Lupus (2017) 0, 1–11

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PAPER

Interferon alpha gene expression and serum level association with

low vitamin D levels in Egyptian female patients with systemic
lupus erythematosus
Sahar M Abdel Galil1,4, Abeer M El-Shafey1, Rehab S Abdul-Maksoud2 and Mohamed El-Boshy3
1
Rheumatology and Rehabilitation Department, Faculty of Medicine, Zagazig University, Egypt; 2Medical Biochemistry Department, Faculty of
Medicine, Zagazig University, Egypt; 3Department of Laboratory Medicine, Faculty of Applied Medical Science, Umm Al-Qura University,
Makkah, Kingdom of Saudi Arabia; and 4Medicine Department, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia

Background: Patients with systemic lupus erythematosus (SLE) are prone to develop vitamin
D (25(OH) D3) deficiency, due to several factors and there is an association between lower
vitamin D levels and higher SLE disease activity. The aim of this research was to assess the
prevalence of vitamin D deficiency in Egyptian female patients with SLE. Furthermore, we
analyzed the potential relationship between this deficiency and SLE manifestations, disease
activity, and its effect on interferon alpha (IFN-a) gene expression and serum level. Methods:
We evaluated the serum levels of vitamin D 25(OH)D3 and IFN-a by enzyme-linked immuno-
sorbent assay (ELISA). IFN-a gene expression was measured by real-time polymerase chain
reaction (PCR) assay in 123 Egyptian female patients with SLE and in 100 females as a healthy
control group. Results: Vitamin D deficiency was prevalent in 20.30%, while insufficiency was
prevalent in 42.40% of the total group of patients. Serum levels of 25(OH)D3 were signifi-
cantly decreased in the group of severe disease, and in the group of patients with lupus
nephritis. 25(OH)D3 showed highly significant negative correlation with the SLE Disease
Activity Index (SLEDAI) in the high activity group and lupus nephritis group. There was a
significant negative correlation between 25(OH)D3 and IFN-a serum level and gene expres-
sion in all patients; more significant in the group with lupus nephritis. Conclusions: The
deficiency of 25(OH)D3 has a direct relationship with increase disease activity and nephritis
in Egyptian SLE patients, suggesting the need for vitamin D supplementation in these
patients. Also, it is directly correlated with increased secretion and gene expression of IFN-
a, suggesting its role in pathogenesis of lupus nephritis, to be confirmed by further longitu-
dinal observational studies. Lupus (2017) 0, 1–11.

