The in vivo metabolism of the third component of complement in systemic lupus erythematosus

Factor B activation products in patients with systemic lupus erythematosus. A marker of severe disease activity

Complement activation patterns were determined in a group of 51 patients with systemic lupus erythematosus (SLE), and the clinical outcomes of these patients at 2 years were correlated with the complement activation patterns. Activation of the classical pathway was monitored by analysis of C4a desArg levels and total C4 levels, and activation of the alternative pathway was monitored by isoelectric focusing/immunofixation and quantitative analyses of Factor B. Activation of C3 (a general measure of complement activation) was determined by an enzyme-linked immunosorbent assay for C3d and by quantitative analysis of C3. Patients were stratified into 3 groups: those with C4 but not C3 activation; those with C4 and C3 but not Factor B activation; and those with C4, C3, and Factor B activation. At the end of 2 years, there was a statistically significant difference in the morbidity and mortality rates of the third group of SLE patients compared with those in the other 2 groups. There was also a statistically significant association between the presence of Ba and cutaneous vasculitis. Unlike the patterns seen with in vitro-activated serum or with membrane-activated plasma, the Bb activation fragment was not present in the activated plasma samples from the SLE patients. These data suggest that activation of the alternative complement pathway may be a marker for severe SLE and that the Bb fragment may be playing a role in the development of this more serious pathologic condition.

The clinical significance of iC3b neoantigen expression in plasma from patients with systemic lupus erythematosus

We studied the expression of an iC3b neoantigen (iC3b-NEO) in plasma from patients with systemic lupus erythematosus (SLE), by using a monoclonal antibody specific for iC3b/C3dg/C3d, to investigate the activation of the third component of complement in SLE. The plasma iC3b-NEO level in 40 untreated patients with active SLE was significantly higher than that in 36 normal subjects (mean +/- SD 31.5 +/- 13.9 micrograms/ml versus 12.3 +/- 3.3 micrograms/ml; P less than 0.001). The plasma iC3b-NEO level was highly correlated with clinical disease activity (tau = 0.62, P less than 0.0001), and it was the parameter most closely correlated with renal histologic activity in lupus nephritis (tau = 0.52, P less than 0.0001). Also, patients with diffuse proliferative lupus nephritis had the highest levels of plasma iC3b-NEO among all World Health Organization classes of lupus nephritis (P less than 0.01). We conclude that the plasma iC3b-NEO level is strongly associated with clinical disease activity and renal histologic activity in patients with SLE, and that plasma iC3b-NEO may be a sensitive and useful measure of complement activation in SLE.

Complement (C3) metabolism in rheumatoid arthritis in relation to the disease course

Metabolic turnover studies of the third component of complement, C3, were performed in 23 patients with rheumatoid arthritis (RA) to get a direct insight in the dynamics of complement synthesis and catabolism. Results of these turnover studies were related to the serum level of the total amount of C3 as well as to that of the activation product C3d. A hypercatabolism of C3 was observed in 12 of the 23 patients studied. Six of these 12 patients showed signs of extra-articular RA; only one patient with extra-articular manifestations had a normal catabolism of C3. Decreased serum levels of C3 were not found in any of the patients with a hypercatabolism of C3, indicating that the accelerated turnover was compensated by an increased synthesis. In RA patients levels of the activation product C3d could not correlate with the turnover of C3. However, in selected RA patients without signs of nodules or extra-articular manifestations, they could. Thus, our results indicate that serum levels of C3 and C3d do not reflect C3 metabolism in RA patients. Furthermore, the existence of extra-articular manifestations is accompanied by a more pronounced activation of the complement system.

Relation between synovial fluid C3 degradation products and local joint inflammation in rheumatoid arthritis, osteoarthritis, and crystal associated arthropathy

C3 degradation products (C3dg/d) were estimated in 288 synovial fluid (SF) samples (rheumatoid arthritis (RA) 93, osteoarthritis (OA) 68, chronic pyrophosphate arthropathy 80, acute pseudogout 20, others 27) from knees of 138 patients (bilateral 67, serial sampling on two to six occasions 40). At each aspiration knees were defined as 'active' or 'inactive' by single observer global assessment using six clinical parameters of inflammation. Lack of correlation between paired SF and plasma C3dg/d implied local C3 activation within joints. Raised SF C3d levels were found in active compared with inactive RA joints (mean (range) 51 (15-105) and 6 (0-15) units/ml respectively). Low SF C3dg/d levels were found in OA (mean (range) 0.8 (0-7) units/ml) and chronic pyrophosphate arthropathy (mean (range) 4 (0-16) units/ml), irrespective of clinical activity. In contrast, very high levels (mean (range) 61 (16-126) units/ml) were present in all cases of pseudogout. These differences remained after correction for SF C3 or albumin. This study is the first to show a positive correlation between SF C3dg/d and local inflammation in RA joints. It further suggests that C3 activation is a constant feature of pseudogout but not an accompaniment of inflammation associated with chronic crystal associated synovitis or OA.

