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1.
Pancreas ; 20(1): 47-54, 2000 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-10630383

RESUMO

Because the development of insulitis and diabetes is predictable in Lyp/Lyp congenic BB rats, we have characterized early islet inflammation in these rats to determine the cell subsets involved in the onset of autoimmune insulitis. Pancreas sections from prediabetic Lyp/Lyp, Lyp/+ and +/+ rats were analyzed by immunohistochemistry. We found W3/25+ cells in the exo- and endocrine tissue from all three genotypes, but intraislet insulitis was never found in Lyp/+ or +/+ rats. The onset of massive, intraislet B- and T-cell infiltration in Lyp/Lyp rats was preceded by Rel B+ cells in and around the islets, followed by ED1+ monocytes/macrophages. Rel B+ cells were more frequent in the parafollicular cortex of pancreatic lymph nodes from Lyp/Lyp than from Lyp/+ and +/+ rats. In the Lyp/Lyp thymus, we found significantly increased expression of IL-12p40 messenger RNA (mRNA; p<0.001), located in the Rel B-protein-rich corticomedullary junction. The NF-KB/Rel B complex specifically transactivates genes involved in antigen presentation in dendritic cells. Rel B+ cells in the islets may therefore mark the onset of autoimmune insulitis and antigen-specific activation of autoreactive T cells in the lymph nodes of diabetes prone Lyp/Lyp BB rats. In the thymus, Rel B+ cells may support the Lyp-dependent development of self-reactive thymocytes by activation of cytokine expression.


Assuntos
Doenças Autoimunes/genética , Células Dendríticas/metabolismo , Diabetes Mellitus Tipo 1/genética , Regulação da Expressão Gênica , Pâncreas/patologia , Pancreatite/genética , Estado Pré-Diabético/genética , Proteínas Proto-Oncogênicas/biossíntese , Fatores de Transcrição/biossíntese , Fatores Etários , Animais , Animais Congênicos , Apresentação de Antígeno , Doenças Autoimunes/metabolismo , Doenças Autoimunes/patologia , Biomarcadores , Células Dendríticas/imunologia , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 1/patologia , Genótipo , Processamento de Imagem Assistida por Computador , Hibridização In Situ , Interleucina-12/biossíntese , Interleucina-12/genética , Ilhotas Pancreáticas/imunologia , Ilhotas Pancreáticas/metabolismo , Ilhotas Pancreáticas/patologia , NF-kappa B/metabolismo , Pâncreas/imunologia , Pâncreas/metabolismo , Pancreatite/imunologia , Pancreatite/metabolismo , Pancreatite/patologia , Estado Pré-Diabético/imunologia , Estado Pré-Diabético/metabolismo , Estado Pré-Diabético/patologia , Proteínas Proto-Oncogênicas/genética , Ratos , Ratos Endogâmicos BB , Timo/metabolismo , Timo/patologia , Fator de Transcrição RelB , Fatores de Transcrição/genética
2.
Autoimmunity ; 31(1): 15-24, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10593565

RESUMO

To investigate whether GAD65 whole molecule, GAD65 p35 or insulin B chain peptide (amino acids 9-23) play an essential role in the pathogenesis of type 1 diabetes in the BioBreeding (BB) rat, we gave serial injections of GAD65, p35 or insulin B chain (9-23) to six groups of BB/Worcester rats. The individual antigens were administered either intrathymically on day 2 and intraperitoneally in MF 59-0 adjuvant 5 times during the first 5 weeks, or by intranasal instillation once neonatally and 5 days/week for the following 6 weeks. Control groups were injected with vehicle only. Age of onset of diabetes and degree of insulitis were not different between controls and antigen-treated rats. Rats that received GAD65 intrathymically and intraperitoneally developed high GAD65-antibody titers without altering diabetes development. In GAD65-treated animals, serum antibodies recognized epitopes at 3 sites on GAD65 in diabetic animals but only at 1 site in non-diabetic animals. GAD65-injected animals also showed a significant reduction of IFN-gamma mRNA expression in the thymus. This study provides evidence against the hypothesis that GAD65 and insulin B chain peptide (9-23) are primary diabetogenic autoantigens in BB rats because immunizations with these antigens and GAD65-induced immune deviation did not alter the development of diabetes.


