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PubMed2005

Environment and systemic lupus erythematosus: an overview.

Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology that manifests as a pleomorphic systemic disease mainly affecting females. The variety of autoantibodies found in the serum of patients indicate that SLE is an autoimmune disease, but the mechanisms leading to the aberrant responses are not clearly understood although it is thought that a number of genetic and environmental factors may be involved. Environmental (or non-genetic) exposures could include infectious agents, chemicals or other compounds capable of modulating immune responses such as occupational/environmental pollutants or drugs, and behavioural factors such as smoking and diet. Environmental exposures may lead to the production of autoreactive T cells and autoantibodies, the stimulation of pro- and antiinflammatory cytokines, and target end-organ damage, but are not so convincing as agents causing SLE. Exposure to viruses increases antibody titres, but these may be the result of polyclonal B cell activation. The amount and timing of exposure to different environmental factors may play a significant and complex role in the pathogenesis of SLE and other autoimmune diseases. A better understanding of the etiopathogenetic mechanism of SLE is required in order to clarify the multiple interactions between environmental exposures and genetic factors.

Animals↗

PubMed1985

Anti-lymphocyte antibodies in systemic lupus erythematosus.

Patients with systemic lupus erythematosus frequently develop antilymphocyte antibodies as measured by complement-dependent cytotoxicity and immunofluorescence assays. Highest titres of both of the major IgM and IgG classes occur during phases of active disease, and their presence is associated with essentially the entire spectrum of immune system functional abnormalities in this disorder. While the full range of antibody specificities requires further clarification, antibodies to many discrete lymphocyte populations have been described, including B cells, T cells, and T cell subsets. Antibodies to T cell subsets are of special interest because of their relationship with subset depletion in vivo, and their capacity to reproduce, through effects on normal cells in vitro, the same types of immunoregulatory abnormalities characteristic of lymphocytes isolated from patients with SLE. Suppressor/inducer and suppressor/effector T cells appear to be the main targets in this regard. Antibodies specific for activated T lymphocytes exist as well, and this type has the unusual property of interfering with events operant in production of/response to interleukin-2, a critical step controlling the expansion of specifically-reactive T cells and the induction of other lymphokines. In addition to complement-mediated lysis and antibody-dependent cell-mediated cytotoxicity, anti-lymphocyte antibodies have the potential to influence immune system function by several non-cytotoxic mechanisms, including surface antigen modulation and ligand/receptor triggering. Despite the large amount of data which has been accumulated concerning the cell type specificity and functional effects of anti-lymphocyte antibodies in SLE, little is known about the nature of the surface membrane molecules with which they react. Application of cell cloning and molecular biology technology should rectify this deficiency in the near future. Although it is likely that antilymphocyte antibodies are of relevance to immune system pathophysiology in SLE, it remains to be determined whether these interesting antibodies reflect secondary events, or have some more fundamental significance.

Antibody Specificity↗

PubMed2005

Transplantation and 6-month follow-up of renal transplantation from a donor with systemic lupus erythematosus and lupus nephritis.

Transplantation of kidneys with pre-existing glomerulonephritis (GN) has rarely been reported. Little is known of the subsequent evolution of donor pathology in the recipient. We report a transplant using a donor with systemic lupus erythematosus (SLE) and a history of remote acute renal failure but normal renal function at death. Although the screening harvest biopsy was unremarkable, time zero post-implantation renal biopsy showed evidence of lupus nephritis (LN). Sequential protocol biopsies demonstrated gradual resolution of the donor pathology, and renal function was stable despite severe cardiac disease in the recipient. Studies examining the role of functional and biopsy data on outcomes in expanded criteria renal transplantation are reviewed, and the limits of guidance from use of this data are discussed. Pre-existing mild GN may not be an absolute donor exclusion for candidates willing to accept expanded criteria donors. Use of expanded pool kidneys should be guided by functional, biopsy and demographic information, as no single factor alone predicts outcome.

Acute Kidney Injury↗

PubMed2003

ALK-negative T-cell anaplastic large cell lymphoma associated with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) appear to have an increased risk of developing malignancies, especially lymphomas. We report the development of a systemic ALK-negative T-cell anaplastic large cell lymphoma, stage IIB, in a 53-yr-old Caucasian female with a 12-yr history of stable SLE. The patient responded poorly to chemotherapy and died 2 yr after diagnosis. Lymphomas that develop in patients with SLE and other autoimmune diseases are virtually always of B-cell origin. To our knowledge this is the first report of a T-cell anaplastic large cell lymphoma in a patient with SLE. This article discusses the association of SLE and lymphoma, with an emphasis on T-lymphoproliferative states.