Key words: SLE; IFN-a; vitamin D; 25(OH)D3; disease activity; nephritis

Introduction from infants to geriatric patients.2 SLE often pre-

sents with renal involvement, with up to 10–60% of
Systemic lupus erythematosus (SLE) is an idio- patients with lupus nephritis ultimately developing
pathic connective tissue disease, characterized by end-stage renal disease.3
the production of autoantibodies which leads to Although the primary function of vitamin D is
immune complex deposition, inflammation, and the regulation of bone mineral homeostasis, several
eventually, permanent organ damage.1 data showed it as an immunosuppressive hormone
It commonly affects women of childbearing age and a regulator of the immune system.4 Vitamin D
with female: male ratio of approximately 6–10:1, receptors were found in most cells of both the
with a peak incidence between the ages of 15 and innate and the adaptive immune system, including
40 years. However, SLE can affect all age groups, macrophages, dendritic cells, B-cells and T-cells.5
Since this discovery, the concept that vitamin D
has roles in the regulation of the immune response
Correspondence to: Sahar M Abdel Galil, Faculty of Medicine,
Zagazig University, 44519 Egypt.
has emerged.6 It has been reported that 1,25-
Email: dr_saharmahfouz@yahoo.com dihydroxy vitamin D3 (24(OH)D3) inhibits inter-
Received 13 February 2017; accepted 23 May 2017 feron (IFN)-c secretion by Th1 cells, negatively
! The Author(s), 2017. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0961203317716321
 IFN-a gene expression in SLE patients
SM Abdel Galil et al.
2
regulates interleukin-12 (IL-12) production by
down-regulation of nuclear factor (NF)-kB, inhi-
bits IL-2 and granulocyte-macrophage colony-
stimulating factor, as well as in lymphocyte
proliferation.7,8
Vitamin D inhibits the adaptive immune
response and may suppress the cytokines involved
in the physiopathology of SLE. It plays an import-
ant role in the inhibition of dendritic cell matur-
ation, Th1 activity, B-cell maturation and
differentiation and Treg cell function.9 Previously,
it was documented that there is an association
between lower vitamin D levels and higher SLE
disease activity.10–12 The problem of vitamin D
deficiency/insufficiency in Egyptian patients with
SLE seems to be common in both juvenile-onset
SLE and adult patients.13 Patients with SLE are
prone to developing vitamin D deficiency, due to
several factors such as avoidance of sunshine due to
photosensitivity,14 sunscreen usage,15 chronic renal
insufficiency,16 some medications such as cortico-
steroids17 and antimalarials.18
IFN-a is a pleiotropic cytokine affecting multiple
cell types involved in pathogenesis of systemic
lupus. It can dramatically affect the development,
progression, and pathogenesis of SLE by affecting
the function and activation state of most major
immune cell subsets, thus acting as a bridge
between innate and adaptive immunity.19
Moreover, IFN-a causes myeloid dendritic cells
from lupus patients to phagocytose and present
self-antigens to T-cells in a stimulatory, rather
than a regulatory manner.20 Such a process leads
to loss of T-cell tolerance to self-antigens with sub-
sequent autoimmunity. IFN-a can prevent apop-
tosis and enhance proliferation of primary B-cells,
the main cell of humoral autoimmunity in SLE,
even in the absence of mitogenic stimuli.21
The major source of IFN-a in SLE patients are
activated dendritic cell (DCs), and vitamin D3 has
been shown to inhibit maturation/activation of
DCs and expression of IFN-a induced genes in
SLE patients.22,23 Thus, vitamin D is considered
to have an immunomodulating effects that result
in an increase or decrease in the levels of pro- and
anti-inflammatory cytokines, which may, in turn,
alter the course of SLE, influencing disease activity
and chronicity.24
In the present work, we have tried to determine
the prevalence of vitamin D deficiency/insufficiency
in Egyptian females with SLE. Also, we tried to
highlight the effect of low vitamin D on IFN-a
gene expression and serum level through its rela-
tionship with disease activity and its association
with clinical manifestations of the disease.
Lupus
Subjects and methods
Participants
This cross-sectional study included 123 Egyptian
female patients with SLE and 100 age matched
females as healthy controls. The control group
reported no history of autoimmune disease and
they were from similar geographical areas as the
patients. SLE patients were diagnosed by being
fulfilling more than four of the American College
of Rheumatology revised classification criteria
for SLE.25
Patients were recruited from inpatient sections
and outpatient clinics of Rheumatology & The
Rehabilitation Department of Zagazig University
Hospitals, Zagazig, Egypt.
The present study was approved by the Research
Ethics Committee of Zagazig University Hospitals,
and all participants provided written informed con-
sent prior to study enrollment.
All participants were nonsmokers and did not
receive vitamin D or calcium supplementation.
Patients were subjected to complete history taking
and general examination for the presenting clinical
manifestations, which were defined as either present
or absent according to the definitions in the SLE
classification criteria. According to the presence of
nephritis, our patients were classified into two
groups, with and without nephritis. Disease activity
was assessed using the SLE Disease Activity Index
(SLEDAI-2K).26 Activity categories have been
defined on the basis of SLEDAI scores: no activity
(SLEDAI ¼ 0), mild activity (SLEDAI ¼ 1–5),
moderate activity (SLEDAI ¼ 6–10), high activity
(SLEDAI ¼ 11–19) and very high activity
(SLEDAI  20).27 Accordingly, our study popula-
tion was also divided into three groups; mild, mod-
erate and high activity groups.
Serum vitamin D levels, serum IFN-a levels and
gene expression were compared between all study
populations, and correlated with the clinical mani-
festations and SLEDAI-2K scores of the disease in
all patient groups.
Laboratory investigations
Blood samples were collected from all participants.
A total of 3 ml of blood was left to clot for 30 min
at room temperature before centrifugation and sera
were separated and frozen at 20 C until analysis.
Urine samples were collected from the patient
groups. The following laboratory investigations
were performed on the patient groups; erythrocyte
sedimentation rate (ESR), urinalysis and 24-hour

