Biomedical subjects

D A Isenberg

Publications and source records attributed to D A Isenberg.

At least 145 records · Page 8Linked to original sources

PubMed1999

Apoptosis in human autoimmune diseases.

The description of apoptosis or programmed cell death nearly thirty years ago did not initially stimulate a great deal of interest. However, the ways cells die is clearly an essential part of biological homeostasis and well worth of study in its own right as the enormous literature on the subject in the past 15 years confirms. In the past decade new avenues of apoptosis research have opened up as the relationship between this form of cell death and autoimmune disease has come under increasing scrutiny. Although most research to date has been in animal study models, there are a variety of studies which have begun to explore links between apoptosis and a wider range of human autoimmune conditions. In this review we analyse briefly the background to what is known about apoptosis and focus on the increasing likelihood that abnormalities in apoptosis are contributory factors in the development of human autoimmunity.

Apoptosis↗

PubMed1999

An international perspective on the well being and health care costs for patients with systemic lupus erythematosus. Tri-Nation Study Group.

OBJECTIVE: To compare health care expenditure and health status for patients with systemic lupus erythematosus (SLE) between nations with distinct mechanisms for funding and delivering health care services. METHODS: Seven hundred eight patients with SLE from 2 centers in each of 3 countries (Canada 229, United States 268, United Kingdom 211) underwent physician assessment of disease activity and damage and reported on physical and psychosocial well being, satisfaction, social support, and health resource utilization. To compare overall utilization, constant prices (1997 Canadian dollars) were applied across countries for each service, enabling diverse resources to be collapsed into a single expression. RESULTS: After adjusting for important patient covariates, Canadian, compared to American and British patients, reported significantly superior health status in 3 of 8 Medical Outcome Survey Short Form-36 (SF-36) subscales, the SF-36 physical component summary score, and the visual analog scale of general health status. There was no consistent trend in patient satisfaction. Overall annual resource utilization did not vary significantly, with mean annual per patient expenditures (adjusted for demographics, disease duration, activity, damage, social support, health status, patient satisfaction, and age and sex adjusted country-specific SF-36 general population norms) totalling $4853, $5285, and $4760 for Canada, US, and the UK, respectively. However, within each resource category, differences were observed. Canadians saw more specialists than the British, the British more generalists. Canadians and Americans were more frequent users of the emergency room; Americans of laboratory/imaging procedures. Canadians had higher hospital costs than Americans. CONCLUSION: After adjustment, Canadian patients reported better well being than their counterparts. Despite considerable differences in the mechanisms of health care funding and service mixture, overall resource utilization did not vary significantly between the countries, although there was a trend towards more intense use of inpatient services in Canada and outpatient services in the United States.

Adult↗

PubMed1999

Myositis overlap syndromes.

Myositis-overlap syndromes are characterized by a heterogeneous group of clinical syndromes of which many are closely linked with specific autoantibodies. Clinical and laboratory-based research into this fascinating group of syndromes have given us clues in elucidating the role of immunogenetic, environmental influences on the etiopathogenesis of autoimmune disease. Patients positive for anti-snU1 RNP antibody often present with a constellation of "autoimmune-related" clinical features, often not fulfilling the diagnostic criteria for a single disease entity. Controversy remains as to whether this represents a single disease entity, namely mixed connective tissue disease, or an undifferentiated autoimmune rheumatic/overlap syndrome. Anti-PM-Scl antibodies are linked with myositis-scleroderma overlap and generally tend to follow a benign course, often responding well to minimal immunosuppression. More recently the number of anti-tRNA synthetase antibody-associated overlap syndromes has expanded; antibodies to the autoantigen histidyl-tRNA synthetase (Jo1) being the commonest and best characterized. Patients with these antibodies often have severe interstitial lung disease and the poorest prognosis, often necessitating aggressive immunosuppressive therapy.

Autoimmune Diseases↗

PubMed1999

The engineered human anti-tumor necrosis factor-alpha antibody CDP571 inhibits inflammatory pathways but not T cell activation in patients with rheumatoid arthritis.