Assuntos
Autoantígenos/imunologia , Diabetes Mellitus Tipo 1/imunologia , Glutamato Descarboxilase/imunologia , Insulina/imunologia , Isoenzimas/imunologia , Fragmentos de Peptídeos/imunologia , Idade de Início , Animais , Anticorpos/sangue , Autoanticorpos/sangue , Citocinas/genética , Citocinas/metabolismo , Diabetes Mellitus Tipo 1/patologia , Glutamato Descarboxilase/administração & dosagem , Humanos , Processamento de Imagem Assistida por Computador , Imunização , Hibridização In Situ , Insulina/administração & dosagem , Isoenzimas/administração & dosagem , Fragmentos de Peptídeos/administração & dosagem , Radioimunoensaio , Ratos , Ratos Endogâmicos BB , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/imunologia , Timo/imunologia
3.
Autoimmunity ; 30(1): 37-42, 1999.
Artigo em Inglês | MEDLINE | ID: mdl-10433093

RESUMO

Lyp controls lymphopenia and T-cell mediated autoimmune diabetes in the BioBreeding (BB) rat possibly by interacting with T-cell maturation in the thymus. The protooncogene vav (p95) is involved in T-cell activation and in the intrathymic selection of developing T cells. We have previously reported increased production of IFN-gamma of self reactive thymocytes in the thymus medulla of Lyp/Lyp BB rats. Lymphopenia and diabetes may therefore be linked to an increase in thymocyte activation leading to a bias in thymocyte development. The purpose of this study was therefore to investigate whether the expression of p95"a" in primary lymphoid tissues from congenic Lyp/Lyp, Lyp/+ and +/+ BB rats was correlated to the Lyp genotype using in situ hybridization and reverse transcription (RT)-PCR. It was found that the expression of vav mRNA in the thymus was increased in Lyp/Lyp compared to Lyp/+ and +/+ rats (p < 0.05). Western blot analysis revealed that the amount of p95 vav protein in Lyp/Lyp thymus was also increased. The results show that vav expression correlates with the lymphopenia phenotype and diabetes development in congenic Lyp/Lyp BB rats. An increase in the availability of p95vav during the development and activation of thymocytes in Lyp/Lyp BB rats may therefore contribute to the generation of islet autoreactivity, lymphopenia or both.


Assuntos
Regulação Neoplásica da Expressão Gênica , Proteínas Oncogênicas/genética , Animais , Animais Congênicos , Western Blotting/veterinária , Colorimetria/veterinária , Primers do DNA/química , Eletroforese em Gel de Poliacrilamida/veterinária , Processamento de Imagem Assistida por Computador , Hibridização In Situ , Linfopenia/genética , Linfopenia/imunologia , Linfopenia/veterinária , Hibridização de Ácido Nucleico , Proteínas Oncogênicas/imunologia , Proteínas Proto-Oncogênicas c-vav , RNA/química , Ratos , Ratos Endogâmicos BB , Reação em Cadeia da Polimerase Via Transcriptase Reversa/veterinária , Organismos Livres de Patógenos Específicos , Timo/química , Timo/imunologia
4.
Mamm Genome ; 10(9): 883-7, 1999 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-10441739

RESUMO

The genetic etiology of Type 1 (insulin-dependent) diabetes mellitus is complicated by the apparent presence of several diabetes susceptibility genetic regions. Type 1 diabetes in the inbred BioBreeding (BB) rat closely resembles the human disorder and was previously shown to involve two genes: the lymphopenia (lyp) region on Chromosome (Chr) 4 and RT1(u) in the major histocompatibility complex (MHC) on Chr 20. In addition, a segregation analysis of an F(2) intercross between the diabetes-prone congenic BB DR(lyp/lyp, u/u) and F344(+/+,)(lv/lv) rats indicated that at least one more genetic factor was responsible for Type 1 diabetes. In this study, we generated F(2)N(2) progeny in a cross between non-diabetic F(2)(DR(lyp/lyp,u/u) x F344)(lyp/lyp,u/u) and diabetic DR(lyp/lyp, u/u) rats. In a subsequent total genome scan, a third factor was mapped to the 21.3-cM region on Chr 2 between D2Mit14 and D2Mit15 (peak LOD score 4.7 with 67% penetrance). Interestingly, the homozygosity of the BB allele (b/b) for the Chr 2 region was significantly associated with a greater weight reduction after fasting than the homozygosity of the F344 allele (f/f, p < 0.008). In conclusion, the development of Type 1 diabetes in the congenic DR(lyp/lyp) rat is controlled by at least three genes: lymphopenia, MHC, and a third factor that may play a role in metabolism and body weight regulation.


