Participation of immunoglobulin E (IgE) in immune-mediated glomerulonephritis

Lupus Nephritis in an Adolescent Girl With Hyper-Immunoglobulin E

We report the case of an adolescent girl with frequent hospital admissions for severe eczematous skin rashes with recurrent epistaxis and chest infections. Investigations revealed persistent severely elevated serum total immunoglobulin E (IgE) levels but normal levels of other immunoglobulins, suggesting hyper-IgE syndrome. The first skin biopsy revealed superficial dermatophytic dermatitis (tinea corpora). Another biopsy performed after six months revealed a prominent basement membrane with dermal mucin, suggesting an underlying autoimmune disease. Her condition was complicated by proteinuria, hematuria, hypertension, and edema. A kidney biopsy revealed class IV lupus nephritis, according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS). Based on the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria, she was diagnosed with systemic lupus erythematosus (SLE). She was first administered with intravenous pulse methylprednisolone (600 mg/m²) for three consecutive days, followed by oral prednisolone (40 mg/m²) daily, mycophenolate mofetil tablets (600 mg/m²/dose) twice daily, hydroxychloroquine (200 mg) once daily, and three classes of antihypertensive medications. She maintained normal renal functions with no lupus morbidity for 24 months, then rapidly progressed to end-stage kidney disease, and was then started on three to four sessions of regular hemodialysis per week. Hyper-IgE is known to be a marker of immune dysregulation as it facilitates the generation of immune complexes (ICs) that mediate lupus nephritis and juvenile SLE. Regardless of the different factors that are impacting the production of IgE, the present case illustrated that juvenile patients with SLE may have increased IgE levels, indicating that higher IgE levels might have a role in lupus pathogenesis and prognosis. The mechanisms regarding the increased levels of IgE in subjects with lupus need further investigation. Further studies are thus required to assess the incidence, prognosis, and possible new specific management for hyper-IgE in juvenile SLE.

Increased IgE serum levels are unrelated to allergic and parasitic diseases in patients with juvenile systemic lupus erythematosus

OBJECTIVE

The aim of this study was to assess the IgE serum levels in juvenile systemic lupus erythematosus patients and to evaluate possible associations with clinical and laboratory features, disease activity and tissue damage.

METHODS

The IgE serum concentrations in 69 consecutive juvenile systemic lupus erythematosus patients were determined by nephelometry. IgG, IgM and IgA concentrations were measured by immunoturbidimetry. All patients were negative for intestinal parasites. Statistical analysis methods included the Mann-Whitney, chi-square and Fisher's exact tests, as well as the Spearman rank correlation coefficient.

RESULTS

Increased IgE concentrations above 100 IU/mL were observed in 31/69 (45%) juvenile systemic lupus erythematosus patients. The mean IgE concentration was 442.0 ± 163.4 IU/ml (range 3.5-9936.0 IU/ml). Fifteen of the 69 patients had atopic disease, nine patients had severe sepsis and 56 patients presented with nephritis. The mean IgE level in 54 juvenile systemic lupus erythematosus patients without atopic manifestations was 271.6 ± 699.5 IU/ml, and only nine of the 31 (29%) patients with high IgE levels had atopic disease. The IgE levels did not statistically differ with respect to the presence of atopic disease, severe sepsis, nephritis, disease activity, or tissue damage. Interestingly, IgE concentrations were inversely correlated with C4 levels (r = -0.25, p = 0.03) and with the SLICC/ACR-DI score (r = -0.34, p = 0.005). The IgE concentration was also found to be directly correlated with IgA levels (r = 0.52, p = 0.03).

CONCLUSIONS

The present study demonstrated for the first time that juvenile systemic lupus erythematosus patients have increased IgE serum levels. This increase in IgE levels was not related to allergic or parasitic diseases. Our results are in line with the hypothesis that high IgE levels can be considered a marker of immune dysregulation.

