1623

LETTERS
HLA-DR antigens and anticardiolipin antibodies in
patients with systemic lupus erythematosus
To the Editor:
Savi and colleagues have reported an association
between HLA-DR7 and anticardiolipin antibodies (aCL),
and between HLA-DR2 and/or HLA-DR3 and anti-Ro
(SS-A) antibodies in northern Italian patients with systemic
lupus erythematosus (SLE) (I). We sought confirmation of
these findings in 46 English patients with SLE.
All patients attended the same connective tissue
disease clinic and all fulfilled the American Rheumatism
Association criteria for SLE (2). Anticardiolipin antibodies
were measured as previously described (3) using an enzyme-
linked immunosorbent assay method validated against inter-
national standards (4), and results were expressed as stan-
dard deviations. Our cutoff point for positivity was >4
standard deviations above the mean of 100 normal sera. Only
IgG aCL results were analyzed, since these are most predic-
tive of clinical events ( 3 3 , and nonspecific binding of
polyclonal IgM may account for some cases of elevated IgM
aCL (3,6). HLA-DR typing was performed using standard
microlymphocytotoxicity methods at the UK Transplant
Service, Bristol, and at the Department of Tissue Typing,
Guy’s Hospital, London. Haplotype frequencies were com-
pared with the UK Transplant Service control population.
Statistical analysis was performed using the chi-square test
with Yates’ correction.
Eight of 46 SLE patients had elevated IgG aCL
levels, of whom 7 were HLA-DR4+ (P < 0.01 compared
with aCL- SLE patients and with normal controls) (Table
1). This value did not reach significance when corrected for
the number of variables tested. The prevalence of HLA-
DR7 was slightly higher in the IgG aCL+ group and was
present in the 1 IgG aCL+, HLA-DR4- individual. These
findings differ from those of Savi et al, who found HLA-DR4
in 3 of 36 aCL+ SLE patients (less than in their aCL-
group), and HLA-DR7 in 22 of 36 aCL+ SLE patients,
compared with 4 of 44 aCL- SLE patients.
This discrepancy is unlikely to be explained by the
smaller populations studied by our group. Although both
studies included SLE populations not selected for the pres-
ence of aCL, the frequency of aCL differs considerably. This
may have occurred because IgM aCL and IgG aCL were
combined by Savi et a1 and not analyzed separately, or it
may be due to differences in the assay technique and cutoff
points for positivity, although our assay has been well
validated against international standards supplied by the
Rayne Institute, St Thomas’ Hospital (4). Other factors
accounting for this discrepancy may be different referral
patterns for SLE patients in the 2 countries, or ethnic differ-
ences in HLA frequency (e.g., lower background HLA-DR7 in
northern Italian controls). We were able to confirm previously
reported associations of anti-La (SS-B) with HLA-DR3 (7,8),
and all 6 patients heterozygous for HLA-DR2/DR3 were
positive for anti-Ro (SS-A) (P< 0.01) (8).
In conclusion, we support the concept that autoanti-
body expression in SLE is genetically determined, but unlike
Savi et al, we have found HLA-DR4, rather than HLA-
DR7, to be the more important determinant of anticardiolipin
antibody expression in our SLE population.
Neil J. McHugh, MB, ChB, FRACP
Peter J. Maddison, MD, FRCP
Royal National Hospital f o r Rheumatic Diseases
Bath, U K
Savi M, Ferraccioli GF, Neri TM, Zanelli P, Dall’aglio PP,
Tincani A, Balestrieri G, Carella G , Cattaneo R: HLA-DR
antigens and anticardiolipin antibodies in northern Italian sys-
temic lupus erythematosus patients. Arthritis Rheum 31: 156%
1570, 1988
Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield

Table 1. HLA-DR antigen and autoantibody frequencies in systemic lupus erythematosus (SLE)
patients*
Patients
HLA Anti-Ro+, Anti-Ro+, Anti-U 1
anti- Total aCL+ aCL- anti-La- anti-La+ RNP+ Controls
gen (n = 46) (n = 8) (n = 38) (n = 10) (n = 9) (n = 16) (n = 318)
DR 1 13 0 15.8 10 0 16.7 20.1
DR2 30.4 25 26.3 50 33.3 16.7 26.4
DR3 45.7 12.5 52.6 60 loot 25 26.4
DR4 34.8 873 23.7 20 0 25 36.1
DR5 6.6 0 7.9 10 0 16.7 13.5
DR6 13 0 15.8 0 22.2 16.7 19.8
DR7 24 37.5 21.1 30 11.1 41.7 27.4
DR8 2.2 0 2.6 0 0 0 4.1
DR9 2.2 12.5 0 0 0 0 1.9
DR2l3 13 0 15.8 30 33.3 0 NA
Blank 32.6 25 34.2 30 33.3 41.7 23.9
* Values are the percent positive; NA = not available.
t P < 0.01 versus SLE patients without anti-La; P < 0.001 versus controls.
f P < 0.01 versus SLE patients without anticardiolipin antibody (aCL) and versus controls.