OBJECTIVE: We investigated the effect of an engineered human anti-tumor necrosis factor-alpha antibody, CDP571, on immune functions as well as bone and cartilage turnover in patients with rheumatoid arthritis (RA) in a placebo controlled trial. We also assessed the effects of repeated treatment with CDP571 in an open label continuation study. METHOD: Thirty-six patients were treated with either placebo or 0.1, 1, or 10 mg/kg of CDP571 given as an intravenous infusion. The followup period was 8 weeks. Lymphocyte phenotype, soluble CD4 (sCD4), soluble interleukin 2 receptor (sIL-2R), IL-6, and stromelysin levels in the blood were measured before and after treatment; bone and cartilage markers (pyridinoline, deoxypyridinoline, N-terminal telopeptide) were similarly assessed in the urine. Patients who completed a placebo controlled trial of CDP571 were offered further treatment with CDP571. They received a maximum of 2 further doses of 1 mg/kg (7 patients) or 10 mg/kg (9 patients) in an open study. RESULTS: Plasma IL-6 level was statistically significantly reduced in the 1 and 10 mg/kg groups. In the 10 mg/kg group, there were also reductions in plasma stromelysin and urine bone markers, although there was no change in sCD4 and sIL-2R levels. Repeat doses of CDP571 were well tolerated and continued to suppress the acute phase response and disease activity. CONCLUSION: Treatment with 10 mg/kg of CDP571 reduced IL-6 and surrogate markers of bone turnover in RA, suggesting that CDP571 might prevent joint damage in RA. Since there was no effect on lymphocyte markers despite the marked reduction in inflammation, CDP571 appears to have no effect on ongoing CD4 T cell activation.

Antibodies↗

PubMed1999

Associates of health status in patients with systemic lupus erythematosus.

OBJECTIVE: To determine the health status of patients with systemic lupus erythematosus (SLE) and to identify the associations of this domain. METHODS: One hundred ninety-five consecutively attending patients with SLE were studied at 2 centers. Health status was measured by 8 composite scales of the Medical Outcomes Study Short Form 36 (SF-36). The mean scores for each subscale of the SF-36 for patients with SLE were compared to those of a healthy population. The effect of patients' age, sex, ethnic origin, marital status, education level, disease duration, disease activity (assessed by the Systemic Lupus Activity Measure), end organ damage (assessed by the Systemic Lupus International Coordinating Clinics/American College of Rheumatology Damage Index), social support (using the Interpersonal Support Evaluation List), and patients' satisfaction with medical care (using the Patient Satisfaction Questionnaire) on each SF-36 subscale was determined. Student's unpaired t test and multiple regression analysis were applied for statistical analysis. RESULTS: Patients with SLE had significantly lower scores in each subscale of the SF-36 compared to a control population. Higher disease activity was associated with worse physical function, role-physical, bodily pain, general health, vitality, and social function. Greater social support was associated with higher scores in physical function, bodily pain, general health, vitality, social function, role-emotional, and mental health. Increasing total end organ damage determined worse physical function and general health. Higher patient general satisfaction with care was associated with better general health. CONCLUSION: The health status of patients with SLE may be improved by increasing patients' social support and satisfaction with health care, as well as controlling SLE disease activity and preventing organ damage.

Adolescent↗

PubMed1999

Randomized clinical trials and longitudinal observational studies in systemic lupus erythematosus: consensus on a preliminary core set of outcome domains.

The OMERACT module on systemic lupus erythematosus (SLE) dealt with the definition of preliminary core sets of outcome domains for randomized clinical trials (RCT) and longitudinal observational studies (LOS). After lectures introducing the problems and addressing the key issues, 6 discussion groups, 3 each for LOS and RCT, discussed and weighted more than a dozen possible items for use as outcome domains. The means of the respective 3 groups were calculated. For both RCT and LOS the same outcome domains received more than 10 of a total maximum of 100 points: disease activity, health related quality of life (HRQOL), damage, and toxicity/adverse events. However, the weights for HRQOL and damage were different for LOS and RCT. A final vote led to the acceptance of these 4 variables as a preliminary core set for outcome in SLE by more than 80% of the participants. This core set will allow for improved design, performance, and evaluation of future studies in SLE. However, a number of domains not included in the core set were regarded as important for further analysis and research.

Decision Making↗

PubMed1998

The nuclear factor interleukin-6 (NF-IL6) and signal transducer and activator of transcription-3 (STAT-3) signalling pathways co-operate to mediate the activation of the hsp90beta gene by interleukin-6 but have opposite effects on its inducibility by heat shock.

