<td>Under development: Not open for comment. Do not cite</td>
<td>Under Development</td>
<td>1.73</td>
<td>Included in OECD Work Plan</td>
</tr>
</tbody>
</table>
</div>
</div>
<div id="coaches">
<h2>Coaches</h2>
<ul>
<li class="contributor" id="coach_17">
Sabina Halappanavar
</li>
</ul>
</div>
<!-- Abstract Section, text as generated by author -->
<div id="abstract">
<h2>Abstract</h2>
<hr>
<p>This AOP describes the linkage between the activation of estrogen receptor (ER)α and the exacerbation of the autoimmune disease systemic lupus erythematosus (SLE). SLE is an autoimmune disease characterized by overproduction of a variety of anti-cell nuclear and other pathogenic autoantibodies. It is characterized by B-cell hyperactivity, polyclonal hypergammaglobulinemia, and immune complex deposition.</p>
<h2>Abstract</h2>
<p>This AOP describes the linkage between the binding to estrogenreceptor (ER)α in immune cells with the exacerbation of the autoimmune disease systemic lupus erythematosus (SLE).</p>
<p>Estrogen Receptors (ERs), ERα and ERβ, are a group of proteins that are activated by the steroid hormone estrogen and are widely expressed in most tissue types, including most immune cells. ERs can be activated with exogenous and endogenous estrogens. Also, there are numerous xenoestrogens that exist in the environment and imitate estrogen. Bisphenol A is an example of a xenoestrogen that is considered an endocrine disrupting compound (EDC).</p>
<p>Estrogen receptors (ERs), ERα and ERβ, are a group of proteins that are activated by the steroid hormone estrogen and are widely expressed in most tissue types, including most immune cells. ERα can be activated with exogenous and endogenous estrogens. Also, there are numerous xenoestrogens that exist in the environment and imitate estrogen. Bisphenol A (BPA) is an example of a xenoestrogen that is considered an endocrine disrupting (ED) compound. SLE is an autoimmune disease characterized by overproduction of a variety of anti-cell nuclear and other pathogenic autoantibodies. It is characterized by B-cell hyperactivity, polyclonal hypergammaglobulinemia, and immune complex deposition.</p>
<p>Estrogen Receptors (ERs), ERα and ERβ, are a group of proteins that are activated by the steroid hormone estrogen and are widely expressed in most tissue types, including most immune cells. ERs can be activated with exogenous and endogenous estrogens. Also, there are numerous xenoestrogens that exist in the environment and imitate estrogen. Bisphenol A is an example of a xenoestrogen that is considered an endocrine disrupting compound (EDC).</p>
<p>Binding to ERα in immune cells by a xenoestrogen or endogenous estrogen marks the molecular initiating event (MIE), which results in induction of GATA3 expression (KE1). One theory of immune regulation involves homeostasis between T-helper 1 (Th1) and T-helper2 (Th2) activity, however GATA3 expression induce increase of Th2 cells producing cytokine interleukin-4 (IL-4) (KE2), which results in increase of anti-DNA antibody from autoreactive B cell (KE3). This sequence of pathway means that the immune system skew from a Th1 to a Th2 profile, which results in the adverse outcome (AO) of exacerbated SLE.</p>
<p>Binding of ER in immune cells by a xenoestrogen or endogenous ER marks the molecular initiating event (MIE), which results in induction of GATA3 expression (KE1). </p>
<p>One theory of immune regulation involves homeostasis between T-helper 1 (Th1) and T-helper2 (Th2) activity. Hyperactivation of ERα skew the immune system from a T helper 1 (Th1) to a Th2 profile and exacerbates autoimmune diseases and allergic diseases.</p>
<p>Complexes formed by the binding of ERα to stressors such as estrogen or EDC transport into cell nuclei, where they activate the transcription of specific genes. Excessive ERα-activation promotes the differentiation of naive CD4+ T cells into mature Th2 cells. This pathway leads to the overproduction of the cytokine interleukin-4 (IL-4) from Th2 cells and anti-single/double-stranded DNA antibody from autoreactive B cell are increased, which results in the adverse outcome of exacerbated SLE.</p>
<p>We have identified a number of key events along this pathway and determined the key event relationships, based on which we have created an AOP for activation of ERα in immune cells leading to exacerbated SLE.</p>
<p>We have identified a number of key events along this pathway and determined the key event relationships, based on which we have created an AOP for binding to ERα in immune cells leading to exacerbated SLE.</p>
<br>
</div>
<!--Background Section, text as generated by author -->
<div id="background">
<h3>Background</h3>
<hr>
<p>It has long been appreciated that most autoimmune disorders are characterized by increased prevalence in females, suggesting a potential role for sex hormones (estrogen) in the etiology of autoimmunity. ERs are involved in a wide range of physiological function. Women generally exhibit a stronger response to a variety of antigens including ER ligands than men, which is perhaps one reason that they are more prone to develop autoimmune and allergic diseases such as SLE in greater severity than men. This AOP could be helpful to assess the type of Th2 dominant autoimmune disorders</p>
<p>Humans and mammals have two ligand-activated transcription factors that bind estrogen, encoded by separate genes, estrogen receptor alpha (ESR1/ERα) and estrogen receptor beta (ESR2/ERβ) (Maria, B. 2015). The estrogen receptors are composed of several domains important for hormone binding, DNA binding, dimer formation, and activation of transcription (Green S. 1986, Kumar V. 1986, Warnmark A. 2003). The ERs’ expression patterns and functions vary in a receptor subtype, cell- and tissue-specific manner. In the adult human, large-scale sequencing approaches show that ERα mRNA is detected in numerous human tissues, with the highest levels in the uterus, liver, ovary, muscle, mammary gland, pituitary gland, adrenal gland, spleen and heart, and at lower levels in the prostate, testis, adipose tissue, thyroid gland, lymph nodes and spleen (Fagerberg L. 2014, Sayers EW. 2012) (www.ncbi.nlm.nih.gov/UniGene). In the same data sets, human ERβ mRNA is primarily detected in the lung and testis. There is increased ERα and decreased ERβ mRNA expression in PBMCs of SLE patients (Inui A. 2007). Although ERs are widely expressed in most tissue types, including most immune cells, this AOP mainly addresses hyperactivation of ERα in immune cells.</p>
<p>The effects of ERα signaling on T cells appear to be estrogen-dose dependent, i.e., low doses of estrogen stimulate a Th1 response, but higher doses promote a Th2 response (Priyanka HP. 2013). This AOP describes events occurring when high levels of estrogen shift the Th1/Th2 balance toward increased Th2 activity．</p>
<h2>AOP Development Strategy</h2>
<div id="context">
<h3>Context</h3>
<p>It is well recognized that allergic diseases and autoimmune diseases are markedly increased the last several decades. About the same time, increasing scientific and social attention had been paid to environmentally dispersed chemicals that can enter the body by ingestion or adsorption and that mimic the actions of estrogens. These chemicals are termed endocrine disruptors (EDs) or environmental estrogens and are found in plastics (bisphenol-A, phthalates), pesticides (DDT, hexachlorobenzene, and dieldrin) and the like. Some of these estrogenic chemicals have also been shown to influence the immune system. Endocrine disruptors mimic hormones, block or alter hormone binding to receptors, or alter the metabolism of natural estrogens. It has been widely noted that females have stronger immune capabilities than males, as evidenced by their better immune responses to a variety of self-antigens and non-self-antigens, or vaccination. Paradoxically, the stronger immune response comes at a steep price, which is the high incidence of autoimmune diseases in females. This phenomenon of gender-based immune capability is largely attributed to the effects of sex hormones. Estrogens regulate the level of serum and uterine IgM, IgA, and IgG, and they augment antibody production to several nonself- antigens and self-antigens. It is possible that endocrine disruptors that mimic estrogenic activity may be involved in the increased incidence of autoimmune diseases such as SLE (Yurino H. 2004, Vaishali RM. 2018).</p>
<br>
</div>
</div>
<!-- AOP summary, includes summary of each of the events associated with this aop -->
<!-- Overall assessment section, *** what is included here? *** -->
<div id="overall_assessment">
<h2>Overall Assessment of the AOP</h2>
<p>The immune system is the most complex and sophisticated in the body's defense mechanisms . Estrogen plays a role in controlling the immune balance. Hyperactivation of ERα can skew the immune system from a Th1 to a Th2 profile. This Th1/Th2 shift is one of the most important immunologic changes during gestation and occurs due to a progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress Th1-mediated responses and stimulate Th2-mediated responses (Doria A. 2006). Incidence of flare in patients with SLE is increased during pregnancy and within the 3-months postpartum (Amanda E. 2018). Thus, ERα activation can potentially induce immunoactivation-derived adverse outcomes, one effect of which could be exacerbation of SLE. The present AOP focused on ERα activation-induced exacerbation of SLE.</p>
<p>In general, ERα is activated when bound to a stressor, which subsequently binds to estrogen response elements (EREs) to transactivate or to suppress specific target genes. In naive CD4+ T cells, T cell expansion shifts toward a Th2 phenotype that produces Th2 cytokines such as IL-4, IL-5, IL-10, and IL-13, thereby increasing antibody production from autoantibody-producing B cells. We have identified a number of key events (KE) along this pathway and used these key event relationships (KER) to create an AOP that describes the activation of ERα leading to exacerbation of SLE. </p>
<p>Ordinary estrogen levels in women are 20-30 pg/mL during diestrus, 100-200 pg/mL during estrus, and 5000-10000 pg/mL during pregnancy (Offner H. 2000). While BPA binds in some assays with less than 2000‑fold affinity compared to the binding of estradiol to estrogen receptors, it still has dramatic effects (Krishnan AV. 1993). Since each KE is quantifiable and shows similar dose responses with the stressors in vitro, the activation of ER leading to exacerbation of SLE comprise a suitable AOP. Additionally, each KER is based on sufficient scientific evidence and exhibits no contradiction with dose response of adjacent KE.</p>
<p>Since ERα expresses in the cells of a vast variety of (vertebrate) species (Maria B. 2015) and there is common functionality in the immune systems of at least humans and mice, this AOP might be applicable to many mammal species, including humans and rodents.</p>
<p>Essentiality of KEs – what would be good is to have a table listing references that have demonstrated occurrence of individual KEs and their relationship with the AO.</p>
<p> </p>
<p>Evidence assessment – here listing knockout or overexpression studies that intervene with a KE to show its essentiality to the AO</p>
<p> </p>
<p>Quantitative assessment – if you have this informaiton</p>
<p> [Otsubo2]We will reconsider it and revise later.</p>
<p> [SH3]It seems like KE1 is not needed as it is not described much.</p>
<p> </p>
<p> [Otsubo4]We want to discuss about it in WebEX meeting.</p>
<p>The proposed AOP describes the activation of ERα leading to exacerbation of SLE is dependent on estrogen level, which means it varies with life stage, sex, and age.SLE frequently develops or progresses when sympathoadrenomedullary and gonadal hormone levels are altered during pregnancy, the postpartum period, or menopause as well as during exposure to estrogen and includes the risk of preeclampsia or premature birth (Wilder RL. 1999, Whitelaw DA. 2008). Women using oral contraceptives that contain estrogen or undergoing hormone replacement therapy are susceptible to major flare ups and exacerbation of the disease (Whitelaw DA. 2007).</p>
<p>It has long been appreciated that most autoimmune disorders are characterized by increased prevalence in females, suggesting a potential role for sex hormones (estrogen) in the etiology of autoimmunity. Females generally exhibit a stronger response to a variety of antigens including ERα ligands than males, which is perhaps one reason that they are more prone to develop autoimmune and allergic diseases such as SLE in greater severity than males. Therefore, this AOP is applicable to females and is dependent on the levels of estrogen, which means it varies with life stage, and age.</p>
