Eckhard Schulze-Lohoff

Comparison of patients with and without digital ulcers in systemic sclerosis: detection of possible risk factors.

Backgroundu2002 Digital ulcers (DU) are a major complication in the course of systemic sclerosis (SSc). In recent years, efficacious, but expensive therapies (e.g. iloprost, sildenafil, bosentan) have been shown to improve healing or to reduce the recurrence of DU. For optimal management it would be useful to identify the risk factors for DU. Such statistical analyses have been rare because they require a high number of patients.

Frequency of disease-associated and other nuclear autoantibodies in patients of the German network for systemic scleroderma: correlation with characteristic clinical features

IntroductionIn the present study, we analysed in detail nuclear autoantibodies and their associations in systemic sclerosis (SSc) patients included in the German Network for Systemic Scleroderma Registry.MethodsSera of 863 patients were analysed according to a standardised protocol including immunofluorescence, immunoprecipitation, line immunoassay and immunodiffusion.ResultsAntinuclear antibodies (ANA) were detected in 94.2% of patients. In 81.6%, at least one of the autoantibodies highly associated with SSc or with overlap syndromes with scleroderma features was detected, that is, anti-centromere (35.9%) or anti-topoisomerase I (30.1%), followed in markedly lower frequency by antibodies to PM-Scl (4.9%), U1-ribonucleoprotein (U1-RNP) (4.8%), RNA polymerases (RNAPs) (3.8%), fibrillarin (1.4%), Ku (1.2%), aminoacyl-transfer RNA synthetases (0.5%), To (0.2%) and U11-RNP (0.1%). We found that the simultaneous presence of SSc-associated autoantibodies was rare (1.6%). Furthermore, additional autoantibodies were detected in 55.4% of the patients with SSc, of which anti-Ro/anti-La, anti-mitochondrial and anti-p25/p23 antibodies were most frequent. The coexistence of SSc-associated and other autoantibodies was common (43% of patients). SSc-associated autoantibodies disclosed characteristic associations with clinical features of patients, some of which were previously not acknowledged.ConclusionsThis study shows that five autoantigens (that is, centromere, topoisomerase I, PM-Scl, U1-RNP and RNAP) detected more than 95% of the known SSc-associated antibody responses in ANA-positive SSc patients and characterise around 79% of all SSc patients in a central European cohort. These data confirm and extend previous data underlining the central role of the determination of ANAs in defining the diagnosis, subset allocation and prognosis of SSc patients.

Differential regulation of smooth muscle markers in human bone marrow-derived mesenchymal stem cells

Objective To study smooth-muscle differentiation and de-differentiation of human bone marrow-derived mesenchymal stem cells (MSCs), which have been shown to enter the circulation and to contribute to vascular repair and atherosclerosis. Design Human MSCs from bone marrow were cultured with 20% fetal calf serum (FCS) or with 10% FCS and various concentrations of dimethyl sulfoxide (DMSO). Expression of smooth muscle markers was determined by Western blot analysis and immunofluorescence. For signalling studies, involvement of the mammalian target of rapamycin (mTOR) pathway was tested by treatment with rapamycin. Results MSCs cultured with 20% FCS acquired a smooth muscle-like appearance and expressed the smooth muscle (sm) markers sm-α-actin, desmin, sm-calponin and myosin light chain kinase (MLCK). DMSO induced a spindle-like morphology with marked reduction of stress fibers. As judged by Western blot analysis, treatment with 2.5% DMSO strongly downregulated expression of sm-calponin (−85%), short MLCK (−98%) and sm-α-actin expression (−51%). Reduced calponin expression was detected by day 2 of treatment with 0.5–2.5% DMSO. After withdrawal of DMSO, MSCs regained high expression of sm-calponin. Treatment with 6 nmol/l rapamycin partly antagonized the effect of DMSO, indicating the involvement of mTOR in regulation of the smooth muscle phenotype of MSCs. Conclusions DMSO strongly downregulates the smooth muscle markers sm-calponin, short MLCK and sm-α-actin in human MSCs, indicating a transition from a smooth muscle-like phenotype to an undifferentiated state by an mTOR-dependent mechanism. Regulating the phenotype of human MSCs may be of relevance for novel therapeutic approaches in atherosclerosis and intimal hyperplasia after vascular injury.

