Objective
Diffuse alveolar hemorrhage (DAH) in lupus patients is >50% fatal. The cause is unknown. The pathogenesis of DAH in C57BL/6 mice with pristane-induced lupus, a model of human lupus-associated DAH, was examined.
Methods
Clinical/pathological and immunological manifestations DAH in pristane-lupus were compared with human DAH. Tissue distribution of pristane was examined by mass spectrometry. Cell types responsible for disease were determined by in vivo depletion using clodronate liposomes (CloLip) and anti-neutrophil monoclonal antibodies (GR1). The effect of complement depletion with cobra venom factor (CVF) was examined.
Results
After i.p. injection, pristane migrated to the lung, causing cell death, small vessel vasculitis, and alveolar hemorrhage similar to human DAH. B-cell-deficient mice were resistant to induction of DAH, but susceptibility was restored by infusing IgM. C3-deficient and CD18-deficient mice also were resistant and DAH was prevented in wild-type mice by CVF. Induction of DAH was independent of TLRs, inflammasomes, and inducible nitric oxide (iNOS). Mortality was increased in IL-10-deficient mice and pristane treatment decreased IL-10 receptor expression in monocytes and Stat3 phosphorylation in lung macrophages. In vivo neutrophil depletion was not protective, whereas treatment with CloLip prevented DAH, suggesting that macrophage activation is central to DAH pathogenesis.
Conclusion
The pathogenesis of DAH involves opsonization of dead cells by natural IgM and complement followed by complement receptor-mediated lung inflammation. The disease is macrophage-dependent and IL-10 is protective. Complement inhibition and/or macrophage-targeted therapies may reduce mortality in lupus-associated DAH.