Semi-synthetic bile acids as novel drug candidate in liver diseases: physico-chemical characterization and HPLC-ES-MS/MS methods for their quali-quantitative analysis in different experimental animal models

The physico-chemical characterization, structure-pharmacokinetic and metabolism studies of new semi synthetic analogues of natural bile acids (BAs) drug candidates have been performed. Recent studies discovered a role of BAs as agonists of FXR and TGR5 receptor, thus opening new therapeutic target for the treatment of liver diseases or metabolic disorders. Up to twenty new semisynthetic analogues have been synthesized and studied in order to find promising novel drugs candidates. In order to define the BAs structure-activity relationship, their main physico-chemical properties (solubility, detergency, lipophilicity and affinity with serum albumin) have been measured with validated analytical methodologies. Their metabolism and biodistribution has been studied in “bile fistula rat”, model where each BA is acutely administered through duodenal and femoral infusion and bile collected at different time interval allowing to define the relationship between structure and intestinal absorption and hepatic uptake ,metabolism and systemic spill-over. One of the studied analogues, 6α-ethyl-3α7α-dihydroxy-5β-cholanic acid, analogue of CDCA (INT 747, Obeticholic Acid (OCA)), recently under approval for the treatment of cholestatic liver diseases, requires additional studies to ensure its safety and lack of toxicity when administered to patients with a strong liver impairment. For this purpose, CCl4 inhalation to rat causing hepatic decompensation (cirrhosis) animal model has been developed and used to define the difference of OCA biodistribution in respect to control animals trying to define whether peripheral tissues might be also exposed as a result of toxic plasma levels of OCA, evaluating also the endogenous BAs biodistribution. An accurate and sensitive HPLC-ES-MS/MS method is developed to identify and quantify all BAs in biological matrices (bile, plasma, urine, liver, kidney, intestinal content and tissue) for which a sample pretreatment have been optimized.

Development of new molecular methods for the diagnosis and the study of viral diseases of fish

The increase in aquaculture operations worldwide has provided new opportunities for the transmission of aquatic viruses. The occurrence of viral diseases remains a significant limiting factor in aquaculture production and for the sustainability. The ability to identify quickly the presence/absence of a pathogenic organism in fish would have significant advantages for the aquaculture systems. Several molecular methods have found successful application in fish pathology both for confirmatory diagnosis of overt diseases and for detection of asymptomatic infections. However, a lot of different variants occur among fish host species and virus strains and consequently specific methods need to be developed and optimized for each pathogen and often also for each host species. The first chapter of this PhD thesis presents a complete description of the major viruses that infect fish and provides a relevant information regarding the most common methods and emerging technologies for the molecular diagnosis of viral diseases of fish. The development and application of a real time PCR assay for the detection and quantification of lymphocystivirus was described in the second chapter. It showed to be highly sensitive, specific, reproducible and versatile for the detection and quantitation of lymphocystivirus. The use of this technique can find multiple application such as asymptomatic carrier detection or pathogenesis studies of different LCDV strains. The third chapter, a multiplex RT-PCR (mRT-PCR) assay was developed for the simultaneous detection of viral haemorrhagic septicaemia (VHS), infectious haematopoietic necrosis (IHN), infectious pancreatic necrosis (IPN) and sleeping disease (SD) in a single assay. This method was able to efficiently detect the viral RNA in tissue samples, showing the presence of single infections and co-infections in rainbow trout samples. The mRT-PCR method was revealed to be an accurate and fast method to support traditional diagnostic techniques in the diagnosis of major viral diseases of rainbow trout.

Neurodegenerative diseases: molecular mechanisms and new strategies for neuroprotection