Anti-dsDNA antibodies in Brazilian patients of mainly African descent with systemic lupus erythematosus: lack of association with lupus nephritis

Renal disease is associated with morbidity and mortality in systemic lupus erythematosus (SLE) and anti-dsDNA antibodies with SLE immunopathogenesis. We investigated the dsDNA antibody profile of 84 Brazilian SLE patients, 27 with lupus nephritis. Thirty-six (39.1%) patients had dsDNA IgG antibodies shown in enzyme-linked immunosorbent assay (454.7 +/- 281.1 WHO units/mL), nine presenting renal disease. The following profile of dsDNA antibodies was demonstrated in Crithidia luciliae test: IgA (seven out of 36; 19.4%), IgG (22 out of 36, 66.1%); IgM (nine out of 36, 25.0%), and IgE (four out of 36, 11.1%). Two or three isotypes of dsDNA antibodies were observed in nine (25.0%) patients, while 11 (30.5%) were seronegative in the C. luciliae test. Patients with dsDNA antibodies had lower serum C3 and C4 when compared with SLE individuals without these immunoglobulins (P < 0.01 and P < 0.001, respectively). There was no association between any dsDNA antibody isotype and lupus kidney disease nor was anti-dsDNA IgM antibody associated with absence of nephritis.

Immunoglobulin E and systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by intense polyclonal production of autoantibodies and circulating immune complexes. Some reports have associated SLE with a Th2 immune response and allergy. In the present study 21 female patients with SLE were investigated for total IgE and IgE antibodies to dust house aeroallergens by an automated enzyme-linked fluorescent assay, and were also evaluated for antinuclear IgE autoantibodies by a modified indirect immunofluorescence test using HEp-2 cells as antigen substrate. Additionally, immunocapture ELISA was used to investigate serum anti-IgE IgG autoantibodies. Serum IgE above 150 IU/ml, ranging from 152 to 609 IU/ml (median = 394 IU IgE/ml), was observed in 7 of 21 SLE patients (33%), 5 of them presenting proteinuria, urinary cellular casts and augmented production of anti-dsDNA antibodies. While only 2 of 21 SLE patients (9.5%) were positive for IgE antibodies to aeroallergens, all 10 patients with respiratory allergy (100%) from the atopic control group (3 males and 7 females), had these immunoglobulins. SLE patients and healthy controls presented similar anti-IgE IgG autoantibody titers (X = 0.37 +/- 0.20 and 0.34 +/- 0.18, respectively), differing from atopic controls (0.94 +/- 0.26). Antinuclear IgE autoantibodies were detected in 17 of 21 (81%) sera from SLE patients, predominating the fine speckled pattern of fluorescence, that was also observed in IgG-ANA. Concluding, SLE patients can present increased IgE levels and antinuclear IgE autoantibodies without specific clinical signs of allergy or production of antiallergen IgE antibodies, excluding a possible association between SLE and allergy.

Induction of anti-DNA IgG and IgE antibodies in BALB/c mice

Immunization of BALB/c mice with denatured DNA (dnDNA)-methylated bovine serum albumin (MBSA) complex along with aluminium hydroxide gel as adjuvant, resulted in the induction of anti-DNA antibodies of both IgG and IgE isotypes demonstrable by avidin-biotin micro enzyme-linked immunosorbent assay (ELISA) and solid phase radioimmunoassay (SPRIA), respectively. In contrast to the high levels of IgG2a and IgG2b anti-DNA antibodies observed in SLE-prone autoimmune mice, more than 90% of the anti-DNA antibodies of IgG isotype were found to be of IgG1 subclass. Specificity of both IgG and IgE antibodies which recognized activated DNA, dnDNA and double-stranded DNA but not RNA was established by competitive ELISA and SPRIA inhibition assays. These antibodies cross-reacted with cibacron blue and chondroitin sulfate but not with various other proteoglycans, nucleosides and nucleotides. Passive cutaneous anaphylaxis reaction in rats showed that these antibodies are capable of inducing in vivo degranulation of mast cells in a dose-dependent manner. These studies lend support to the concept that IgE antibodies directed against DNA may mediate mast cell degranulation and thus contribute to immediate-type hypersensitivity phenomena including hives seen in patients with systemic lupus erythematosus and to the localization of IgE-nucleic acid complexes.