Arthritis and Rheumatism, Vol. 32, No. 12 (December 1989)

 LETTERS

NF, Schaller JG, Talal N, Winchester RJ: The 1982 revised Table 1. HLA-DR antigen frequencies in a population of 319
criteria for the classification of systemic lupus erythematosus. northern Italian controls
Arthritis Rheum 25:1271-1277, 1982
3. McHugh NJ, Maymo J, Skinner RP, James I, Maddison PJ: HLA No. (%)
Anticardiolipin antibodies, livedo reticularis and major cere- antigen positive
brovascular and renal disease in systemic lupus erythematosus. DR I 40 (12.54)
Ann Rheum Dis 47: 110-1 15, 1988 DR2 77 (24.17)
4. Harris EN, Gharavi AE, Patel SP, Hughes GRV: Evaluation of DR3 54 (16.93)
the anticardiolipin antibody test: report of an international work- DR4 36 (11.28)
shop held on 4th April 1986. Clin Exp Immunol68:215-222. 1987 DR5 139 (43.57)
5. Hams EN, Chan JKH, Asherson RA, Aber VR, Gharavi AE, DRw6* 30 (21.43)
Hughes GRV: Thrombosis, recurrent foetal loss and thrombo- DR7 81 (25.39)
cytopenia. Arch Intern Med 146:2153-2156, 1986 DRw8 13 (4.07)
6. Cowchock S, Fort J, Munoz S, Norberg R, Maddrey W: False DR9* 4 (2.85)
positive ELISA tests for anticardiolipin antibodies in sera from DRwlOt 1 (2.00)
patients with repeated abortion, rheumatological disorders and
primary biliary cirrhosis: correlation with elevated polyclonal *n = 140.
IgM and applications for patients with repeated abortion. Clin tn = 50.
Exp Immunol73:28%294, 1988
7. Smolen JS, Klippel JH, Penner E, Reichlin M, Steinberg AD,
Chused TM, Scherak 0, Graninger W, Hartter E, Zielinski CC,
Wolf A, Davey RJ, Mann DL, Mayr WR: HLA-DR antigens in sible for the higher frequency of the DR4 antigen among
systemic lupus erythematosus: association with specificity of aCL+ English SLE patients.
autoantibody responses to nuclear antigens. Ann Rheum Dis The results obtained by McHugh and Maddison d o
46:457-462, 1987 not contradict our findings. Both DR4 and DR7 are con-
8. Hamilton RG, Harley JB, Bias WB, Roebber M, Reichlin M,
Hochberg MC, Arnett FC: Two Ro (SS-A) autoantibody re- tained in DRw53, since both of these antigens share the
sponses in systemic lupus erythematosus: correlation of HLA- DR@ chain (6). It is our view that both sets of data confirm
DWDQ specificities with quantitative expression of Ro (SS-A) that anticardiolipin antibody expression in SLE patients is
autoantibody. Arthritis Rheum 31:496505, 1988 genetically controlled by t h e HLA-DR@ gene.

Reply
To the Editor:
T h e different frequencies of anticardiolipin antibod-
ies (aCL) detected by McHugh and Maddison cannot be
attributed, in our opinion, to the methodology we used
because our test has been validated by the results of 2
different international workshops (1,2). Various investiga-
tors have previously reported different frequencies of aCL in
systemic lupus erythematosus (SLE) patients, ranging from
23% (3) t o 84% (4), and these variations may be due to
random selection of the patients. These findings confirm our
previously reported results (5).
The significance of high IgM aCL titers in SLE
patients is a subject of debate. Nonetheless, we observed
IgM positivity in only 3 of 30 patients, and of these, only 1
was DR7 + .
There are ethnic differences in HLA-DR antigen fre-
quencies between the English and northern Italian popula-
tions, primarily with regard to the DR4 and DR5 antigens
(Table 1). The DR4 antigen shows an increased frequency in
the English and a decreased frequency in northern Italians,
while the DR5 antigen shows an increased frequency in
northern Italians and a decreased frequency in the English.
However, the DR7 antigen has the same frequency in both
populations. Thus, ethnic differences may be partly respon-
M. Savi, MD
G. F. Ferraccioli, MD
T. M. Neri, MD
P. Zanelli, MD
University of Parma
Parma, Italy
A. Tincani, MD
G. Balestrieri, MD
G. Carella, PhD
R. Cattaneo, MD
Spedali Civili
Brescia , Italy
I. Hams EN, Gharavi AE, Patel SP, Hughes GRV: Evaluation of
the anticardiolipin antibody test: report of an international work-
shop held on 4th April 1986. Clin Exp lmmunol68:215-222, 1987
2. Harris EN: The second international workshop on the anticardi-
olipin antibody test. In preparation
3. McHugh NJ, Maymo J, Skinner RP, James 1, Maddison PJ:
Anticardiolipin antibodies, livedo reticularis and major cere-
brovascular and renal disease in systemic lupus erythematosus.
Ann Rheum Dis 47: 110-1 15, 1988
4. Colaco CB, Male DK: Antiphospholipid antibodies in syphilis
and a thrombotic subset of SLE: distinct profiles of epitope
specificity. Clin Exp Immunol59:449-456, 1985
5 . Tincani A, Meroni PL, Brucato A, Zanussi C, Allegri F, Mantelli
P, Cattaneo R, Balestrieri G: Antiphospholipid and antimito-
chondrial type M5 antibodies in systemic lupus erythematosus.
Clin Exp Rheumatol 3:321-325, 1985
6. Gorski J, Rollini P, Mach B: Structural comparison of the genes
of two HLA DR supertypic groups: the loci encoding DRwS2 and
DRw53 are not truly allelic. Immunogenetics 25:797-402, 1987