<p>SLE frequently develop and progress in setting in which sympathoadrenomedullary and gonadal hormone levels are changing, e.g., during pregnancy, the postpartum period, or estrogen administration in menopause (Wilder RL. 1999). Women using oral contraceptives that contain estrogen or undergoing hormone replacement therapy are susceptible to major flare ups and exacerbation of the disease (Whitelaw DA. 2007).</p>
<p>Since stressor-induced outcomes in humans are mimicked by similar responses in rodents, Th2 dominant conditions induced by activation of ERα is considered likely to occur in a variety of mammalian species.</p>
<p>The mechanisms described in this AOP are applicable to rodents and humans, and then the findings of this AOP are not found in any other species. However, Th2 dominant conditions induced by binding to ERα is considered likely to occur in a variety of mammalian species since ERα are expressed in all vertebrates (Eick GN. 2011).</p>
<h3>Essentiality of the Key Events</h3>
<p>Stressor , MIE and later events: ER knock out (KO) mice</p>
<h3>Essentiality of the Key Events</h3>
<p>Stressor , MIE and later events:</p>
<p>It has been determined in a murine model of SLE that ERα is required for disease progression and that ERα deficiency impedes the course of the disease (Bynote KK. 2008).</p>
<p>The NZB/W F1 mouse is the oldest classical model of lupus generated by the F1 hybrid between the NZB and NZW strains. The administration of the estrogen antagonist tamoxifen diminishes immune complex deposition in the kidneys and increases survival in NZB/W F1 strain. Renal disease was evaluated by the development of albuminuria and histological changes in the kidney (Wu WM. 2000). In females of the NZB/NZW F1 strain, disruption of ERα attenuated glomerulonephritis and increased survival and reduced anti-dsDNA antibodies (Bynote KK. 2008, Isenberg DA. 2007) and ovariectomy of NZB/W F1 mice not only delayed onset of the disease but also decreased autoantibody titer Meanwhile, restoration of estradiol in ovariectomized NZB/W F1 mice reestablished high numbers of autoantibody-producing (DNA-specific) B cells, and thereby suggests a pathogenic role of estrogen in lupus (Daniel P. 2011). Both NZB and NZW display limited autoimmunity, while NZB/W F1 hybrids develop severe lupus-like phenotypes comparable to that of lupus patients. In NZM female mice, ERα inactivation markedly prolonged life-span, lowered proteinuria, and ameliorated glomerulonephritis but resulted in higher serum anti-dsDNA antibody levels (Svenson JL. 2008).</p>
<p> </p>
<p>The NZB/W F1 mouse is the oldest classical model of lupus generated by the F1 hybrid between the NZB and NZW strains. Both NZB and NZW display limited autoimmunity, while NZB/W F1 hybrids develop severe lupus-like phenotypes comparable to that of lupus patients. SLE in the NZB/W F1 strain is strongly biased toward females, and this is at least in part due to estrogen levels. Indeed, ovariectomy of NZB/W F1 mice not only delayed onset of the disease but also decreased autoantibody titer. Meanwhile, restoration of estradiol in ovariectomized NZB/W F1 mice reestablished high numbers of autoantibody-producing (DNA-specific) B cellsDNA-specific B cells, and thereby suggests a pathogenic role of estrogen in lupus (Daniel P. 2011).</p>
<p>KE1 and later events:</p>
<p>In females of the lupus-prone NZB/NZW F1 strain, disruption of estrogen receptor-α (ERα or Esr1) both attenuated glomerulonephritis and increased survival. ERα deficiency also retarded development of anti-histone/DNA antibodies, suggesting that ERα promotes loss of immunologic tolerance. The presence of many autoantibodies is a hallmark of SLE. In particular, autoantibodies directed to double-stranded DNA (dsDNA) are characteristic (Isenberg DA. 2007). ERα deficiency in NZB/NZW F1 males increased survival and reduced anti-dsDNA antibodies, suggesting that ERα also modulates lupus in males (Bynote KK. 2008).</p>
<p>GATA3 mRNA expression has potential to induced IL-4 production in CD4+T cell (Lambert KC. 2005). The differentiation of activated CD4+T cells into the T helper type 1 (Th1) or Th2 fate is regulated by cytokines and the transcription factors T-bet and GATA-3. Early GATA-3 expression, required for Th2 differentiation, was induced by T cell factor 1 (TCF-1) and its cofactor β-catenin, mainly from the proximal Gata3 promoter upstream of exon 1b. TCF-1 blocked Th1 fate by negatively regulating interferon-γ (IFN-γ) expression independently of β-catenin. Thus, TCF-1 initiates Th2 differentiation of activated CD4+T cells by promoting GATA-3 expression and suppressing IFN-γ expression. Higher GATA-3 expression promotes IL-4 production and initiates Th2 differentiation (Qing Y. 2009). GATA-3 mRNA expression also increased in patients with SLE, compared with the healthy control groups (Zheng H. 2015, Sonia GR. 2012).</p>
<p> </p>
<p>KE1 and later events: Stat6 KO mice</p>
<h4>KE2 and later events:</h4>
<p>CD4 T cells from Stat6-knockout mice are not able to drive Th2 differentiation and cell expansion under null Th cell (ThN) conditions with added with IL-4 (Zhu J. 2001)</p>
<p>Administration of mAb against IL-4 before the onset of lupus was effective in preventing the onset of lupus nephritis (Nakajima A. 1997).</p>
<p> </p>
<p>KE1 and later events: GATA3 KO mice</p>
<p>KE3 and later events:</p>
<p>Th2 differentiation is completely abolished both in vitro and in vivo when GATA3 is conditionally deleted in peripheral CD4 T cells. Th2 cells from both knockout animals showed reduction in IL-4, IL-5, IL-13, and IL-10 production. Conversely, IFN-γ production was increased even under Th2 conditions (Zhu J. 2004, Pai SY. 2004).</p>
<p>In a study to investigate a novel subpopulation of B-1 cells and its roles in murine lupus, anti-double-stranded DNA (anti-dsDNA) autoantibodies were preferentially secreted by a subpopulation of CD5+ B-1 cells that expressed programmed death ligand 2 (L2pB1 cells) (Xuemei Z. 2009). A substantial proportion of hybridoma clones generated from L2pB1 cells reacted to dsDNA. L2pB1 cells are potent antigen-presenting cells and a dramatic increase of circulating L2pB1 cells in lupus-prone BXSB mice correlates with elevated serum titers of anti-dsDNA antibodies (Xuemei Z. 2009).</p>
<td>MIE=>KE 1：Binding, Estrogen receptor α in immune cells leads to Induction, GATA3 expression</td>
<td>
<p>Empirical support of the MIE => KE1 is weak.</p>
<p>Rationale：</p>
<p>MIE: XXX</p>
KE XX: XXXX</td>
</tr>
<tr>
<td>KE 1=> KE 2: Induction, GATA3 expression leads to Increase, Th2 cells producing IL-4</td>
<td>
<p>Empirical support of the KE 1=> KE 2 is strong.</p>
<p>Rationale：</p>
<p>KE XX: XXXX</p>
AO: XXXX</td>
</tr>
<tr>
<td>KE 2=> KE 3: Increase, Th2 cells producing IL-4 leads to Increase, anti-DNA antibody production from autoreactive B cell</td>
<td>
<p>Empirical support of the KE 2=> KE 3 is weak.</p>
<p>Rationale：</p>
<p>KE XX: XXXX</p>
AO: XXXX</td>
</tr>
<tr>
<td>KE 3=>AO: Increase, antibody production from anti-DNA antibody production from autoreactive B cell leads to Exacerbation, systemic lupus erythematosus (SLE)</td>
<td>
<p>Empirical support of the KE 3 => AO is strong.</p>
<p>Rationale：</p>
<p>KE XX: XXXX</p>
AO: XXXX</td>
</tr>
</tbody>
</table>
<p> </p>
<h3>Quantitative Consideration</h3>
<p>KER1：</p>
<p>CD4<sup>+</sup>T cell expressed GATA3 mRNA cultured with 10<sup>-9</sup> M (272.4 pg/mL) concentrations of 17β-estradiol for 12-16 hr (Lambert KC. 2005). </p>
<p>BPA (0.1 mM) also indirectly induced GATA3 expression of Th cells, and this effect is mediated by dendritic cells exposed to BPA for 24 hr (Guo H. 2010). Naïve Th cells increased GATA3 expression cultured with dendritic cells exposure of BPA (0.1 mM) for 7 days.</p>
<p> </p>
<p>KER2：</p>
<p>Pre-stimulation 16 hr of 17β-estradiol (the concentration 10<sup>-9</sup> M = 272.4 pg/mL) increased IL-4 secretion from CD4<sup>+</sup>T cell (Lambert KC. 2005). </p>
<p> </p>
<p>KER3：</p>
<p>PBMCs or B cells were cultured for 7 days with 17β-estradiol (10<sup>–8</sup> mol/L) and then, IgG and IgM production were increased up to about 150% (PBMC) and 200% (B cells) (Kanda N. 1999).</p>
<p> </p>
<p>KER4：</p>
<p>XXXX</p>
</div>
<!-- potential consierations, text as entered by author -->
<!-- reference section, text as of right now but should be changed to be handled as table -->
<div id="references">
<h2>References</h2>
<hr>
<ol>
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<li>Inui A, Ogasawara H, Ogawa H, et al. Estrogen receptor expression by peripheral blood mononuclear cells of patients with systemic lupus erythematosus. Clin Rheumatol. 2007;26(10):1675-8.</li>
<li>Sayers EW, Barrett T, Federhen S, et al. Database resources of the National Center for Biotechnology Information. Nucleic acids research. 2012; 40: D13-25.</li>
<li>Priyanka HP, Krishnan HC, Singh RV, Hima L, Thyagarajan S. Estrogen modulates in vitro T cell responses in a concentration- and receptor-dependent manner: effects on intracellular molecular targets and antioxidant enzymes. Mol Immunol. 2013;56(4):328-39.</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-56.</li>
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<li>Vaishali RM. Sex Hormones in Acquired Immunity and Autoimmune Disease. Frontiers in Immunology 2018. 9: 2279; 1-21.</li>
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<li>Whitelaw DA, Jessop SJ. Major flares in women with SLE on combined oral contraception. Clin Rheumatol. 2007; 26(12):2163-2165.</li>
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<li>Wu WM, Lin BF, Su YC, et al. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
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<li>Qing Y., Archna S., Sun Y. O., Hyung-Geun M., M Zulfiquer H., Theresa M. S., Karen E. L., Hansen D., Beibei W., Marian L. W., Zhou Z. and Jyoti M. S., T cell factor 1 initiates the T helper type 2 fate by inducing the transcription factor GATA-3 and repressing interferon-γ. Nat Immunol. 2009; 10(9): 992–999.</li>
<li>Zheng H, Guo X, Zhu Y, et al., Distinct role of Tim-3 in systemic lupus erythematosus and clear cell renal cell carcinoma. Int J Clin Exp Med 2015;8(5):7029-7038.</li>
<li>Sonia GR, et al. Altered AKT1 and MAPK1 Gene Expression on Peripheral Blood Mononuclear Cells and Correlation with T-Helper-Transcription Factors in Systemic Lupus Erythematosus Patients. Mediators of Inflammation 2012, Article ID 495934</li>
<li>Nakajima A, Hirose S, Yagita H and Okumura K, Roles of IL-4 and IL-12 in the development of lupus in NZB/W F1 mice. J Immunol 1997; 158 (3) 1466-1472.</li>
<li>Xuemei, Z., Stanley, L., et al. (2009). A Novel Subpopulation of B-1 Cells Is Enriched with Autoreactivity in Normal and Lupus-Prone Mice. Arthritis & Rheumatology 60 (12):3734-3743.</li>
<li>Guo H, Liu T, Ling F, et al. Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity. Cell Mol Immunol. 2010;7(3):227-34.</li>
<li>Kanda N. and Tamaki, K. (1999). Estrogen enhances immunoglobulin production by human PBMCs. The Journal of Allergy and Clinical Immunology 103(2): 282-288.</li>
</ol>
<br>
</div>
<div id="appendicies">
<h2>Appendix 1</h2>
<h3>List of MIEs in this AOP</h3>
<div>
<div>
<h4><a href="/events/1710">Event: 1710: Activation of estrogen receptor in immune cells</a><br></h4>
<h5>Short Name: Activation of estrogen receptor</h5>
</div>
<h4><a href="/events/1710">Event: 1710: Binding to estrogen receptor (ER)-α in immune cells</a></h4>
<h5>Short Name: Binding to estrogen receptor (ER)-α</h5>
<div>
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<td><a href="/aops/314">Aop:314 - Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<p>ERα is mainly expressed in uterus, prostate (stroma), ovary (theca cells), testes (Leydig cells), epididymis, bone, breast, various regions of the brain, liver, and white adipose tissue (Dahlman-Wright K. 2006). ERs is widely expressed in most tissue types including most immune cells (Couse JF. 1997). ERα and ERβ show a high degree of similarity when compered at the amino acid level (Dahlman-Wright K. 2006). Interspecies sequence identities for the entire ERα receptor are 88.5% (human-mouse), 87.5% (human-rat), and 97.5% (mouse-rat). For the ligand binding domain (ERα-LBD) alone, the interspecies sequence identities are 95.5% (human-mouse), 95.1% (human-rat), and 99.2% (mouse-rat) (White R. 1987). ERα is found in female reproductive organs, yet is robustly expressed in kidney, liver, heart, and lungs in males and females, as well as on most immune cells (Chelsea C. 2017).</p>
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<h4>Key Event Description</h4>