Complement (C3) metabolism in systemic lupus erythematosus in relation to the disease course

Metabolic turnover studies of complement components (C3) provide a direct insight into the dynamics of the complement regulation (synthesis and catabolism). To obtain information about the role of the complement system in relation to the disease course in patients with systemic lupus erythematosus (SLE), a prospective study was performed. The results of the C3 turnover studies were also correlated to the complement levels (C3) and to the presence of C3 conversion products (C3d) in circulation. In nearly all SLE patients (in 21 of the 26 metabolic turnover studies) a C3 hypercatabolism was found, with a quantitative difference depending on the disease phase. In the period preceding an exacerbation an impaired C3 synthesis was observed (in three of the four studies), in contrast to SLE patients in stable disease phase where in one case only a decrease C3 synthesis was calculated (1 out of 15 observations). A linear correlation was found between the serum C3-levels and the ratio of C3d/C3, suggesting that both serologic parameters are quantitatively indicative for C3 hypercatabolism. The study shows that in all SLE patients, irrespective of the disease stage, an increased C3 consumption is found, which supports the concept that a chronic inflammatory process is constantly present.

Complement activation in rheumatoid arthritis evaluated by C3dg and the terminal complement complex

Complement activation was evaluated in plasma and synovial fluid from patients with rheumatoid arthritis. The activation fragment C3dg and the fluid-phase terminal complement complex were used as indicators of initial and terminal activation, respectively. Considerable activation of the whole complement cascade was demonstrated in most synovial fluid samples and in one-third of the plasma samples. No correlation was found between the level of activation products in synovial fluid and the level in plasma. Therefore, both compartments must be examined in order to evaluate local and systemic complement activation in rheumatoid arthritis.

Sequential studies of complement activation in systemic lupus erythematosus

C1 and C3 activation, measured as C1r-C1s-C1 inactivator C1s-C1r-C1IA complexes in serum and circulating C3d were studied in serial samples from 33 patients with SLE. All patients demonstrated exacerbations during observation periods of 10-30 months and were divided into groups according to principal clincal features (mild SLE, severe extra-renal SLE, and lupus glomerulonephritis). Increased C1 activation was consistently found during exacerbation. C3d in plasma was a feature associated with severe disease flares. Activation of C1, but not of C3, was documented before flare-ups of disease activity, but such predictive information was mostly restricted to patients with extra-renal disease. C2 cleavage in plasma, studied serially in a few patients, appeared to be closely associated with C1 activation. Circulating immune complexes, measured with solid-phase C1q assay, did not always increase before development of clinical manifestations. Remission of symptoms was paralleled by decreasing concentrations of C1r-C1s-C1IA and of, when present, C3d. Similar findings were made for immune complexes but only in severe disease. Persisting C3d was observed in 3 patients, who subsequently developed renal failure. C1q levels were transiently low during flare-ups of lupus glomerulonephritis, but otherwise the concentrations of C1q, C4 and C3 did not show consistent patterns of variation in relation to disease activity.

Determination of the half-life of C3 in patients and its relation to the presence of C3-breakdown products and/or circulating immune complexes

Measurement of complement components in serum may not accurately assess the degree of activation of the complement system. An alternative approach is the measurement of conversion products of the complement components. The relation between the presence of an increased concentration of C3-conversion products and the metabolism of C3 was investigated. In a group of patients, circulating immune complexes were also measured (Clq-binding test) to see whether the combination of those markers yielded information on the C3 metabolism. In this study it is shown that static measurements of serum C3 levels is of no value for the degree of complement activation. Measurement of C3-conversion products may indicate C3 hypercatabolism (in 8 of the 11 patients with C3-conversion products), but it does not imply depressed C3 synthesis. Detection of circulating immune complexes by the C1q-binding assay did not always indicate a C3 hypercatabolism. Of 12 SLE patients studied, in 9 of them, a C3 hypercatabolism was detected, and 5 of these patients were clinically characterized by the presence of minor disease symptoms. Overall, the results indicated that detection of circulating immune complexes and/or C3-conversion products could not be used as an absolute measure for insight into the C3 metabolism.