High frequency of corticosteroid and immunosuppressive therapy in patients with systemic sclerosis despite limited evidence for efficacy

IntroductionIn systemic sclerosis (SSc) little evidence for the effectiveness of anti-inflammatory and immunosuppressive therapy exists. The objective of this study was to determine the extent to which SSc patients are treated with corticosteroids and immunosuppressive agents.MethodsData on duration and dosage of corticosteroids and on the type of immunosuppressive agent were analyzed from 1,729 patients who were registered in the German Network for Systemic Scleroderma (DNSS).ResultsA total 41.3% of all registered SSc patients was treated with corticosteroids. Corticosteroid use was reported in 49.1% of patients with diffuse cutaneous SSc and 31.3% of patients with limited cutaneous SSc (P < 0.0001). Among patients with overlap disease characteristics, 63.5% received corticosteroids (P < 0.0001 vs. limited cutaneous SSc). A total 16.1% of the patients received corticosteroids with a daily dose ≥ 15 mg prednisone equivalent. Immunosuppressive therapy was prescribed in 35.8% of patients. Again, among those patients with overlap symptoms, a much higher proportion (64.1%) was treated with immunosuppressive agents, compared with 46.4% of those with diffuse cutaneous SSc sclerosis and 22.2% of those with limited cutaneous SSc (P < 0.0001). The most commonly prescribed drugs were methotrexate (30.5%), cyclophosphamide (22.2%), azathioprine (21.8%) and (hydroxy)chloroquine (7.2%). The use of these compounds varied significantly between medical subspecialties.ConclusionsDespite limited evidence for the effectiveness of corticosteroids and immunosuppressive agents in SSc, these potentially harmful drugs are frequently prescribed to patients with all forms of SSc. Therefore, this study indicates the need to develop and communicate adequate treatment recommendations.

Erfolgreiche Rapamycin-Therapie bei idiopathischer pulmonaler Fibrose (IPF) im Präfinalstadium

ZusammenfassungHintergrund:Die idiopathische pulmonale Fibrose (IPF) ist eine chronisch progrediente Erkrankung des unteren Respirationstrakts. Das führende klinische Bild besteht in einer zunehmenden Luftnot, insbesondere unter Belastung. Eine Überproduktion und Ablagerung von Kollagen sowie die Proliferation von mesenchymalen Zellen stellen die histopathologischen Charakteristika dar. Rapamycin ist eine immunsuppressive Substanz, die antifibrotischen Wirkungen auf Mesenchymzellen einschließlich Fibroblasten ausübt . Dies war die Rationale für eine Therapie mit Rapamycin zur Behandlung einer rapid progressiven IPF.Fallbeschreibung:Bei einer 73-jährigen Patientin mit einer 2-monatigen Krankheitsgeschichte einer IPF erbrachte eine Behandlung mit Steroiden und Interferon γ-1b keine Verbesserung des rasch progressiven Krankheitsverlaufs. Nach Umstellung der Therapie auf Rapamycin kam es innerhalb weniger Wochen zu einer deutlichen Verbesserung des klinischen Bildes wie auch der radiologischen Befunde. Die Patientin wird bislang 18 Monate behandelt.Schlussfolgerung:Die Autoren nehmen an, dass die partielle Remission durch eine Blockade der progressiven Fibrose und vermehrten Kollagensynthese durch Rapamycin zu erklären ist. Weitere Studien müssen zeigen, ob Rapamycin eine Therapieoption bei der Behandlung der IPF darstellt.AbstractBackground:Idiopathic pulmonary fibrosis (IPF) is a progressive chronic disorder of the lower respiratory tract. The main clinical feature is a progressive shortness of breath, particularly on exercise. An overproduction and deposition of collagen and a proliferation of mesenchymal cells are the histopathologic characteristics. Rapamycin is an immunosuppressive agent with antiproliferative effects on mesenchymal cells including fibroblasts. It was this rationale that prompted the authors to administer rapamycin in a case of rapidly progressive IPF.Case Report:In a 73-year-old female with a 2-month history of IPF, treatment with steroids and interferon γ-1b did not improve the detrimental clinical course. Treatment with rapamycin was started; subsequently, clinical condition and objective findings improved markedly within weeks. She is now under treatment for 18 months.Conclusion:The authors presume that partial remission is related to rapamycin which may be effective in blocking the progressive fibrosis and increased collagen synthesis thought to be pathophysiologically relevant in this disease. Further studies have to show whether rapamycin may be a treatment option in idiopathic pulmonary fibrosis.

Regulation of mesangial cell function by vasodilatory signaling molecules.