<p>Estrogen receptor alpha (ERα) was discovered in the late 1960s and was cloned and characterized in 1985 (Melissa C. 2011). ERα and ERβ show a high degree of similarity when compared at the amino acid level (Dahlman-Wright K. 2006). 17β-estradiol (E2) activates ERα and ERβ with the same affinity although they share only 56% similarity in their ligand binding domains (Monroe DG. 2005, Papoutsi Z. 2009). The hormone binding domain of the estrogen receptor is required not only for binding estradiol but also to form stable homodimers of the protein and mediate transcriptional activation by the receptor. A direct genomic interaction occurs between the estrogen receptor (ER) ligand complex and specific sequences of DNA known as estrogen response elements (ERE). (Parker MG. 1993, Goldstein RA. 1993, Sasson S. 1991, Brandt ME. 1997). Transcriptional activation by ERα is mediated by two distinct activation functions: the constitutively active AF-1 domain, located in the N-terminal domain of the receptor protein, and the ligand-dependent AF-2 domain, located in the C-terminal domain of the receptor protein (Delaunay F. 2000). In addition to above classical mechanism, ERα is also able to play roles both in ER binding and transcriptional activation; phosphorylation of ER and other proteins involved in transcriptional activation with cellular amounts of coactivators and adaptor proteins (Carolyn MK. 2001).</p>
<p>ERs are expressed in a variety of immunocompetent cells, including CD4+ (Th1, Th2, Th17, and Tregs) and CD8+ cells and macrophages (Salem ML. 2004, Robinson DP. 2014). One recent study examined ERα expression in resting and activated PBMC subsets and found that ERα was expressed at higher levels in CD4+ T cells than B cells (Melissa C. 2011).</p>
<p>Since ERα expresses in the cells of a vast variety of (vertebrate) species (Maria B. 2015) and there is common functionality in the immune systems of at least humans and mice, this AOP might be applicable to many mammal species, including humans and rodents. The estrogen receptors are composed of several domains important for hormone binding, DNA binding, dimer formation, and activation of transcription (Green S. 1986, Kumar V. 1986, Warnmark A. 2003). Interspecies sequence identities for the entire ERα are 88.5% (human-mouse), 87.5% (human-rat), and 97.5% (mouse-rat). For the ligand binding domain (ERα-LBD) alone, the interspecies sequence identities are 95.5% (human-mouse), 95.1% (human-rat), and 99.2% (mouse-rat) (White R. 1987).</p>
<p> </p>
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<h4>How it is Measured or Detected</h4>
<p>Recombinant human estrogen receptor hormone-binding domain (HBD) fragment is isolated from Escherichia coli. Purified HBD peptide is assayed for their ability to bind estradiol, [3H] estradiol binding using low concentrations (0.15 nM), by Radioreceptor Assay. Moreover HBD dimer dissociation is measured using size exclusion chromatography (Brandt ME. 1997).</p>
<p>ERα is widely expressed in most tissue types including most immune cells in males and females (Couse JF. 1997, Chelsea C. 2017). The ERs’ expression patterns and functions vary in a receptor subtype, cell- and tissue-specific manner. In the adult human, large-scale sequencing approaches show that ERα mRNA is detected in numerous human tissues, with the highest levels in the uterus, liver, ovary, muscle, mammary gland, pituitary gland, adrenal gland, spleen and heart, and at lower levels in the prostate, testis, adipose tissue, thyroid gland, lymph nodes and spleen (Fagerberg L. 2014, Sayers EW. 2012) (www.ncbi.nlm.nih.gov/UniGene).</p>
<p>On the other hand, a conditionally active form of STAT (the signal transducers and activator of transcription) 6 by fusing the HBD of a modified form of the mouse estrogen receptor (ER) gene is prepared as STAT6-ER fusion protein (STAT6:ER). 4-Hydroxytamoxifen (4-HT), estrogen analogue, (Research Biochemicals Institute, Natick, MA) was used to activate STAT6 fusion protein. M12.4.1 cells, transfected with the luciferase reporter gene by inserting three copies of human STAT6 binding site oligonucleotide, are used nuclear extracts and electrophoretic mobility shift assay (EMSA) with 1 μM 4HT. STAT6:ER DNA-binding activity is strongly and rapidly (within 1 hr) induced after addition of 4HT to these cells. BA/F3 cells prepared as the same manner are stimulated with 1 μM 4HT for 24 h at 37°C. The cells were harvested and assayed for luciferase activities using a Luciferase Assay Kit (Promega, Madison, WI). (Kamogawa et al. 1998).</p>
<p>Estrogen level is higher in women than men. Ordinary estrogen levels in women are 20-30 pg/mL during diestrus, 100-200 pg/mL during estrus, and 5000-10000 pg/mL during pregnancy (Offner H. 2000). Therefore, the influence of ligand binding to ERα in immune cells is expressed more strong in women than men, especially high estrogen level period.</p>
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<h4>Key Event Description</h4>
<p>ERα is expressed in all vertebrates (Eick GN. 2011). ERα was discovered in the late 1960s and was cloned and characterized in 1985 (Melissa C. 2011). ERα is expressed in a variety of immunocompetent cells, including thymocytes, CD4+ (Th1, Th2, Th17, and Tregs) and CD8+ cells and macrophages (Melissa C. 2011, Salem ML. 2004, Robinson DP. 2014). One study examined ERα expression in resting and activated PBMC subsets and found that ERα was expressed at higher levels in thymocytes, CD4+ T cells than B cells (Melissa C. 2011). ERα is a nuclear hormone transcription factor that classically binds with ligand (stressors), further stabilizing dimers that subsequently bind estrogen response elements (ERE) or non-ERE to transactivate or suppress specific target genes (Parker MG. 1993, Goldstein RA. 1993, Sasson S. 1991, Brandt ME. 1997, Carolyn MK. 2001).</p>
<h4>How it is Measured or Detected</h4>
<p>The binding affinities of E<sub>2</sub> and BPA for ERα can be confirmed by radio receptor assay, and its dimer dissociation is measured using size exclusion chromatography (Brandt ME. 1997, Takayanagi S. 2006, OECD TG440 [<em>in vivo</em>] and TG455 [<em>in vitro</em>]). While the binding affinities of PPT for ERα was determined by competitive radiometric binding assays by chemiluminescence (Kraichely DM. 2000, Carlson KE. 1997).</p>
<h4>References</h4>
<ol>
<h4>References</h4>
<ol>
<li>Eick GN, Thornton JW. Evolution of steroid receptors from an estrogen-sensitive ancestral receptor. Molecular and cellular endocrinology. 2011; 334: 31-38.</li>
<li>Melissa, C. and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40:66-73.</li>
<li>Dahlman-Wright, K., Cavailles, V., Fuqua, S. A., Jordan, V. C., Katzenellenbogen, J. A., Korach, K. S., Maggi, A., Muramatsu, M., Parker M. G. and Jan-Åke, G. (2006). International Union of Pharmacology. LXIV. Estrogen Receptors. Pharmacological Review 58: 773-781.</li>
<li>Monroe DG, Secreto FJ, Subramaniam M, Getz BJ, Khosla S, Spelsberg TC. Estrogen receptor alpha and beta heterodimers exert unique effects on estrogen- and tamoxifen-dependent gene expression in human U2OS osteosarcoma cells. Molecular endocrinology (Baltimore, Md). 2005; 19:1555–1568.</li>
<li>Papoutsi Z, Zhao C, Putnik M, Gustafsson JA, Dahlman-Wright K. Binding of estrogen receptor alpha/beta heterodimers to chromatin in MCF-7 cells. J Mol Endocrinol. 2009; 43:65–72.</li>
<li>Salem ML. (2004). Estrogen, a double-edged sword: modulation of Th1- and Th2-mediated inflammations by differential regulation of Th1/Th2 cytokine production. Current Drug Targets - Inflammation & Allergy 3(1): 97-104.</li>
<li>Robinson DP, Hall, O. J., Nilles, T. L., Bream, J.H. and Klein, S.L. (2014). 17β-estradiol protects females against influenza by recruiting neutrophils and increasing virus-specific CD8 T cell responses in the lungs. Journal of Virology 88 (9): 4711-4720.</li>
<li>Parker MG, Arbuckle N, Dauvois S, Danielian P, White R. Structure and function of the estrogen receptor. Ann N Y Acad Sci. 1993. 684:119-26.</li>
<li>Goldstein RA, Katzenellenbogen JA, Wolynes PG, et al. Three-dimensional model for the hormone binding domains of steroid receptors. Proc Natl Acad Sci. 1993;90(21):9949-53.</li>
<li>Goldstein RA, Katzenellenbogen JA, Wolynes PG, et al. Three-dimensional model for the hormone binding domains of steroid receptors. Proc Natl Acad Sci. 1993;90(21):9949-53.</li>
<li>Sasson S. Equilibrium binding analysis of estrogen agonists and antagonists: relation to the activation of the estrogen receptor. Pathol Biol (Paris). 1991;39(1):59-69.</li>
<li>Brandt ME, Vickery LE. Cooperativity and dimerization of recombinant human estrogen receptor hormone-binding domain. J Biol Chem. 1997;272(8):4843-9.</li>
<li>Delaunay, F., Pettersson, K., Tujague, M., and Gustafsson, J. A. (2000). Functional Differences between the Amino-Terminal Domains of Estrogen Receptors α and β. Molecular Pharmacology 58: 584-590.</li>
<li>Salem M. L. (2004). Estrogen, a double-edged sword: modulation of TH1- and TH2-mediated inflammations by differential regulation of TH1/TH2 cytokine production. Current Drug Targets - Inflammation & Allergy 3(1): 97-104.</li>
<li>Robinson, D. P., Hall, O. J., Nilles, T. L., Bream, J.H. and Klein, S.L. (2014). 17β-estradiol protects females against influenza by recruiting neutrophils and increasing virus-specific CD8 T cell responses in the lungs. Journal of Virology 88 (9): 4711-4720.</li>
<li>Kamogawa, Y., Lee, H.J., Johnston, J.A., McMahon, M., O’Garra, A., and Arai, N. (1998). Cutting Edge: A conditionally active form of STAT6 can mimic certain effects of IL-4. J. Immunol. 161, 1074–1077.</li>
<li>Couse JF, Lindzey J, Grandien K, Gustafsson JA, Korach KS. (1997) Tissue distribution and quantitative analysis of estrogen receptor-alpha (ERalpha) and estrogen receptor-beta (ERbeta) messenger ribonucleic acid in the wild-type and ERalphaknockout mouse. Endocrinology 138(11):4613–4621.</li>
<li>White, R., Lees, JA., Needham, M., Ham, J. and Parker, M. (1987). Structural Organization and Expression of the Mouse Estrogen Receptor. Molecular Endocrinology 1 (10): 735–744.</li>
<li>Chelsea, C., Neelakshi, R., J., Matteo C., Michael, M., x. and Roberto C. (2017). Estrogen Receptor a Signaling Exacerbates Immune-Mediated Nephropathies through Alteration of Metabolic Activity. The Journal of Immunology 200:512-522</li>
<li>Takayanagi, S. Tokunaga, T., et al. (2006). Endocrine disruptor bisphenol A strongly binds to human estrogen-related receptor γ (ERRγ) with high constitutive activity. Toxicology Letters, 167 (2):95-105.</li>
<li>OECD Guideline for the Testing of Chemicals [Test No. 440: Uterotrophic Bioassay in Rodents]</li>
<li>OECD Guideline for the Testing of Chemicals [Test No. 455: <a href="https://www.oecd-ilibrary.org/environment/test-no-455-performance-based-test-guideline-for-stably-transfected-transactivation-in-vitro-assays-to-detect-estrogen-receptor-agonists-and-antagonists_9789264265295-en">Performance-Based Test Guideline for Stably Transfected Transactivation In Vitro Assays to Detect Estrogen Receptor Agonists and Antagonists</a>]</li>
<li>Kraichely, DM. Sun, J. Katzenellenbogen, JA. Katzenellenbogen, BS. (2000). Conformational changes and coactivator recruitment by novel ligands for estrogen receptor-α and estrogen receptor-β: correlations with biological character and distinct differences among SRC coactivator family members. Endocrinology, 141 (10):3534–3545.</li>
<li>Carlson, KE. Choli, I. Gee, A. Katzenellenbogen, BS. Katzenellenbogen, JA. (1997) Altered Ligand Binding Properties and Enhanced Stability of a Constitutively Active Estrogen Receptor:  Evidence That an Open Pocket Conformation Is Required for Ligand Interaction. Biochemistry, 36:14897-14905.</li>
<li>Maria, B., Ruixin, H., Chin-Yo, L., Cecilia, W., Jan-Ake, G. (2015). Estrogen receptor signaling during vertebrate development. Biochim Biophys Acta 1849: 142-151.</li>
<li>Green S, Walter P, Chambon P, et al. Human oestrogen receptor cDNA: sequence, expression and homology to v-erb-A. Nature. 1986; 320:134-139.</li>
<li>Kumar V, Green S, Chambon P, et al. Localisation of the oestradiol-binding and putative DNA-binding domains of the human oestrogen receptor. The EMBO journal. 1986; 5: 2231-2236.</li>
<li>Warnmark A, Treuter E, Gustafsson JA, et al. Activation functions 1 and 2 of nuclear receptors: molecular strategies for transcriptional activation. Molecular endocrinology (Baltimore, Md). 2003; 17:1901-1909.</li>
<li>White, R., Lees, JA., Needham, M., Ham, J. and Parker, M. (1987). Structural Organization and Expression of the Mouse Estrogen Receptor. Molecular Endocrinology 1 (10): 735-744.</li>
<li>Couse JF, Lindzey J, Grandien K, Gustafsson JA, Korach KS. (1997) Tissue distribution and quantitative analysis of estrogen receptor-alpha (ERalpha) and estrogen receptor-beta (ERbeta) messenger ribonucleic acid in the wild-type and ERalphaknockout mouse. Endocrinology 138(11):4613-4621.</li>