The levels of the 90 kDa heat-shock protein (hsp90) and the activity of the hsp90beta gene promoter are increased in response to treatment by interleukin (IL)-6. The hsp90beta gene promoter contains binding sites for the transcription factors nuclear factor IL-6 (NF-IL6) and signal transducer and activator of transcription 3 (STAT-3), which are activated respectively by the mitogen-activated-protein-kinase and Jak-kinase pathways following IL-6 treatment. Both these factors can activate the hsp90 promoter and have a strong synergistic effect on its activity, which appears to be critical for IL-6-mediated activation of the promoter. Interestingly, the two factors interact differently with the heat-shock factor (HSF) and a heat-shock stress. Thus STAT-3 reduces the stimulatory effect of heat shock whereas NF-IL6 enhances it. When applied together, heat shock and IL-6 produce only weak activation of the hsp90 promoter compared with either stimulus alone, indicating that the inhibitory effect of STAT-3 on HSF predominates under these conditions. In contrast, IL-1, which activates only the NF-IL6 pathway, synergizes with heat shock to produce strong activation of hsp90. These effects are discussed in terms of the multiple stimuli that may regulate the hsp90 promoter in unstressed cells and their interaction with its stress-mediated activation.

CCAAT-Enhancer-Binding Proteins↗

PubMed1998

Genetic, structural and functional properties of an IgG DNA-binding monoclonal antibody from a lupus patient with nephritis.

Antibodies binding to double-stranded (ds) DNA are strongly associated with renal involvement in patients with systemic lupus erythematosus (SLE). We have generated two new IgG DNA-binding monoclonal antibodies (mAb), RH-14 and DIL-6, from the peripheral blood lymphocytes of two SLE patients with glomerulonephritis using the heteromyeloma cell line CB-F7. RH-14 is an IgG1 lambda antibody which also bound to single-stranded DNA, histones and nucleosomes. DIL-6 is an IgG3 lambda antibody with restricted antigen binding specificity. cDNA encoding the variable regions of the heavy (V(H)) and light (V(L)) chains of RH-14 was sequenced and the antigen binding site of this mAb was computer modelled. Sequence analysis of V(H) and V(L) regions of RH-14 showed that V(H) is derived from germ-line gene V3-7, a member of the V(H)3 family, and V(L) is derived from DPL 11, a member of the V(lambda)2 family. Somatic mutations and basic amino acid residues are identified in the complementarity-determining regions of both V(H) and V(L) regions. The nephritogenic properties of these mAb were analyzed by implanting and growing the hybridoma cells secreting the mAb in the peritoneum of SCID mice. The animals that received the RH-14 hybridoma produced higher levels of proteinuria (3 to > or = 4) (p < 0.001) compared to the groups that received DIL-6 (trace to > or = 1) or CB-F7 (trace). Electron microscopy of kidney sections from all the RH-14-implanted animals showed granular immunoglobulin deposition in the renal glomerular capillaries and mesangium. In this study we have shown for the first time using electron microscopy that a human IgG anti-dsDNA mAb, RH-14, is nephritogenic and that deposition of such an antibody alone is sufficient to induce renal damage.

Amino Acid Sequence↗

PubMed1998

Zinc is an essential cofactor for recognition of the DNA binding domain of poly(ADP-ribose) polymerase by antibodies in autoimmune rheumatic and bowel diseases.