urine protein, blood urea, serum creatinine and
serum complement components C3 and C4. Anti-
double stranded DNA (anti-ds-DNA) antibodies
were estimated using enzyme-linked immunosorb-
ent assay (ELISA) (Immulisa, Immco Diagnostic,
NY, USA) according to the manufacturer’s
protocol.
Measurement of serum vitamin D and IFN-
concentrations
Serum 25(OH)D3 level is the best indicator of over-
all vitamin D status, because it reflects total vitamin
D from dietary intake and sunlight exposure, as
well as the conversion of vitamin D from stores in
the liver.28 Therefore, serum 25(OH)D3 levels were
measured by a competitive ELISA (kit provided by
Immundiagnostik, USA). Values of 25(OH)D3 
20 ng/ml were considered ‘deficient’; values ranging
from 21–29 ng/ml were considered ‘insufficient’ and
levels 30 ng/ml were considered ‘sufficient’.29
Serum levels of IFN-a were measured using a
human IFN-a ELISA kit (Bender MedSystems,
CA, USA) according to the manufacturer’s instruc-
tions with some modifications. Mouse serum at 5%
was added to the assay buffer to neutralize hetero-
trophile antibodies and avoid false-positive
results.30
RNA extraction and reverse transcription
Total RNA was isolated from whole blood using
QIAamp RNA blood mini kit (Qiagen, CA, USA)
according to the manufacturer’s protocol. RNA
concentration was determined spectrophotometric-
ally at 260 nm and stored at 80 C. RNA was
reverse transcribed using QuantiTect reverse tran-
scription kit (Qiagen) according to the manufac-
turer’s instructions.
Real-time PCR assay of IFN-
The expression of IFN-a was carried out using real-
time thermal cycler (MJ Research Inc, Watertown,
Massachusetts, USA) according to Palmer et al.31
Glyceraldehyde-3 phosphate dehydrogenase
(G3PDH) was used as internal control for data nor-
malization. Primers used for PCR were as follow:
IFN-a (sense: 50 TTCCTCCTGYYTGAWGGAC
AGA-3; antisense: 50 -GATCTCATGATTTCTGC
TCTGACA-30 ), G3PDH (sense: 50 -GGTATCGT
GGAAGGACTCATGAC-30 ; antisense: 50 -ATGC
CAGTGAGCTTCCCGTTCAGC-30 ). Real-time
PCR was performed in a total volume of 20 ml
containing: 2 ml of cDNA, 10 ml of Syber Green
PCR Master Mix (Roche Diagnostics USA) and
IFN-a gene expression in SLE patients
SM Abdel Galil et al.
3
10 pmol of each primer. The cycling conditions
were as follows: 95 C for 4 min; 35 cycles of 95 C
for 30 s, 55 C for 30 s and 72 C for 30 s. A final
elongation step was performed at 72 C for
10 min. Each measurement was performed in dupli-
cate. Melting curves were performed to confirm the
specificity of PCR products. IFN-a gene expression
was calculated using the 2-
Ct method where

Ct ¼ Ct of IFN-a -Ct of GAPDH.32
Statistical analysis
All statistical analyses were performed with SPSS,
version 21.0 (IBM Corp, NY, USA).
The normality of continuous variables was estab-
lished by means of the Kolmogorov–Smirnov test.
Normally distributed variables were summarized
using the mean and standard deviation (SD). The
median and interquartile ranges (IQR) were used
for asymmetrically distributed variables. The
prevalence of vitamin D insufficiency and deficiency
was calculated as the ratio between the number of
patients with 25(OH)D3. The comparison of con-
tinuous variables of mild, moderate and severe dis-
ease groups were analyzed by means of one-way
analysis of variance and Kruskal–Wallis test of
parametric and non-parametric data respectively.
Comparisons of continuous variables between
active and inactive lupus nephritis groups were
done using the independent Student’s t-test in the
case of normal variables and the Mann–Whitney
U-test in the case of non-normal variables. The
results were considered significant at p < 0.05.
Spearman correlation coefficients were used to
evaluate the association between 25(OH)D3,
IFN-a and SLEDAI-2K.
Results
Prevalence of 25(OH)D3 in SLE patients
The demographic characteristics of the 123 SLE
female patients included in this study are summar-
ized in Table 1. The mean level of serum 25(OH)D3
was 25.96  8.21 ng/ml in all of our SLE patients.
A total of 52 of those patients (42.30%) had
25(OH)D3 insufficiency while 25 (20.30%) had
25(OH)D3 deficiencies.
Characterization of patients according to
disease severity
Demographic and clinical data (in different groups
of patients) associated with disease severity are dis-
played in Table 1. Patient ages and disease duration
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 IFN-a gene expression in SLE patients
SM Abdel Galil et al.
4

