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Indonesian Journal of Rheumatology Vol 14 Issue 2 20221. Introduction
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that can cause clinical manifestations involving various organs. The basis of the pathogenesis of this disease is the presence of organ damage due to autoantibodies to tissues and the accumulation of immune complexes.1 Many autoantibodies have been reported to be abnormally elevated in this disease, but anti-dsDNA antibodies are the specific autoantibodies found in SLE. Anti-dsDNA antibody levels are also associated with the severity of SLE disease activity.2 Increased levels of these
antibodies have even become one of the diagnostic criteria for SLE.3
Although anti-dsDNA is a specific marker for SLE, previous studies have shown an inconsistent relationship between the levels of these antibodies and the clinical manifestations seen as shown as organ involvement in SLE.4 This condition raises controversy regarding the central role of these antibodies in the pathogenesis of SLE.5 This study aims to provide an additional description of the relationship between increased levels of these antibodies and the emerging clinical manifestations of
The Relationship between Anti-dsDNA Antibody Levels and Clinical Manifestation in Systemic Lupus Erythematosus Patients
Noviantoro Sunarko1*, Ayu Paramaiswari1, Deddy Nur Wachid1
1Department of Internal Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
ARTICLE INFO Keywords:
Anti-dsDNA
Clinical manifestation Organ involvement
Systemic lupus erythematosus
*Corresponding author:
Noviantoro Sunarko
E-mail address:
noviantoro.s.p.@mail.ugm.ac.id
All authors have reviewed and approved the final version of the manuscript.
https://doi.org/10.37275/IJR.v14i2.166
A B S T R A C T
Background: Anti-double-stranded deoxyribonucleic acid (anti-dsDNA) antibodies have been long known as specific autoantibodies in systemic lupus erythematosus (SLE) patients. Their central role in the pathogenesis of SLE also had been proposed for a long time. But many studies have failed to show a consistent association between anti-dsDNA levels and clinical manifestation in SLE patients. This phenomenon raised controversies about anti-dsDNA’s role in the development of the disease. This study aimed to give more description of the relationship between anti-dsDNA antibodies level and clinical manifestation of SLE. Methods: This study took place in Dr.
Sardjito General Hospital, Yogyakarta, Indonesia, from July 2017 to July 2020. This study is a descriptive-analytic study with a cross-sectional design. Sixty-three females with new cases of SLE were included in this study. We used Alegria® ORGENTEC ORG204S kits to measure anti-dsDNA antibody levels in those patients. All organ involvement and anti-dsDNA level data were collected from the subject’s medical record. We categorized the patient into two groups, one group with a high level of anti-dsDNA antibodies and the other with the normal one. The statistical analysis was conducted by using the chi-square test to associate the anti-dsDNA antibodies level with the clinical manifestation of SLE that developed in those patients. Results:
The haematological manifestation was the most prevalent clinical manifestation of SLE (69.8%), followed by cutaneous (66.7%) and musculoskeletal manifestation (63.5%), respectively. Thirty subjects had a high level of anti-dsDNA, and 33 subjects had the normal one. Anti-dsDNA antibody levels were only significantly associated with the development of haematological manifestation (p=0.026). Conclusion: Haematological manifestation tends to develop in SLE patients with high anti-dsDNA antibody levels.
Indonesian Journal of Rheumatology
Journal Homepage: https://journalrheumatology.or.id/index.php/IJR
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SLE. The existence of a significant relationship between the two will strengthen the suspicion of the central role of these antibodies in the pathogenesis of SLE. This study aimed to give more description of the relationship between anti-dsDNA antibodies level and clinical manifestation of SLE.
2. Methods
This study is a descriptive-analytic study with a retrospective cross-sectional design. The subjects of this study were female patients who were newly diagnosed with SLE based on ACR 1997 and SLICC criteria at Dr. Sardjito Hospital, Yogyakarta, Indonesia, from July 2017 to July 2020 periods.
Patients who were pregnant were excluded from the study. All patients who met the eligibility criteria were included as study subjects.
Research data, both anti-dsDNA antibody levels and clinical manifestations of SLE, are secondary data from the medical records of SLE patients. The maximum distance between the measurement of anti- dsDNA antibody levels and clinical manifestations is one week. Examination of antibody levels using the ELISA method with the ORGENTEC ORG 204S with Alegria® strips. Anti-dsDNA antibody levels were grouped into two, the one with increased anti-dsDNA antibody levels and normal anti-dsDNA antibody levels. The cut-off point of the anti-dsDNA level used in this study was 50 IU/mL. This value is two times the upper normal limit value of the examination instrument used, as stated in the SLICC criteria.
