Omega-3 Polyunsaturated Fatty Acid Intervention Against Established Autoimmunity in a Murine Model of Toxicant-Triggered Lupus

Workplace exposure to respirable crystalline silica dust (cSiO2) has been etiologically linked to the development of lupus and other human autoimmune diseases. Lupus triggering can be recapitulated in female NZBWF1 mice by four weekly intranasal instillations with 1 mg cSiO2. This elicits inflammatory/autoimmune gene expression and ectopic lymphoid structure (ELS) development in the lung within 1 week, ultimately driving early onset of systemic autoimmunity and glomerulonephritis. Intriguingly, dietary supplementation with docosahexaenoic acid (DHA), an ω-3 polyunsaturated fatty acid (PUFA) found in fish oil, beginning 2 week prior to cSiO2 challenge, prevented inflammation and autoimmune flaring in this novel model. However, it is not yet known how ω-3 PUFA intervention influences established autoimmunity in this murine model of toxicant-triggered lupus. Here we tested the hypothesis that DHA intervention after cSiO2-initiated intrapulmonary autoimmunity will suppress lupus progression in the NZBWF1 mouse. Six-week old NZWBF1 female mice were fed purified isocaloric diet for 2 weeks and then intranasally instilled with 1 mg cSiO2 or saline vehicle weekly for 4 consecutive weeks. One week after the final instillation, which marks onset of ELS formation, mice were fed diets supplemented with 0, 4, or 10 g/kg DHA. One cohort of mice (n = 8/group) was terminated 13 weeks after the last cSiO2 instillation and assessed for autoimmune hallmarks. A second cohort of mice (n = 8/group) remained on experimental diets and was monitored for proteinuria and moribund criteria to ascertain progression of glomerulonephritis and survival, respectively. DHA consumption dose-dependently increased ω-3 PUFA content in the plasma, lung, and kidney at the expense of the ω-6 PUFA arachidonic acid. Dietary intervention with high but not low DHA after cSiO2 treatment suppressed or delayed: (i) recruitment of T cells and B cells to the lung, (ii) development of pulmonary ELS, (iii) elevation of a wide spectrum of plasma autoantibodies associated with lupus and other autoimmune diseases, (iv) initiation and progression of glomerulonephritis, and (v) onset of the moribund state. Taken together, these preclinical findings suggest that DHA supplementation at a human caloric equivalent of 5 g/d was an effective therapeutic regimen for slowing progression of established autoimmunity triggered by the environmental toxicant cSiO2.

Requisite Omega-3 HUFA Biomarker Thresholds for Preventing Murine Lupus Flaring

Lupus is a systemic autoimmune disease typified by uncontrolled inflammation, disruption of immune tolerance, and intermittent flaring - events triggerable by environmental factors. Preclinical and clinical studies reveal that consumption of the marine ω-3 highly unsaturated fatty acids (HUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) might be used as a precision nutrition intervention to lessen lupus symptoms. The anti-inflammatory and pro-resolving effects of ω-3 HUFAs are inextricably linked to their presence in membrane phospholipids. The ω-3 HUFA score, calculated as [100 × (ω-3 HUFAs/(ω-3 HUFAs + ω-6 HUFAs))] in red blood cells (RBCs), and the Omega-3 Index (O3I), calculated as [100 × ((DHA+EPA)/total fatty acids)] in RBCs, are two biomarkers potentially amenable to relating tissue HUFA balance to clinical outcomes in individuals with lupus. Using data from three prior preclinical DHA supplementation studies, we tested the hypothesis that the ω-3 HUFA score and the O3I inversely correlate with indicators of autoimmune pathogenesis in the cSiO2-triggered lupus flaring model. The three studies employed both low and high fat rodent diets, as well as more complex diets emulating the U.S. dietary pattern. The ω-3 HUFA scores in RBCs were comparatively more robust than the O3I at predicting HUFA balances in the kidney, liver, spleen, and lung. Importantly, increases in both the ω-3 HUFA score (>40%) and the O3I (>10%) were strongly associated with suppression of cSiO2-triggered (1) expression of interferon-regulated genes, proinflammatory cytokine production, leukocyte infiltration, and ectopic lymphoid structure development in the lung, (2) pulmonary and systemic autoantibody production, and (3) glomerulonephritis. Collectively, these findings identify achievable ω-3 HUFA scores and O3I thresholds that could be targeted in future human intervention studies querying how ω-3 HUFA consumption influences lupus and other autoimmune diseases.