<li>Fagerberg L, Hallstrom BM, Edlund K, et al. Analysis of the human tissue- specific expression by genome-wide integration of transcriptomics and antibody-based proteomics. Molecular & cellular proteomics. 2014; 13:397-406.</li>
<li>Sayers EW, Barrett T, Federhen S, et al. Database resources of the National Center for Biotechnology Information. Nucleic acids research. 2012; 40: D13-25.</li>
<li>Offner H, Adlard K, Zamora A, Vandenbark AA. Estrogen potentiates treatment with T-cell receptor protein of female mice with experimental encephalomyelitis. J Clin Invest. 2000;105(10):1465-72.</li>
<li>Monroe DG, Secreto FJ, Subramaniam M, Getz BJ, Khosla S, Spelsberg TC. Estrogen receptor alpha and beta heterodimers exert unique effects on estrogen- and tamoxifen-dependent gene expression in human U2OS osteosarcoma cells. Molecular endocrinology (Baltimore, Md). 2005; 19:1555–1568.</li>
<li>Papoutsi Z, Zhao C, Putnik M, Gustafsson JA, Dahlman-Wright K. Binding of estrogen receptor alpha/beta heterodimers to chromatin in MCF-7 cells. J Mol Endocrinol. 2009; 43:65-72.</li>
<li>Okasha SA, Ryu S, Do Y, McKallip RJ, Nagarkatti M, Nagarkatti PS. Evidence for estradiol-induced apoptosis and dysregulated T cell maturation in the thymus. Toxicology. 2001, 163 (1):49-62.</li>
<li>Takayanagi S, Tokunaga T, Liu X, Okada H, Matsushima A, Shimohigashi Y. Endocrine disruptor bisphenol A strongly binds to human estrogen-related receptor γ (ERRγ) with high constitutive activity. Toxicology Letters, 2006, 167 (2):95-105.</li>
<li>Krishnan, AV., Stathis, P., Permuth, S. F., Tokes, L. and Feldman, D. (1993). Bisphenol-A: an estrogenic substance is released from polycarbonate flasks during autoclaving. Endocrinology 132; 2279-2286.</li>
<li>Li, J., McMurray, RW. (2006). Effects of estrogen receptor subtype-selective agonists on immune functions in ovariectomized mice. International Immunopharmacology, 6 (9):1413-1423.</li>
</ol>
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<h3>List of Key Events in the AOP</h3>
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<h4><a href="/events/1711">Event: 1711: Induction of GATA3 expression by STAT6:ER fusion protein</a><br></h4>
<h5>Short Name: Induction of GATA3 expression</h5>
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<td><a href="/aops/314">Aop:314 - Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
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<h4>Domain of Applicability</h4>
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<p>Involvement of GATA3 and STAT6 in Th2 cell development through ER is common in humans, rodents, and other mammalian species (Ho IC. 2009). A constitutively activated form of Stat6 introduced into CD4 T cells resulted in both Th2 differentiation and enhanced cell expansion. Stat6 is not only necessary but also sufficient to drive IL-4-mediated Th2 differentiation and cell expansion in naive CD4 T cells (Zhu J. 2001). CD4 T cells from Stat6-knockout mice are not able to drive Th2 differentiation and cell expansion under ThN conditions with added with IL-4 (Zhu J. 2001).</p>
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<h4>Key Event Description</h4>
<p>Transcription factors are critical for Th cell differentiation and cytokine production. Cell fate determination in each lineage requires at least two types of transcription factors: the master regulators as well as the signal transducers and activator of transcription (STAT) proteins (Zhu J. 2010). The ability of STAT6: ER to induce a Th2 phenotype correlates with the induction of GATA-3 mRNA expression. GATA3 is the Th2 master regulator (Zhu J．2010, Sung-Yun. 2004, Zhu J. 2004, Zheng W. 1997, Zhang DH. 1997), but it also plays important roles in multiple steps of CD4 T cell development (Ho IC. 2009).</p>
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<h4>How it is Measured or Detected</h4>
<p>Purified naive T cells were cultured and expanded under Th1 culture conditions in the presence or absence of 0.3 μM 4-HT (Research Biochemicals Institute) for 2 weeks starting from days 1, 7, 14, or 21. GATA-3 mRNAs can be measured using RNase protection assay in developing Th1 cells. RNase protection assay was performed with RiboQuant multiprobe kit (PharMingen) following the manufacturer’s method using GATA-3. Stat6:ER Th1 cells expressed significant amounts of both GATA-3 mRNAs in a 4-HT-dependent manner. (Kurata H. 1999, Zhu J. 2001).</p>
<p>Constitutively activated Stat6 (Stat6VT) is primed under null Th cell (ThN) conditions in the absence of human (h)IL-4. The expression level of Gata3 in this primed cells are checked by RT-PCR (Zhu J. 2001).</p>
<p>Involvement of GATA3 in Th2 cell development through ER is common in humans, rodents, and other mammalian species (Ho IC. 2009). protein sequence conservation between all six vertebrate members (mouse, human, dog, cow, armadillo, capuchin and opossum) identifies GATA3 as having the highest sequence similarity with both its GATA paralogs and orthologs, suggesting that it may be closest to the ancestral mammalian GATA factor (<a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Tremblay%20M%5BAuthor%5D&cauthor=true&cauthor_uid=30348673">Tremblay M</a>. 2018).</p>
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<h4>Key Event Description</h4>
<p>Naïve CD4 T cells can differentiate into several different types of T helpers, and Th2 cells, capable of producing IL-4, IL-5 and IL-13, are involved in humoral immunity against extracellular pathogens and in the induction of asthma and other allergic diseases. It was reported that GATA-3 promotes Th2 responses through three different mechanisms (Zhu J. 2006). Cell fate determination in each lineage requires at least two types of transcription factors: the master regulators (GATA3) as well as the signal transducers and activator of transcription (STAT) proteins (Zhu J. 2010). A direct role in bridging distant regulatory elements has been demonstrated for GATA3 at Th2 cytokine loci (Spilianakis and Flavell, 2004). GATA3 is the Th2 master regulator (Zhu J．2010, Sung-Yun. 2004, Zhu J. 2004, Zheng W. 1997, Zhang DH. 1997), but it also plays important roles in multiple steps of CD4 T cell development (Ho IC. 2009). GATA3 can act as pioneer factors by initiating local chromatin opening and allowing the recruitment of other transcription factors to regulatory elements (Spilianakis and Flavell, 2004). Th2 differentiation is completely abolished both in vitro and in vivo when GATA3 is conditionally deleted in peripheral CD4 T cells (Zhu J. 2004, Pai SY. 2004). GATA-3 mRNA expression also increased in patients with SLE, compared with the healthy control groups (Zheng H. 2015, Sonia GR. 2012).</p>
<h4>How it is Measured or Detected</h4>
<p>GATA3 mRNA in CD4 T cells can be detected by Real-time PCR (RT-PCR) (Lambert KC. 2005, Kurata H. 1999, Zhu J. 2001). </p>
<h4>References</h4>
<ol>
<h4>References</h4>
<ol>
<li>Zhu J, Yamane H, Paul WE. Differentiation of effector CD4 T cell populations. Annu Rev Immunol. 2010; 28:445-89.</li>
<li><a href="https://www.nature.com/articles/ni1115#auth-1">Spilianakis</a> CG & <a href="https://www.nature.com/articles/ni1115#auth-2">Flavell</a> RA, Long-range intrachromosomal interactions in the T helper type 2 cytokine locus. <a href="https://www.nature.com/ni">Nature Immunology</a>. 2004; 5: 1017-1027.</li>
<li>Zhu J, Paul WE. Peripheral CD4 T cell differentiation regulated by networks of cytokines and transcription factors. Immunol Rev. 2010; 238(1):247-62.</li>
<li>Sung-Yun, Morgan L. T. I-Cheng H. (2004). GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proceedings of the National Academy of Sciences. 101 (7): 1993-1998.</li>
<li>Zhu J, Min B, Paul WE, et al. Conditional deletion of Gata3 shows its essential function in T(H)1-T(H)2 responses. Nat Immunol. 2004;5(11):1157-65.</li>
<li>Zheng W, Flavell RA. The transcription factor GATA-3 is necessary and sufficient for Th2 cytokine gene expression in CD4 T cells. Cell. 1997. 16;89(4):587-96.</li>
<li>Zhang DH, Cohn L, Ray P, Bottomly K, Ray A. Transcription factor GATA-3 is differentially expressed in murine Th1 and Th2 cells and controls Th2-specific expression of the interleukin-5 gene. J Biol Chem. 1997. 22;272(34):21597-603.</li>
<li>Zhu, J., Guo, L., Watson, C. J., Hu-Li, J. and Paul, W. E. (2001). STAT6 is necessary and sufficient for IL-4's role in Th2 differentiation and cellexpansion. The Journal of Immunology 166 (12): 7276-7281.</li>
<li>Ho IC, Tai TS, Pai SY. GATA3 and the T-cell lineage: essential functions before and after Thelper-2-cell differentiation. Nat Rev Immunol. 2009;9(2):125-35.</li>
<li>Zheng H, Guo X, Zhu Y, et al., Distinct role of Tim-3 in systemic lupus erythematosus and clear cell renal cell carcinoma. Int J Clin Exp Med 2015;8(5):7029-7038.</li>
<li>Sonia GR, et al. Altered AKT1 and MAPK1 Gene Expression on Peripheral Blood Mononuclear Cells and Correlation with T-Helper-Transcription Factors in Systemic Lupus Erythematosus Patients. Mediators of Inflammation 2012, Article ID 495934</li>
<li>Lambert KC, Curran EM, et al. <a href="https://pubmed.ncbi.nlm.nih.gov/16237062/?from_term=Estrogen+Receptor%2C+Deficiency+in+macrophages+results+in+increased+stimulation&from_pos=2">Estrogen receptor alpha (ERalpha) deficiency in macrophages results in increased stimulation of CD4+ T cells while 17beta-estradiol acts through ERalpha to increase IL-4 and GATA-3 expression in CD4+ T cells independent of antigen presentation.</a> J Immunol. 2005; 175(9): 5716-23.</li>
<li>Kurata, H., Lee, H. J., O’Garra, A. and Arai, N. (1999). Ectopic expression of activated STAT6 induces the expression of Th2-specific cytokines and transcription factors in developing Th1 cells. Immunity 11: 677-688.</li>
<li>Zhu, J., Guo, L., Watson, C. J., Hu-Li, J. and Paul, W. E. (2001). STAT6 is necessary and sufficient for IL-4's role in Th2 differentiation and cell expansion. The Journal of Immunology 166(12): 7276-7281.</li>
<li><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Tremblay%20M%5BAuthor%5D&cauthor=true&cauthor_uid=30348673">Tremblay M</a>, GATA transcription factors in development and disease. 2018; 22:145(20).</li>
<li>Guo H, Liu T, Ling F, et al. Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity. Cell Mol Immunol. 2010;7(3):227-34.</li>
</ol>
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<h4><a href="/events/1712">Event: 1712: Overproduction of IL-4 from Th2 cell</a><br></h4>
<h5>Short Name: Overproduction of IL-4</h5>
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<h4>AOPs Including This Key Event</h4>
<h4><a href="/events/1712">Event: 1712: Increase of Th2 cells producing IL-4</a></h4>
<h5>Short Name: Increase of Th2 cells producing IL-4</h5>
<td><a href="/aops/314">Aop:314 - Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
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<h4>Key Event Description</h4>
<p>Th2 cells produce IL-4, which stimulates B-cells to proliferate, to switch immunoglobulin classes, and to differentiate into plasma and memory cells. The receptor for IL-4 is IL-4Rα, which expresses in B cells. IL4 also plays an important role in the development of certain immune disorders, particularly allergies and some autoimmune diseases and especially when there is Th2 polarization.</p>
<br>
<h4>How it is Measured or Detected</h4>
<p>Purified naive T cells were activated and infected with RV-Stat6:ER. The cells were cultured and expanded under Th1 culture conditions in the presence or absence of 0.3 μM 4-HT (Research Biochemicals Institute) for 2 weeks starting from days 1, 7, 14, or 21 and the cells were analyzed for cytokine (IL-4) expression by flow cytometer analysis of intracellular cytokine production or cytokine ELISA (Kurata H. 1999, Zhu J. 2001).</p>
<p>Single-cell suspensions of lymph nodes removed from BALB/c mice 7 days after priming with KLH absorbed to aluminium hydroxide adjuvant in the footpads, were prepared and cultured in vitro with KLH in the absence or presence of either BPA (0.1, 1, 10, 50 and/or 100 μM) or NP. After 4 days, the levels of IL-4 and IFN-γ in the cell supernatants were determined by a sandwich enzyme-linked immunosorbent assay (ELISA) and mRNA levels of IL-4, IL-6 and IL-10 in the cells were assayed by reverse transcription–polymerase chain reaction (RT–PCR) (Lee MH. 2003). To evaluate the effects of exposure to BPA in adulthood, male Leishmania major– susceptible BALB/c and –resistant C57BL/6 mice were subcutaneously injected with BPA (0.625, 1.25, 2.5 and 5 μmol) dissolved in corn oil 1 week before being infected with L. major. A single cell suspension containing splenocytes from each mouse was incubated in 24-well tissue-culture plates in RPMI 1640 medium supplemented with 10% FCS, penicillin (100 IU/mL), and streptomycin (100 μg/mL) at 37°C in a humidified atmosphere of 5% CO2 and 95% air. Cells were stimulated with L. major antigen (3 μg/mL) during the cultivation. Culture supernatants were collected 48 hr later. Concentrations of IL-4, IL-10, IL-13, and IFN-γ in culture supernatants were determined using CBA kits (Huimin Y. 2008).</p>