The term neurodegeneration defines numerous conditions that modify neuron’s normal functions in the human brain where is possible to observe a progressive and consistent neuronal loss. The mechanisms involved in neurodegenerative chronic and acute diseases evolution are not completely understood yet, however they share common characteristics such as misfolded proteins, oxidative stress, inflammation, excitotoxicity, and neuronal loss. Many studies have shown the frequency to develop neurodegenerative chronic diseases several years after an acute brain injury. In addition, many patients show, after a traumatic brain injury, motor and cognitive manifestations that are close to which are observed in neurodegenerative chronic patients. For this reason it is evident how is fundamental the concept of neuroprotection as a way to modulate the neurodegenerative processes evolution. Neuroinflammation, oxidative stress and the apoptotic process may be functional targets where operate to this end. Taking into account these considerations, the aim of the present study is to identify potential common pathogenetic pathways in neurodegenerative diseases using an integrated approach of preclinical studies. The goal is to delineate therapeutic strategies for the prevention of neuroinflammation, neurodegeneration and dysfunctions associated to Parkinson’s disease (PD) and cerebral ischemia. In the present study we used a murine model of PD treated with an isothiocyanate, 6-MSITC, able to quench ROS formation, restore the antioxidant GSH system, slow down the apoptotic neuronal death and counteract motor dysfunction induced by 6-OHDA. In the second study we utilized a transgenic mouse model knockout for CD36 receptor to investigate the inflammation involvement in a long term study of MCAo, which shows a better outcome after the damage induced. In conclusion, results in this study allow underlying the connection among these pathologies, and the importance of a neuroprotective strategy able to restore neurons activity where current drugs therapies have shown palliative but not healing abilities.

Controllo dei parassiti nel rettilario del Bioparco di Roma

Poiché le infestazioni parassitarie dei rettili in cattività possono incidere sulla loro salute, è stato condotto uno studio sui parassiti intestinali e gli ectoparassiti su 213 rettili del Bioparco di Roma. In cattività, dove gli animali sono confinati in piccoli spazi, la concentrazione di parassiti può essere più alta. Alcuni di essi sono innocui, ma altri, specialmente in associazione allo stress, possono essere pericolosi, causare malattie e portare anche alla morte se non trattati. Inoltre, i rettili parassitati hanno una vita più breve, sono più suscettibili ad altre malattie, hanno scarsa fertilità, ridotta crescita ed alta mortalità. Tra Gennaio 2012 e Dicembre 2014 sono stati raccolti campioni da 213 rettili che non mostravano alcun segno clinico e che includevano 23 specie di sauri, 20 specie di cheloni, 20 specie di ofidi e 4 specie di alligatori. I campioni sono stati esaminati per la presenza di parassiti intestinali mediante copromicroscopia di tipo qualitativo previa sedimentazione e successiva flottazione, mentre la tecnica di Zihel-Neelsen è stata usata per la ricerca di oocisti di Cryptosporidium . I campioni di feci sottoposti ad esame copromicroscopico qualitativo sono risultati positivi per almeno una tipologia di endoparassiti nel 49% dei casi. Il 35% dei campioni è risultato positivo per ossiuri, il 22% per coccidi, l’1% per strongili ed il 5% per ascaridi. Degli strisci fecali colorati con la tecnica di Zihel-Neelsen, il 25% sono risultati positivi per Cryptosporidium spp. Ossiuri e coccidi sono stati più prevalenti nei sauri rispetto ai cheloni, agli ofidi e agli alligatori e nel 14% è stata osservata la presenza di entrambi. Inoltre, per quanto riguarda gli ectoparassiti, sono state rilevate uova di Myocoptes musculinus nel 24% dei rettili esaminati. Tutti gli strisci risultati positivi per Cryptosporidium spp. sono stati inviati all’Università di Santiago de Compostela per essere sottoposti alla tecnica PCR.

Regulatory T cell-mediated suppression of Th9 cell development and effector function

T helper (Th) 9 cells are an important subpopulation of the CD4+ T helper cells. Due to their ability to secrete Interleukin-(IL-)9, Th9 cells essentially contribute to the expulsion of parasitic helminths from the intestinal tract but they play also an immunopathological role in the course of asthma. Recently, a beneficial function of Th9 cells in anti-tumor immune responses was published. In a murine melanoma tumor model Th9 cells were shown to enhance the anti-melanoma immune response via the recruitment of CD8+ T cells, dendritic cells and mast cells. In contrast to Th9 effector cells regulatory T cells (Tregs) are able to control an immune response with the aid of different suppressive mechanisms. Based on their ability to suppress an immune response Tregs are believed to be beneficial in asthma by diminishing excessive allergic reactions. However, concerning cancer they can have a detrimental function because Tregs inhibit an effective anti-tumor immune reaction. Thus, the analysis of Th9 suppression by Tregs is of central importance concerning the development of therapeutic strategies for the treatment of cancer and allergic diseases and was therefore the main objective of this PhD thesis.rnIn general it could be demonstrated that the development of Th9 cells can be inhibited by Tregs in vitro. The production of the lineage-specific cytokine IL-9 by developing Th9 cells was completely suppressed at a Treg/Th9 ratio of 1:1 on the transcriptional (qRT-PCR) as well as on the translational level (ELISA). In contrast, the expression of IRF4 that was found to strongly promote Th9 development was not reduced in the presence of Tregs, suggesting that IRF4 requires additional transcription factors to induce the differentiation of Th9 cells. In order to identify such factors, which regulate Th9 development and therefore represent potential targets for Treg-mediated suppressive mechanisms, a transcriptome analysis using “next-generation sequencing” was performed. The expression of some genes which were found to be up- or downregulated in Th9 cells in the presence of Tregs was validated with qRT-PCR. Time limitations prevented a detailed functional analysis of these candidate genes. Nevertheless, the analysis of the suppressive mechanisms revealed that Tregs probably suppress Th9 cells via the increase of the intracellular cAMP concentration. In contrast, IL-9 production by differentiated Th9 cells was only marginally affected by Tregs in vitro and in vivo analysis (asthma, melanoma model). Hence, Tregs represent very effective inhibitors of Th9 development whereas they have only a minimal suppressive influence on differentiated Th9 cells.rn