The clinical manifestations analyzed in this study were organ involvement based on SLICC criteria with certain modifications, the skin, mucosal, musculoskeletal, serosal, neurological, renal, and haematological manifestations. This research has received ethical approval from the Ethical Committee of the Faculty of Medicine, Public Health, and Nursing at Universitas Gadjah Mada, number KE/FK/0606/EC/2020.
Univariate data analysis was conducted to analyze the distribution and frequency of each research variable. Bivariate analysis using the chi-square test was performed to determine the relationship between anti-dsDNA antibody levels and each clinical manifestation of SLE that developed. Fisher's exact test was performed when needed. A p-value <0.05 indicates a statistically significant relationship.
3. Results
This study involved 63 samples of female patients with new cases of SLE. Most patients are under 50 years of age. The distribution of patients with high and normal levels of anti-dsDNA antibody was fairly balanced, with 30 and 33 patients in each group, respectively. The clinical manifestations most often found in this study were haematological, cutaneous, and musculoskeletal manifestations, with the percentage of occurrences 69.8%, 66.7%, and 63.5%, respectively. The clinical characteristics of the subjects are summarized in Table 1
.
Table 1. Clinical characteristics of study subjects.
Variable n Percentage (%)
Age group
Older adult 61 96.8
Younger adult 2 3.2
Anti-dsDNA antibody levels group
High 30 47.6
Normal 33 52.4
Clinical manifestations
Cutaneous manifestations 42 66.7
Mucosal manifestations 24 38.1
Musculoskeletal manifestations 40 63.5
Serosal manifestations 12 19.0
Neurological manifestations 6 9.5
Renal manifestations 18 28.6
Haematological manifestations 44 69.8
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We conducted a bivariate analysis using the chi- square test to look for differences in the proportion between groups of anti-dsDNA antibody levels with each clinical manifestation that appeared in the study subjects. Among all clinical manifestations, a statistically significant difference in the proportion of
anti-dsDNA levels was found only in the haematological manifestations (p = 0.026). With an odds ratio of 3.68 and a 95% confidence interval ranging from 1.12-12.02. The results of the bivariate analysis for all variables can be seen in Table 2.
Table 2. Bivariate analysis of anti-dsDNA antibody levels and SLE clinical manifestations.
Anti-dsDNA
antibody levels Clinical manifestation p Odds ratio
(95% CI) Cutaneous
Yes No
High 17 13 0.108* 0.41 (0.14-1.22)
Normal 25 8
Mucosal
Yes No.
High 10 20 0.458* 0.67 (0.24-1.89)
Normal 14 19
Musculoskeletal
Yes No
High 19 11 0.980* 0.98 (0.35-2.75)
Normal 21 12
Serosal
Yes No
High 6 24 0.854* 1.12 (0.32-3.95)
Normal 6 27
Neurological
Yes No
High 3 27 0.902* 1.11 (0.20-5.97)
Normal 3 30
Renal
Yes No
High 12 18 0.056* 3.00 (0.95-9.44)
Normal 6 27
Haematological
Yes No
High 25 5 0.026*† 3.68 (1.12-12.02)
Normal 19 14
*Chi-square test; †statistically significant.
4. Discussion
This study showed that the majority of patients were under 50 years of age. This is consistent with previous research in Indonesia6 and global epidemiological data, which shows the highest incidence of SLE in the second to fifth decades of life.7 Increased levels of anti-dsDNA antibodies were found in 47.6 patients, according to epidemiological data in Indonesia.8 The most common manifestations are haematological, cutaneous, and musculoskeletal manifestations. These findings are consistent with
epidemiological data in Indonesia, all three of which are clinical manifestations that often appear in SLE patients.8
Anti-dsDNA antibodies have long been recognized as SLE-specific antibodies. This is why these antibodies are thought to play a central role in the pathogenesis of this disease. It is hoped that evidence of the central role of these antibodies in the pathogenesis of this disease opens the possibility of developing targeted therapies for these antibodies in the management of SLE.4 However, previous studies
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have shown an inconsistent relationship between these antibody levels and clinical manifestations that arise.5
This study found that increased levels of anti- dsDNA antibodies were only significantly associated with the onset of haematological manifestations alone.