Proliferation of mesangial cells and expansion of mesangial matrix is a hallmark of glomerular disease leading to end-stage renal failure and requiring renal replacement therapy. Independently from the type of injury, e.g. in glomerulonephritis or diabetic nephropathy, the response to injury is remarkably uniform. Chronic glomerular disease is frequently associated with increases in systemic blood pressure and altered intraglomerular hemodynamics. Furthermore, reduction of systemic blood pressure and inhibition of the vasoconstrictor peptide angiotensin II have been shown to delay end-stage renal failure in various types of human kidney disease. Since vasoconstrictors of mesangial cells and efferent glomerular arterioli, such as angiotensin II, are thought to be detrimental for the progression of chronic glomerular disease, we propose that vasodilatory factors which antagonize the effects of angiotensin II, might have beneficial effects during the course of progressive kidney disease. To support this concept we will summarize currently available data on the role of vasodilatory signaling molecules such as natriuretic peptides (ANP, BNP and CNP), nitric oxide (NO), the prostaglandines PGE2 and prostacycline, and the purine mediator adenosine in the regulation of mesangial function.

Glomeruläre Proteinurie bei Hantavirus-Nephritis

Zusammenfassung.Hintergrund:Infektionen mit dem Hantavirus-Subtyp Puumala sind durch ein schweres Krankheitsgefühl, Fieber, Flankenschmerzen und Sehstörungen charakterisiert. Sie lösen eine tubulointerstitielle Nephritis aus, die zum akuten Nierenversagen führt.Fallbeschreibungen:Bei vier Patienten mit Hantavirus-Nephritis und akutem Nierenversagen wurde die Proteinurie mittels Mikroelektrophorese untersucht, um mögliche Ursachen des renalen Eiweißverlusts näher zu charakterisieren. Die Patienten (drei Männer, eine Frau) stellten sich mit Fieber, Kopf- und Flankenschmerzen und einem akuten Nierenversagen vor (sonographisch vergrößerte Nieren, Serumkreatinin 7,7/3,4/3,2/7,8 mg/dl, Proteinurie 1,7/0,5/1,5/9,0 g/l, positiver IgM-Antikörper-Nachweis gegen Hantavirus, Subtyp Puumala). Die Mikroelektrophorese der Urine zeigte bei allen Patienten eine große Fraktion höhermolekularer Proteine wie Transferrin und Immunglobuline als Hinweis auf eine unselektive glomeruläre Proteinurie. Histologisch zeigten die drei durchgeführten Nierenbiopsien eine normale Morphologie der Glomeruli und der Gefäße. Tubulointerstitiell lagen hämorrhagische Einblutungen und eine Infiltration mononukleärer Zellen vor. Nach 14 Tagen hatte sich die Nierenfunktion bei allen Patienten normalisiert. Eine persistierende Proteinurie entwickelte sich nicht.Schlussfolgerung:Die Hantavirus-Nephritis kann zu einer glomerulären Proteinurie führen. Die normale glomeruläre Morphologie und ein rascher Rückgang der Proteinurie weisen auf eine transiente Schädigung der glomerulären Filtrationsbarriere hin. Möglicherweise wird die vorübergehende glomeruläre Permeabilitätssteigerung durch die immunologische Auseinandersetzung mit dem Virus verursacht.Abstract.Background:Infection with hantavirus of the Puumala type is known to cause severe illness, fever, loin pain and impaired vision. Tubulointerstitial nephritis leads to acute renal failure.Case Reports:In four patients presenting with hantavirus infection and acute renal failure, proteinuria was analyzed by microelectrophoresis to explore possible causes of renal protein loss in hantavirus nephritis. The patients (three men, one woman) presented with a short history of fever, headache, loin pain and acute renal failure (enlarged kidneys in ultrasonography, serum creatinine 7.7/3.4/3.2/7.8 mg/dl, urinary protein excretion 1.7/0.5/1.5/9.0 g/l, IgM antibodies against hantavirus positive in all patients, subtype Puumala). Microelectrophoresis of the urine revealed a major fraction of higher molecular weight proteins such as transferrin and immunoglobulins indicating unselective glomerular-type proteinuria in all four patients. In three renal biopsy specimens obtained, morphology of glomeruli and vasculature was normal as judged by light microscopy. The tubulointerstitium exhibited interstitial hemorrhage and round-cell infiltrates. After 2 weeks, renal function had completely recovered in all patients and no persistent proteinuria developed.Conclusion:Hantavirus nephritis may lead to glomerular-type proteinuria. Glomerular morphology may be normal and proteinuria may cease within 2 weeks indicating a transient lesion of the glomerular filtration barrier. Transiently increased glomerular permeability may be caused by an immunologic response to virus infection.