Adult↗

PubMed1999

Delayed onset of systemic lupus erythematosus in patients with "full-house" nephropathy.

Three patients are described who presented with a glomerulopathy suggestive of lupus nephritis in the absence of other clinical and biological evidence of systemic lupus erythematosus (SLE). Renal biopsies showed a "full-house" immunofluorescence pattern and two patients also had cytoplasmic tubuloreticular inclusions by electron microscopy. All these patients developed antinuclear and anti-double-stranded DNA antibodies 3, 5, and 10 years after their original presentation. Subsequently, 1 patient also developed clinical symptoms of lupus. Reviewing all renal biopsies performed in our department, we found 14 additional patients who presented with a "full-house" immunofluorescence glomerulonephritis in the absence of other features of SLE. After a mean follow-up of 5.8 years, these patients have not developed serological or clinical evidence of SLE. We conclude that a "full-house" glomerulopathy in children may be the first symptom of SLE, especially when cytoplasmic tubuloreticular inclusions are detected. The appearance of other clinical and biological symptoms may be delayed by several years.

Adolescent↗

PubMed2002

Systemic lupus erythematosus in three ethnic groups. XII. Risk factors for lupus nephritis after diagnosis.

The purpose of this study was to determine the cumulative incidence of lupus nephritis (LN) and the factors predictive of its occurrence in a multiethnic systemic lupus erythematosus (SLE) cohort. We studied 353 SLE patients as defined by the American College of Rheumatology (ACR) criteria (65 Hispanics, 93 African-Americans and 91 Caucasians). First, we determined the cumulative incidence of LN in all patients. Next, we determined the predictors for LN in those with nephritis occurring after diagnosis. The dependent variable, LN, was defined by: (1) A renal biopsy demonstrating World Health Organization (WHO), class II-V histopathology; and/or (2) proteinuria > or = 0.5 g/24 h or 3+ proteinuria attributable to SLE; and/or (3) one of the following features also attributable to SLE and present on two or more visits, which were performed at least 6 months apart--proteinuria > or = 2+, serum creatinine > or = 1.4 mg/dl, creatinine clearance < or = 79 ml/min, > or = 10 RBCs or WBCs per high power field (hpf), or > or = 3 granular or cellular casts per hpf. Independent variables assessed at diagnosis, and if absent, at baseline, were from four domains: sociodemographic, clinical, immunologic and immunogenetic (including the complete antibody profile and MHC class II alleles), and health habits. Variables with P < 0.05 by chi square analyses were entered into domain-specific stepwise logistic regression analyses controlling for disease duration, with LN as the dependent variable. Significant domain-specific regression variables (P < or = 0.1) were then entered into an overall model. The cumulative incidence of LN was 54.3% in all patients, and 35.3% for those developing LN after diagnosis. LN after diagnosis occurred in 43.1% of 65 Hispanics, 50.5% of 93 African-Americans, and 14.3% of 91 Caucasians, P < 0.0001. The duration of follow-up for those with LN after diagnosis was 5.5+/-2.4 vs 4.0+/-2.9 years for those without LN. Hispanic (odds ratio (OR) = 2.71, 95% confidence limits (CL) = 1.07-6.87, P < 0.04) and African-American ethnicities (OR = 3.13, 95% CL = 1.21-8.09, P < 0.02), not married or living together (OR = 3.45, 95% CL = 1.69-7.69, P < 0.0003), higher SLAM score (OR = 1.11, 95% CL = 1.02-1.19, P < 0.007), anti-dsDNA (OR = 3.14, 95% CL = 1.50-6.57, P < 0.0001) and anti-RNP (OR = 4.24, CL = 1.98-9.07, P < 0.0001) antibodies were shown to be significant predictors of the occurrence of LN. Repeated analyses excluding the patients with missing HLA data showed that absence of HLA-DQB1*0201 was also a significant predictor for the occurrence of LN (OR = 2.34, CL = 1.13-5.26, P < 0.04). In conclusion, LN occurred significantly more often in Hispanics and African-Americans with SLE. Sociodemographic, clinical and immunologic/immunogenetic factors seem to be predictive of LN occurring after the diagnosis of SLE has been made.