<p>Th2 cell-related cytokine (IL-4 and -10) in BPA (50 μM)-stimulated primary cultured mouse lymphocytes were evaluated using immunoblot analysis and reverse-transcription polymerase chain reaction (RT-PCR) (Lee et al. 2010).</p>
<p>Production of IL-4 from Th2 is common in humans, rodents, and other mammalian species.</p>
<br>
<h4>Key Event Description</h4>
<p>In naive CD4+ T cells, T cell expansion shifts toward a Th2 phenotype that produces Th2 cytokines such as IL-4, IL-5, IL-10, and IL-13, thereby increasing antibody production from autoantibody-producing B cells. Th2 cells produce IL-4, IL-5, IL-10, and IL-13, meanwhile Th1 cells produce IL-12, TNF-α, and IFN-γ. During Th2 polarization, IL-4 produced by Th2 cell. IL-12 plays a central role in promoting the differentiation of naive CD4+ T cells into mature Th1 effector cells. Secretion of IL-10 from Th2 has been suggested to downregulate the DC-derived IL-12 production and lead to a Th2 differentiation (Aste-Amezaga M. 1998). Th2 cells produce IL-4, which stimulates B-cells to proliferate, to switch immunoglobulin classes, and to differentiate into plasma and memory cells. The receptor for IL-4 is IL-4Rα, which expresses in B cells. IL-4 also plays an important role in the development of certain immune disorders, particularly allergies and some autoimmune diseases and especially when there is Th2 polarization. Th2 cells from GATA3 and STAT6 knockout animals showed reduction in IL-4 production (Zhu J. 2004, Pai SY. 2004). </p>
<h4>How it is Measured or Detected</h4>
<p>The levels of IL-4 in the cell supernatants were determined by a sandwich enzyme-linked immunosorbent assay (ELISA), cytometric bead array (CBA) kits, or immunoblot analysis (Lee MH. 2003, Huimin Y. 2008, Lee J. 2010), and mRNA levels of IL-4 in the cells were assayed by reverse transcription–polymerase chain reaction (RT-PCR) (Lee MH. 2003, Lee J. 2010). </p>
<h4>References</h4>
<ol>
<li>Kurata, H., Lee, H. J. Lee, O’Garra, A. and Arai, N. (1999). Ectopic expression of activated STAT6 induces the expression of Th2-specific cytokines and transcription factors in developing Th1 cells. Immunity 11: 677-688.</li>
<li>Lee, M. H., Chung, S. W., Kang, B. Y., Park, J., Lee, C. H., Hwang, S. Y. and Kim, T. S. (2003). Enhanced interleukin-4 production in CD4+ T cells and elevated immunoglobulin E levels in antigen-primed mice by bisphenol A and nonylphenol, endocrine disruptors: involvement of nuclear factor-AT and Ca2+. Immunology 109(1): 76-86.</li>
<li>Huimin, Y., Masaya, T. and Kazuo, S. (2008).Exposure to Bisphenol A Prenatally or in Adulthood Promotes TH2 Cytokine Production Associated with Reduction of CD4+CD25+ Regulatory T Cells.Environmental Health Perspective 116(4): 514–519.</li>
<h4>References</h4>
<ol>
<li>Aste-Amezaga M, Ma X, Sartori A, Trinchieri G. Molecular mechanisms of the induction of IL-12 and its inhibition by IL-10. J Immunol. 1998. 15;160(12):5936-44.</li>
<li>Zhu J, Min B, Paul WE, et al. Conditional deletion of Gata3 shows its essential function in T(H)1-T(H)2 responses. Nat Immunol. 2004;5(11):1157-65.</li>
<li>Pai SY, Truitt ML, Ho IC. GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proc Natl Acad Sci U S A. 2004 Feb 17;101(7):1993-8.</li>
<li>Lee, MH, Chung, S. W., Kang, B. Y., Park, J., Lee, C. H., Hwang, S. Y. and Kim, T. S. (2003). Enhanced interleukin-4 production in CD4+ T cells and elevated immunoglobulin E levels in antigen-primed mice by bisphenol A and nonylphenol, endocrine disruptors: involvement of nuclear factor-AT and Ca2+. Immunology 109(1): 76-86.</li>
<li>Huimin, Y., Masaya, T. and Kazuo, S. (2008).<font color="#0782c1"> </font>Exposure to Bisphenol A Prenatally or in Adulthood Promotes Th2 Cytokine Production Associated with Reduction of CD4+CD25+ Regulatory T Cells. Environmental Health Perspective 116(4): 514–519.</li>
<li>Lee, J. and Lim K. T. (2010). Plant-originated glycoprotein (36kDa) suppresses interleukin-4 and -10 in bisphenol A-stimulated primary cultured mouse lymphocytes. Drug and Chemical Toxicology. 33(4): 421-429.</li>
<li>Lambert KC, Curran EM, et al. <a href="https://pubmed.ncbi.nlm.nih.gov/16237062/?from_term=Estrogen+Receptor%2C+Deficiency+in+macrophages+results+in+increased+stimulation&from_pos=2">Estrogen receptor alpha (ERalpha) deficiency in macrophages results in increased stimulation of CD4+ T cells while 17beta-estradiol acts through ERalpha to increase IL-4 and GATA-3 expression in CD4+ T cells independent of antigen presentation.</a> J Immunol. 2005; 175(9): 5716-23.</li>
</ol>
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<h4><a href="/events/1713">Event: 1713: Increase of anti-single/double-stranded DNA antibody from autoreactive B cell</a><br></h4>
<h5>Short Name: Increase of autoantibody production</h5>
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<h4>AOPs Including This Key Event</h4>
<h4><a href="/events/1713">Event: 1713: Increase of anti-DNA antibody from autoreactive B cell</a></h4>
<h5>Short Name: Increase of autoantibody production</h5>
<td><a href="/aops/314">Aop:314 - Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<p>Antibody production from B cells is common in humans, rodents, and other mammalian species. Since almost experiment are performed in female, it is considered that this event in SLE are noted more frequently in females.</p>
<h4>Key Event Description</h4>
<p>The receptor for IL-4 is IL-4Rα, which expresses in B cells. IL-4 produced by Th2 stimulates B-cells to proliferate, to switch immunoglobulin classes, and to differentiate into plasma and memory cells. Anti-DNA antibodies are produced from autoreactive B cell. In murine models, addition of estrogen or prolactin can lead to an autoimmune phenotype with an increase in mature high-affinity autoreactive B cells (Daniel P. 2011).</p>
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<h4>Key Event Description</h4>
<p>In the development of T-cell dependent antibody producing cells, the interaction between IL-4 and its receptor delivers the first signal for switching to IgE. IL-4 produced by Th2 stimulates B-cells to proliferate, to switch immunoglobulin classes, and to differentiate into plasma and memory cells. The engagement of CD40 on B cells by CD154 (CD40L) expressed on T cells and DC provides the second signal required for switching to IgE.</p>
<p>In a study to investigate a novel subpopulation of B-1 cells and its roles in murine lupus, anti-double-stranded DNA (anti-dsDNA) autoantibodies were preferentially secreted by a subpopulation of CD5+ B-1 cells that expressed programmed death ligand 2 (L2pB1 cells) (Xuemei et al. 2009). A substantial proportion of hybridoma clones generated from L2pB1 cells reacted to dsDNA. L2pB1 cells are potent antigen-presenting cells and a dramatic increase of circulating L2pB1 cells in lupus-prone BXSB mice correlates with elevated serum titers of anti-dsDNA antibodies (Xuemei et al. 2009).</p>
<h4>How it is Measured or Detected</h4>
<p>[<em>in vivo </em>assay]</p>
<p>Bisphenol-A (BPA) as well as E2 and DES enhanced anti-Br-RBC autoantibody production by B1 cells in vivo. IgM production by B1 cells in the presence of EDs was more prominent on aged BWF1 mice developing lupus nephritis. B1 cells from aged mice exhibited increased expression of ERα mRNA compared to young mice (Yurino H. 2004).</p>
<br>
<h4>How it is Measured or Detected</h4>
<p>For the detection of anti-DNA antibodies in serum of female NZB/W F1 mice administrated of the estrogen antagonist tamoxifen, enzyme-linked immunosorbent assay (ELISA) was carried out. For the quantitated of total B cells and CD5+B cells expression in spleen and in peritoneal exudates were analyzed with fluorescence activated cell sorting (FACScan) (Wu et al. 2000). For the B cell subset analysis (including immature (transitional T1 and T2) and mature (MZ and follicular)) in BALB/c R4Ag-gamma 2b transgenic mice administrated the tamoxifen were performed with FACScan (Peeva et al. 2005).</p>
<p>NZB/W F1 mice are used as model of SLE (Wu WM. 2000). BALB/c R4Ag-gamma 2b transgenic mice are used for evaluation of autoreactive B cells (Peeva E. 2005). These mice are administrated of the estrogen antagonist tamoxifen. Disruption of ERα (Bynote KK. 2008, Isenberg DA. 2007) and ovariectomy of NZB/W F1 mice are used as model of estrogen dysfunction (Daniel P. 2011). Survival and glomerulonephritis of these animals were evaluated.</p>
<p>In another study, used ERα deficiency in NZB/WF1 mice, autoantibody (anti-dsDNA antibodies) development and concentration was assessed by ELISA using serum isolated from blood collected monthlyvia (Bynote et al. 2008).</p>
<p>Using female NZB/WF1 mice, silastic implants containing the powdered form of endocrine disruptors were placed subcutaneously on the back of ovariectomized mice. The implants were left in situ for 3 to 4 months and blood samples were collected periodically, and anti-DNA antibody was measured in ELISA using dsDNA (Yurino H. 2004).</p>
<p>Using female NZB/WF1 mice, silastic implants containing the powdered form of endocrine disruptors were placed subcutaneously on the back of ovariectomized mice, and 3 to 4 months blood samples were collected peritoneal. 4 months after implantation, peritoneal lavage cells and splenic cells were obtained from mice. Anti-DNA antibody was measured in ELISA using ssDNA for the culture supernatant of and dsDNA for the serum. To examine the effect of EDs on autoantibody production by B1 cells, a PFC assay using autologous bromelain-treated erythrocytes (Br-RBC) was conducted. To evaluate autoantibody (IgG) production including plaque forming cell (PFC) assay for anti-RBC Ab. It has been reported</p>
<p> </p>
<p>that B1 cells produce autoantibody against phosphatidylcholine expressed on bromelain-treated red blood cells (Br-RBC) using PFC assay (Yurino H. 2004).</p>
<p>[<em>in vitro </em>assay]</p>
<p>To examine a direct effect of endocrine disruptors on IgM antibody production by B1 or B2 cells, B1 cells were prepared from peritoneal cells and B2 cells from spleen, B1 or B2 cells were cultured in the presence of endocrine disruptors (E2: 100 nM, DES: 100 nM, BPA: 1 μM) for 4 days. The amount of total IgM and IgM anti-DNA Ab in the culture supernatant was measured by ELISA. Expression level of ERα and ERβ genes in B cells was examined by RT-PCR and quantitative real-time PCR analysis (Yurino H. 2004).</p>
<p>The amounts of anti-dsDNA, anti-glomerular antigens (GA), total IgG and IgM in the culture supernatants were measured by ELISA (Kanda N. 1999, Wu WM. 2000, Yurino H. 2004, Gabriela T. 2019, John LS. 2008, Wang Y.1996). Proliferative responses PBMCs or B cells were measured by [3H]-thymidine uptake, and the cell viability was assessed by a trypan blue exclusion test (Kanda N. 1999). Fluorescence activated cell sorting (FACScan) was used for the quantitated of total B cells and CD5+B cells expression in spleen and in peritoneal exudates or B cell subset analysis (Wu WM. 2000, Peeva E. 2005). Plaque forming cell (PFC) assay using autologous bromelain-treated erythrocytes (Br-RBC) was conducted to examine the effect of EDs on autoantibody production by B1 cells (Yurino H. 2004).</p>
<p>For the investigate the in vitro effects of 17β-estradiol (E2) on spontaneous immunoglobulin production by human PBMCs, PBMCs from healthy human volunteers were cultured with E2. Levels of IgG and IgM and cytokine activity were measured by ELISA. Proliferation was determined by [3H]-thymidine uptake. The cell viability was assessed by a trypan blue exclusion test (Kanda et al. 1999).</p>
<br>
<p>Enzyme-linked immunospot (ELISPOT) analysis confirmed a significant increase in the number of high-affinity anti-DNA antibody-secreting B cells in the spleens of E2-treated mice (Bynoe MS. 2000).</p>
<h4>References</h4>
<ol>
<li>Xuemei, Z., Stanley, L., Chunyan, B., Nicolas, D., Nichol, E. H., Scott, J. S., Joseph, T., Wenda, G. and Thomas, L. R. (2009). A Novel Subpopulation of B-1 Cells Is Enriched with Autoreactivity in Normal and Lupus-Prone Mice. Arthritis & Rheumatology 60 (12):3734-3743</li>
<li>Goto, M., Takano-Ishikawa, Y., Ono, H., Yoshida, M., Yamaki, K. and Shinmoto, H. (2007). Orally Administered Bisphenol A Disturbed Antigen Specific Immunoresponses in the Naive Condition. Bioscience, Biotechnology, and Biochemistry 71(9): 2136–2143.</li>