Assuntos
Peso Corporal/genética , Diabetes Mellitus Tipo 1/genética , Ratos Endogâmicos BB/genética , Animais , Animais Congênicos , Mapeamento Cromossômico , Cruzamentos Genéticos , Feminino , Humanos , Masculino , Fenótipo , Ratos , Ratos Endogâmicos BB/anatomia & histologia , Ratos Endogâmicos F344
5.
Diabetes ; 48(1): 43-9, 1999 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9892221

RESUMO

Platelet-activating factor (PAF) has been implicated in the development of type 1 diabetes. Our previous studies have suggested that PAF inhibitors reduce insulitis and the frequency of diabetes in BB rats. In this study, serum PAF levels were reduced to address the hypothesis that PAF is important for the development of insulitis. From the age of 35 days on, DP-BB rats were treated with human recombinant PAF acetylhydrolase (rPAF-AH), which efficiently inactivates PAF. Our data indicate that intraperitoneal injections of rPAF-AH reduce the incidence of diabetes in the DP-BB rat. Daily intraperitoneal injections of 6.0 mg/kg body wt rPAF-AH reduced the frequency of diabetes in saline-injected rats from 90% (27/30) to 57% (17/30) (P = 0.004). As found by morphometric analysis on pancreatic islets, DP-BB rats protected from diabetes had less severe degrees of insulitis in a dose-dependent manner. DP-BB rats protected by rPAF-AH also had a higher percentage of insulin-positive cells in pancreas sections compared with those from diabetic animals. We therefore speculated that the beta-cells were protected from insulitis by rPAF-AH.


Assuntos
Diabetes Mellitus/epidemiologia , Predisposição Genética para Doença , Fosfolipases A/farmacologia , 1-Alquil-2-acetilglicerofosfocolina Esterase , Animais , Diabetes Mellitus/fisiopatologia , Relação Dose-Resposta a Droga , Imuno-Histoquímica , Incidência , Insulina/metabolismo , Ilhotas Pancreáticas/patologia , Masculino , Pâncreas/metabolismo , Pâncreas/patologia , Pancreatite/patologia , Pancreatite/prevenção & controle , Fosfolipases A/sangue , Ratos , Ratos Endogâmicos BB , Proteínas Recombinantes , Análise de Sobrevida
7.
Diabetologia ; 40(7): 786-92, 1997 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-9243099

RESUMO

The lymphopenia gene (lyp) on rat chromosome 4 is closely linked to autoimmune diabetes in the BioBreeding (BB) rat. Lyp controls the number of peripheral lymphocytes by reducing T cells of the RT6+ phenotype by almost 90%. Following nine cycle of marker-assisted cross-intercross breeding we have developed congenic lyp/lyp, lyp/+ and +/+ (wildtype) rats on the background of DR rats. Prediabetic and insulitis free lyp/lyp, lyp/+ and +/+ rats were used to determine the effect of lyp on cytokine expression in the thymus. In situ hybridization of thymus cryosections showed that the interferon gamma (IFN gamma) mRNA expression was highest in lyp/lyp rats and the hybridization signal was restricted to the medullary compartment. The frequency of IFN gamma and interleukin (IL)-10 mRNA expressing cells in isolated thymocytes determined by quantitative image analysis, demonstrated an increased IFN gamma: IL-10 ratio in thymocytes from lyp/lyp homozygotes compared to lyp/+ and +/+ rats. This confirmed a lyp gene dose-dependent segregation of the IFN gamma high phenotype. Recombinant human glutamic acid decarboxylase (GAD65) increased the number of IFN gamma and IL-10 mRNA expressing thymocytes after in vitro culture. We conclude that the quantitative ratio of cytokine producing thymocytes is associated with the lyp genotype. These potentially autoreactive thymocytes may explain the establishment of beta-cell directed autoimmunity in the BB rat despite peripheral lymphopenia.