Table 1 Demographic, clinical and laboratory characteristic Table 2 Demographic, clinical and laboratory characteristic
data for all study patients data (mean  SD) between different groups of patients by
disease activity
Variable SLE (n ¼ 123) Control (n ¼ 100)
Mild Moderate High
Age year (mean  SD) 38.34  9.38 36.24  7.54 activity activity activity
Disease duration year 7.31  4.04 NA Groups n ¼ 60 n ¼ 42 n ¼ 21
(mean  SD)
SLEDAI-2K (mean  SD) 6.54  3.84 NA Age (year) 38.70  9.48a 38.19  9.90a 40.52  8.23a
C3 mg/dl (mean  SD) 47.08  15.90 125.25  25.24 Disease duration (year) 6.52  3.48a 6.81  4.58a 7.52  4.09a
C4 mg/dl (mean  SD) 19.67  7.55 45.25  12.45 SLEDAI-2K score 3.87  2.04a 6.98  1.28b 13.48  1.47c
ESR mm/hr (median  IQR) 47.16  21.00 9.51  2.1 C3 (mg/dl) 50.08  11.14a 41.47  11.45b 26.85  6.93c
Positive anti-ds-DNA, n (%) 85 (69) NA C4 (mg/dl) 22.51  6.36a 20.72  6.252a 9.43  1.94b
Anti-ds-DNA U/ml 455  221 NA Creatinine (mg/dl) 1.21  0.248b 1.25  0.241b 1.76  0.261a
(median  IQR) Urea (mg/dl) 45.65  6.06b 49.47  8.90b 58.81  8.55a
Serum creatinine mg/dl 1.32  0.33 0.95 ESR (mm/hr) 35.85  11.54c 50.36  8.57b 97.42  14.29a
(mean  SD) Anti-ds-DNA (U/ml)
Urea mg/dl (mean  SD) 49.21  8.84 29.5  5.1 Median  IQR 395  92.75c 567  170b 865  122a
Malar rash, n (%) 97 (81) NA 25(OH)D3 (ng/ml) 29.25  6.74a 27.30  5.80b 13.85  3.69c
Discoid rash, n (%) 20 (16) NA 25(OH)D3 28 (46.6) 21 (50) 3 (14.3)
Photosensitivity, n (%) 71 (58) NA insufficiency (%)
Oral ulcers, n (%) 20 (16) NA 25(OH)D3 2 (3.4) 5 (11.9) 18 (85.7)
None erosive arthritis, n (%) 50 (41) NA deficiency (%)
Serositis, n (%) 12 (10) NA IFN-a level (pg/ml) 45.60  14.62a 59.48  14.51b 85.76  13.80c
Fatigue, n (%) 97 (79) NA (mean  SD)
Renal disorders (proteinuria 51 (41.46) NA IFN-a expression 1.52  0.81a 3.51  2.36b 6.45  1.71c
and/or hematuria) (mean  SD)
Vit-D3 ng/ml (mean  SD) 25.96  8.21 45.82  9.17
Vit-D3 insufficiency (%) 52 (42.3) NA
anti-ds-DNA: anti-double stranded DNA; ESR: erythrocyte sedimen-
Vit-D3 deficiency (%) 25 (20.3) NA
tation rate; IFN: interferon; IQR: interquartile range; NA: not applic-
IFN-a level (pg/ml) (mean  SD) 57.6  20.36 10.63  3.56
able; SD: standard deviation; SLEDAI-2K: systemic lupus
IFN-a expression (mean  SD) 3.06  2.45 1.07  0.31
erythematosus disease activity index; Vit-D3: vitamin D3.
a,b,c
The mean or the median of the same raw data not followed by the
anti-ds-DNA: anti-double stranded DNA; ESR: erythrocyte sedimen- same letters differ significantly, (p < 0.05).
tation rate; IFN: interferon; IQR: interquartile range; NA: not
applicable; SD: standard deviation; SLEDAI-2K: systemic lupus ery-
thematosus disease activity index; Vit-D3: vitamin D3. Furthermore, the serum levels of IFN-a were sig-
nificantly higher in the highly active group of
patients in comparison with the mild and moderate
were not significantly different between different
groups (85.76  13.80 versus 45.60  14.62 and
groups. The SLEDAI-2K score was significantly 59.48  14.51 respectively) as shown in Table 2.
higher in the highly active group as compared
with other groups. Regarding the serum levels of IFN- gene expression
the anti-ds-DNA, ESR, serum creatinine and urea,
they were significantly elevated in highly active There was overexpression of the IFN-a gene in the
group as compared with mild and moderately SLE group compared with the control group
active groups. The high activity group had a signifi- (3.06  2.45 versus 1.07  0.31 respectively) as
cant decrease in serum levels of C3 and C4 com- shown in Table 1. When stratified by SLE disease
pared with other SLE groups. The prevalence (%) activity, the expression level was much higher in the
of 25(OH)D3 deficiency was higher among patients highly active group than in the mild and moder-
of the active group than in the mild and moderate ately active groups (6.45  1.71 versus 1.52  0.81
groups (85.7% versus 3.4% and 11.9%, respect- and 3.51  2.36 respectively) as shown in Table 2.
ively). Moreover, the prevalence of 25(OH)D3 When comparing those with and without lupus
insufficiency was 46.6%, 50% and 14.3% in mild, nephritis, IFN-a gene expression was much higher
moderate and high active SLE groups respectively. in the nephritis group in comparison with those
The serum levels of 25(OH)D3 were significantly without nephritis (5.42  2.02 versus 1.93  0.85
decreased in highly active group when compared respectively).
with mild and moderate groups (Table 2).
Regarding IFN-a serum level, it was significantly Correlation between 25(OH)D3 and SLE
higher in all SLE patients in comparison with disease activity
the healthy control group (57.6  20.36 versus There was a highly significant negative correlation
10.63  11.56 respectively) as shown in Table 1. between serum 25(OH)D3 concentration and
Lupus
 IFN-a gene expression in SLE patients
SM Abdel Galil et al.
5