<li>Yoshino S., Yamaki, K., Li, X., Sai, T., Yanagisawa, R., Takano, H., Taneda, S., Hayashi, H. and Mori, Y. (2004). Prenatal exposure to bisphenol A up-regulates immune responses, including T helper 1 and T helper 2 responses, in mice. Immunology 112: 489–495.</li>
<li>Wu WM., Lin, B.-F., Su, Y.-C., Suen, J.-L. and Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<h4>References</h4>
<ol>
<li>Daniel, P., Allison, S., Yiming, Y., Ying-Yi, Z. and Laurence, M. Murine Models of Systemic Lupus erythematosus. Journal of Biomedicine and Biotechnology 2011: ArticleID 271694</li>
<li>Wu WM., Lin, B.-F., Su, Y.-C., Suen, J.-L. Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<li>Peeva, E., Venkatesh, J. and Diamond, B. (2005). Tamoxifen Blocks Estrogen-Induced B Cell Maturation but Not Survival. The Journal of Immunology 175: 1415-1423.</li>
<li>Bynote, K. K., Hackenberg, J. M., Korach, K.S., Lubahn, D. B., Lane, P. H.and Gould, K. A. (2008). Estrogen receptor-alpha deficiency attenuates autoimmune disease in (NZB xNZW) F1 mice. Genes and Immunity. 9: 137-152.</li>
<li>Kanda N. and Tamaki, K. (1999). Estrogen enhances immunoglobulin production by human PBMCs. The Journal of Allergy and Clinical Immunology 103(2): 282-288.</li>
<li>Bynote, KK., Hackenberg, J. M., Korach, K.S., Lubahn, D. B., Lane, P. H.and Gould, K. A. (2008). Estrogen receptor-alpha deficiency attenuates autoimmune disease in (NZB xNZW) F1 mice. Genes and Immunity. 9: 137-152.</li>
<li>Isenberg, DA., Manson, JJ., Ehrenstein, MR. and Rahman, A. (2007). Fifty years of anti-ds DNA antibodies: are we approaching journey’s end? Rheumatology 46:1052-6.</li>
<li>Yurino, H., Ishikawa, S., Sato, T., Akadegawa, K., Ito, T., Ueha, S., Inadera, H. and Matsushima, K. (2004). Endocrine disruptors (environmental estrogens) enhance autoantibody production by B1 cells. Toxicological Sciences 81(1): 139-147.</li>
<li>Kanda N. and Tamaki, K. (1999). Estrogen enhances immunoglobulin production by human PBMCs. The Journal of Allergy and Clinical Immunology 103(2): 282-288.</li>
<li>Grimaldi CM, Cleary J, Dagtas AS, Moussai D, Diamond B. Estrogen alters thresholds for B cell apoptosis and activation. J Clin Invest. 2002;109(12):1625-33.</li>
<li>Peeva E, Grimaldi C, Spatz L, Diamond B. Bromocriptine restores tolerance in estrogen-treated mice. J Clin Invest. 2000;106(11):1373-9.</li>
<li>Gabriela, T., Yessia, H., Maria, R. B. and Mario, R. (2019), A Spontaneous Mouse Model of Lupus: Physiology and Therapy. IntechOpen Limited: 1-24.</li>
<li>John, L. S., Jackie, E., Phil, R., Kenneth, S. K. and Gary, S. G. (2008), Impact of estrogen receptor deficiency on disease expression in the NZM2410 lupus prone mouse. Clin Immunol. 128(2): 259-268.</li>
<li>Wang, Y., Hu, Q., Madri, J. A., Rollins, S.A., Chodera, A, and Matis, L. A. (1996), Amelioration of lupus-like autoimmune disease in NZB/W F1 mice after treatment with a blocking monoclonal antibody specific for complement component C5. Proc Natl Acad Sci U S A. 93(16):8563-8568.</li>
<li>Bynoe MS, Grimaldi CM, Diamond B. Estrogen up-regulates Bcl-2 and blocks tolerance induction of naı¨ve B cells. PNAS 2000; 97(6):2703-8.</li>
</ol>
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<h3>List of Adverse Outcomes in this AOP</h3>
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<h4><a href="/events/1714">Event: 1714: Exacerbation of systemic lupus erythematosus</a><br></h4>
<h5>Short Name: Exacerbation of SLE</h5>
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<td><a href="/aops/314">Aop:314 - Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<tr><th scope="col">Level of Biological Organization</th></tr>
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<h4>Domain of Applicability</h4>
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<p>Exacerbation of SLE is common in humans and rodents, and is considered likely to occur in other animal species, as well. SLE is an autoimmune disease that occurs primarily in women (9:1 compared to men) (Rider et al., 2001). SLE is an autoimmune disease that affects predominantly women during reproductive years, and its evolution is altered by hormonal events such as menses, menopause, and especially pregnancy (Luis et al., 2014). The incidence of SLE is markedly increased in females of child-bearing age (Grainne et al., 2013). Th1/Th2 shift is one of the most important immunologic changes during gestation. It is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses. For this reason, Th1-mediated diseases, such as rheumatoid arthritis, tend to improve, while Th2-mediated diseases, such as systemic lupus erythematosus (SLE) tend to worsen during pregnancy(Doria et al., 2006).</p>
<br>
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<h4>Key Event Description</h4>
<p>SLE is an autoimmune disease characterized by overproduction of a variety of anti-cell nuclear and other pathogenic autoantibodies. It is characterized by B-cell hyperactivity, polyclonal hypergammaglobulinemia, and immune complex deposition. Epstein– Barr virus (EBV) has been identified as a possible factor in the development of lupus. Over 100 drugs have been reported to cause drug-induced lupus (DIL), including a number of the newer biologics and antiviral agents. Although the pathogenesis of DIL is not well understood, these drugs may alter gene expression in CD4+ T cells by inhibiting DNA methylation and induce over-expression of lymphocyte function-associated antigen 1, thus promoting autoreactivity. Generally, sunlight is the most obvious environmental factor that may exacerbate SLE. High estrogen levels and BPA-induced ER activation skewed T cells toward a Th2 phenotype, thereby inducing hyperactivity by B-cells, which leads to exacerbation of SLE. T cell dysfunction is a characteristic of SLE, which is also associated with high levels of autoantibodies (Crispin et al. 2010).</p>
<p>Exacerbation of SLE is common in humans and rodents, and is considered likely to occur in other animal species, as well. SLE is an autoimmune disease that occurs primarily in women (9:1 compared to men) (Rider V. 2001). SLE is an autoimmune disease that affects predominantly women during reproductive years, and its evolution is altered by hormonal events such as menses, menopause, and especially pregnancy (Luis JJ. 2014). The incidence of SLE is markedly increased in females of child-bearing age (Grainne M. 2013). Th1/Th2 shift is one of the most important immunologic changes during gestation. It is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses. For this reason, Th1-mediated diseases, such as rheumatoid arthritis, tend to improve, while Th2-mediated diseases, such as SLE tend to worsen during pregnancy (Doria A. 2006).</p>
<p>Female MRL/lpr mice that developed lymphadenopathy and a lupus-like disease also exhibited a 50% higher mortality rate than males at 5 months of age. In (NZB×NZW) F1 mice too, females develop signs of SLE several months before males, with severe autoimmune hemolytic anemia, glomerulonephritis, and autoantibodies to single-stranded DNA, doublestranded DNA, and histones (Carlsten H. 1992).</p>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Melissa, and Gary 2011). Low serum levels (60‑100 pg/mL or 0.26‑0.43 nM) of estradiol have been shown to increase Th1 T-cell development in vitro through an ERα mediated mechanism (Maret A. 2003). In contrast of SLE exacerbated by Th2, treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated autoimmune diseases (multiple sclerosis; MS, rheumatoid arthritis; RA, and experimental autoimmune encephalomyelitis; EAE, etc.) caused by Th1, while high doses (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset polarized T-cells to a Th2 phenotype in the EAE model (Bebo BF. 2001).</p>
<h4>How it is Measured or Detected</h4>
<p>Most of the mouse models of lupus produce autoantibodies and develop immune complex glomerulonephritis. For the disease onset, mice can monitor by proteinuria levels, body weights, blood urea nitrogen and appearance over time. Additionally, serum levels of anti-dsDNA, anti-glomerular antigens (GA), total IgG can measure by ELISA. (Gabriela et al., 2019, Yurino et. al.,2004, John et. al.,2008, Wang et. al.1996).</p>
<h4>Key Event Description</h4>
<p>SLE is an autoimmune disease characterized by overproduction of a variety of anti-cell nuclear and other pathogenic autoantibodies. It is characterized by B-cell hyperactivity, polyclonal hypergammaglobulinemia, and glomerulonephritis as immune complex deposition. Once SLE is suspected, the initial evaluation should include an antinuclear antibody (ANA) test. This is a highly sensitive test, with positive results in about 94% of patients with SLE. However, it also has low specificity, and may be positive in healthy patients. If ANA results show a 1:40 titer or higher, more specific tests should be performed, including measurement of anti–double-stranded DNA (anti-dsDNA), anti-Smith, anti-RNP, anticardiolipin, beta-2 glycoprotein antibodies and lupus anticoagulant; elevated levels of one or more of these biomarkers increase the likelihood of SLE (Nguyet-Cam VL. 2016). In the Systemic Lupus International Collaborating Clinics 2012 classification for SLE, biopsy-proven lupus nephritis plus positive ANA or anti-dsDNA is sufficient to fulfil SLE classification criteria (Bernard T. 2017). SLE is the prototypic multisystem autoimmune disorder with a broad spectrum of clinical presentations encompassing almost all organs and tissues including skin, kidney, heart, lungs, and joints. The pathogenesis of SLE includes both genetic and environmental components with female sex strongly influencing pathogenesis. These factors lead to an irreversible break in immunological tolerance manifested by immune responses against endogenous nuclear antigens (Daniel P. 2011).</p>
<p>It has been determined in a murine model of SLE that ERα is required for disease progression and that ERα deficiency impedes the course of the disease (Bynote KK. 2008). There is increased ERα mRNA expression in PBMCs of SLE patients (Inui A. 2007). It is considered that MIE affect later events and result in SLE.</p>
<br>
<h4>How it is Measured or Detected</h4>
<p>[<em>in vivo </em>assay]</p>
<p>Murine lupus models such as New Zealand Black (NZB)×New Zealand White (NZW) F1 (NZB/W F1), NZB.H-2bm12, NZB×SWR F1 (SNF1), MRL.lpr/lpr, and BXSB mice have led to a better understanding of the pathogenic mechanisms of lupus. All of these species of mice develop anti-dsDNA antibody, which is a characteristic of lupus, and die of uremia in early life. Among these murine lupus models, the natural course of NZB/W F1 mice is closer to human lupus than MRL.lpr/lpr and BXSB mice (Zhang DH. 1997, Pai SY. 2004, Daniel P. 2011).</p>
<p>For the disease onset, mice can monitor by proteinuria levels, body weights, blood urea nitrogen and appearance over time. (Gabriela T. 2019, John LS. 2008, Wang Y.1996). The major cause of death in the NZB/W F1 female is chronic glomerulonephritis with heavy mesangial deposits, tubular cast formation, proliferation of glomerular cells, prominent crescent formation, and a significant periglomerular and interstitial monocytic infiltrate. Extraglomerular renal deposits of IgG2a and C3 are present in the peritubular tissue and arterioles, and increase in frequency with age. Histological alterations in the kidney were assessed by Hematoxylin Eosin (H&E) and Periodic acid-Schiff (PAS) staining, expression of IgG and C3 was detected by immunohistochemistry (Gabriela T. 2019, Brian S. 1978).</p>
<p>To examine the relationship between oral contraceptive (OC) use and the development of SLE, analyzed data (1976 - 1990) from the Nurses’ Health Study cohort. The questionnaire used to assemble biennially the group sought information on a variety of health conditions and exposures, such as use of OCs, use of post-menopausal hormones (PMH), current and past cigarette smoking habits and other health practices. Incidence of SLE was defined by; 1) strict American College of Rheumatology (ACR) classification criteria (> or = 4 ACR criteria), 2) > or = 4 ACR criteria and any physician's diagnosis, 3) > or = 4 ACR criteria and diagnosis by an ACR-certified rheumatologist, 4) > or = 3 ACR criteria, or 5) diagnosis by a physician even if the patient did not meet the ACR criteria. (Bertsias G. 2012, Sanchez-Guerrero J.1997). </p>
<p>Typical clinical symptoms include combinations of renal disease, swollen joints, skin rash, hematologic disorders, respiratory, and neurologic dysfunction.</p>
<p> </p>
<h4>Regulatory Significance of the AO</h4>