Assuntos
Citocinas/biossíntese , Linfopenia/genética , Linfócitos T/imunologia , Timo/imunologia , Transcrição Gênica , Animais , Células Cultivadas , Glutamato Descarboxilase/farmacologia , Homozigoto , Humanos , Interferon gama/biossíntese , Interleucina-10/biossíntese , Linfopenia/imunologia , Dados de Sequência Molecular , RNA Mensageiro/biossíntese , Ratos , Ratos Endogâmicos BB , Proteínas Recombinantes/farmacologia , Linfócitos T/efeitos dos fármacos
8.
Appl Environ Microbiol ; 62(7): 2586-92, 1996 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-16535364

RESUMO

A moderately thermostable pyranose oxidase (PROD) was purified to apparent homogeneity with a yield of 71% from mycelium extracts of the white rot fungus Phlebiopsis gigantea by an efficient three-step procedure that included heat treatment, immunoaffinity chromatography, and gel filtration on Superdex 200. PROD of P. gigantea is a glycoprotein with a pI between pH 5.3 and 5.7. The relative molecular weight (M(infr)) of native PROD is 295,600 (plusmn) 5% as determined by four independent methods. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of PROD revealed two distinct but similar stained bands corresponding to polypeptides with M(infr)s of 77,000 and 70,000, suggesting a heterotetrameric enzyme structure. The tetrameric structure of PROD was confirmed by electron microscopic examinations, which additionally showed the ellipsoidal shape (4.6 by 10 nm) of each subunit. Spectral analyses and direct determinations showed the presence of covalently bound flavin adenine dinucleotide with a stoichiometry of 3.12 mol/mol of enzyme. A broad pH optimum was determined in the range pH 5.0 to 8.0 in 100 mM sodium phosphate, and the activation energy for d-glucose oxidation was 24.7 kJ/mol. The main substrates of PROD are d-glucose, l-sorbose, and d-xylose, for which K(infm) values 1.2, 16.5, and 22.2 mM were determined, respectively. PROD showed high stability during storage. In 100 mM sodium phosphate (pH 6.0 to 8.0), the half-life of PROD activity was >300 days at 40(deg)C, >110 days at 50(deg)C (pH 7.0), and 1 h at 65(deg)C.

10.
Autoimmunity ; 19(4): 231-8, 1994.
Artigo em Inglês | MEDLINE | ID: mdl-7578849

RESUMO

By using an immunoprecipitation assay, we analysed reactivity of autoantibodies to human recombinant GAD65 and GAD67 in sera from patients with autoimmune polyendocrine syndrome Type II (APS II) with and without Type 1 (insulin-dependent) diabetes mellitus (IDDM) compared to patients with organ-specific autoimmunity. Overall antibodies to GAD65 were correlated with IDDM in all study groups, whereas GAD67 antibodies were associated with IDDM when APS II coexists. Antibodies to GAD65 and GAD67 were detected in 13 (44.8%) and 7 (24.1%) out of 29 APS II patients with IDDM, but in only 4 (13.8%) and 2 (6.9%) out of 29 APS II patients without IDDM, respectively (p < 0.05). In short-standing IDDM (< 1 year), antibodies to GAD67 were significantly more frequent in patients with APS II (5 of 9 [55.6%] subjects) compared to matched diabetic patients without coexisting polyendocrinopathy (1 of 18 [5.6%] subjects) (p < 0.02). The levels of GAD65 (142 +/- 90 AU) and GAD67 antibodies (178 +/- 95 AU) were significantly higher in patients with polyglandular disease than in patients with isolated IDDM (91 +/- 85 AU and 93 +/- 57 AU) (p < 0.02). Interestingly, all 11 GAD67 antibody positive subjects also had GAD65 antibodies (p < 0.0001), and in 10 of 11 anti-GAD67 positive sera the GAD67 antibodies could be blocked by either GAD67 or GAD65, suggesting the presence of cross-reactive autoantibodies. No correlation was observed between GAD antibodies and age, sex or any particular associated autoimmune disease, besides IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)