The Influence of Diet and Obesity on Gene Expression in SLE

This review provides an overview of the known effects of diet, obesity, and the intake of different nutrients on systemic lupus erythematosus (SLE). It summarizes and discusses the studies in rodents that identified how different diets can regulate gene expression in the disease, together with a description of the effects of diet on lupus patients’ inflammatory state and disease severity. The identification of selected dietary candidates that can modulate SLE onset and progression is analyzed in relation to possible targeted approaches that could ultimately ameliorate the management and prognosis of this disease.

Association of polyphenols from oranges and apples with specific intestinal microorganisms in systemic lupus erythematosus patients

Our group has recently shown the existence of a gut microbial dysbiosis in systemic lupus erythematosus (SLE), supporting previous evidence involving intestinal bacteria in the initiation and amplification of autoimmune diseases. While several studies have addressed the use of dietary fibres to modify intestinal microbiota, information about other correlated components, such as polyphenols, is scarce. The aim of this work was to identify dietary components able to influence this altered microbiota in 20 SLE women and 20 age-matched controls. Food intake was recorded by means of a food frequency questionnaire. The intake of fibres was calculated from Marlett tables, and Phenol-Explorer was used for polyphenol consumption. Results showed positive associations between flavone intake and Blautia, flavanones and Lactobacillus, and dihydrochalcones and Bifidobacterium in the SLE group. Regarding the controls, dihydroflavonols were directly associated with Faecalibacterium, whereas flavonol intake was inversely associated with Bifidobacterium. From the food sources of these polyphenols related to microbiota, orange intake was directly associated with Lactobacillus and apple with Bifidobacterium in SLE, whilst red wine was the best contributor to Faecalibacterium variation. The association between common foods and particular microbial genera, reported to be decreased in SLE, could be of great importance for these patients.

Diet and nutritional aspects in systemic lupus erythematosus

The authors reviewed the influence of nutritional factors on systemic lupus erythematosus (SLE) and discussed an alternative treatment option. The autoimmunity and inflammatory process of SLE are related to the presence of dyslipidemia, obesity, systemic arterial hypertension, and metabolic syndrome, which should be properly considered to decrease cardiovascular risk. A diet with moderate protein and energy content, but rich in vitamins, minerals (especially antioxidants), and mono/polyunsaturated fatty acids can promote a beneficial protective effect against tissue damage and suppression of inflammatory activity, in addition to helping the treatment of those comorbidities. Diet therapy is a promising approach and some recommendations may offer a better quality of life to patients with SLE.

Epidemiology, etiology, detection, and treatment of autoantibody-associated congenital heart block in neonatal lupus

Neonatal lupus syndrome is a model of passively acquired autoimmunity in which the pregnant woman's serum contains specific antibodies to 52 or 60 kd SSA/Ro and/or 48 kd SSB/La, which cross the placenta and are associated with the development of congenital heart block in the fetus and/or a transient rash or various liver and blood cell abnormalities in the newborn. To date, congenital heart block is a permanent condition that entails significant morbidity and mortality, with nearly all affected infants requiring pacemakers and with an 80% cumulative probability of survival at 3 years of age. An intensive search is on for the specific etiopathophysiology and for new clinical tools to approach and treat this disease.

Effects of vitamins C and E on oxidative stress markers and endothelial function in patients with systemic lupus erythematosus: a double blind, placebo controlled pilot study

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) experience excess morbidity and mortality due to coronary artery disease (CAD) that cannot be fully explained by the classical CAD risk factors. Among emerging CAD risk factors, oxidative stress is currently being emphasized. We evaluated the effects of longterm antioxidant vitamins on markers of oxidative stress and antioxidant defense and endothelial function in 39 patients with SLE.

METHODS

Patients were randomized to receive either placebo or vitamins (500 mg vitamin C and 800 IU vitamin E daily) for 12 weeks. Markers of oxidative stress included malondialdehyde (MDA) and allantoin. Antioxidants measured included erythrocyte superoxide dismutase and glutathione peroxidase, plasma total antioxidant power (as FRAP value), and ascorbic acid and vitamin E concentrations. Endothelial function was assessed by flow-mediated dilatation (FMD) of the brachial artery and plasma concentration of von Willebrand factor (vWF) and plasminogen activator inhibitor type 1 (PAI-1). Primary outcome of the study included the change in lipid peroxidation as revealed by MDA levels. Secondary outcomes included changes in allantoin and antioxidant levels and change in endothelial function.