<p>There are concerns about the increase in autoimmune diseases caused by estrogen-like substances, and its accurate in vitro toxicity assessment system is required in international regulations. The OECD has published a revised version of the guidance document on standardized test guidelines for evaluating ED (OECD. 2019).</p>
<h4>References</h4>
<ol>
<li>Crispín, J. C., Stamatis-Nick, C. L., Katalin Kis-Toth1, Linda A. Lieberman1, Vasileios C. Kyttaris1, Yuang-Taung Juang1, and George C. Tsokos1. (2010) Pathogenesis of human systemic lupus erythematosus: recent advance. Trends in Molecular Medicine 16(2): 47-57.</li>
<li>Wu, W.-M., Lin, B.-F., Su, Y.-C., Suen, J.-L. and Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<h4>References</h4>
<ol>
<li>Nguyet-Cam Vu Lam, Maria V. Ghetu and Marzena L. BIENIEK. Systemic Lupus Erythematosus: Primary Care Approach to Diagnosis and Management. American Family Physician, 2016; 94 (4): 284-294.</li>
<li>Bernard Thong and Nancy J. Olsen. Systemic lupus erythematosus diagnosis and management. Rheumatology 2017; 56: i3-i13.</li>
<li>Daniel, P., Allison, S., Yiming, Y., Ying-Yi, Z. and Laurence, M. Murine Models of Systemic Lupus erythematosus. Journal of Biomedicine and Biotechnology 2011: ArticleID 271694</li>
<li>Bynote, KK, Hackenberg, JM., Korach, K.S., Lubahn, D. B., Lane, P. H. and Gould, K. A. (2008). Estrogen receptor-alpha deficiency attenuates autoimmune disease in (NZB xNZW) F1 mice. Genes and Immunity. 9: 137-152.</li>
<li>Inui A, Ogasawara H, Ogawa H, et al. Estrogen receptor expression by peripheral blood mononuclear cells of patients with systemic lupus erythematosus. Clin Rheumatol. 2007;26(10):1675-8.</li>
<li>Zhang DH, Cohn L, Ray P, Bottomly K, Ray A. Transcription factor GATA-3 is differentially expressed in murine Th1 and Th2 cells and controls Th2-specific expression of the interleukin-5 gene. J Biol Chem. 1997. 22;272(34):21597-603.</li>
<li>Pai SY, Truitt ML, Ho IC. GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proc Natl Acad Sci U S A. 2004 Feb 17;101(7):1993-8.</li>
<li>Gabriela, T., Yessia, H., Maria, R. B. and Mario, R. (2019), A Spontaneous Mouse Model of Lupus: Physiology and Therapy. IntechOpen Limited: 1-24.</li>
<li>John, L. S., Jackie, E., Phil, R., Kenneth, S. K. and Gary, S. G. (2008), Impact of estrogen receptor deficiency on disease expression in the NZM2410 lupus prone mouse. Clin Immunol. 128(2): 259-268.</li>
<li>Wang, Y., Hu, Q., Madri, J. A., Rollins, S.A., Chodera, A, and Matis, L. A. (1996), Amelioration of lupus-like autoimmune disease in NZB/W F1 mice after treatment with a blocking monoclonal antibody specific for complement component C5. Proc Natl Acad Sci U S A. 93(16):8563-8568.</li>
<li>Brian S. Andrews, Robert A. Eisenberg, Argyrios N. Theofilopoulos, S Izui, Curtis B. Wilson, Patricia J. McConahey, Edwin D. Murphy, John B. Roths and Frank J. Dixon. Spontaneous Murine Lupus-Like Syndromes. Clinical and Immunopathological Manifestations in Several Strains. J. EXP. Med. 1978; 148(5):1198-215</li>
<li>Bertsias G, Ricard Cervera and Dimitrios T. Boumpas. Systemic Lupus Erythematosus: Pathogenesis and Clinical Features. 20_Eular_Fpp.indd. 2012; 476-505.</li>
<li>Sanchez-Guerrero J. Karlson EW. Liang MH. Hunter DJ,. Speizer F. E, and Colditz. G. A. Past Use of Oral Contraceptives and the Risk of Developing Systemic Lupus Erythematosus. Arthritis Rheum. 1997; 40 (5): 804-808.</li>
<li>Rider, V. and Abdou, N. I. (2001). Gender differences in autoimmunity: molecular basis for estrogen effects in systemic lupus erythematosus. International Immunopharmacology 1(6): 1009-1024.</li>
<li>Luis, J. J., Gabriela, M., Pilar, C.-D., Carmen, N., Olga V.-L. and Miguel., A. S. (2014). Risk factors of systemic lupus erythematosus flares during pregnancy. Immunologic Research 60: 184–192</li>
<li>Luis, J. J., Gabriela, M., Pilar, C.-D., Carmen, N., Olga V.-L. and Miguel., A. S. (2014). Risk factors of systemic lupus erythematosus flares during pregnancy. Immunologic Research 60: 184-192</li>
<li>Grainne, M. and David, I. (2013). Effect of gender on clinical presentation in systemic lupus erythematosus. Rheumatology 52: 2108-2115</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256</li>
<li>Buyon JP. Oral contraceptives in women with systemic lupus erythematosus. Ann Med Interne (Paris) (1996) 147(4):259–264.</li>
<li>Buyon JP. Hormone replacement therapy in postmenopausal women with systemic lupus erythematosus. J Am Med Womens Assoc (1998) 53(1):13–17.</li>
<li>Gabriela, T., Yessia, H., Maria, R. B. and Mario, R. (2019), A Spontaneous Mouse Model of Lupus: Physiology and Therapy. IntechOpen Limited: 1-24</li>
<li>Yurino, H., Ishikawa, S., Sato, T., Akadegawa, k., Ito, T., Ueha, S., Inadera, H., and Matsushima, K. (2004), Endocrine Disruptors (Environmental Estrogens) Enhance Autoantibody Production by B1 Cells. Toxicological Sciences 81: 139–147.</li>
<li>John, L. S., Jackie, E., Phil, R., Kenneth, S. K. and Gary, S. G. (2008), Impact of estrogen receptor deficiency on disease expression in the NZM2410 lupus prone mouse. Clin Immunol. 128(2): 259–268.</li>
<li>Wang, Y., Hu, Q., Madri, J. A., Rollins, S.A., Chodera, A, and Matis, L. A. (1996), Amelioration of lupus-like autoimmune disease in NZB/W F1 mice after treatment with a blocking monoclonal antibody specific for complement component C5. Proc Natl Acad Sci U S A. 93(16):8563-8568.</li>
<li>George, B., Ricard, C. and Dimitrios, T. B. (2012). Systemic Lupus Erythematosus: Pathogenesis and Clinical Feature. EULAR Textbook on Rheumatic Diseases</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256.</li>
<li>Carlsten H, Nilsson N, Tarkowski A, et al. Estrogen accelerates immune complex glomerulonephritis but ameliorates T cell-mediated vasculitis and sialadenitis in autoimmune MRL lpr/lpr mice. Cell Immunol. 1992;144(1):190-202.</li>
<li>Melissa, C and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40: 66-73.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512-521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology. 166: 2080-2089.</li>
<li>Grimaldi CM, Cleary J, Dagtas AS, Moussai D, Diamond B. Estrogen alters thresholds for B cell apoptosis and activation. J Clin Invest. 2002;109(12):1625-33.</li>
<li>Peeva E, Grimaldi C, Spatz L, Diamond B. Bromocriptine restores tolerance in estrogen-treated mice. J Clin Invest. 2000;106(11):1373-9.</li>
<li>Buyon JP. Hormone replacement therapy in postmenopausal women with systemic lupus erythematosus. J Am Med Womens Assoc (1998) 53(1):13-17.</li>
<li>OECD Series on Testing and Assessment [Revised Guidance Document 150 on Standardised Test Guidelines for Evaluating Chemicals for Endocrine Disruption. 2019].</li>
</ol>
<br>
<!-- end event text -->
</div>
<h2>Appendix 2</h2>
<h2>List of Key Event Relationships in the AOP</h2>
<!-- Evidence for relationship links section, this lists the relationships and then supports them -->
<div id="evidence_supporting_links">
<hr>
<h3>List of Adjacent Key Event Relationships</h3>
<div>
<h4><a href="/relationships/2020">Relationship: 2020: Activation of estrogen receptor leads to Induction of GATA3 expression</a></h4>
<div id="evidence_supporting_links">
<h3>List of Adjacent Key Event Relationships</h3>
<div>
<h4><a href="/relationships/2020">Relationship: 2020: Binding to estrogen receptor (ER)-α leads to Induction of GATA3 expression</a></h4>
<td><a href="/aops/314">Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<td>adjacent</td>
<td>Moderate</td>
<td>Moderate</td>
</tr>
</thead>
<tbody>
<tr>
<th><a href="/aops/314">Activation of estrogen receptor in immune cells leading to exacerbation of systemic lupus erythematosus</a></th>
<th>adjacent</th>
<th>Moderate </th>
<th>Moderate</th>
</tr>
</tbody>
</table>
</div>
<h4>Key Event Relationship Description</h4>
<p>Stressors bind to the ERs in immune cells, a ligand-activated transcription factor that regulates transcription of target genes in the nucleus or located in or adjacent to the plasma membrane (Deroo BJ. 2006). ERα is a nuclear hormone transcription factor that classically binds ligand stressors estrogen or EDC, further stabilizing dimers that subsequently bind estrogen response elements to transactivate or suppress specific target genes.</p>
<!-- if nothing shows up in any of these fields, then evidence supporting this KER will not be displayed -->
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>The GATA3 expression induced by TNF-α was enhanced in the presence of BPA. However, the T-bet expression did not change when tested at various culture conditions (Guo H. 2010, Uemura Y. 2008). Naive Th cells primed by BPA/TNF-α-matured DCs differentiated into Th2 cells with characteristically high IL-5/IFN-γ, IL-10/IFN-γ, and IL-13/IFN-γ ratios. However, the IFN-γ production was not affected at all, thus indicating that Th2 bias was induced by enhanced Th2 cytokine production (Guo H. 2010, Uemura Y. 2008). Also, dendritic cells exposed to BPA (100 nM) and TNF-α produced high levels of IL-10 relative to IL-12, and this induced Th2 deviation (Liu Y. 2009).</p>
<strong>Uncertainties and Inconsistencies</strong>
<p>Dendritic cells exposed to human exposure-relevant concentrations of BPA (10-100 nM) preferentially skewed T cells toward a Th2 phenotype. Th cells were primed by BPA/TNF-α-DCs. The administration of 17β-estradiol enhanced the differentiation of dendritic cells and increased IFN-γ production by dendritic cells in C57BL/6 mice.</p>
</tbody>
</table>
</div>
<h4>Evidence Supporting Applicability of this Relationship</h4>
<div>
</div>
<div>
</div>
<div>
</div>
<p>XXXX</p>
<h4>Key Event Relationship Description</h4>
<p>The hormone binding domain (HBD) of the ERα is required not only for binding ligand but also to form stable homodimers of the protein and mediate transcriptional activation by the receptor. There are two ligand-dependent signaling pathway. One is “classical” and the other is “tethered” pathway. A direct genomic interaction occurs between the ER ligand complex and specific sequences of DNA known as estrogen response elements (ERE) (Parker MG. 1993, Goldstein RA. 1993, Sasson S. 1991, Brandt ME. 1997). Transcriptional activation by ERα is mediated by two distinct activation functions: the constitutively active AF-1 domain, located in the N-terminal domain of the receptor protein, and the ligand-dependent AF-2 domain, located in the C-terminal domain of the receptor protein (Delaunay F. 2000). This is called “classical” signaling pathway. In addition to above classical mechanism, ligand-activated ERα interact with other transcription factor complexes and bind to non-EREs by attaching to other transcription factors and not with ERE directly. (Carolyn MK. 2001). This is also called “tethered” signaling pathway. The transcription factors GATA3 and STAT6 are essential for the establishment and/or maintenance of these interactions (Spilianakis and Flavell, 2004). In the tethered pathway, STAT6-ER fusion protein induce GATA-3 mRNA expression. Furthermore, in mammary gland but not in immune cells, GATA3 and ERα regulate each other and, along with FOXA1, can nucleate a remodeling complex at heterochromatic enhancer regions of ERα target genes, leading to the opening and epigenetic marking of sites for active transcription (Eeckhoute J. 2007, Kong SL. 2011). Alone, FOXA1 or ERα are not sufficient to fully open the chromatin, supporting a bona fide pioneer activity for GATA3 (Eeckhoute J. 2007, Kong SL. 2011).</p>
<h4>Quantitative Understanding of the Linkage</h4>
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>STAT6-ER fusion protein (STAT6:ER) induce expression of GATA-3 mRNAs in presence of 4-Hydroxytamoxifen (4-HT), estrogen analogue (Kurata H. 1999, Zhu J. 2001). Furthermore, A constitutively active form of Stat6 (STAT6VT) introduced GATA3 expression and resulted in both Th2 differentiation and enhanced cell expansion without IL-4 (Zhu J. 2001, Horiuchi S. 2011). CD4 T cells from Stat6-knockout mice are not able to drive Th2 differentiation and cell expansion under ThN conditions with added IL-4 (Zhu J. 2001). Therefore, it is considered that activated STAT6 after ligand-biniding to ERα induce GATA3 expression in immune cells.</p>
<strong>Response-response relationship</strong>
<p>When estrogen levels are low, T cell expansion shifts toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ. This response results in cellular immunity inducing inflammation and exacerbating cellular autoimmune diseases such as multiple sclerosis (MS), rheumatoid arthritis (RA), and experimental autoimmune encephalomyelitis (EAE) rather than SLE.</p>
<strong>Empirical Evidence</strong>