Funktionelle Charakterisierung der Protein-Kinase CK2 in der Suppression Th2-vermittelter Immunantworten durch regulatorische T-Zellen

Regulatorische T-Zellen (Tregs) leisten durch ihre suppressiven Eigenschaften einen essenziellen Beitrag zur Aufrechterhaltung der immunologischen Toleranz. Sie verhindern schädliche Immunreaktionen gegen Autoantigene, kommensale Bakterien, sowie harmlose Nahrungsmittel-bestandteile. Gleichzeitig gewährleisten sie die Entwicklung effektiver Immunantworten gegen eindringende Pathogene, wie z.B. Parasiten, Bakterien und Viren. Damit haben Tregs direkten Einfluss auf das Gleichgewicht zwischen Immunität und Toleranz. Fehler in der suppressiven Funktionsweise von Tregs begünstigen daher auf der einen Seite die Entstehung zahlreicher autoimmuner Erkrankungen und Allergien. Auf der anderen Seite können Tregs Immunreaktionen bei chronischen Infektionen reduzieren, sowie die Entstehung effektiver Immunantworten gegen Tumore hemmen. Ihre Beteiligung an der Ätiologie all dieser Krankheiten macht Tregs zu einem bedeutenden potenziellen Zielobjekt, um diese Krankheiten effektiv zu therapieren. Die Erweiterung des Grundwissens um die molekularen Mechanismen der Treg-vermittelten Suppression ist daher ein notwendiger Schritt bei der Entwicklung Treg-basierter Theraphieansätze. 2003 konnte mit Foxp3 ein Transkriptionsfaktor identifiziert werden, der maßgeblich die suppressiven Funktionen von Tregs steuert. Um weiteren Einblick in die der Suppression zugrundeliegenden Signalwege zu erhalten, wurde im Institut für Immunologie ein komparativer Kinomarray durchgeführt, anhand dessen die Casein Kinase 2 (CK2) als eine der aktivsten Kinasen in Tregs identifiziert wurde (Daten freundlicherweise von Prof. Dr. Tobias Bopp bereitgestellt). rnBasierend auf den Ergebnissen des Kinomarrays wurde in dieser Arbeit die Funktion der CK2 in Tregs untersucht. Dabei konnte in in vitro Experimenten die Treg-vermittelte Suppression durch den pharmakologische CK2 Inhibitor DMAT aufgehoben werden. Weil derartige Inhibitoren jedoch nicht absolut spezifisch die Aktivität nur einer Kinase supprimieren, wurden außerdem Mäuse mit konditionalem „knockout“ der CK2β Untereinheit spezifisch in Tregs gekreuzt (CK2βTreg-/- Mäuse). Die Analyse dieser Tiere offenbarte eine essenzielle Beteiligung der CK2 an den suppressiven Funktionen von Tregs. So entwickeln CK2βTreg-/- Mäuse mit zunehmendem Alter Splenomegalien und Lymphadenopathien, von denen in besonderem Maße die Mukosa-assoziierten Lymphknoten betroffen sind. Eine Analyse des Aktivierungsstatus der T-Zellen in den Tieren konnte zudem einen erhöhten Anteil sogenannter Effektor-Gedächtnis T-Zellen aufdecken, die charakteristische Merkmale eines Th2 Phänotyps zeigten. Erhöhte Titer des Antikörperisotyps IgE in den Seren von CK2βTreg-/- Mäusen suggerieren zusätzlich eine fehlerhafte Suppression speziell Th2-vermittelter Immunantworten durch CK2β-defiziente Tregs. In Th2-vermittelten Asthma Experimenten in vivo konnte der Verdacht der fehlerhaften Kontrolle von Th2-Antwort bestätigt werden, wobei zusätzlich aufgedeckt wurde, dass bereits unbehandelte CK2βTreg-/- Mäuse Zeichen einer Entzündungsreaktion in der Lunge aufweisen. Bei der Suche nach den molekularen Ursachen der fehlerhaften Suppression Th2-vermittelter Immunantworten durch CK2β-defiziente Tregs konnten zwei mögliche Erklärungsansätze gefunden werden. Zum einen zeigen CK2β-defiziente Tregs eine verringerte Expression von Foxp3, was, in Analogie zu Ergebnissen der Gruppe von R. Flavell (Wang Y.Y. Nature. 445, 766-770 (2007)), zu einer Konversion von Tregs zu Th2 Zellen und damit zur Entstehung eines Th2-basierten, autoimmunen Phänotyps führt. Des Weiteren weisen CK2β-defiziente Tregs eine reduzierte Expression des Transkriptionsfaktors IRF4 auf, der in Tregs entscheidend für die Kontrolle Th2-basierter Immunreaktionen ist (Zheng Y. Nature. 19; 351-356 (2009)). Die dargelegten Ergebnisse identifizieren die CK2 damit als Kinase, die entscheidend an der Treg-vermittelten Suppression speziell Th2-basierter Immunantworten beteiligt ist. Demnach könnten pharmakologische CK2 Inhibitoren beispielsweise dazu eingesetzt werden, um die Treg-vermittelte Suppression im Rahmen chronischer Parasiten-Infektionen aufzuheben. Die in CK2βTreg-/- Mäusen beobachtete Prävalenz der Funktion der CK2 für Mukosa-assoziierte Organe stellt dabei einen zusätzlichen Vorteil dar, weil systemische Nebenwirkungen, die durch die Blockade der Treg-vermittelte Suppression entstehen, zumindest in nicht-Mukosa-assoziierten Geweben nicht zu erwarten sind.rn