OBJECTIVE: To characterize autoantibody response to poly(ADP-ribose) polymerase (PARP) and to assess the significance of autoantibodies to the 2 zinc fingers of this enzyme in patients with autoimmune rheumatic and bowel diseases. METHODS: The specificity of antienzyme autoantibodies was established by dot immunoassay with recombinant human PARP and by enzyme-linked immunosorbent assay using the recombinant N-terminal fragment containing the DNA binding domain of PARP, the recombinant C-terminal catalytic domain (40-kd fragment), a peptide containing the nuclear localization signal (NLS) of PARP, 2 synthetic peptides (and mutated peptides) corresponding to zinc-finger motifs F1 and F2 that are present in the DNA binding domain, zinc fingers from other self antigens (e.g., peptides from Ro60, Ro52, and U1C proteins), and poly(ADP-ribose). Sera from patients with autoimmune rheumatic and bowel diseases were tested, as were affinity-purified antibodies. Histocompatibility typing of systemic lupus erythematosus (SLE) patients was performed by serology. RESULTS: Antibodies from the patient sera reacted only weakly with the recombinant N- and C-terminal domains and with the NLS peptide. In contrast, the 2 synthetic peptides corresponding to zinc-finger motifs F1 and F2 represented immunodominant targets for IgG antibodies from patients with SLE, mixed connective tissue disease (MCTD), Crohn's disease, and ulcerative colitis. The sera from patients with SLE and MCTD showed much weaker reactivity with mutant peptides F1 and F2, which contain mutations at the cysteine residues involved in zinc coordination. F1/F2 antibodies did not cross-react with zinc fingers from other self proteins. No correlation was found between the presence of F1/F2 autoantibodies in SLE sera and the presence of other autoantibodies typical of this disease (e.g., anti-double-stranded DNA and poly[ADP-ribose] antibodies). The presence of F2 antibodies in the serum of SLE patients was negatively associated with HLA-DR6. CONCLUSION: An autoimmune response to PARP is potentially important because this enzyme is involved in DNA repair and is rapidly cleaved during the "execution phase" of apoptosis. The high prevalence in certain autoimmune rheumatic and bowel diseases of antibodies to F1 and F2, which are directly involved in this process, is further evidence implicating involvement of the DNA repair system in chronic inflammatory diseases.

Amino Acid Sequence↗

PubMed1998

Elevation of IL-6 in transgenic mice results in increased levels of the 90 kDa heat shock protein (hsp90) and the production of anti-hsp90 antibodies.

Treatment of human peripheral blood lymphocytes (PBL) in vitro with the cytokine interleukin-6 (IL-6) induces increased levels of the 90 kDa heat shock protein (hsp90). Hsp90 levels are also elevated in PBLs of human patients with systemic lupus erythematosus (SLE) and in MRL/lpr mice with autoimmune disease. Although IL-6 is elevated in both these situations it has not been shown that it is involved in stimulating elevation of hsp90 levels in vivo. Here we show directly that the elevation of IL-6 in vivo either in mice transgenic for the IL-6 gene or in knock-out mice lacking a functional gene for the transcription factor C/EBP beta (NF-IL-6) does indeed result in elevated hsp90 levels. This overexpression is associated with the specific production of autoantibodies to hsp90 in these mice which is also observed in SLE patients and MRL/1pr mice. Hence IL-6 is likely to play a critical role in the regulation of hsp90 levels both in autoimmune disease states and potentially in normal cells in vivo. In turn the elevated levels of hsp90 produced in autoimmune diseases are likely to be responsible for the observed production of anti-hsp90 autoantibodies.

Animals↗

PubMed1998

Properties of whole human IgG molecules produced by the expression of cloned anti-DNA antibody cDNA in mammalian cells.

Antibodies to DNA are believed to play an important role in systemic lupus erythematosus (SLE). High affinity IgG antibodies which show marked specificity for double stranded DNA (dsDNA) are particularly closely linked to the occurrence and severity of tissue damage. Sequence analysis of mouse and human monoclonal antibodies has previously suggested that mutations in the complementarity determining regions (CDRs) play a major role in determining these binding properties. In many cases such mutations increase the overall number of basic residues in the CDRs. To further elucidate the role played by such mutations it is important to develop methods of expressing cloned autoantibody cDNA in the form of functional whole immunoglobulin molecules. We describe a system in which autoantibody VH and VL cDNA from monoclonal human anti-DNA antibodies, B3 and WRI176 were cloned into separate vectors which allowed their expression as whole heavy and whole light chains respectively. By cotransfecting mammalian cells with pairs of heavy and light chain vectors it was possible to produce whole IgG molecules from each of the four possible VH/VL combinations. Only antibody produced by homologous VH and VL pairs bound DNA, suggesting that in these autoantibodies both chains are important in conferring this property.

Amino Acid Sequence↗

PubMed1998

Autoimmune thrombocytopenia in primary antiphospholipid syndrome and systemic lupus erythematosus: the response to splenectomy.

