Regulatory T cells (CD4+CD25+FOXP3+) in lupus nephritis

Mohd Khairul Mohd Kamil, Rozita Mohd, Rizna Abdul Cader, Azlin Ithnin, Shamsul Azhar Mohd Shah


Background: Systemic lupus erythromatosus (SLE) is an autoimmune disease with 20–65% of patients developing lupus nephritis (LN). Studies have reported 10% of LN patients will end up with end stage renal disease and their mortality rate is higher compared to patients without LN. Abnormality of regulatory T cells (Tregs) level is thought to be a potential factor for this LN development. The aim of study was to evaluate the percentage of Tregs in LN patients.

Methods: This was a comparative cross sectional study involving LN patients and age and gender matched controls with a 2:1 ratio. The patients were grouped into active and inactive LN based on their lupus activity index; complement levels, ANA, dsDNA antibodies, ESR, SLE Disease Activity Index (SLEDAI2K) score and also urine PCI (uPCI>0.05 for active group). Disease history, demographic data, routine blood test, peripheral blood for differentials count were taken and recorded. Peripheral blood mononuclear cells were stained with CD4, CD25 and Foxp3 antibodies and percentage of Tregs was analysed using BD fluorescence-activated cell sorting (FACS) cytometer. We compared demographic and laboratory parameters between healthy controls and LN patients as well as active and inactive LN patients.

Results: A total of 34 LN patients (32 females, 2 males) were recruited. Their mean age and disease duration were 37.97±11.14 years and 110.95±65.07 months respectively.  Thirteen matched controls with mean age 35.23±7.89 years were enrolled. There was no demographic difference between 2 groups of LN patients. Tregs were significantly lower in active LN compared to inactive LN and healthy control (0.44±0.37% vs. 1.89±0.46% vs. 3.12±0.56% of the CD4+, P<0.001). C3 and C4 complement fragments were significantly reduced in patients with active disease (C3; 50.92±28.43 vs. 76.31±25.63, P=0.011) and (C4; 11.17±8.41 vs. 16.70±6.50 P=0.044). Proteinuria was significantly higher while serum albumin levels were significantly lower in active patients compared to inactive patients and healthy control (urine PCI; 0.25(0.15-0.3) vs. 0.03(0.01-0.05) vs. 0.01, P<0.001) and (albumin; 29.89±6.87 vs. 36.87±3.58 vs. 40.62±1.89mmol/L, P<0.001). We found positive inversely correlation between Tregs with SLEDAI2K (r = -0.572, P=0.011) and proteinuria (r = -0.451, P=0.007).

Conclusions: Tregs, C3 and C4 complements, and albumin were significantly lower while proteinuria was significantly higher in active LN. There was positive inversely correlation between the percentage of Tregs with SLEDAI2K score and proteinuria.


CD4+CD25+Foxp3+, Lupus nephritis, Regulatory T cells, Systemic lupus erythematosus, Tregs

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Tan EM. Autoantibodies and autoimmunity: A three decade perspective. A tribute to Henry G, Kunkel. Ann N Y Acad Sci. 1997;815:1-4.

Alarcón GS. Multiethnic lupus cohorts: what have they taught us? Reumatol Clin. 2011;7:3-6.

Yap DY, Tang CS, Ma MK, Lam MF, Chan TM. Survival analysis and causes of mortality in patients with lupus nephritis. Nephrol Dial Transplant. 2012;27:3248-54.

Chen YE, Korbet SM, Katz RS, Schwartz MM, Lewis EJ. Collaborative Study Group. Value of a complete or partial remission in severe lupus nephritis. Clin. J Am Soc Nephrol. 2009;3:46-53.

Shlomchik MJ, Craft JE, Mamula MJ. From T to B and back again: Positive feedback in systemic autoimmune disease. Nat Rev Immunol. 2001;1:147-54.

Gutcher I, Becher B. APC-derived cytokines and T cell polarization in autoimmune inflammation. J Clin Investig. 2007;117:1119-27.

Arthur C Guyton. Textbook of Medical Physiology by Guyton and Hall, 6th ed. Mississippi, US: W B Saunders; 1981:448.

BD Biosciences. Application note: human regulatory T-cell isolation and measurement of function, 2010. Available at: Accessed 22 November 2018.

Baecher-Allan C, Brown JA, Freeman GJ, Hafler DA. CD4+ CD25high regulatory cells in human peripheral blood. J Immunol. 2001;167:1245-53.

Bonelli M, Göschl L, Blüml S, Karonitsch T, Steiner CW, Steiner G, Smolen JS, Scheinecker C. CD4+ CD25-Foxp3+ T cells: A marker for lupus nephritis? Arthritis Res Ther. 2014;16:104.

Hsu WT, Suen JL, Chiang BL. The role of CD4+ CD25+ T cells in autoantibody production in murine lupus. Clin Exp Immunol. 2006;145:513-9.

Crispin JC, Martnez A, Alcocer-Varela J. Quantification of regulatory T cells in patients with systemic lupus erythematosus. J Autoimmu. 2003;21:273-6.

Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheumatol. 1997;40:1725.

Weening JJ, D'agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int. 2004;65:521-30.

Hahn BH, Mcmahon MA, Wilkinson A, Wallace WD, Daikh DI, Fitzgerald JD, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res. 2012;64:797-808.

Wang F, Wang CL, Tan CT, Manivasagar M. Systemic lupus erythematosus in Malaysia: a study of 539 patients and comparison of prevalence and disease expression in different racial and gender groups. Lupus. 1997;6:248-53.