Neue wasserlösliche Cystein-Protease-Inhibitoren mit Aziridin-2,3-dicarbonsäure-Baustein

Die Leishmaniose gehört zu den „vernachlässigten tropischen Erkrankungen“. Sie wird durch parasitäre Protozoen der Gattung Leishmania ausgelöst. Weltweit sind ca. 12 Mio. Menschen infiziert, ca. 70 Tausend erliegen ihr jährlich. Die aktuelle Therapie wird überschattet von Toxizitäts- und Teratogenitätsproblemen und von aufkommenden Resistenzen. Die von den Leishmanien exprimierten Cysteinproteasen spielen vielfältige Rollen bei Wachstum und Vermehrung der Erreger. Aufgrund der evolutionären Verwandtschaft der Enzyme sind die parasitären Cysteinproteasen strukturell den humanen sehr ähnlich. Die Herausforderung bei der Entwicklung antiparasitärer Wirkstoffe, basierend auf der Hemmung dieser Proteasen, besteht deshalb darin, sehr selektive Inhibitoren zu entwickeln, die die Wirtsproteasen nicht, oder nur in einem vertretbaren Rahmen, inhibieren. Das Ziel dieser Arbeit war die Weiterentwicklung der Aziridin-2,3-dicarbonsäure-basierten Cysteinproteaseinhibitoren RV122C bzw. CS09 hinsichtlich Selektivität und Aktivität gegenüber der parasitären Cathepsin-L-ähnlichen Cystein-Protease LmCPB2.8 durch Design, incl. Docking, Synthese und Testung. Neben der gezielten Variation nicht essenzieller Gruppen wurde molekulares Docking mittels AutoDock Vina an Cruzain als verwandtes Modellenzym durchgeführt, um durch Variationen K.O.-Kandidaten für die Differenzierung zwischen zwei postulierten Bindungsmodi zu finden. Die Ergebnisse der Enzymassays zeigen eine Verbesserung der Hemmeigenschaften bei gleichzeitig verbesserter Selektivität sowie erhöhter ligand efficiency und ligand lipophilic efficiency für Derivate mit sterisch anspruchsvolleren Ester-Resten und für Derivate mit einer freien Carbonsäurefunktion am Aziridin-Ring (Halbester).