The in-vivo metabolism of C3 in ankylosing spondylitis

Turnover studies with radioactively labelled C3 were performed in 7 patients with ankylosing spondylitis and in 14 healthy individuals . As a group the patients had a moderately higher fractional catabolic rate of C3 than the controls. A possible explanation is that the complement system is activated by immune complexes. The serum levels of C3 were high. The hypercatabolism was therefore more than compensated for by an increased synthesis rate.

Measurement of the complement C3 breakdown product C3d by rocket immunoelectrophoresis

A method is described for quantitative measurement of C3d in plasma and synovial fluid by the use of rocket immunoelectrophoresis after fractionation of the samples with 22% polyethylene glycol. This method has the advantage over radial immunodiffusion of being more sensitive (detecting C3d down to 3 mg/l) whilst proving equally reproducible. Investigations indicate that the collection of blood samples in EDTA prevents in vitro activation of C3 even after storage for up to 6 h at room temperature and up to 12 weeks at -70 degrees C. Elevated levels of C3d were found in a proportion of SLE and RA plasma samples and in synovial fluids from patients with inflammatory synovitis. It is suggested that C3 conversion in vivo may be assessed by measurement of C3d by the technique described, and when used in conjunction with measurements of complement components and immune complexes, offers a means of investigating complement catabolism by the classical and alternative pathways.

Quantitation of human complement fragment C4ai in physiological fluids by competitive inhibition radioimmune assay

A method is described to quantitate complement fragment C4ai in human plasma, synovial fluid, and urine. Samples are first precipitated with 50% saturated (NH4)2SO4 to remove cross-reactive macromolecules C4 and pro-C4. Whereas greater than 97% of C4 is removed by this precipitation step, 88% of C4ai remains in solution. Second, the concentration of C4ai in supernatant fractions is determined by double antibody competitive inhibition radioimmunoassay. C4a was recently completely sequenced (Moon et al., 1981) and is readily available as a pure standard. Examination of the specificity of this method confirmed it was indeed specific for C4a antigenicity. Immunochemically depleted C4-deficient plasma and inulin-activated reconstituted C4-deficient plasma exhibited less than 0.1% of the immunoreactivity of untreated plasma. In addition, good agreement was observed in analyses of aggregated IgG activated serum between the experimentally determined concentration of C4ai and that expected from the initial concentration of C4. As a result, recovery and measurement of C4ai in physiological fluids with this method appear both quantitative and specific. Based on results from 17 adult volunteers, the average concentration of C4ai in normal plasma is 488 ng/ml. Interestingly, significant correlation could not be demonstrated between the levels of C4 and C4ai in normal plasma. The mean concentration of C4ai in human urine is 0.5 ng/ml.

Serum complement abnormalities in the antinuclear antibody-positive relatives of children with systemic lupus erythematosus

Serum C3, C4 and total hemolytic complement (CH50) levels were measured for 21 children with systemic lupus erythematosus (SLE) and 81 first degree relatives. The mean serum C4 and CH50 levels of the 12 relatives with antinuclear antibodies (ANA( were depressed to levels equal to those of the index cases. A similar depression was not found for C3, nor was there a depression of C3, C4, or CH50 in the relatives without ANA. If preexistent depression of C4 levels can be documented in the ANA-positive relatives of index cases, it may provide an explanation for the inherited predisposition to SLE in some families.

Immunoelectrophoretic assay for synovial fluid C3 with correction for synovial fluid globulin

Synovial fluid C3 was measured by electroimmunoassay. When C3 was expressed as mg/ml, the amounts found in Reiter's disease, psoriatic arthritis, gout, and systemic lupus erythematosus were significantly different from degenerative arthritis. When C3 was corrected for total protein, the levels for rheumatoid arthritis, Reiter's disease, psoriatic arthritis, and systemic lupus were significantly different from degenerative arthritis. When C3 was corrected for synovial fluid globulin, only rheumatoid arthritis and systemic lupus were significantly different from degenerative arthritis. Correction of C3 for globulin increases the difference between rheumatoid arthritis and degenerative arthritis. A proportion of gouty fluids with a relative decrease in C3 is demonstrated. It is argued that correction of C3 for globulin is more meaningful than correction for total protein. While many nonrheumatoid inflammatory effusions demonstrate split products of C3, the majority of fluids from patients with systemic lupus have none.