RESULTS

After treatment, plasma ascorbic acid and alpha-tocopherol concentrations were significantly (p < 0.05) increased only in the vitamin-treated group, associated with a significant decrease (p < 0.05) in plasma MDA. Other oxidative stress markers and antioxidant levels remained unchanged in both groups. FMD and vWF and PAI-1 levels remained unchanged in both groups.

CONCLUSION

Combined administration of vitamins C and E was associated with decreased lipid peroxidation, but did not affect endothelial function in patients with SLE after 3 months of therapy.

Systemic lupus erythematosus with celiac disease: a report of five cases

Systemic lupus erythematosus and celiac disease (CD) are rarely reported in combination. We report five cases seen over a 4-year period. The two conditions occurred concomitantly in one patient, whereas the CD antedated the lupus in one patient and postdated the lupus in the remaining three patients. Villous atrophy on duodenal biopsy specimens with a favorable response to a gluten-free diet was noted in all five patients. Only four patients had positive serological tests for CD and only three had abdominal symptoms.

Nutrient intake and diet quality in patients with systemic lupus erythematosus on a culturally sensitive cholesterol lowering dietary program

OBJECTIVE

To evaluate the effect of a culturally sensitive cholesterol lowering dietary program on energy, protein, fiber, vitamin and mineral intake, diet quality, and hemoglobin levels in patients with systemic lupus erythematosus (SLE).

METHODS

Seventeen patients with SLE were randomized to a Step II diet intervention group or a control group for 12 weeks. The diet intervention was made up of weekly group sessions during the first 6 weeks followed by telephone counseling every 2 weeks for the last 6 weeks. Food intake was assessed by 3-day food record at baseline, 6, and 12 weeks. Diet quality was assessed by expressing the nutrients as a percentage of the Dietary Reference Intakes of the US National Academy of Sciences, or as a percentage of the nutrient guidelines by the National Cholesterol Education Program, Adult Treatment Panel III. Between- and within-group changes in nutrient intakes were assessed by repeated measures ANOVA.

RESULTS

The changes in nutrient intakes were not significantly different between the groups for any of the nonfat nutrients except vitamin B12 (p = 0.05), which decreased in the diet group and increased in the control group. Within-group analysis showed a significant reduction (p = 0.0003 to 0.02) in the diet group in energy and sodium intake at 6 and 12 weeks and B12 intake at 12 weeks compared to the respective baseline values (28-32%, 37-41%, and 43%, respectively). Sodium intake decreased to 66-71% of the total sodium allowance (< 2400 mg per day) in the diet group. The intervention was successful in maintaining adequate intakes or even increasing intakes of most nutrients except B12, dietary fiber, folate, calcium, and iron, which were slightly higher or below 67% of the Dietary Reference Intakes or other dietary guidelines. Anemia, as assessed by hemoglobin levels, was present throughout the study and did not correlate with iron intake.

CONCLUSION

This culturally sensitive cholesterol reducing diet program was successful in decreasing sodium intake and maintaining adequate intakes of most nutrients except B12, dietary fiber, iron, calcium, and folate. Future intervention studies in patients with SLE need to pay special attention to these nutrients and the presence of anemia.

[Characteristics of rehabilitation in patients with rheumatic diseases]

The paper deals with problems of rehabilitation of patients with rheumatoid arthritis, osteoarthrosis and systemic lupus erythematosus. These problems are rather topical in view of high prevalence of rheumatic diseases, their severe course and a high rate of invalidization at the most productive age. Relevant multifactorial therapeutic measures should be staged, aimed at lowering and stabilization of the disease activity. The role of updated medication, joint surgery, diet therapy, etc. is shown.

Diet and systemic lupus erythematosus: a 4 year prospective study of Japanese patients

OBJECTIVE

To investigate the associations of dietary factors with the occurrences of active disease and vascular damage in female patients with systemic lupus erythematosus (SLE).

METHODS

Clinical and questionnaire data were collected from 279 female patients with SLE in a 1995 baseline survey. Dietary nutrients were estimated by a semiquantitative food frequency questionnaire and disease activity was evaluated based on the Lupus Activity Criteria Count. Patients were followed over 4 years (1995-99) and changes in disease activity and occurrences of major organ damage were determined. Using data from 216 patients with inactive disease whose dietary data were complete at baseline, the association of each nutrient intake with occurrence of active disease was evaluated. The relation of diet with the development of 3 types of vascular injury (ischemic heart disease, cerebrovascular accident, thrombotic events) was examined in 196 patients who had been inactive with no history of these injuries. Patients who developed these vascular events were put in one category and nutrient intakes at baseline were compared between patients who did or did not develop vascular events.