Several previous studies have also shown a significant relationship between these antibody levels and the onset of haematological manifestations in SLE.4,9 The cross-reaction between these antibodies and the lymphocyte cell membrane is one of the explanations for the occurrence of haematological manifestations, especially lymphopenia.10
This study did not find a significant relationship between anti-dsDNA antibody levels and the development of skin manifestations in SLE. Other studies in Indonesia and in Egypt found the same thing.4,9 However, another study that divided skin manifestations more specifically showed that antibody levels were associated with the development of a malar rash, which is an acute skin manifestation of SLE, and was not associated with other subtypes of skin manifestations.11
The level of anti-dsDNA antibody was also not associated with the presence of mucosal manifestations in SLE. Previous studies have obtained different results. Urman's cohort study showed that the levels of these antibodies were not associated with the development of oral ulcers in SLE patients.12 But recent studies have shown significantly higher levels of anti-dsDNA antibodies in SLE patients with oral ulcer manifestations compared with those without.13 The proportion of patients with musculoskeletal manifestations was also not significantly different in the group of patients with increased anti-dsDNA antibody levels from the group with normal antibody levels. Previous studies in Indonesia also obtained the same results.6,9 However, other studies in Africa and Europe found that antibody levels were associated with the onset of musculoskeletal manifestations in SLE.4,14,15
Other autoantibodies, such as anti-citrulline- containing peptide (anti-CCP) and anti-
ribonucleoprotein (anti-RNP), have been associated with the development of musculoskeletal manifestations in SLE.16,17 The racial difference factor may affect which antibody has a predominant role in the pathogenesis of these manifestations.
Anti-dsDNA antibody levels also did not significantly influence the appearance of serosal manifestations in SLE. Previous research in Indonesia also obtained similar results.9 A cohort study by Fabrizio et al. even showed that these manifestations were more prevalent in SLE patients with negative anti-dsDNA antibodies.17 Another autoantibody, anti- Sjogren's syndrome-related antigen B (anti-SSB), has been associated with serosal manifestations in SLE.18
Neurological manifestations are one of the most severe manifestations of SLE. The presence of anti- dsDNA antibodies that cross-react with the NR2 glutamate receptor on neurons is thought to be the main pathogenesis of neurological manifestations in SLE.19 Based on this theory, the increase in anti- dsDNA antibody levels should be associated with the emergence of neurological manifestations in SLE patients.
However, this study showed different results, and the antibody levels were not significantly associated with the onset of neurological manifestations in SLE.
This finding is in line with a meta-analysis by Bougea et al., who also found no significant relationship between the two. Other autoantibodies have been reported that have a significant association with the development of neurological manifestations, including anti-ribosomal protein P (anti-P), anti-RNP, and anti- Smith (anti-Sm) antibodies.20
The renal manifestation is one of the most important manifestations of SLE. Kidney manifestations in the form of lupus nephritis increase the risk for end-stage chronic kidney disease, cardiovascular events, and death in general in SLE patients.21 The development of lupus nephritis is often used as a model for the involvement of anti-dsDNA antibodies in the pathogenesis of LES. This is supported by previous studies which showed a relationship between increased levels of anti-dsDNA
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antibodies and renal manifestations in SLE patients.9,22,23
However, one recent study showed no significant association between increased levels of anti-dsDNA antibodies and the onset of renal manifestations in SLE patients.4 This study also found a similar result.
There is a case report showing no detection of anti- dsDNA antibodies in SLE patients with severe lupus nephritis. The accumulation of anti-dsDNA antibodies in the glomerular basement membrane is thought to result in undetectable anti-dsDNA antibody levels in the patient's peripheral blood samples. In these patients, there was also an increase in levels of other antibodies, anti-Sjogren's syndrome-related antigen A/anti-Ro (anti-SSA/Ro) antibodies which may also play a role in the pathogenesis of renal manifestations in SLE patients, specifically those with undetectable anti-dsDNA.24
This study only included a new SLE case study subject to minimize exposure to immunosuppressant therapy, which could affect both anti-dsDNA antibody levels and emerging clinical manifestations.4,25 Patients who were included as subjects were only non- pregnant females. Sex and pregnancy conditions were also shown to influence the levels of these antibodies and organ involvement in the SLE.26
The use of secondary data from medical records in this study increases the risk of bias in the data obtained because the researcher cannot control the validity of the data. More research subjects will provide a more representative picture of the general SLE patient population. The limitation of the anti-dsDNA antibody level measuring instrument, which cannot provide precise antibody level if it is above 200 IU/mL, causes the receiver operating characteristic (ROC) curve analysis to be not carried out to look for the cut- off point of the increase in anti-dsDNA antibody levels.
The use of ROC curve analysis is expected to be able to provide a cut-off point that is more appropriate to the studied population.
5. Conclusion
Haematological manifestation tends to develop in SLE patients with high anti-dsDNA antibody levels.
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