Figure 1 (a) The correlation between serum IFN-a level and SLEDAI-2K in all patient group; (b) The correlation between serum
IFN-a level and SLEDAI-2K without nephritis group; (c) The correlation between serum IFN-a level and SLEDAI-2K with
nephritis group.
INF: interferon; SLEDAI: systemic lupus erythematosus disease activity index.

SLEDAI-2K scores in all SLE patients (r ¼ 0.591,
p < 0.001). This negative correlation was significant in
the moderately active group (r ¼ 0.373, p ¼ 0.014)
while highly significant in the highly active group
of patients (r ¼ 0.616, p < 0.001). Furthermore,
low serum 25(OH)D3 levels were highly signifi-
cantly inversely correlated with SLEDAI-2K score
in the nephritis group (r ¼ 0.825, p < 0.001) than
in the group without nephritis.
Correlation of serum IFN- with SLE
disease activity
Serum IFN-a levels showed a highly significant
positive correlation with SLEDAI-2K scores
(r ¼ 0.640, p < 0.001) in all SLE patients
(Figure 1(a)). Moreover, this positive correlation
with SLEDAI-2K score was more significant in
the nephritis group than in patients without
nephritis (r ¼ 0.846, p < 0.001 versus r ¼ 0.255,
p < 0.032) (Figure 1(b–c)).
Correlation of IFN- gene expression with
SLE disease activity
As shown in Figure 2(a–c), a strong positive
correlation was observed between IFN-a gene
expression and SLEDAI-2K scores (r ¼ 0.748,
p < 0.001) in all SLE patients, with a higher
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 IFN-a gene expression in SLE patients
SM Abdel Galil et al.
6