RESULTS

A total of 9966 person-months were accumulated from the 216 inactive patients, among whom 43 patients developed active disease. The proportional hazard model including indicator variables for tertiles of each nutrient, total energy, and confounding variables revealed an inverse association of intake of vitamin C (p for trend = 0.005) and crude fiber (p for trend = 0.06) with the risk of active disease. The inverse association with vitamin C intake was also significant after Bonferroni adjustment. Patients who developed vascular events (n = 7) consumed a greater amount of vegetable fat at baseline than patients who did not (p = 0.04).

CONCLUSION

Our findings suggest that dietary nutrients may modify clinical course of disease in female patients with SLE. Vitamin C intake is inversely associated with the risk of active disease, suggesting that vitamin C intake may prevent the occurrence of active SLE disease.

Dietary CLA decreased weight loss and extended survival following the onset of kidney failure in NZB/W F1 mice

In an earlier study, we showed that feeding CLA immediately after weaning prolonged survival of NZB/W F1 mice after onset of proteinuria. In the present study, the feeding of CLA was delayed until mice had developed proteinuria. Thirty NZB/W F1 mice were fed a regular rodent chow after weaning. Urine samples were collected to detect proteinuria. Once a mouse was proteinuria positive, it was then randomly assigned to a 0.5% CLA supplement semipurified diet or a control diet (supplement 0.5% corn oil). The next proteinuria positive mouse was then assigned to the opposite diet to which the first mouse was assigned. Mice fed the control diet lost 25% more body weight (13.0 g) than mice fed the CLA diet (9.7 g). Moreover, CLA-fed mice survived an average 1.7-fold longer (148 d) than mice fed the control diet (89 d) after the onset of proteinuria. This follow-up study confirmed that dietary CLA had a beneficial effect in the autoimmune NZB/W F1 mouse. In summary, the cachectic symptom of systemic lupus erythematosus was decreased by dietary CLA and survival days were increased over control group.

Food restriction and fish oil suppress atherogenic risk factors in lupus-prone (NZB x NZW) F1 mice

Atherosclerosis-mediated coronary artery disease is a significant cause of mortality in lupus patients. Both an activated immune system and hyperlipidemia are implicated in the pathogenesis of the atherosclerotic lesions of lupus. In this study, the increases in anticardiolipin antibodies, total cholesterol, and LDL cholesterol with age were significantly lowered by fish oil and food restriction, either alone or in combination. Food restriction also significantly decreased the elevation in anti-dsDNA antibody production seen with age in ad libitum groups. Interestingly, effects of food restriction and fish oil on both lipid profile and autoantibody production were seen from a young age. Accumulation of leukocytes in the blood vessels and deposition of IgG in the glomerular mesangium also were suppressed by food restriction. Thus, beneficial effects of fish oil and food restriction on lupus nephritis and survival could be, at least in part, due to their selective effect on atherogenic risk factors.

Effect of a culturally sensitive cholesterol lowering diet program on lipid and lipoproteins, body weight, nutrient intakes, and quality of life in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the effect of a culturally sensitive cholesterol lowering diet program on lipid and lipoproteins, body weight, nutrient intakes, and quality of life (QOL) in patients with systemic lupus erythematosus (SLE).

METHOD

Seventeen patients with SLE were randomized to a Step 2 diet intervention group or a control group for 12 weeks. The diet intervention was made up of weekly group sessions during the first 6 weeks followed by telephone counseling every 2 weeks for the last 6 weeks. Data on fasting lipid and lipoproteins, body weight, food intake (3 day food record), and QOL were collected at baseline, 6 weeks, and 12 weeks. Program acceptability was assessed in the diet group at 6 weeks.