Teh CL, Ling GR, Aishah WS. The Sarawak lupus cohort: clinical features and disease patterns of 633 SLE patients in a single tertiary centre from East Malaysia. Rheumatol Int. 2015;35:153-7.

Shaharir SS, Hussein H, Rajalingham S, Said MS, Gafor AH, Mohd R, et al. Damage in the Multiethnic Malaysian Systemic Lupus Erythematosus (SLE) Cohort: Comparison with Other Cohorts Worldwide. Plos One. 2016;11.

Matsukawa Y, Kujime K, Mitamura K, Okuda S, Shimizu T, Kitamura N, et al. Substituting prednisolone for methylprednisolone improved ESR and eosinophilia in a patient with systemic lupus erythematosus. BioDrugs. 1999;12:359-61.

Li C, Mu R, Lu XY, He J, Jia RL, Li ZG. Antilymphocyte antibodies in systemic lupus erythematosus: association with disease activity and lymphopenia. J Immunol Res. 2014;2014.

Valencia X, Yarboro C, Illei G, Lipsky PE. Deficient CD4+ CD25high T regulatory cell function in patients with active systemic lupus erythematosus. J Immunol. 2007;178:2579-88.

Lyssuk EY, Torgashina AV, Soloviev SK, Nassonov EL, Bykovskaia SN. Reduced number and function of CD4+ CD25 high FoxP3+ regulatory T cells in patients with systemic lupus erythematosus. Immune-Mediated Dis. 2007:113-9.

Barath S, Aleksza M, Tarr T, Sipka S, Szegedi G, Kiss E. Measurement of natural (CD4+ CD25high) and inducible (CD4+ IL-10+) regulatory T cells in patients with systemic lupus erythematosus. Lupus. 2007;16:489-96.

Chowdary Venigalla RK, Tretter T, Krienke S, Max R, Eckstein V, Blank N, et al. Reduced CD4+, CD25-T cell sensitivity to the suppressive function of CD4+, CD25high, CD127−/low regulatory T cells in patients with active systemic lupus erythematosus. Arthritis Rheumatol. 2008;58:2120-30.

Yates J, Whittington A, Mitchell P, Lechler RI, Lightstone L, Lombardi G. Natural regulatory T cells: number and function are normal in the majority of patients with lupus nephritis. Clin Exp Immunol. 2008;153:44-55.

Miyara M, Amoura Z, Parizot C, Badoual C, Dorgham K, Trad S, Net al. Global natural regulatory T cell depletion in active systemic lupus erythematosus. J Immunol. 2005;175:8392-400.

Tselios K, Sarantopoulos A, Gkougkourelas I, Boura P. CD4+ CD25highFOXP3+ T regulatory cells as a biomarker of disease activity in systemic lupus erythematosus: a prospective study. Clin Exp Rheumatol. 2014;32:630.

Szmyrka-Kaczmarek M, Kosmaczewska A, Ciszak L, Szteblich A, Wiland P. Peripheral blood Th17/Treg imbalance in patients with low-active systemic lupus erythematosus. Advances in Hygiene and Experimental Med. 2014:68.

Xing Q, Su H, Cui J, Wang B. Role of Treg cells and TGF-1 in patients with systemic lupus erythematosus: A possible relation with lupus nephritis. Immunol Invest. 2012;41:15-27.

Ma J, Yu J, Tao X, Cai L, Wang J, Zheng SG. The imbalance between regulatory and IL-17-secreting CD4+ T cells in lupus patients. Clin Rheumatol. 2010;29:1251-8.

Dolff S, Bijl M, Huitema MG, Limburg PC, Kallenberg CG, Abdulahad WH. Disturbed Th1, Th2, Th17 and T reg balance in patients with systemic lupus erythematosus. Clin Immunol. 2011;141:197-204.

Habibagahi M, Habibagahi Z, Jaberipour M, Aghdashi A. Quantification of regulatory T cells in peripheral blood of patients with systemic lupus erythematosus. Rheumatol Int. 2011;31:1219-25.

Marinić I, Cepika AM, Morović-Vergles J, Soldo-Jureša D, Gagro A. Effect of steroid on the frequency of regulatory T cells and expression of FOXP3 in a patient with systemic lupus erythematosus: A two-year follow-up. In Annual Meeting of the Croatian Immunological Society 2007.

Karagiannidis C, Akdis M, Holopainen P, Woolley NJ, Hense G, Rückert B, et al. Glucocorticoids upregulate FOXP3 expression and regulatory T cells in asthma. J Allergy Clin Immunol. 2004;114:1425-33.

Suárez A, López P, Gómez J, Gutiérrez C. Enrichment of CD4+ CD25 high T cell population in patients with systemic lupus erythematosus treated with glucocorticoids. Ann Rheum Dis. 2006;65:1512-7.

Sfikakis PP, Souliotis VL, Fragiadaki KG, Moutsopoulos HM, Boletis JN, Theofilopoulos AN. Increased expression of the FoxP3 functional marker of regulatory T cells following B cell depletion with rituximab in patients with lupus nephritis. Clin Immunol. 2007;123:66-73.

Vigna-Perez M, Hernández-Castro B, Paredes-Saharopulos O, Portales-Pérez D, Baranda L, Abud-Mendoza C, et al. Clinical and immunological effects of Rituximab in patients with lupus nephritis refractory to conventional therapy: a pilot study. Arthritis Res Ther. 2006;8:83.