Figure 2 (a) The correlation between IFN-a expression and SLEDAI-2K in all patient group; (b) The correlation between IFN-a
expression and SLEDAI-2K without nephritis group; (c) The correlation between IFN-a expression and SLEDAI-2K with neph-
ritis group.
INF: interferon; SLEDAI: systemic lupus erythematosus disease activity index

significance in patients with nephritis (r ¼ 0.729,
p < 0.001) than in patients without nephritis
(r ¼ 0.257, p < 0.030).
Comparison between groups of patients with and
without nephritis
The ages of patients and disease durations, were
nonsignificantly different between both groups.
C3, C4 and 25(OH)D3 were significantly decreased,
while other parameters (SLEDAI-2K score, serum
creatinine, urea, 24-hour urine protein, ESR, anti-
ds-DNA, IFN-a serum level and gene expression)
were more significantly elevated in the group with
Lupus
nephritis than in that without nephritis (data not
shown).
Correlation between IFN- serum level and gene
expression with serum vitamin D3
There is a significant negative correlation between
vitamin D3 and IFN-a serum level (Figure 3(a)),
(r ¼ 0.53, p < 0.001) and gene expression
(Figure 4(a)), (r ¼ 0.454, p < 0.001) in all of our
study patients. Also, vitamin D3 was significantly
negatively correlated with both of them, more in
the nephritis group than that without nephritis
Figure 3(b–c) and Figure 4(b–c).

Figure 3 (a) The correlation between serum IFN-a level and vitamin D3 in all patient group; (b) The correlation between serum
IFN-a level and vitamin D3 without nephritis group; (c) The correlation between serum IFN-a level and vitamin D3 with nephritis
group.
INF: interferon.
Correlation of vitamin D with laboratory parameters
In the nephritis group, low 25(OH)D3 levels
showed significant negative correlation with anti-
ds-DNA (r ¼ 0.537, p < 0.001) and ESR
(r ¼ 0.649, p < 0,001), while positively correlated
with C3 (r ¼ 0.506, p < 0.001) and C4 (r ¼ 0.691,
p < 0.001), confirming its potential association
with active lupus nephritis in SLE patients.
Discussion
Association of vitamin D levels with immuno-
logical abnormalities and changes in the expression
IFN-a gene expression in SLE patients
SM Abdel Galil et al.
7
of T-helper cells and B-cells, suggests that this vita-
min can play a role in autoantibody production and
in the clinical manifestations of SLE.24,33 Low
levels of vitamin D among SLE patients were
demonstrated, first, in 1979.34 Since then; several
studies have confirmed that the majority of SLE
patients have decreased levels of vitamin D.35–37
It was mentioned that, vitamin D deficiency is
highly prevalent among SLE patients and severe
deficiency can increases the risk for moderate to
severe disease activity.38
Our results here, confirm these studies, where, we
have found that vitamin D insufficiency is prevalent
in about 42.3%, while complete deficiency was
prevalent in about 20.3% of the total SLE patients,
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 IFN-a gene expression in SLE patients
SM Abdel Galil et al.
8
Figure 4 (a) The correlation between IFN-a expression and vitamin D3 serum level in all patient groups; (b) The correlation
between IFN-a expression and vitamin D3 serum level without nephritis group; (c) The correlation between IFN-a expression and
vitamin D3 serum level with nephritis group.
INF: interferon
which is concordant with the preceding accumulat-
ing data denoting prevalence of vitamin D insuffi-
ciency and deficiency in SLE patients, of about 38–
96% and 8–30%, respectively.38
Also, in agreement with several previous stu-
dies,6,22,38–42 our results demonstrated low levels
of 25(OH)D3 to be associated with higher SLE dis-
ease activity measured by SLEDAI-2K score, while
we are contradictory to other studies which found
no association.43,44 The wide variation between dif-
ferent studies can be related to different ethnicities
of participants in each study, geographic location,
and/or seasonal variations at the time of these
studies.
Lupus
In the present study, we observed that the renal
disorders (proteinuria and/or hematuria), high
titers of anti-ds-DNA levels and lower C3, C4
levels as well as high ESR measures were associated
with a significant decrease in the mean values of
serum 25(OH)D3 concentrations, confirming its
close relation to active lupus nephritis and higher
disease activity,45–49 and in favor with the earlier
observations reporting associated low levels of
1,25(OH)2D and 25(OH)D with chronic kidney
diseases.50 On the contrary, Monticielo et al.35 did
not find any significant correlation between vitamin
D deficiency and clinical or laboratory manifest-
ations of SLE. Also, El Garf et al.13 mentioned