RESULTS

The intervention was found to be highly acceptable and culturally sensitive. The changes in nutrient intakes at 6 and 12 weeks in the diet group were -49% and -33%, respectively, for cholesterol, -44% and -32%, respectively, for percentage calories from fat, and -46% and -32%, respectively, for percentage calories from saturated fat. The corresponding figures in the control group were +22% and -8% for cholesterol, +9% and +6% for percentage calories from fat, and +5% and +7% for percentage calories from saturated fat. The treatment by time interaction was significant for all the dietary variables (p = 0.0003 to 0.02). QOL was reported to improve by 15-17% in the diet group and decrease by 4-6% in the control group, and the treatment by time interaction was significant (p = 0.05). The changes in the physiological variables at 6 and 12 weeks in the diet group were -10% and -6%, respectively, for total cholesterol, -10% and -2%, respectively, for low density lipoprotein (LDL) cholesterol, -11% and -4%, respectively, for high density lipoprotein (HDL) cholesterol, -25% and -34%, respectively, for very low density lipoprotein (VLDL) cholesterol, -8% and -24%, respectively, for triglycerides, and -2% and -5%, respectively, for body weight. The corresponding figures in the control group were -5% and -3% for total cholesterol, -6% and -5% for LDL cholesterol, 0% and +12% for HDL cholesterol, +4% and -8% for VLDL cholesterol, -6% and -15% for triglycerides, and -5% and -6% for body weight. The treatment by time interaction was significant for HDL cholesterol (p = 0.04). A significant reduction was seen in the diet group for total cholesterol at 6 and 12 weeks, LDL and HDL cholesterol at 6 weeks, and body weight at 12 weeks (p = 0.0002 to 0.01).

CONCLUSION

This culturally sensitive cholesterol reducing diet program was highly accepted and effective in changing the diet and QOL of patients with SLE. The effect on serum lipids, lipoproteins, and body weight, however, was modest. A larger randomized study with a longer intervention period is necessary to test the effectiveness of a cholesterol-lowering diet on lipids and lipoproteins in patients with SLE.

Current concepts for the management of systemic lupus erythematosus in adults: a therapeutic challenge

Systemic lupus erythematosus (SLE) is a chronic, autoimmune rheumatic disease with many clinical presentations typically affecting women of childbearing age. The successful therapy of SLE depends upon treating both symptoms and the underlying inflammation. Both non-pharmacological as well as pharmacological therapies are invariably required. Non-pharmacological therapy includes avoiding over-exposure to sunlight with the use of adequate sunscreen protection, avoiding "live" vaccination if on immunosuppressive agents, adherence to a diet low in saturated fat and high in fish oil, stress avoidance, and smoking cessation. Pharmacological measures revolve around four main classes of drugs: non-steroidal anti-inflammatory drugs, antimalarials, corticosteroids, and cytotoxic agents. Cyclophosphamide and azathioprine are the two most commonly used cytotoxic agents and these in combination with corticosteroids need to be employed early if there is major organ involvement to prevent or minimise irreversible damage. The potential side effects of corticosteroids and cytotoxic agents need constant consideration. The rapid developments in biotechnology of recent years may soon lead to new and more specific therapies for patients with SLE.

Natural medicine and nutritional therapy as an alternative treatment in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder without a known cure. Conventional medicine typically approaches the disease with a treatment plan that includes the use of corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), antimalarial drugs, and chemotherapeutic agents. The results vary and safety is questionable. Conservative treatment methods, such as the use of vitamins, minerals, and fatty acids, have been shown to have an impact on the activity of the disease. Alternative medicine treatments, including the use of dehydroepiandrosterone (DHEA) and Chinese medicines, such as Tripterygium wilfordii Hook F (TwHF), have gained a growing interest recently and may prove to be viable treatment options in the future. The elimination of possible associated factors, such as food allergens and SLE-symptom eliciting foods like alfalfa seeds, have also been shown to affect disease activity. Conservative alternative medicine approaches have been shown to provide some benefit in SLE studies; however, the evidence is limited, and the overall effectiveness and long-term safety have not been established. More research must be conducted in this area to further establish firm treatment protocols which provide maximum therapeutic benefit and minimum treatment-related side effects.

Diet and lupus

The effect of dietary modifications has been extensively studied in lupus animal models. Calorie, protein, and especially fat restriction, caused a significant reduction in immune-complex deposition in the kidney, reduced proteinuria and prolongation of the mice's life span. The addition of polyunsaturated fatty acids (PUFAs), such as fish oil or linseed oil, was also related to decreased mice morbidity and mortality in animal models of lupus and of antiphospholipid syndrome. PUFAs such as eicosapetaenoic acid (EPA) and docosahexaenoic acid (DHA) competitively inhibit arachidonic acid with a resultant decrease in inflammatory eicosanoids and cytokines. Human studies support the effect of a PUFAs-enriched diet, both scrologically and clinically. Large scale clinical studies are needed to confirm the primary results.