Rho/Rho Kinase Pathway Regulates Maintenance of the Differentiated Tubular Epithelial Cell Phenotype on Laminin-1

Background: Maintenance of a polarized tubular epithelium by appropriate intracellular signaling and extracellular matrix is critical both in normal renal function as well as in acute and chronic tubular injury. We examined the hypothesis that maintenance of a differentiated epithelial phenotype on the basement membrane glycoprotein laminin-1 is controlled by the Rho/Rho kinase pathway. Methods: Using the tubular epithelial cell lines LLC-PK1 and MDCK which were cultured on laminin-1 vs. collagen IV, we analyzed cell morphology and motility (cohort migration assay) as well as expression of differentiation and dedifferentiation markers (immunofluorescence microscopy). Results: Cohort migration of LLC-PK1 cells was significantly slowed down on laminin-1 (10.7 ± 2.2 m.u. (migratory units)) compared with collagen IV (16.6 ± 2.3 m.u.; BSA control: 2.8 ± 2.5 m.u.). Inhibition of the Rho/Rho kinase pathway by C3 exotoxin (1 µg/ml) or the Rho kinase inhibitor Y27632 (10 µM) significantly augmented cohort migration on laminin-1 (14.5 ± 1.4 and 16.0 ± 1.8 m.u. vs. 10.7 ± 2.2 m.u.). In parallel to the increased migratory activity, inhibition of the Rho/Rho kinase pathway resulted in a more mesenchymal phenotype of LLC-PK1 cells on laminin-1 with increased formation of lamellopodia and filopodia, distinct loss of focal contacts and stress fibers, upregulation of the dedifferentiation marker vimentin, and loss of cell-cell contacts with translocation of β-catenin from the adherens junctions to the cytosol and nucleus. Similarly, cohort migration of MDCK cells was retarded on laminin-1 when compared with collagen IV, and addition of the Rho kinase inhibitor Y27632 resulted in enhanced motility and a change in cell morphology. Conclusion: The study demonstrates that the Rho/Rho kinase pathway is required to maintain a non-migratory epithelial phenotype of cultured renal tubular LLC-PK1 and MDCK cells on the basement membrane glycoprotein laminin-1.

[Glomerular-type proteinuria in hantavirus nephritis].

Zusammenfassung.Hintergrund:Infektionen mit dem Hantavirus-Subtyp Puumala sind durch ein schweres Krankheitsgefühl, Fieber, Flankenschmerzen und Sehstörungen charakterisiert. Sie lösen eine tubulointerstitielle Nephritis aus, die zum akuten Nierenversagen führt.Fallbeschreibungen:Bei vier Patienten mit Hantavirus-Nephritis und akutem Nierenversagen wurde die Proteinurie mittels Mikroelektrophorese untersucht, um mögliche Ursachen des renalen Eiweißverlusts näher zu charakterisieren. Die Patienten (drei Männer, eine Frau) stellten sich mit Fieber, Kopf- und Flankenschmerzen und einem akuten Nierenversagen vor (sonographisch vergrößerte Nieren, Serumkreatinin 7,7/3,4/3,2/7,8 mg/dl, Proteinurie 1,7/0,5/1,5/9,0 g/l, positiver IgM-Antikörper-Nachweis gegen Hantavirus, Subtyp Puumala). Die Mikroelektrophorese der Urine zeigte bei allen Patienten eine große Fraktion höhermolekularer Proteine wie Transferrin und Immunglobuline als Hinweis auf eine unselektive glomeruläre Proteinurie. Histologisch zeigten die drei durchgeführten Nierenbiopsien eine normale Morphologie der Glomeruli und der Gefäße. Tubulointerstitiell lagen hämorrhagische Einblutungen und eine Infiltration mononukleärer Zellen vor. Nach 14 Tagen hatte sich die Nierenfunktion bei allen Patienten normalisiert. Eine persistierende Proteinurie entwickelte sich nicht.Schlussfolgerung:Die Hantavirus-Nephritis kann zu einer glomerulären Proteinurie führen. Die normale glomeruläre Morphologie und ein rascher Rückgang der Proteinurie weisen auf eine transiente Schädigung der glomerulären Filtrationsbarriere hin. Möglicherweise wird die vorübergehende glomeruläre Permeabilitätssteigerung durch die immunologische Auseinandersetzung mit dem Virus verursacht.Abstract.Background:Infection with hantavirus of the Puumala type is known to cause severe illness, fever, loin pain and impaired vision. Tubulointerstitial nephritis leads to acute renal failure.Case Reports:In four patients presenting with hantavirus infection and acute renal failure, proteinuria was analyzed by microelectrophoresis to explore possible causes of renal protein loss in hantavirus nephritis. The patients (three men, one woman) presented with a short history of fever, headache, loin pain and acute renal failure (enlarged kidneys in ultrasonography, serum creatinine 7.7/3.4/3.2/7.8 mg/dl, urinary protein excretion 1.7/0.5/1.5/9.0 g/l, IgM antibodies against hantavirus positive in all patients, subtype Puumala). Microelectrophoresis of the urine revealed a major fraction of higher molecular weight proteins such as transferrin and immunoglobulins indicating unselective glomerular-type proteinuria in all four patients. In three renal biopsy specimens obtained, morphology of glomeruli and vasculature was normal as judged by light microscopy. The tubulointerstitium exhibited interstitial hemorrhage and round-cell infiltrates. After 2 weeks, renal function had completely recovered in all patients and no persistent proteinuria developed.Conclusion:Hantavirus nephritis may lead to glomerular-type proteinuria. Glomerular morphology may be normal and proteinuria may cease within 2 weeks indicating a transient lesion of the glomerular filtration barrier. Transiently increased glomerular permeability may be caused by an immunologic response to virus infection.