Black or African American↗

PubMed1980

Laboratory investigation of systemic lupus erythematosus.

Diagnosis of systemic lupus erythematosus (SLE) requires documentation of multisystem involvement and the presence of antinuclear antibodies. In almost all cases of SLE, these autoantibodies are detected at significant titer with a sensitive screening test such as the fluorescent antinuclear antibody test. After other diagnostic possibilities, such as rheumatoid arthritis, have been excluded, several laboratory tests (hematocrit determination, complement tests, anti-native DNA assays) are available to monitor the response to therapy.

Adult↗

PubMed2000

Disseminated zygomycosis simulating cerebrovascular disease and pulmonary alveolar haemorrhage in a patient with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) may be complicated with serious cerebrovascular accidents and pulmonary alveolar haemorrhage. The authors report an autopsy-proven angioinvasive zygomycosis in a patient with SLE. The clinical features of systemic zygomycosis in this patient masqueraded as SLE-related stroke and pulmonary haemorrhage. The case demonstrates that the simultaneous occurrence of complications that clinically suggest pulmonary haemorrhage and multiple brain infarcts in SLE patients should include the rare disseminated zygomycosis in the differential diagnosis.

Adolescent↗

PubMed1995

Pulmonary involvement in systemic lupus erythematosus.

Pulmonary disorders in systemic lupus erythematosus involve a variety of clinical presentations and pathologic patterns, which can be difficult to diagnose due to systemic dysfunction, infection, or complications of therapy. The causes of dyspnea in systemic lupus erythematosus are multifactorial, and the clinical manifestations of lung disease widely vary. Biopsy is frequently relied on to evaluate and diagnose pulmonary disease in systemic lupus erythematosus. The patient who has systemic lupus erythematosus-associated lung disease is effectively treated with various immunosuppressive drugs, in conjunction with careful evaluation of the patient's systemic involvement, drug-induced complications, and the ever-present threat of infection.

Adult↗

PubMed1999

Regional cerebral blood flow in patients with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) with or without definite neuropsychiatric symptoms/signs were studied. Technetium-99m (Tc-99m) hexamethylpropylenamine (HMPAO) brain images were used to detect basal ganglion and cerebral cortex regional cerebral blood flow (rCBF) in patients with SLE with brain involvement. One hundred nine female patients with SLE were investigated using Tc-99m HMPAO brain images with fan-beam single-photon emission computed tomography (SPECT) and surface three-dimensional (3D) display. These patients were separated into 2 subgroups: group 1, 74 cases with definite neuropsychiatric symptoms/signs; and group 2, 35 cases without any neuropsychiatric symptoms/signs. Fan-beam SPECT demonstrated unilateral or bilateral hypoperfusion of basal ganglia or thalamus in 22% and 9% of patients in groups 1 and 2, respectively. Local hypoactivity anomalies were found in the brain cortex of 89% and 20% of patients in groups 1 and 2, respectively, using surface 3D display of the brain. In either group 1 or group 2 patients, parietal and frontal lobes are the most common areas and cerebellum and thalamus are the least common areas of brain involvement, respectively. This study suggests that in comparison with traditional brain imaging techniques, Tc-99m HMPAO brain imaging with fan-beam SPECT in combination with surface 3D display may provide objective information for detection of anomalies of rCBF in patients with SLE.

Adult↗

PubMed1979

NIH conference. Systemic lupus erythematosus: evolving concepts.

Systemic lupus erythematosus, a disease of unknown cause and protean manifestations, continues to excite substantial investigational interest. These papers bring together recent advances in concepts of its immunopathogenesis, evidence for a major genetic role in the causation of the process, developing systems for the morphologic assessment of its often fatal nephritis, and data from ongoing trials of cytotoxic drugs in its management.

Adolescent↗

PubMed1984

Presence of complement-fixing anti-endothelial cell antibodies in systemic lupus erythematosus.