Lupus erythematosus and nutrition: a review of the literature

The purpose of this review was to search the scientific literature for dietary compounds that alleviate or exacerbate symptoms of lupus erythematosus (LE) in both animal and human models. A detailed literature review was undertaken to find articles showing a relationship between LE and nutrition by using MEDLINE/INDEX MEDICUS (1950-March 2000) for English-language articles, followed by cross-referencing. Aggravating substances appear to include excess calories, excess protein, high fat (especially saturated and omega-6 polyunsaturated fatty acids), zinc, iron, and L-canavanine found in alfalfa tablets. Possible beneficial dietary compounds include vitamin E, vitamin A (beta-carotene), selenium, fish oils (omega-3 polyunsaturated fatty acids), evening primrose oil, flaxseed, a plant herb (Tripterygium wilfordii), dehydroepiandrosterone, and calcium plus vitamin D (if taking corticosteroids). Some people with systemic LE placed on food allergy elimination diets reported improvement in their LE symptoms; however, this may be related to a decrease of other substances in the diet. Also, although no direct evidence was reported on the beneficial effects of either bromelain or a vegetarian diet (possibly allowing fish), it is suggested that they might be beneficial. Limitations to this research are that the findings are based on relatively few studies, many of which were without control groups or extrapolated from animal models. No large-scale studies have been performed with LE patients to substantiate the benefit, if any, of these individual dietary interventions, and if they were conducted, the remission and exacerbation pattern of LE may interfere with elucidating their effectiveness. Also, dietary changes should not be attempted without a physician's approval/monitoring.

Dietary conjugated linoleic acid protects against end stage disease of systemic lupus erythematosus in the NZB/W F1 mouse

Conjugated linoleic acid (CLA) is a naturally occurring fatty acid with anti-carcinogenic, anti-atherosclerotic and immune-enhancing activities. Dietary CLA accelerated the onset of proteinuria in autoimmune-prone NZB/W F1 mice but did not affect anti-DNA antibody production. Body weight of the CLA group was decreased compared to the control group at the time proteinuria first developed. CLA group also had slightly earlier mortality than control fed mice, however the mean days of survival did not differ between CLA and control fed mice. Body weight loss between proteinuria onset and death was approximately twice as much in the control group as in the CLA group. Moreover, duration between proteinuria and death was longer in the CLA than in the control group. Our data suggested that dietary CLA may accelerate the autoimmune symptoms of NZB/W F1 mice, however, CLA protected against the disease related body weight loss and prolonged survival after proteinuria.

The dietary treatment of inflammatory arthritis: case reports and review of the literature

Two patients with seropositive inflammatory arthropathies who experienced clinical improvement on the Waianae diet are presented. The scientific literature validates the usefulness of fasting in the control of joint inflammation. Elimination diets are variably successful. Fasting followed by a vegetarian diet can produce a sustained positive response measured clinically and by laboratory variables of inflammation; the efficacy of such an approach appears to hinge on the alteration of fecal flora. Swaying the balance of dietary fats in favor of the omega 3 and omega 6 fatty acids has an antiinflammatory effect, but does not appear to correct the basic immunologic processes involved in the development of the arthropathies. Practical guidelines for the application of this information are offered.

Polyunsaturated fatty acids and renal disease

An upregulation of arachidonate metabolism often accompanies renal pathophysiologic states. The resulting eicosanoids contribute to, or modify, the underlying process. Recent investigations suggest that platelet-neutrophil interactions, as well as alterations in the expression of the inducible isoform of cyclooxygenase, play a critical role in mediating changes in arachidonate metabolism in renal inflammation. The importance of arachidonate to renal pathophysiology has been highlighted by prior investigations which have demonstrated a beneficial effect of dietary polyunsaturated fatty acid (PUFA) modulation in a variety of models of experimental renal disease. More recent work has established that this beneficial effect may depend upon alterations in both lipid mediator generation as well as changes in cell function. In light of the benefits of dietary PUFA modulation in models of experimental renal disease, there have been numerous recent clinical trials of dietary (n-3) PUFA supplementation in patients with a variety of renal disorders. These clinical trials suggest that such therapy may be an important addition to the clinical armamentarium, especially in the treatment of IgA nephropathy.