Blood-CNS barriers in neurodegenerative diseases

The blood-brain barrier (BBB) and the blood-spinal cord barrier (BSCB) separate the brain and the spinal cord from the circulating blood and are important for the maintenance of the CNS homeostasis. They build a physical barrier thereby protecting the CNS from pathogens and toxic agents, and their disruption plays a crucial role in the pathogenesis of several CNS disorders. In this thesis, the blood-CNS-barriers were studied via in vitro models in two case studies for neurodegenerative disorders, in particular Alzheimer’s disease (AD) and amyotrophic lateral sclerosis (ALS). The first model evaluates treatment possibilities of AD using nanotechnology-based strategies. Since the toxic amyloid-β42 (Aβ42) peptide plays a crucial role in the pathogenesis of AD, reduced generation or enhanced clearance of Aβ42 peptides are expected to modify the disease course in AD. Therefore, several Aβ42-lowering drugs like flurbiprofen had been tested in clinical trials, but most of them failed due to their low brain penetration. Here, flurbiprofen was embedded in polylactide (PLA) nanoparticles and its transport was examined in an in vitro BBB model. The embedding of flurbiprofen into the nanoparticles disguised its cytotoxic potential and enabled the administration of higher drug concentrations which resulted in a sufficient transport of the drug across an endothelial cell monolayer. These results demonstrate that non-permeable drugs can be transported efficiently via nanoparticles and that these nanotechnology-based strategies are a promising tool to generate novel therapeutic options for AD and other CNS diseases. rnThe focus of the second project was to investigate the impaired integrity of the BSCB in a mouse model for ALS. About 20% of all familial ALS cases are associated with missense mutations or small deletions in the gene that encodes Cu/Zn-superoxide dismutase 1 (SOD1). To date, the molecular mechanisms resulting in ALS are still unknown, but there is evidence that the disruption of the BSCB is one of the primary pathological events. In both familial and sporadic ALS patients, loss of endothelial integrity and endothelial cell damage was observed, and studies with SOD1 transgenic mice demonstrated that the BSCB disruption was found prior to motor neuron degeneration and neurovascular inflammation. Thus, an in vitro model for ALS endothelial cells was generated which exhibited comparable integrity characteristics and tight junction (TJ) protein expression profiles as isolated primary endothelial cells of the BSCB of SOD1 transgenic mice. In this, an alteration of the βcat/AKT/FoxO1 pathway, which regulates the expression of the TJ protein claudin-5, could be observed. These data furthermore indicate that ALS is a neurovascular disease, and understanding of the primary events in ALS pathogenesis will hopefully provide ideas for the development of new therapeutic strategies. rn

In vitro detection of cytotoxic T and NK cells in peripheral blood of patients with various drug-induced skin diseases

BACKGROUND: Cytotoxic cells are involved in most forms of drug-induced skin diseases. Till now, no in vitro test addressed this aspect of drug-allergic responses. Our report evaluates whether drug-induced cytotoxic cells can be detected in peripheral blood of nonacute patients with different forms of drug hypersensitivity, and also whether in vitro detection of these cells could be helpful in drug-allergy diagnosis. METHODS: GranzymeB enzyme-linked immunosorbent spot-forming (ELISPOT) and cell surface expression of the degranulation marker CD107a were evaluated on peripheral blood mononuclear cells from 12 drug-allergic patients in remission state and 16 drug-exposed healthy controls. RESULTS: In 10/12 allergic patients culprit but not irrelevant drug elicited granzymeB release after 48-72 h stimulation. It was clearly positive in patients with high proliferative response to the drug, measured in lymphocyte transformation tests. In patients, who showed moderate or low proliferation and low drug-response in granzymeB ELISPOT, overnight preincubation with interleukin (IL)-7/IL-15 enhanced drug-specific granzymeB release and allowed to clearly identify the offending agent. CD107a staining was positive on CD4+/CD3+, CD8+/CD3+ T cells as well as CD56+/CD3- natural killer cells. None of the drug-exposed healthy donors reacted to the tested drugs and allergic patients reacted only to the offending, but not to tolerated drugs. CONCLUSION: GranzymeB ELISPOT is a highly specific in vitro method to detect drug-reacting cytotoxic cells in peripheral blood of drug-allergic patients even several years after disease manifestation. Together with IL-7/IL-15 preincubation, it may be helpful in indentifying the offending drug even in some patients with weak proliferative drug-response.