Vasculitis in systemic lupus erythematosus (SLE) is associated with the deposition of IgG and complement in blood vessel walls. However, it is not known whether immune injury to endothelial cells is a part of this process. Therefore, we used a solid phase radioimmunoassay to study the ability of IgG from normal human sera and sera from patients with SLE to bind to endothelial cells. In this assay, cultured human umbilical venous endothelial cells were sequentially incubated with normal or SLE sera, goat anti-human IgG, and 125I-labeled staphylococcal protein A (*SPA). After exposure to normal sera, 2.5 +/- 0.5% (mean +/- SD) of the added *SPA bound to the cells, whereas after exposure to SLE sera 13.8 +/- 7.6% of the added *SPA bound to these cells. This difference in binding was highly significant (P less than 0.001). Binding was partially reduced when SLE sera were preincubated with B-lymphocytes or monocytes, but not after exposure to erythrocytes, platelets, or T lymphocytes. Incubation of endothelial cells with the 7S fraction of SLE sera or with the F(ab')2 fragment of SLE-IgG resulted in the deposition of greater than 80% as much IgG as was deposited on endothelial cells by whole serum. However, since higher molecular weight fractions (greater than 7S) of SLE sera were also active, we tested the capacity of endothelial cells to bind IgG complexes. Endothelial cells bound heat-aggregated IgG (HA-IgG) in a saturable manner at one log concentration below the binding of normal monomeric IgG. Binding of HA-IgG to endothelial cells was markedly enhanced by preincubation with a serum source of complement. Both HA-IgG and SLE-IgG also bound to freshly obtained endothelial cells in suspension, as detected by automated fluorescence flow cytometry. Binding of SLE-IgG and HA-IgG to endothelium initiated complement activation, deposition of the third component of complement, and disruption of the monolayer. In addition, SLE-IgG and HA-IgG caused endothelial cells to secrete prostacyclin and caused the adherence of platelets, confirmed by scanning electron microscopy. These studies demonstrate that IgG anti-endothelial antibodies are present in the sera of patients with active SLE. These sera may also contain IgG complexes that are capable of binding to endothelial cells. The association of IgG and complement with endothelial cells may initiate vascular injury in SLE and other human disorders.

Antibody Specificity↗

PubMed2004

Anti-neutrophil cytoplasmic antibodies (ANCA) in systemic lupus erythematosus: prevalence, clinical associations and correlation with other autoantibodies.

AIM: This study was undertaken to clarify the nature of anti-neutrophil cytoplasmic antibodies (ANCA) along with other autoantibodies in lupus nephritis (LN) patients and in systemic lupus erythematosus (SLE) patients without nephritis and to know their correlation with clinical manifestations and presence of other autoantibodies. MATERIAL AND METHODS: Fourty one LN patients and 18 SLE patients without nephritis were studied. LN patients were subdivided into diffuse proliferative glomerulonephritis (DPGN), focal proliferative glomerulonephritis (FPGN), rapidly progressive glomerulonephritis (RPGN) and membranoproliferative glomerulonephritis (MPGN). Anti-neutrophil cytoplasmic antibodies (ANCA) were detected by indirect immunofluorescence and confocal laser scanning microscope using PMN and HL60 cells. ANCA specificities like anti-myeloperoxidase (anti-MPO), anti-proteinase 3 (anti-PR3), anti-lactoferrin (anti-LF) and anti-cathepsin G (anti-CG) were detected by ELISA. Other autoantibodies like anti-nuclear antibodies (ANA), anti-double stranded DNA (anti-dsDNA), anti-single stranded DNA(anti-ssDNA), anti-ribonucleoproteins (anti-nRNP), anti-Smith antibodies (anti-Sm) and rheumatoid factor (RF) were also tested. RESULTS: ANCA was detected in 37.3% patients. The predominant ANCA pattern was perinuclear (p-ANCA). ANCA positivity was higher in LN patients and when confirmed by ELISA, 54.5% ANCA positives had anti-myeloperoxidase (anti-MPO). The cytoplasmic ANCA (c-ANCA) pattern was not seen in any patient. Two patients having FPGN with crescents showed atypical 'X-ANCA' pattern with dual specificity to anti-MPO and anti-PR3 by ELISA. The titers of ANCA were more in LN as compared to SLE without nephritis. LN cases having DPGN, FPGN, RPGN with crescents had higher titer p-ANCA positivity with corresponding anti-MPO antibodies, along with ANA, anti-dsDNA, anti-ssDNA and anti-Sm + anti-nRNP and also high SLEDAI scores. CONCLUSION: ANCA in SLE may be used as a serological marker along with clinical and histopathological assessment to differentiate vasculitides in LN cases from SLE without nephritis.

