alfonso S, Ortego-Centeno N, Martin J, Alarcón-Riquelme ME, Kozyrev SV (2010). "Promoter insertion/deletion in the IRF5 gene is highly associated with susceptibility to systemic lupus erythematosus in distinct populations, but exerts a modest effect on gene expression in peripheral blood mononuclear cells". J. Rheumatol. 37 (3): 574–8. doi:10.3899/jrheum.090440. PMID 20080916.
  14. ↑ Sigurdsson S, Nordmark G, Garnier S, Grundberg E, Kwan T, Nilsson O, Eloranta ML, Gunnarsson I, Svenungsson E, Sturfelt G, Bengtsson AA, Jönsen A, Truedsson L, Rantapää-Dahlqvist S, Eriksson C, Alm G, Göring HH, Pastinen T, Syvänen AC, Rönnblom L (2008). "A risk haplotype of STAT4 for systemic lupus erythematosus is over-expressed, correlates with anti-dsDNA and shows additive effects with two risk alleles of IRF5". Hum. Mol. Genet. 17 (18): 2868–76. doi:10.1093/hmg/ddn184. PMC 2525501. PMID 18579578.
  15. ↑ Kariuki SN, Kirou KA, MacDermott EJ, Barillas-Arias L, Crow MK, Niewold TB (2009). "Cutting edge: autoimmune disease risk variant of STAT4 confers increased sensitivity to IFN-alpha in lupus patients in vivo". J. Immunol. 182 (1): 34–8. PMC 2716754. PMID 19109131.
  16. ↑ Taylor KE, Remmers EF, Lee AT, Ortmann WA, Plenge RM, Tian C, Chung SA, Nititham J, Hom G, Kao AH, Demirci FY, Kamboh MI, Petri M, Manzi S, Kastner DL, Seldin MF, Gregersen PK, Behrens TW, Criswell LA (2008). "Specificity of the STAT4 genetic association for severe disease manifestations of systemic lupus erythematosus". PLoS Genet. 4 (5): e1000084. doi:10.1371/journal.pgen.1000084. PMC 2377340. PMID 18516230.
  17. ↑ Kawasaki A, Ito I, Hikami K, Ohashi J, Hayashi T, Goto D, Matsumoto I, Ito S, Tsutsumi A, Koga M, Arinami T, Graham RR, Hom G, Takasaki Y, Hashimoto H, Behrens TW, Sumida T, Tsuchiya N (2008). "Role of STAT4 polymorphisms in systemic lupus erythematosus in a Japanese population: a case-control association study of the STAT1-STAT4 region". Arthritis Res. Ther. 10 (5): R113. doi:10.1186/ar2516. PMC 2592800. PMID 18803832.
  18. ↑ Yap SN, Phipps ME, Manivasagar M, Tan SY, Bosco JJ (1999). "Human Fc gamma receptor IIA (FcgammaRIIA) genotyping and association with systemic lupus erythematosus (SLE) in Chinese and Malays in Malaysia". Lupus. 8 (4): 305–10. doi:10.1191/096120399678847876. PMID 10413210.
  19. ↑ Ito I, Kawasaki A, Ito S, Hayashi T, Goto D, Matsumoto I, Tsutsumi A, Hom G, Graham RR, Takasaki Y, Hashimoto H, Ohashi J, Behrens TW, Sumida T, Tsuchiya N (2009). "Replication of the association between the C8orf13-BLK region and systemic lupus erythematosus in a Japanese population". Arthritis Rheum. 60 (2): 553–8. doi:10.1002/art.24246. PMID 19180478.
  20. ↑ Gregersen PK, Olsson LM (2009). "Recent advances in the genetics of autoimmune disease". Annu. Rev. Immunol. 27: 363–91. doi:10.1146/annurev.immunol.021908.132653. PMC 2992886. PMID 19302045.
  21. ↑ Yokoyama K, Su Ih IH, Tezuka T, Yasuda T, Mikoshiba K, Tarakhovsky A, Yamamoto T (2002). "BANK regulates BCR-induced calcium mobilization by promoting tyrosine phosphorylation of IP(3) receptor". EMBO J. 21 (1–2): 83–92. doi:10.1093/emboj/21.1.83. PMC 125810. PMID 11782428.