Das Jo-1-Syndrom und seine klinischen Manifestationen

ZusammenfassungNamensgebend für das Jo-1-Syndrom sind Autoantikörper gegen das Jo-1-Antigen, die bei diesem Krankheitsbild im Serum der betroffenen Patienten nachgewiesen werden. Der Name Jo-1 leitet sich von dem ersten Patienten (John P.) ab, bei dem diese Antikörper gefunden wurden. Dieser Patient litt an einer Polymyositis und fibrosierenden Alveolitis. Das Jo-1-Antigen ist identisch mit der Histidyl-Transfer-RNA-Synthetase im Zytosol. Das Jo-1-Syndrom gehört zu einer Familie von Autoimmunerkrankungen, die als Anti-Synthetase- Syndrome bezeichnet werden. Diese Syndrome haben gemeinsam, dass jeweils Autoantikörper gegen unterschiedliche Aminosäure-Transfer-RNASynthetasen nachweisbar sind. Klinisch handelt es sich beim Jo-1-Syndrom um eine Sonderform der Poly- bzw. Dermatomyositis von bisher ungeklärter Ätiologie. Neben einer Muskelbeteiligung kommt es charakteristischerweise zu einer interstitiellen Lungenbeteiligung, die auch prognostisch das Krankheitsbild bestimmt. Zusätzlich können klinisch eine Polyarthritis und weitere Symptome bestehen, die dem klinischen Bild anderer Kollagenosen ähneln. Ebenso wie die Polymyositis und Dermatomyositis kann sich das Jo-1-Syndrom in sog. Myositis-Overlap-Syndromen präsentieren. Zu dieser Diagnose führt ein Symptomenkomplex, der die klare Zuordnung zu einer einzelnen Erkrankung nicht möglich macht. Häufig werden in solchen Fällen U1-RNP-Antikörper nachgewiesen. Therapeutisch spricht das Jo-1-Syndrom auf die Gabe von Kortikosteroiden und—falls notwendig—Azathioprin, Methotrexat und Cyclophosphamid an. Eine Kurzbeschreibung von zwei klinischen Fällen stellt das Krankheitsbild anschaulich dar.AbstractThe Jo-1 syndrome is an autoimmune disease which is characterized by the presence of autoantibodies against the Jo-1 antigen. The designation Jo-1 is derived from the name of the first patient (John P.) who was tested positive for this antibody. This patient suffered from polymyositis and fibrosing alveolitis. The Jo-1 antigen was identified as histidyl-transfer-RNA synthetase present in the cytosol. The Jo-1 syndrome is a member of a family of autoimmune dieases, called anti-synthetase syndromes. These syndromes are characterized by autoantibodies directed against aminoacyl-transfer-RNA synthetases. The etiology of the Jo-1 syndrome is unknown. The most frequent clinical manifestation is myositis, which may present as polymyositis or dermatomyositis. In addition to muscle involvement, interstitial lung disease is frequently found and critical for the prognosis. Furthermore, symptoms of other autoimmune disorders such as polyarthritis may occur. Similar to polymyositis and dermatomyositis, the Jo-1 syndrome may present as myositis overlap syndrome. In these cases, antibodies against U1-RNP are detected. The Jo-1 syndrome responds to treatment with corticosteroids and, if necessary, azathioprine, methotrexate or cyclophosphamide. The clinical manifestations of the Jo-1 syndrome are illustrated by two clinical cases.