OBJECTIVE: To study the outcome of splenectomy in the management of thrombocytopenia. METHODS: Cases of systemic lupus erythematosus (SLE) or primary antiphospholipid syndrome (PAPS) complicated by severe thrombocytopenia were identified from a database of patients attending outpatients over the period 1978 to 1996. Clinical presentation, laboratory investigations, and response to medical treatment and/or splenectomy were documented. RESULTS: A total of 17 patients had severe thrombocytopenia; splenectomy was performed on 13: 9 with SLE, 3 with PAPS, and 1 with lupus-like disease (LLD). After splenectomy, six of nine patients with SLE and all three patients with PAPS gained complete remission of thrombocytopenia. There were no complications from splenectomy. The remaining four patients, three with SLE and one with PAPS, remained in a stable partial or full remission with oral medication and did not require splenectomy. CONCLUSION: This study re-emphasizes the place for splenectomy in SLE patients and supports its role in the management of thrombocytopenia in PAPS.

Adult↗

PubMed1998

Immunoglobulin variable region sequences of human monoclonal anti-DNA antibodies.

OBJECTIVE: Anti-DNA antibodies are believed to be important in the pathogenesis of systemic lupus erythematosus (SLE). Antibodies that bind specifically and with high affinity to dsDNA are most closely involved in tissue damage. Analysis of the sequences of the variable regions of human monoclonal anti-DNA antibodies is useful in defining the structural features that give rise to these binding properties. This article systematically reviews the evidence derived from such sequences. METHOD: Previous reviews of this subject have been hampered by incomplete knowledge of the human immunoglobulin variable region repertoire. In this article, the original sequence data from reports of over 50 human monoclonal antibodies (mAb) are reinterpreted by alignment to the most similar alleles of the most similar germline genes. This allows accurate estimation of the site and nature of somatic mutations. RESULTS: Human IgG monoclonal anti-DNA antibodies generally carry more mutations than IgM. In many cases these have been selected by an antigen-driven process. In many of the more specific, higher affinity dsDNA binders, there is an accumulation of basic residues in the complementarity determining regions. However, many exceptions to this rule exist, particularly among IgM mAb. CONCLUSIONS: Unlike murine anti-DNA antibodies, these human mAb show little evidence for preferential use of particular V(H), V(K) and V(lambda) genes or families to encode antibodies of this specificity.

Antibodies, Antinuclear↗

PubMed1998

The regulation of heat shock proteins and their role in systemic lupus erythematosus.

OBJECTIVES: After a serendipitous suggestion, it was established that a significant subset of patients with systemic lupus erythematosus (SLE) overexpress the 90-kD heat shock protein (Hsp90). In this review, we have analyzed our own data and that of others, to explore the link between Hsp90 and SLE. METHODS: We performed a detailed literature review focusing on the potential role of Hsp in the etiopathogenesis of SLE. RESULTS: Data are discussed showing surface expression of this Hsp in patients with lupus, a similar overexpression in the splenocytes of MRL/Ipr mice before the onset of disease, the detection of antibodies to Hsp90 in a proportion of both lupus patients and lupus-prone mice, and most recently, an analysis of the transcription factors that regulate the production of this protein and the influence of key cytokines on these factors. CONCLUSIONS: These observations provide a model to show how a protein with key physiological roles in healthy individuals may, on occasion, become the target of an autoimmune attack with clinical consequences recognized in both mouse and human. Given that up to now, other heat shock proteins are not targeted in a similar fashion, the specificity of these responses is remarkable.

Animals↗

PubMed1998

The role of in vitro expression systems in the investigation of antibodies to DNA.

OBJECTIVES: Antibodies to DNA are believed to be important in the development of tissue inflammation and clinical activity in systemic lupus erythematosus (SLE). Sequence analysis of monoclonal murine and human anti-DNA antibodies suggests that somatic mutations and basic residues are important features at the DNA-binding site. To test this hypothesis, it is possible to alter these residues by site-directed mutagenesis of cloned variable region cDNA. The mutagenized cDNA sequence is then expressed in the form of a protein molecule whose properties can be tested in assays of binding or pathogenicity. The purpose of this article is to provide a systematic review of the evidence derived by such methods in the study of anti-DNA antibodies. METHODS: Various different expression systems are available. Experiments using bacterial and eukaryotic expression systems are considered in turn. The advantages and disadvantages of the systems are described and the results obtained are compared. RESULTS AND CONCLUSIONS: High yields of antibody fragments such as scFv and Fab can be achieved by expression in bacteria. Such studies tend to confirm that reversion of somatic mutations or removal of basic residues at the antigen binding site reduce affinity for DNA. Tests of pathogenicity can only be performed by expressing whole antibodies in eukaryotic cells. The limited data available from expression of mutagenized cDNA in such systems argue against a simple relationship between changes in DNA binding affinity and changes in pathogenic potential. Further studies are therefore required to analyze the sequence requirements for pathogenicity.