Effects of in vivo administration of interferon (IFN)-gamma, anti-IFN-gamma, or anti-interleukin-4 monoclonal antibodies in chronic autoimmune graft-versus-host disease

These studies examined the role of cytokines in chronic autoimmune graft-versus-host disease (GVHD) in B6D2F1 mice injected with lymphoid cells from DBA/2 mice. Anti-interleukin (IL)-4 and anti-interferon (IFN)-gamma mAb, or IFN-gamma, were used in vivo to modulate B cell hyperactivity and disease. Kinetic experiments showed that, 2-3 weeks after induction, GVH mice had 100x elevated serum IgE, while IgG1 and IgG2a were 10x above normal. Early treatment with anti-IL-4 mAb or IFN-gamma decreased serum IgE and IgG1 and had no effect on IgG2a. Anti-IFN-gamma mAb treatment increased serum IgE and IgG1 while reducing IgG2a. This increase in serum immunoglobulins could be correlated with an increased spontaneous secretion of IL-4, IL-5, and IL-6 in spleen cell cultures from anti-IFN-gamma mAb-treated GVH mice. While neither anti-IFN-gamma nor IFN-gamma treatments altered the disease course, anti-IL-4 treatment delayed proteinuria and death in GVH mice. These observations suggest an important role for IL-4 in immune complex-mediated glomerulonephritis in chronic GVHD.

Demonstration of IgE antibodies to nucleic acid antigens in patients with SLE

Using a combination of avidin-biotin microELISA and solid phase radioimmunoassay, we examined sera from 23 patients with systemic lupus erythematosus (SLE), two patients with established sensitivity to ingested shrimp, and 15 healthy normal subjects. In addition to IgG antibodies, varying amounts of IgE antibodies specific for native DNA (nDNA), denatured or single-stranded DNA (dnDNA), RNA, and tRNA were demonstrable in the sera of SLE patients, but not in the sera of normal subjects. A comparison of the specificity of nucleic acid-specific IgE antibodies present in the sera of shrimp-sensitive patients with those present in the sera of seven SLE patients revealed that the IgE antibodies in the sera of shrimp-sensitive patients specifically recognized shrimp tRNA but not yeast tRNA, calf thymus RNA, or calf thymus DNA, while those present in the sera of patients with SLE recognized all these nucleic acid antigens. The IgE antibodies directed against nDNA, dnDNA, RNA, and tRNA may mediate mast cell and basophil degranulation and thus contribute both to immediate-type hypersensitivity phenomena including hives seen in patients with SLE and to the localization of IgE-nucleic acid complexes in target tissues.

Anti-IgE autoantibodies in systemic lupus erythematosus. Prevalence and biologic activity

IgG and IgM autoantibodies directed against IgE were determined in 95 serum samples from 67 patients with systemic lupus erythematosus, by an enzyme-linked immunosorbent assay. IgM anti-IgE autoantibodies were found in 18 patients (27%) and IgG anti-IgE autoantibodies were detected in 23 patients (34%). The specificity of the immunoassay was confirmed by the ability to inhibit binding with IgE myeloma, but not other immunoglobulin isotypes and the demonstration that the reactivity was directed to the Fc epsilon fragment of IgE. The IgG fraction of certain sera with anti-IgE activity was capable of inducing histamine release from control basophils and cutaneous mast cells. Clinical associations with the presence of anti-IgE activity were sought by retrospective chart analysis of 61 patients. Significant correlation was found with articular involvement, lymphadenopathy, and anti-DNA antibodies (P less than 0.05). Anti-IgE autoantibodies are observed in a significant number of patients with systemic lupus erythematosus and may contribute to the pathogenesis of the vascular and articular lesions characteristic of this disease.

Chronic glomerulonephritis with massive IgA deposits

A total of 234 patients with chronic glomerulonephritis, detected on the basis of clinical, immunological and pathomorphological criteria, have been examined. A group of 23 chronic glomerulonephritis patients with massive deposits of immunoglobulin A found by immunofluorescent examination, has been separated on the basis of immunohistochemical studies. In this group, occurrence of different morphological forms of glomerulonephritis has been observed: 30.4% mesangial-proliferative glomerulonephritis, 13% submicroscopic glomerulonephritis and one case of membranous glomerulonephritis. Complete haemolytic activity of complement, level of complement components C3 and C4, immunological complexes circulating in blood, properdin and immunoglobulin A levels, fibrin and fibrinogen (FDP) degradation product concentrations and their 24-hour excretions with urine have been determined. Preliminary observations of this group of patients seem to indicate a positive effect of steroid therapy in glomerulonephritis with IgA deposits, irrespective of the morphological form of the disease.