[Swiss registry for TNF-alpha blockers in children and adolescents with rheumatological diseases]

We created a registry to evaluate long term outcome, efficacy and adverse events for children treated wit TNF-alpha inhibitors in Switzerland. 106 patients (68 female/38 male) were included. 61 patients were treated with Etanercept (Enbrel) and 45 with Infliximab (Remicade). Concomitant treatment at baseline included corticosteroids in 26% and Methotrexate in 75% of the patients. Subjective disease activity three months after initiation of TNF-alpha was better in 81%, worse in 4% and stable in 15% of the patients. In total 24 adverse events in 21 patients were reported. Treatment with TNF-alpha inhibitors seems to be safe and effective for children and adolescents with rheumatologic diseases.

Expression, regulation and clinical significance of soluble and membrane CD14 receptors in pediatric inflammatory lung diseases

BACKGROUND: Inflammatory lung diseases are a major morbidity factor in children. Therefore, novel strategies for early detection of inflammatory lung diseases are of high interest. Bacterial lipopolysaccharide (LPS) is recognized via Toll-like receptors and CD14. CD14 exists as a soluble (sCD14) and membrane-associated (mCD14) protein, present on the surface of leukocytes. Previous studies suggest sCD14 as potential marker for inflammatory diseases, but their potential role in pediatric lung diseases remained elusive. Therefore, we examined the expression, regulation and significance of sCD14 and mCD14 in pediatric lung diseases. METHODS: sCD14 levels were quantified in serum and bronchoalveolar lavage fluid (BALF) of children with infective (pneumonia, cystic fibrosis, CF) and non-infective (asthma) inflammatory lung diseases and healthy control subjects by ELISA. Membrane CD14 expression levels on monocytes in peripheral blood and on alveolar macrophages in BALF were quantified by flow cytometry. In vitro studies were performed to investigate which factors regulate sCD14 release and mCD14 expression. RESULTS: sCD14 serum levels were specifically increased in serum of children with pneumonia compared to CF, asthma and control subjects. In vitro, CpG induced the release of sCD14 levels in a protease-independent manner, whereas LPS-mediated mCD14 shedding was prevented by serine protease inhibition. CONCLUSIONS: This study demonstrates for the first time the expression, regulation and clinical significance of soluble and membrane CD14 receptors in pediatric inflammatory lung diseases and suggests sCD14 as potential marker for pneumonia in children.

Spectral-domain optical coherence tomography use in macular diseases: a review

The introduction of spectral-domain optical coherence tomography (SD-OCT) has improved the clinical value for assessment of the eyes with macular disease. This article reviews the advances of SD-OCT for the diagnostic of various macular diseases. These include vitreomacular traction syndrome, cystoid macular edema/diabetic macular edema, epiretinal membranes, full-thickness macular holes, lamellar holes, pseudoholes, microholes, and schisis from myopia. Besides offering new insights into the pathogenesis of macular abnormalities, SD-OCT is a valuable tool for monitoring macular disease.

[Molecular analyses for (early) recognition of hematologic diseases - sense and sensibility for molecular analysis: the art of intelligent decision-making]

During the last 10 years several molecular markers have been established as useful tools among the armamentarium of a hematologist. As a consequence, the number of performed hematologic molecular analyses has immensely increased. Often, such tests replace or complement other laboratory methods. Molecular markers can be useful in many ways: they can serve for diagnostics, describe the prognostic profile, predict which types of drugs are indicated, and can be used for the therapeutic monitoring of the patient to indicate an adequate response or predict resistance or relapse of the disease. Many markers fulfill more than one of these aspects. Most important, however, is the right choice of analyses at the right time-points!

Pregnancy and reproduction in autoimmune rheumatic diseases

Despite evidence for the important role of oestrogens in the aetiology and pathophysiology of chronic immune/inflammatory diseases, the previous view of an unequivocal beneficial effect of oestrogens on RA compared with a detrimental effect on SLE has to be reconsidered. Likewise, the long-held belief that RA remits in the majority of pregnant patients has been challenged, and shows that only half of the patients experience significant improvement when objective disease activity measurements are applied. Pregnancies in patients with SLE are mostly successful when well planned and monitored interdisciplinarily, whereas a small proportion of women with APS still have adverse pregnancy outcomes in spite of the standard treatment. New prospective studies indicate better outcomes for pregnancies in women with rare diseases such as SSc and vasculitis. Fertility problems are not uncommon in patients with rheumatic disease and need to be considered in both genders. Necessary therapy, shortly before or during the pregnancy, demands taking into account the health of both mother and fetus. Long-term effects of drugs on offspring exposed in utero or during lactation is a new area under study as well as late effects of maternal rheumatic disease on children.