Assuntos
Diabetes Mellitus Tipo 1/imunologia , Glutamato Descarboxilase/imunologia , Isoenzimas/imunologia , Poliendocrinopatias Autoimunes/imunologia , Adolescente , Adulto , Idoso , Especificidade de Anticorpos , Autoanticorpos/sangue , Criança , Diabetes Mellitus Tipo 1/enzimologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peso Molecular , Especificidade de Órgãos/imunologia , Poliendocrinopatias Autoimunes/enzimologia
11.
Autoimmunity ; 17(3): 189-94, 1994.
Artigo em Inglês | MEDLINE | ID: mdl-7948603

RESUMO

Since the 64kDa-protein glutamic acid decarboxylase (GAD) is one of the major autoantigens in T-cell mediated Type 1 diabetes, its relevance as a T-cell antigen needs to be clarified. After isolation of splenic T-cells from non-obese diabetic (NOD) mice, a useful model for human Type 1 diabetes, we found that these T-cells proliferate spontaneously when incubated with human GAD65, but only marginally after incubation with GAD67, both recombinated in the baculovirus system. No effect was observed with non-diabetic NOD mice or with T-cells from H-2 identical NON-NOD-H-2g7 control mice. It has been published previously that NOD mice develop autoantibodies against a 64kDa protein detected with mouse beta cells. In immunoprecipitation experiments with sera from the same NOD mice and 35S-methionine-labelled GAD, no autoantibody binding could be detected. We conclude firstly that GAD65 is an important T-cell antigen which is relevant early in the development of Type 1 diabetes and secondly that there is an antigenic epitope in the human GAD65 molecule recognized by NOD T-cells, but not by NOD autoantibodies precipitating conformational epitopes. Our results therefore provide further evidence that GAD65 is a T-cell antigen in NOD mice, being possibly also involved in very early processes leading to the development of human Type 1 diabetes.


Assuntos
Autoanticorpos/imunologia , Diabetes Mellitus Tipo 1/imunologia , Glutamato Descarboxilase/imunologia , Linfócitos T/imunologia , Animais , Feminino , Glutamato Descarboxilase/metabolismo , Ativação Linfocitária/imunologia , Camundongos , Camundongos Endogâmicos NOD , Testes de Precipitina
12.
J Clin Invest ; 92(3): 1394-9, 1993 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-8376591

RESUMO

We investigated the presence of autoantibodies to baculovirus-expressed human recombinant 65- and 67-kD isoforms of glutamate decarboxylase (GAD65 and GAD67) in insulin-dependent diabetes mellitus (IDDM). In the immunoprecipitation test using [35S]methionine-labeled GADs antibodies to GAD65 were detected in 13/15 (87%) islet cell antibody (ICA)-positive and in 1/35 (2.9%) ICA-negative first-degree relatives of patients with IDDM, in 6/11 (54.5%) ICA-positive nondiabetic schoolchildren, and in 35/50 (70%) patients with newly diagnosed IDDM. GAD67 antibodies were positive only in five (33%) of the ICA-positive relatives (P < 0.05) and in nine (18%) IDDM patients at onset (P < 0.00001). After onset of IDDM antibodies to GAD65 and GAD67 declined but were still positive in 25 and 9.4% of subjects with long-standing IDDM (> 10 yr). In all study groups antibodies to GAD67 were only detected in GAD65 antibody-positive sera. An immunotrapping enzyme activity assay for GAD65 antibodies was positive in 64/75 (85.3%) of sera that were GAD antibody positive in the immunoprecipitation test (r = 0.870, P < 0.0001). In two (2.7%) sera GAD65 antibodies that block GAD enzyme activity were found. Our data suggest that antibodies to GAD65 but not to GAD67 represent sensitive markers for preclinical and overt IDDM. The immunotrapping assay here described represents a valuable technique for specific and sensitive screening for GAD antibodies.