Adolescent↗

PubMed2001

An analysis of clinical disease activity and nephritis-associated serum autoantibody profiles in patients with systemic lupus erythematosus: a cross-sectional study.

OBJECTIVE: To establish the correlation between lupus nephritis-associated autoantibody levels and the presence/activity of lupus nephritis and global disease activity using cross-sectional data in patients with systemic lupus erythematosus (SLE). METHODS: Disease activity was assessed using the British Isles Lupus Assessment Group (BILAG) index. Antibody levels against single-stranded DNA (ssDNA), double-stranded DNA (dsDNA), histones, nucleosomes and heparan sulphate (HS) were analysed by ELISA in SLE patients with (n=11) and without (n=22) nephritis and in normal controls (n=21). Antibody subclasses were also analysed. RESULTS: Higher levels of anti-dsDNA and anti-HS antibodies were found in patients with lupus nephritis, the level of anti-HS antibodies correlating with the BILAG renal score. Predominant subclasses were IgG1 and IgG3 for dsDNA antibodies, IgG2 for anti-nucleosome antibodies, and IgG2 and IgG3 for anti-HS antibodies. CONCLUSION: Correlation was demonstrated between antibodies to dsDNA, ssDNA, histones, nucleosomes and HS. There is a strong correlation between the level of anti-HS antibodies and disease activity in patients with lupus nephritis as measured by BILAG.

Adult↗

PubMed1992

Lupus anticoagulant in systemic lupus erythematosus: a clinical and renal pathological study.

Circulating lupus anticoagulant (LA) is associated with thrombosis in large and small vessels. To determine how often the presence of LA is associated with thrombosis within the renal microcirculation, 33 patients with systemic lupus erythematosus (SLE), renal dysfunction, and LA were identified over a 25-year period (LA group) and 32 patients with renal SLE but with normal gross coagulation screen were matched for age, sex, and biopsy timing (C group). Prevalences of serositis, neuropsychiatric illness, leukopenia, thrombocytopenia, hemolysis, anti-DS-DNA elevation, and complement reduction were similar. Arthritis was less and biologic false-positive (BFP) syphilis serology more common in LA. More LA patients had thrombotic events (LA 39% v C 13%; P = 0.014); bleeding episodes, including postbiopsy, were similar. At biopsy, hypertension (LA 55%, C 41%), serum creatinine (mean +/- SD: LA 186 +/- 168 mumol/L [2.1 +/- 1.9 mg/dL] v C 150 +/- 168 mumol/L [1.7 +/- 1.9 mg/dL]) and proteinuria (LA 2.6 +/- 3.1 g/24 h v C 3.1 +/- 2.7) were similar. Lesions by World Health Organization (WHO) class, activity, and chronicity indices, as well as immunofluorescence (IF) and electron microscopy (EM) findings, were not significantly different. Occlusive glomerular, arteriolar, and arterial fibrin thrombi, along with varying degrees of renal thrombotic microangiopathy, were seen in five of 33 patients with LA, but zero of 32 C patients (P = 0.053); three of these five patients died soon after biopsy. Overall, mortality was not different between LA and C. We conclude that the majority of patients with SLE, renal dysfunction, and LA exhibit renal morphologic findings indistinguishable from patients without LA. However, a significant minority of LA patients have thrombotic microangiopathy in their biopsy, which is accompanied by a worse prognosis.

Adolescent↗

PubMed1999

Catastrophic antiphospholipid syndromes in systemic lupus erythematosus.