Nutritional consequences of chronic maternal conditions during pregnancy and lactation: lupus and diabetes

Few treated chronic conditions preclude the ability of a mother to conceive. However, consequences of the condition may undermine the pregnancy or aggravate maternal disease. Most chronic conditions require nutritional intervention beyond the normal needs of pregnancy. Insulin-dependent diabetes mellitus (IDDM) and systemic lupus erythematosus (SLE) are two common autoimmune disorders that affect women of childbearing age. Little has been published about the long-term consequences of current medication regimens for SLE and their interactions with either nutrient metabolism or requirements. More information is available on macronutrient dietary needs and metabolism during pregnancy and lactation in women with IDDM, but little is published about the metabolism of other nutrients in this condition. Thus, the nutritional consequences of treating these diseases during pregnancy and lactation must be evaluated continually.

Suppression of autoimmune disease by dietary n-3 fatty acids

Previous studies have demonstrated that dietary fish oil preparations have anti-inflammatory effects in humans and in experimental animals, but the individual components of fish oils that are responsible for their anti-inflammatory effects have not been documented. We therefore investigated in (NZB x NZW)F1 mice, a model for human systemic lupus erythematosus, the effects of diets containing ethyl esters of two purified n-3 fatty acids, eicosapentaenoic acid (EPA-E) and docosahexaenoic acid (DHA-E), a refined fish oil triglyceride (FO) which contained 55% n-3 fatty acids, and beef tallow (BT) which contains no n-3 fatty acids. The diets were initiated prior to the development of overt renal disease at age 22 weeks, and continued for 14 weeks. The extent of the renal disease was quantified by light microscopy and by proteinuria. Diets containing either 10 wt% FO, 10% EPA-E, or 6% or 10% DHA-E alleviated the severity of the renal disease, compared to the BT diet, whereas diets containing either 3% or 6% EPA-E or 3% DHA-E were less effective. Two diets containing approximately 3:1 mixtures of EPA-E and DHA-E alleviated the renal disease to a greater extent than expected for either of these fatty acids given singly. We believe that these experiments provide the first demonstration of anti-inflammatory effects of individual dietary n-3 fatty acids. The results also indicate that the anti-inflammatory effects of fish oils depend on synergistic effects of at least two n-3 fatty acids.

Dietary fish oil and the severity of symptoms in patients with systemic lupus erythematosus

A prospective, double blind, cross over study assessing the effects of a low fat, high marine oil diet in 27 patients with active systemic lupus erythematosus has been performed. The patients were given 20 g daily of MaxEPA (eicosapentaenoic acid) or 20 g of olive oil (placebo) in matching capsules added to a standardised isoenergetic low fat diet. When individual outcome measures of the 17 patients who completed the full 34 week study were considered 14 who were receiving MaxEPA achieved useful or ideal status, whereas 13 receiving placebo were rated as worse or no change. The difference between the two types of capsule was statistically significant. No major side effects were noted, and it is suggested that dietary modification with additional marine oil may be a useful way of modifying disease activity in systemic lupus erythematosus.

Effect of MaxEPA in patients with SLE. A double-blind, crossover study

Seventeen patients with moderately active SLE participated in a double-blind, crossover study on the effect of MaxEPA, using olive oil as the control substance. During the first 3 months, 8/17 on Max EPA but only 2/17 on the control substance clinically and serologically improved (p = 0.05), but at 6 months there was no difference. The beneficial effect (if any) of MaxEPA on the disease was short-lived.

Effect of eicosapentaenoic acid rich menhaden oil and MaxEPA on the autoimmune disease of Mrl/l mice

The Mrl lpr/lpr (Mrl/l) mouse is a model for systemic lupus erythematosus and rheumatoid arthritis in humans. The diet of Mrl/l mice was supplemented with EPA (see Introduction) in menhaden oil or in the commerical fish oil MaxEPA. The survival of mice was not affected by the dietary manipulations. The addition of menhaden oil decreased the severity of the renal pathology. However, MaxEPA containing the same amount of eicosapentaenoic acid was considerably less effective. A diet deficient in polyunsaturated fatty acids did not ameliorate any manifestations of the disease. Anti-DNA antibody levels in serum were not influenced by the therapy. Myocardial abscesses and/or ulcerating valvular lesions were observed in about one third of the mice, irrespective of the diet given.

The therapeutic effects of dietary fatty acid supplementation in the autoimmune disease of the MRL-mp-lpr/lpr mouse

The effect of dietary fatty acids on the spontaneous autoimmune disease systemic lupus erythematosus of the MRL-mp-lpr/lpr mouse was investigated after onset of disease. Parameters monitored included auto-antibody levels (by ELISA), proteinuria, body weights, clinical appearance and survival. The preliminary study (using five mice per group) showed that dietary restriction improved survival (P less than 0.001) per se, and further that all mice receiving the fish oil diet benefited considerably (P less than 0.005), whilst males on the fish oil/evening primrose oil diet also lived longer than expected (P less than 0.005).