IgE associated nephropathy in a patient with subcutaneous eosinophilic lymphoid granuloma (Kimura's disease)

A patient with subcutaneous eosinophilic lymphoid granuloma (Kimura's disease) associated with a high serum IgE level and a marked blood eosinophilia, had a glomerulonephritis with electron dense deposits in mesangial, paramesangial, subendothelial, intramembranous and epimembranous areas. By immunofluorescence, all the glomeruli showed predominant depositions of IgE and IgG along the paramesangial areas and capillary walls together with complement components. The germinal centers in the lymph follicles formed in both the subcutaneous granuloma and the kidney interstitium also contained mainly IgE and IgG but no complement components. These features of this disease suggest that the glomerular lesion is one of the systemic manifestations of Kimura's disease.

Serum concentrations of immunoglobulins E and G and alpha 2-macroglobulin in childhood renal disease

Serum concentrations of IgE, IgG, and alpha 2-macroglobulin (alpha 2-M) were determined in 67 children with renal disease and in appropriate controls. IgE concentrations were significantly elevated in patients with renal disease and proteinuria, including those with minimal change nephrotic syndrome (MCNS). IgG concentrations were lower and alpha 2-M concentrations higher in patients with proteinuria than in patients without proteinuria. In 16 patients with nephrotic syndrome who had a decrease in proteinuria with therapy, there was a concomitant decrease in mean serum IgE level. All nine with MCNS had a decrease in serum IgE following therapy whereas eight of the nine had a concomitant increase in serum IgG. The findings suggest the possibility that IgE may play an etiologic role in the proteinuria of childhood nephrotic syndrome, and that both elevated serum IgE and proteinuria may represent unusual responses to antigens that are seldom identified. Elevations of IgE secondary to lowered IgG or to entirely nonspecific alterations in IgE metabolism in proteinuric renal disease are other possibilities. Further studies to elucidate the role of IgE in renal disease, including the nature of the altered metabolism of this immunoglobulin, are warranted.

Evidence of an immediate hypersensitivity mechanism in systemic lupus erythematosus

In 30 patients with systemic lupus erythematosus the number of a circulating basophils was countered in different stages of activity. An inverse correlation was found between the absolute basophils count and anti-DNA antibodies and presumptive circulating immune complexes (as judged by polyethylene glycol precipitation of serum). A positive correlation was found between the absolute basophil count and C3 or C4 levels. IgE on the basophil surface was determined by radioimmunoassay in 7 patients. All of them showed a significantly higher surface IgE number. When the count of circulating basophils was roughly normal, 5 out of the 6 patients showed a positive basophil degranulation test with native DNA. These results suggest the existence of an anti-DNA specific IgE in lupus patients. Depression of the circulating basophil count may be a useful index of lupus activity.

The prevalence of IgE antinuclear antibodies in rheumatoid arthritis and systemic lupus erythematosus

Antinuclear antibodies (ANA) of the IgE class were studied in sera from patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and healthy controls. Sixty per cent of 20 RA patients with neutropenia were found to have IgE granulocyte-specific (GS-)ANA, whereas only 16% of RA patients without neutropenia had IgE antibodies of similar specificity. About 5% in each group of RA patients had IgE organ-nonspecific (ON-)ANA. Eleven of 15 patients with active SLE and only 4 of 20 with inactive SLE had IgE ON-ANA. Sera from five patients with lupus nephritis all contained IgE ON-ANA. None of 100 sera from controls showed presence of IgE ANA. IgE ANA titres in RA and SLE patients correlated to the titres of ANA of the other four immunoglobulin classes. Gel filtration studies at neutral and acid pH of RA sera containing high titres of IgE GS-ANA indicated the presence of these antibodies in immune complexes. Studies of serum cryoprecipitates supported this conclusion. IgE ANA production may be of pathogenetic importance in RA and SLE by eliciting type-I reactions.

Allergy in systemic lupus erythematosus. IgE levels and reaginic phenomenon

Twenty-seven patients with systemic lupus erythematosus (SLE) were investigated for the presence of allergic reactivity, and serum IgE levels were measured by immunoassay. Compared to controls, SLE patients had significant increases of only allergic rhinitis and drug allergy. Despite the usual hyperimmunoglobulinemia in SLE, IgE levels were not elevated (mean: 251 IU). Because recent reports have noted elevated IgE in rheumatoid arthritis, this finding may suggest basic immunologic differences between rheumatoid arthritis and SLE.