The objective of this study was to look for the occurrence of catastrophic antiphospholipid syndromes (APS) and to try to detect discriminating factors for predicting a worse prognosis, related to Lupus anticoagulant (LA) and antiphospholipid antibodies (aPL), in systemic lupus erythematosus (SLE) with main renal involvement. Regression, recursive partition and logistic regression analyses were applied to our 80 SLE patients prospectively followed up since 1980. Immunologic and other laboratory parameters including beta 2-glycoprotein 1 dependence, resistance to activated protein C caused by a substitution on the coagulation factor V gene, induction of monocyte procoagulant activity. Regression studies demonstrated an overall worse prognosis in term of both thrombosis and death for the group of LA/aPL positive patients (33/80). However, recursive partition analysis was able to isolate a small high risk-subgroup (8/33) characterized by persistent LA/aPL antibodies positive result, widespread signs of noninflammatory vasculopathy (skin, brain, kidney) and renal pathology mimicking that of thrombotic microangiopathy or arteriolosclerosis, also in the absence of classic SLE-nephritis. Only in this subset, three catastrophic APS were recorded, while, in traditional SLE nephritis, even persistent LA/aPL positive results (sometimes after one previous thrombosis) did not seem to imply a particularly severe prognosis. All serologic criteria employed are unable to identify high-risk patients. We conclude that catastrophic APS is a rare event in renal SLE. Before more predictive serologic markers become available, a simple algorithm, dealing with clinical data and renal histologic patterns, may help physicians to identify putatively high risk-LA/aPL antibodies in SLE patients with main renal involvement. This ominous subset does not belong to the group of classic SLE-nephritis.

Adolescent↗

PubMed1999

The role of sex hormones in systemic lupus erythematosus.

The disease systemic lupus erythematosus (SLE) is a complex one. One major clinical manifestation that relates to both cause and pathogenesis of all autoimmune diseases but specifically SLE is the sexual predilection for females. A consideration of mechanisms for this manifestation is the subject of this paper. The cytokine network is a major aspect of immune regulation and directly affected by sex steroids. The sexual dimorphism of the immune system relates to both organ-specific and general synthesis of sex steroids that are affected by and in turn affect cytokine profiles of T helper cells. There are also specific responses in cells from diseased patients that support the molecular activities of sex hormones on cells. Among these is the rise of calcineurin mRNA in SLE T cells in response to estrogen. Clinical research provides support for a more estrogenic environment in patients with SLE of both sexes. A preferential hydroxylation of estrone and increased oxidation of testosterone in patients with SLE maximizes the effects of estrogens on T cell functions. The effects of gonadotrophins like prolactin are discussed as stimulants of immune functions when elevated in SLE. Last, while the roles of exogenous estrogens on immune functions are known, the effects of such steroids alone or in combination with progestogens on SLE are not known. Investigation of both hormone replacement therapy and premenopausal hormone use are in progress.

Female↗

PubMed2006

Anti-dsDNA antibody subtypes and anti-C1q antibodies: toward a more reliable diagnosis and monitoring of systemic lupus erythematosus and lupus nephritis.

The putative distinct diagnostic and pathogenic potential of aDNA-Ab subtypes, differing in their affinity or epitope specificity, was subject of several studies with controversial results. Comparing five assays, characterized by different reaction conditions and nature/source of dsDNA, we investigated the abovementioned problem in a retrospective study on 100 systemic lupus erythematosus (SLE) patients and 100 controls (other CTD, autoimmune hepatopathies). As demonstrated, only assay 3 (Farrzyme, TBS, UK) and 5 (Farr-RIA, Trinity Biotech, Ireland) are really suitable to detect primarily high avidity aDNA-Ab. Both were significantly linked to lupus nephritis (specificity 84%) and highly specific for SLE (95 and 96%). Thereby, assay 3 was found to be the first solid phase ELISA probably suitable to replace the Farr-RIA. Classical ELISAs (assay 1, Orgentec, Germany, and 2, Bindazyme, TBS, UK), detecting aDNA-Ab more or less independent from their avidity, or tests with only intermediate specificity for high avidity Ab (assay 4, ELIAdn, Sweden Diagnostics, Germany), were less specific for SLE (83, 79, 91%, respectively) and not associated with renal involvement (specificity 54-57%). At least in the patients studied here, obvious antigen-related differences could not be observed. With slight differences, all assays were suitable to monitor disease activity and therapy in SLE, agreeing with the ECLAM score in about 70-80% of cases. For lupus nephritis, aC1q-Ab are as specific as high avidity aDNA-Ab and capable to close a diagnostic gap in some cases. Thus, to enhance the specificity (up to 98%) and to consider the distinct diagnostic/pathogenic potential of aDNA-Ab subtypes in SLE, under routine clinical laboratory conditions it should be recommended to combine a sensitive screening test with a more specific second assay.

Adult↗