Animals↗

PubMed1998

Immunopathogenesis of SLE.

Systemic lupus erythematosus (SLE) is an autoimmune rheumatic disease characterized by the deposition of autoantibodies and immune complexes, leading to tissue damage. The immunopathogenesis of SLE is like a jigsaw puzzle, some pieces of which are missing or have not fallen into place. In predisposed individuals, the initial stimulus is likely to be one or more of the environmental agents interacting with susceptibility genes. Once the critical threshold is breached there is a failure of the immune system to downregulate the ensuing abnormal immune response, involving polyclonal B cell activation and hyperactive T cell help. Key questions include, what are the processes behind the availability of autoantigens and the breakdown of tolerance that give rise to the pathogenic autoantibodies? Current areas of research also involve the roles played by cytokines, adhesion molecules, co-stimulatory molecules and apoptosis.

Autoantibodies↗

PubMed1998

Spontaneous immunoglobulin-producing capacity of cultures from lupus patients and normal donors following depletion of cells expressing CD19 or CD38.

Cells spontaneously secreting IgG or IgM (ISC) are present at a high level in the blood of patients with systemic lupus erythematosus (SLE). By use of magnetic-bead techniques, mononuclear cells from such patients and healthy donors were fractionated according to expression of CD19 or CD38 and the cell fractions were then cultured in the absence of added mitogen/antigen for 5/6 days. Supernatant IgG and IgM were determined and, in addition, in the CD38 experiments ISC were enumerated both before and after culture. Much of the immunoglobulin-producing capacity of unfractionated cells (UFC) from both donor groups was recovered in the CD19- fraction, and no immunoglobulin was produced by CD19+ cells suggesting, unexpectedly, that ISC were not expressing CD19. By contrast, CD38 fractionation resulted in nearly all ISC passing to the CD38+ fraction which produced levels of immunoglobulin approaching 50% that of UFC. On culture of CD38- cells there was a build up in the number of IgG and IgM ISC, this being particularly striking in the controls with numbers well in excess of those in UFC. Not all these new ISC became CD38+, but the maturation process was more efficient in the SLE patients. The possibility is discussed that the spontaneous response in the CD38- populations is due to removal of CD38+ natural killer (NK) cells. Removal of ISC that are present preculture is a helpful initial step in studying ISC generation in the disease.

ADP-ribosyl Cyclase↗

PubMed1998

Sequence analysis of V(4-34)-encoded antibodies from single B cells of two patients with systemic lupus erythematosus (SLE).

SLE is an autoimmune disease characterized by the presence of autoantibodies against double-stranded (ds)DNA. A large proportion (approx. 40%) of patients with lupus also have increased levels of serum immunoglobulin encoded by the V(4-34) heavy chain gene, which often fluctuate with disease activity, and this gene is utilized by a subset of anti-dsDNA antibodies. In order to probe the nature of the V(4-34)-encoded immunoglobulin, B cells were isolated from the blood of two patients with active disease, using the 9G4 MoAb specific for the immunoglobulin gene product. Following cell picking, single-cell polymerase chain reaction (PCR) amplification of cDNA was used to investigate both V(H) and V(L) genes. Sequences were obtained from B cells synthesizing IgM (n = 10), IgG (n = 4) and IgA (n = 1). For V(H), all were derived from V(4-34) as expected, and the isotype-switched sequences and 2/6 IgM sequences were somatically mutated. In contrast, V(L) (12 kappa and 3 lambda) showed a low level of mutation, possibly indicating secondary rearrangements. The three most highly mutated V(H) sequences were associated with unmutated V(L) sequences. Analysis of the distribution of mutations revealed only minor clustering in complementarity-determining regions (CDRs) characteristic of antigen selection. The CDR3 lengths of V(H) ranged from five to 19 amino acids, and in 3/15 there was evidence of an excess of positively charged amino acids, compared with the normal expressed repertoire. Basic amino acids were also found at the V(L)-J(L) junctions in 4/15. These findings provide insight into the V(4-34)-V(L) gene combinations used by B cells in patients with SLE which might have clinical relevance.

Adolescent↗