New approaches to treating systemic lupus erythematosus

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs Homer A. Boushey, Associate Professor of Medicine, and David G. Warnock, Associate Professor of Medicine, under the direction of Dr Lloyd H. Smith, Jr, Professor of Medicine and Associate Dean in the School of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.

Abnormal responses to ingested substances in murine systemic lupus erythematosus: apparent effect of a casein-free diet on the development of systemic lupus erythematosus in NZB/W mice

To assess the development of oral tolerance to casein in NZB/W female mice, they must be bred and raised on a casein free diet. We examined the specific immune responses of the mice to the long term experimental feeding of casein. Twelve of fifteen casein free mice were still alive at 10 months of age, although by this age only 1/10 mice eating the normal diet was still alive. The casein free mice had markedly less anti-DNA antibody, their IgM to IgG antinative DNA switch was delayed and deposits of immunoreactants in the glomeruli were greatly decreased. The reason for this apparent effect of the removal of casein from the diet is unknown; however, immunostimulatory and endorphin-like regions have recently been reported in casein.

Effects of dietary supplementation on autoimmunity in the MRL/lpr mouse: a preliminary investigation

The effects of dietary fatty acid supplementation on various disease parameters in the spontaneously autoimmune MRL-mp-lpr/lpr mouse model of systemic lupus erythematosus before onset of disease were investigated. A fat deficient diet was supplemented with the following oils: olive oil, sunflower oil, evening primrose oil (EPO), fish oil, and a fish oil/EPO mixture. The mice receiving a diet enriched with EPO showed an increase in survival, as did those receiving the fish oil/EPO mixture. These results, taken together with those of the other parameters monitored, suggest that EPO may be of benefit in alleviating the murine form of the disease.

The role of diet in animal models of systemic lupus erythematosus: possible implications for human lupus

Studies of diet in the mouse model of SLE have established the beneficial effects of a low calorie, low fat diet in these animals as well as the importance of the specific source of dietary fat. The role of zinc in murine and human SLE is less clear. The reported improvement of patients with SLE and other related diseases on a low phenylalanine and tyrosine diet high in fish content, and the lupus inducing capacity of a nonphysiologic amino acid present in alfalfa are also reviewed. The need for carefully controlled prospective studies of diet in patients with SLE is noted, and a diet of potential therapeutic benefit is described.

A fish oil diet rich in eicosapentaenoic acid reduces cyclooxygenase metabolites, and suppresses lupus in MRL-lpr mice

Dietary supplementation of fish oil as the exclusive source of lipid suppresses autoimmune lupus in MRL-lpr mice. This marine oil diet decreases the lymphoid hyperplasia regulated by the lpr gene, prevents an increase in macrophage surface Ia expression, reduces the formation of circulating retroviral gp70 immune complexes, delays the onset of renal disease, and prolongs survival. We show that a fatty acid component uniquely present in fish oil but not in vegetable oil decreases the quantity of dienoic prostaglandin E, thromboxane B, and prostacyclin normally synthesized by multiple tissues, including kidney, lung, and macrophages, and promotes the synthesis of small amounts of trienoic prostaglandin in autoimmune mice. We suggest that this change in endogenous cyclooxygenase metabolite synthesis directly suppresses immunologic and/or inflammatory mediators of murine lupus.

NIH conference. Systemic lupus erythematosus: insights from animal models

Systemic lupus erythematosus is a multisystem, antibody-mediated, autoimmune disorder that occurs spontaneously in humans and mice. Genetic factors appear to play an important predisposing role in the disorder: The presence of certain genes may produce a generalized immune abnormality, whereas others may lead to specific autoantibodies. Environmental triggers increase autoantibody production and augment the expression of illness. Bacterial and viral illnesses can provide stimulation by activating macrophages and T cells that, in turn, stimulate B cells. In the absence of normal control mechanisms, the stimulatory process is not suppressed, and excessive stem cell proliferation results in abnormal B-cell proliferation. A trigger for the disease is the signaling of the proliferating B cells to differentiate into antibody-forming cells. Most autoantibody-producing B cells can be eliminated from mice with lupus erythematosus by virtue of the presence of the gene, xid. In addition, administration of an analog of arachidonic acid is an effective treatment for murine lupus erythematosus.