Assuntos
Autoanticorpos/imunologia , Diabetes Mellitus Tipo 1/imunologia , Glutamato Descarboxilase/imunologia , Especificidade de Anticorpos , Autoantígenos/imunologia , Diabetes Mellitus Tipo 1/diagnóstico , Glutamato Descarboxilase/química , Humanos , Ilhotas Pancreáticas/imunologia , Peso Molecular , Fatores de Risco
13.
Diabetologia ; 36(5): 385-90, 1993 May.
Artigo em Inglês | MEDLINE | ID: mdl-8314441

RESUMO

Type 1 (insulin-dependent) diabetes mellitus is a T-cell mediated autoimmune disease with a number of different proteins being implicated as target autoantigens. A 38 kDa protein residing in the insulin secretory granule of insulinoma tissue is recognized by T-cell clones from a newly-diagnosed Type 1 diabetic patient. We have investigated the capacity of normal rat pancreatic beta-cell extracts and various subcellular fractions of transplantable RIN tissue to induce proliferation of T cells from non-obese diabetic (NOD) mice and H-2 identical NON.NOD-H-2g7 control mice. Normal rat islet beta-cell protein fractions induced intense, dose-dependent proliferation of NOD splenic T cells, but only marginal proliferative responses of NON.NOD-H-2g7 splenic T cells. To further localize the target antigens, four different subcellular fractions from RIN tissue were used as a source of antigen; here in particular the cytosolic proteins showed dose-dependent activation capacity with splenic T cells in NOD animals. These activities were absent in control mice. There was no proliferation after incubation with microsome preparations from other rat endocrine tissues. Purified carboxypeptidase H did not have any stimulatory activity on NOD T cells. Fractionation of the RIN cytosolic proteins showed a large number of different fractions eliciting proliferative activity. These results demonstrate that NOD T cells respond to a large number of potential islet beta-cell target antigens and it will be necessary to utilize NOD T-cell clones to identify the number and nature of these antigens.


Assuntos
Antígenos de Neoplasias/imunologia , Insulinoma/imunologia , Ilhotas Pancreáticas/imunologia , Camundongos Endogâmicos NOD/imunologia , Neoplasias Pancreáticas/imunologia , Linfócitos T/imunologia , Animais , Antígenos de Neoplasias/farmacologia , Linhagem Celular , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 1/imunologia , Feminino , Complexo Principal de Histocompatibilidade , Camundongos , Ratos , Valores de Referência , Baço/imunologia , Frações Subcelulares/imunologia , Linfócitos T/efeitos dos fármacos , Células Tumorais Cultivadas
14.
Clin Investig ; 71(4): 299-304, 1993 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-8097124

RESUMO

To determine the value of soluble intercellular adhesion molecule 1 (sICAM-1) as a measure of disease activity in patients with systemic lupus erythematosus (SLE), 25 patients with SLE were studied in an active and in a less active state. Disease activity was assessed according to the New York Hospital for Special Surgery System (NYHSS) score. The levels of sICAM-1 were significantly higher in an active than in a less active state of the disease (P < 0.001). The correlation between ICAM and the NYHSS score was r = 0.3412 (P < 0.001) and that between NYHSS index and soluble interleukin-2 receptors (sIL-2R) was r = 0.6620 (P < 0.001). There was a good correlation between levels of sICAM-1 and sIL-2R (r = 0.6792, P < 0.001). Both sICAM-1 and sIL-2R were positively and significantly correlated with an increase in the erythrocyte sedimentation rate, but only sIL-2R levels were significantly correlated with increased dsDNA antibodies and with a decrease in serum complement factor C3. Our data suggest that sICAM-1 reflects disease activity in patients with SLE, but this parameter per se should not be used to guide the therapeutic decision in SLE patients suspected of suffering from exacerbation of disease.


Assuntos
Moléculas de Adesão Celular/sangue , Lúpus Eritematoso Sistêmico/sangue , Adulto , Biomarcadores , Feminino , Humanos , Molécula 1 de Adesão Intercelular , Interleucina-2/sangue , Lúpus Eritematoso Sistêmico/imunologia , Lúpus Eritematoso Sistêmico/patologia , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença
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