that, there was no significant correlation between
levels of 25(OH)D3 and disease activity index, dis-
ease manifestations (nephritis or neuropsychiatric
manifestations) or laboratory parameters (ESR,
anti-ds-DNA, low complement levels) that may
reflect the disease activity or severity in a cohort
of children with juvenile-onset SLE. This discrep-
ancy may also due to the shorter disease duration in
children with SLE than with the adults.
Several possible explanations for the vitamin D
deficiency among lupus patients have been men-
tioned before.14–18,51–53 Additionally, urinary
losses of 25(OH)D3 and D-binding protein in pro-
teinuric nephropathies, as occurred in lupus neph-
ritis, contribute to vitamin D deficiency.54 All of
these factors help in introducing SLE patients in a
vicious circle of deteriorating renal function and
descending serum level of vitamin D.
Significant elevation of IFN-a gene expression,
as well as its serum levels, in SLE patients than in
their matched healthy control (HC) group. In add-
ition to their negative correlation with serum
25(OH)D3 and more significant elevation in the
group with than that without nephritis, was
observed in our study. These results are in line
with previous studies which found that patients
with lupus have higher serum IFN-a activity as
compared with healthy unrelated individuals.55
We are also in agreement with another study per-
formed on Indian SLE patients, that showed a sig-
nificant negative correlation between 25(OH)D3
levels and plasma IFN-a levels and gene expression,
in addition to the significant negative correlation
between both of them and disease activity.39
It was proved that vitamin D acts upon inhib-
ition of dendritic cell maturation, decreasing the
expression of IFN-a induced genes in SLE
patients56 and can inhibit monocyte production of
inflammatory cytokines such as IL-1, IL-6, IL-8,
IL-12 and tumor necrosis factor (TNF)-a.57
Also, we have found IFN-a serum level signifi-
cantly elevated in patients of the nephritis group.
This is consistent with previous results reporting
higher serum IFN-a significantly prevalent in SLE
patients complaining from cutaneous and renal dis-
ease,58–60 and thus positively correlating with SLE
disease activity.19 On the other hand, it was proved
that IFN-a gene overexpression occurs in lupus
patients with low serum vitamin D compared with
individuals with normal serum vitamin D and can
be diminished after receiving vitamin D supplemen-
tation.61,62 Additionally, Castellano et al.63 con-
cluded that an IFN-a signature is detectable in
infiltrating plasmacytoid DC and renal tubular
epithelial cells in patients with lupus nephritis.
IFN-a gene expression in SLE patients
SM Abdel Galil et al.
9
This leads to local synthesis of IFN-a by primary
human renal proximal tubular cells (RPTECs). By
this autocrine loop, IFN-a might have a pathogenic
role in lupus nephritis activating pro-inflammatory
and antigen presentation pathways in RPTECs.63
The observed significant inverse relationship
between vitamin D level and IFN-a gene expression
and serum level in our study, suggests an indirect
role of vitamin D in the pathogenesis of lupus
nephritis through its effect on IFN-a secretion
and gene expression by the activated DCs.22,23,39
Conclusion
In conclusion, low levels of serum 25(OH)D3 are
commonly prevalent in SLE patients and have an
inverse relationship with SLE disease activity and
active lupus nephritis, through its effects on IFN-a
gene expression and secretion in plasma by mono-
cytes and dendritic cells. The positive correlations
between IFN-a gene expression and serum levels
with SLE disease activity, raise the possibility of
using this cytokine as a biomarker of the disease,
especially for lupus nephritis, that needs more
extended follow up and observational studies.
Vitamin D supplementations should be added as
an important supportive immunomodulatory treat-
ment besides cytotoxic, immunosuppressive and
other lines of treatment of SLE.
Declaration of conflicting interests
The authors declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
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