  22. ↑ Kozyrev SV, Abelson AK, Wojcik J, Zaghlool A, Linga Reddy MV, Sanchez E, Gunnarsson I, Svenungsson E, Sturfelt G, Jönsen A, Truedsson L, Pons-Estel BA, Witte T, D'Alfonso S, Barizzone N, Barrizzone N, Danieli MG, Gutierrez C, Suarez A, Junker P, Laustrup H, González-Escribano MF, Martin J, Abderrahim H, Alarcón-Riquelme ME (2008). "Functional variants in the B-cell gene BANK1 are associated with systemic lupus erythematosus". Nat. Genet. 40 (2): 211–6. doi:10.1038/ng.79. PMID 18204447.
  23. ↑ Harley JB, Alarcón-Riquelme ME, Criswell LA, Jacob CO, Kimberly RP, Moser KL, Tsao BP, Vyse TJ, Langefeld CD, Nath SK, Guthridge JM, Cobb BL, Mirel DB, Marion MC, Williams AH, Divers J, Wang W, Frank SG, Namjou B, Gabriel SB, Lee AT, Gregersen PK, Behrens TW, Taylor KE, Fernando M, Zidovetzki R, Gaffney PM, Edberg JC, Rioux JD, Ojwang JO, James JA, Merrill JT, Gilkeson GS, Seldin MF, Yin H, Baechler EC, Li QZ, Wakeland EK, Bruner GR, Kaufman KM, Kelly JA (2008). "Genome-wide association scan in women with systemic lupus erythematosus identifies susceptibility variants in ITGAM, PXK, KIAA1542 and other loci". Nat. Genet. 40 (2): 204–10. doi:10.1038/ng.81. PMC 3712260. PMID 18204446.
  24. ↑ Moisan J, Grenningloh R, Bettelli E, Oukka M, Ho IC (2007). "Ets-1 is a negative regulator of Th17 differentiation". J. Exp. Med. 204 (12): 2825–35. doi:10.1084/jem.20070994. PMC 2118518. PMID 17967903.
  25. ↑ 25.0 25.1 Gateva V, Sandling JK, Hom G, Taylor KE, Chung SA, Sun X, Ortmann W, Kosoy R, Ferreira RC, Nordmark G, Gunnarsson I, Svenungsson E, Padyukov L, Sturfelt G, Jönsen A, Bengtsson AA, Rantapää-Dahlqvist S, Baechler EC, Brown EE, Alarcón GS, Edberg JC, Ramsey-Goldman R, McGwin G, Reveille JD, Vilá LM, Kimberly RP, Manzi S, Petri MA, Lee A, Gregersen PK, Seldin MF, Rönnblom L, Criswell LA, Syvänen AC, Behrens TW, Graham RR (2009). "A large-scale replication study identifies TNIP1, PRDM1, JAZF1, UHRF1BP1 and IL10 as risk loci for systemic lupus erythematosus". Nat. Genet. 41 (11): 1228–33. doi:10.1038/ng.468. PMC 2925843. PMID 19838195.
  26. ↑ Wojcik H, Griffiths E, Staggs S, Hagman J, Winandy S (2007). "Expression of a non-DNA-binding Ikaros isoform exclusively in B cells leads to autoimmunity but not leukemogenesis". Eur. J. Immunol. 37 (4): 1022–32. doi:10.1002/eji.200637026. PMID 17357110.
  27. ↑ Petry F, Botto M, Holtappels R, Walport MJ, Loos M (2001). "Reconstitution of the complement function in C1q-deficient (C1qa-/-) mice with wild-type bone marrow cells". J. Immunol. 167 (7): 4033–7. PMID 11564823.
  28. ↑ Li R, Peng H, Chen GM, Feng CC, Zhang YJ, Wen PF, Qiu LJ, Leng RX, Pan HF, Ye DQ (2014). "Association of FCGR2A-R/H131 polymorphism with susceptibility to systemic lupus erythematosus among Asian population: a meta-analysis of 20 studies". Arch. Dermatol. Res. 306 (9): 781–91. doi:10.1007/s00403-014-1483-5. PMID 24997134.
  29. ↑ Sepehr A, Wenson S, Tahan SR (2010). "Histopathologic manifestations of systemic diseases: the example of cutaneous lupus erythematosus". J. Cutan. Pathol. 37 Suppl 1: 112–24. doi:10.1111/j.1600-0560.2010.01510.x. PMID 20482683.

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