<p>Expression of GATA3 was induced in T cells treated with E<sub>2</sub> at a concentration of 10<sup>-9</sup> M (272.4 pg/mL) for 12-16 hours (Lambert KC. 2005). In contrast, expression of T-bet was decreased, which means E<sub>2</sub> skew the immune system from a Th1 to a Th2 profile. Stat6:ER Th1 cells expressed significant amounts of both GATA3 mRNAs in a 4-HT-dependent manner (Kurata H. 1999, Zhu J. 2001). Constitutively activated Stat6 (Stat6VT) is primed under null Th cell (ThN) conditions in the absence of human (h)IL-4. The expression level of Gata3 in this primed cells are checked by RT-PCR (Zhu J. 2001).</p>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Melissa, and Gary 2011). Low serum levels (60–100 pg/mL or 0.26–0.43 nM) of estradiol have been shown to increase Th1 T-cell development in vitro through an ERα mediated mechanism (Maret et al. 2003). Treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated disease, while high doses (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset and polarized T-cells to a Th2 phenotype in the EAE model (Bebo et al. 2001). High levels of estrogen during pregnancy have been reported to ameliorate T cell mediated diseases such as multiple sclerosis (Korn-Lubetzki et al. 1984).</p>
<p>M12.4.1 cells, transfected with the luciferase reporter gene by inserting three copies of human STAT6 binding site oligonucleotide, are used nuclear extracts and electrophoretic mobility shift assay (EMSA) with 1 μM 4-HT. STAT6:ER DNA-binding activity is strongly and rapidly (within 1 hr) induced after addition of 4-HT to these cells. BA/F3 cells prepared as the same manner are stimulated with 1 μM 4-HT for 24 h at 37°C. The cells were harvested and assayed for luciferase activities using a Luciferase Assay Kit (Kamogawa Y. 1998).</p>
<strong>Uncertainties and Inconsistencies</strong>
<p>The “tethered” pathway is confirmed indirectly using artificial STAT6-ER fusion protein but not endogenous STAT6. It remains unknown whether the “classical” pathway is utilized after binding to ERα in immune cells.</p>
<h4>Quantitative Understanding of the Linkage</h4>
<strong>Response-response relationship</strong>
<p>MIE:</p>
<p>XXXX</p>
<p>KE XX:</p>
<p>XXXX</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during the menstrual cycle and gestation. Immune activity shifts across the menstrual cycle, with higher follicular-phase Th1 cell activity and higher luteal-phase Th2 cell activity (Tierney et al. 2015). This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria et al. 2006).</p>
<strong>Time-scale</strong>
<p>XXXX</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during the menstrual cycle and gestation. Immune activity shifts across the menstrual cycle, with higher follicular-phase Th1 cell activity and higher luteal-phase Th2 cell activity (Tierney KL. 2015). This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria A. 2006). The effects of ERα signaling on T cells appear to be estrogen-dose dependent, i.e., low doses of estrogen stimulate a Th1 response, but higher doses promote a Th2 response (Priyanka HP. 2013).</p>
<strong>Known Feedforward/Feedback loops influencing this KER</strong>
<p>XXXX</p>
<h4>References</h4>
<ol>
<li>Deroo BJ, Korach KS. Estrogen receptors and human disease. J Clin Invest. 2006 Mar;116(3):561-70.</li>
<li>Guo H, Liu T, Ling F, et al. Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity. Cell Mol Immunol. 2010;7(3):227-34.</li>
<li>Uemura Y, Liu TY, Narita Y, Suzuki M, Matsushita S. 17 Beta-estradiol (E2) plus tumor necrosis factor-alpha induces a distorted maturation of human monocyte derived dendritic cells and promotes their capacity to initiate T-helper 2 responses. Hum Immunol. 2008;69(3):149-57.</li>
<li>Liu Y, Shi J, Ding B. Activation of peroxisome proliferator-activated receptor-gamma potentiates pro-inflammatory cytokine production, and adrenal and somatotropic changes of weaned pigs after Escherichia coli lipopolysaccharide challenge. Innate Immun. 2009;15(3):169-78.</li>
<li>Kamogawa, Y., Lee, H.J., Johnston, J.A., McMahon, M., O’Garra, A., and Arai, N. (1998). Cutting Edge: A conditionally active form of STAT6 can mimic certain effects of IL-4. J. Immunol. 161, 1074–1077.</li>
<li>Melissa, C. and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40: 66-73.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512-521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology. 166: 2080-2089</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231.</li>
<li>Tierney, K. L., Julia, R. H. and Gregory, E. D. (2015). Sexual activity modulates shifts in Th1/Th2 cytokine profile across the menstrual cycle: An observational study. Fertility and Sterility 104 (6): 1513–1521.</li>
<h4>References</h4>
<ol>
<li>Parker MG, Arbuckle N, Dauvois S, Danielian P, White R. Structure and function of the estrogen receptor. Ann N Y Acad Sci. 1993. 684:119-26.</li>
<li>Goldstein RA, Katzenellenbogen JA, Wolynes PG, et al. Three-dimensional model for the hormone binding domains of steroid receptors. Proc Natl Acad Sci. 1993;90 (21):9949-53.</li>
<li>Sasson S. Equilibrium binding analysis of estrogen agonists and antagonists: relation to the activation of the estrogen receptor. Pathol Biol (Paris). 1991;39(1):59-69.</li>
<li>Brandt ME, Vickery LE. Cooperativity and dimerization of recombinant human estrogen receptor hormone-binding domain. J Biol Chem. 1997;272(8):4843-9.</li>
<li>Delaunay, F., Pettersson, K., Tujague, M., and Gustafsson, J. A. (2000). Functional Differences between the Amino-Terminal Domains of Estrogen Receptors α and β. Molecular Pharmacology 58: 584-590.</li>
<li><a href="https://www.nature.com/articles/ni1115#auth-1">Spilianakis</a> CG & <a href="https://www.nature.com/articles/ni1115#auth-2">Flavell</a> RA, Long-range intrachromosomal interactions in the T helper type 2 cytokine locus. <a href="https://www.nature.com/ni">Nature Immunology</a>. 2004; 5: 1017-1027.</li>
<li>Eeckhoute J, Positive Cross-Regulatory Loop Ties GATA-3 to Estrogen Receptor α Expression in Breast Cancer. Cancer Res. 2007; 67(13):6477-83.</li>
<li>Kong SL, Cellular reprogramming by the conjoint action of ERα, FOXA1, and GATA3 to a ligand‐inducible growth state. Mol Syst Biol (2011)7:526</li>
<li>Kurata, H., Lee, H. J., O’Garra, A. and Arai, N. (1999). Ectopic expression of activated STAT6 induces the expression of Th2-specific cytokines and transcription factors in developing Th1 cells. Immunity 11: 677-688.</li>
<li>Zhu, J., Guo, L., Watson, C. J., Hu-Li, J. and Paul, W. E. (2001). STAT6 is necessary and sufficient for IL-4's role in Th2 differentiation and cell expansion. The Journal of Immunology 166(12): 7276-7281.</li>
<li>Horiuchi S, Genome-wide analysis reveals unique regulation of transcription of Th2-specific genes by GATA3. (2011) J Immunol. 1;186(11):6378-89.</li>
<li>Lambert KC, Curran EM, et al. <a href="https://pubmed.ncbi.nlm.nih.gov/16237062/?from_term=Estrogen+Receptor%2C+Deficiency+in+macrophages+results+in+increased+stimulation&from_pos=2">Estrogen receptor alpha (ERalpha) deficiency in macrophages results in increased stimulation of CD4+ T cells while 17beta-estradiol acts through ERalpha to increase IL-4 and GATA-3 expression in CD4+ T cells independent of antigen presentation.</a> J Immunol. 2005; 175(9): 5716-23.</li>
<li>Kamogawa, Y., Lee, H.J., Johnston, J.A., McMahon, M., O’Garra, A., and Arai, N. (1998). Cutting Edge: A conditionally active form of STAT6 can mimic certain effects of IL-4. J. Immunol. 161, 1074-1077.</li>
<li>Tierney, K. L., Julia, R. H. and Gregory, E. D. (2015). Sexual activity modulates shifts in Th1/Th2 cytokine profile across the menstrual cycle: An observational study. Fertility and Sterility 104 (6): 1513-1521.</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256.</li>
<li>Priyanka HP, Krishnan HC, Singh RV, Hima L, Thyagarajan S. Estrogen modulates in vitro T cell responses in a concentration- and receptor-dependent manner: effects on intracellular molecular targets and antioxidant enzymes. Mol Immunol. 2013;56(4):328-39.</li>
</ol>
</div>
<br>
<div>
<h4><a href="/relationships/2021">Relationship: 2021: Induction of GATA3 expression leads to Overproduction of IL-4</a></h4>
<div>
<h4><a href="/relationships/2021">Relationship: 2021: Induction of GATA3 expression leads to Increase of Th2 cells producing IL-4</a></h4>
<td><a href="/aops/314">Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<td>adjacent</td>
<td>Moderate</td>
<td>Moderate</td>
</tr>
</thead>
<tbody>
<tr>
<th><a href="/aops/314">Activation of estrogen receptor in immune cells leading to exacerbation of systemic lupus erythematosus</a></th>
<th>adjacent</th>
<th>Moderate </th>
<th>Moderate</th>
</tr>
</tbody>
</table>
</div>
<h4>Key Event Relationship Description</h4>
<p>Th2 cells produce IL-4, IL-5, IL-10, and IL-13, meanwhile Th1 cells produce IL-12, TNF-α, and IFN-γ. During Th2 polarization, IL-4 produced by Th2 cell. IL-12 plays a central role in promoting the differentiation of naive CD4+ T cells into mature Th1 effector cells. Secretion of IL-10 from Th2 has been suggested to downregulate the DC-derived IL-12 production and lead to a Th2 differentiation (Aste-Amezaga M. 1998).</p>
<!-- if nothing shows up in any of these fields, then evidence supporting this KER will not be displayed -->
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>IFN-γ is noticeably reduced in pregnant women compared with non-pregnant women or in response to high levels of estrogen (Kruse et al. 2000). Thus, pharmacological or pregnancy levels of estrogen may skew the immune system from a Th1 to a Th2 profile (Ebru et al. 2011). Th2 differentiation is completely abolished both in vitro and in vivo when GATA3 is conditionally deleted in peripheral CD4 T cells from GATA-3-deficient (FF and FF cre) mice (Sung-Yun. 2004, Zhu J. 2004). Antigen-specific immune response is evaluated with lymphocyte from FF and FF cre mice injected with KLH, and cytokine production was measured by sandwich ELISA (Sung-Yun. 2004). Mouse lymphocytes stimulated with a massive amount of BPA (50 μM) were Th2 polarized, with prominent elevation of IL-4 as well as IL-10 (Lee MH. 2010). Similarly, BPA enhanced IL-4 production in antigen-activated T cells by ELISA or RT-PCR, although the concentrations of BPA that they utilized (10–50 μM) were high (Lee MH. 2003). In this experiment, IL-4 level is confirmed baseline when treated with anti-CD4 mAb. Exposure to BPA in adulthood mice promoted antigen-stimulated levels of IL-4, IL-10, and IL-13, but not IFN-γ (Huimin et al. 2008).</p>
</tbody>
</table>
</div>
<h4>Evidence Supporting Applicability of this Relationship</h4>
<div>
</div>
<div>
</div>
<div>
</div>
<p>XXXX</p>
<strong>Empirical Evidence</strong>
<p>The proliferation of Stat6:ER Th1 cells was enhanced in a dose-dependent manner on days 10 and 31 after polarization by [<sup>3</sup>H]thymidine incorporation (the effective concentration of 4-HT was between 0.08 and 2 μM, and the toxic concentration was greater than 5 μM) (Kurata H. 1999, Zhu J. 2001).</p>
<h4>Key Event Relationship Description</h4>
<p>Intrachromosomal interactions in the Th2 cytokine locus may form the basis for the coordinated transcriptional regulation of cytokine-encoding genes by the Th2 locus control region (Spilianakis and Flavell, 2004). During Th2 cell differentiation, binding patterns of PcG and TrxG proteins are dynamically changed at the <em>Gata3 </em>gene locus, and these epigenetic changes result in GATA3 protein upregulation, which consequently induces chromatin remodeling at the Th2 cytokine gene loci, including <em>Il4</em>, <em>Il5</em>, and <em>Il13</em> (Ansel KM. 2006, Horiuchi S. 2011).</p>
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>Th2 differentiation is completely abolished both in vitro and in vivo when GATA3 is conditionally deleted in peripheral CD4 T cells. Th2 cells from both knockout animals showed reduction in IL-4 production. (Zhu J. 2004, Pai SY. 2004).</p>
<p>The GATA3 expression induced by TNF-α was enhanced in the presence of BPA. However, the T-bet expression did not change when tested at various culture conditions (Guo H. 2010, Uemura Y. 2008). IL-4 may serve multiple roles in the development of lupus: it may enhance autoantibody production via its direct B-cell effects (Ram RS. 2003).</p>
<strong>Uncertainties and Inconsistencies</strong>
<p>The essential transcription factors of Th2 are GATA-3 and STAT5. Activation of GATA-3 and STAT5 induce IL-4 production in naïve CD4 T cells. IL-4-mediated STAT6 activation promotes Th2 differentiation (Kaplan MH. 1996, Shimoda K. 1996, Takeda K. 1996).</p>
<strong>Empirical Evidence</strong>
<p>The proliferation of Stat6:ER Th2 cells was enhanced in a dose-dependent manner on days 10 and 31 after polarization by [<sup>3</sup>H]thymidine incorporation (the effective concentration of 4-HT was between 0.08 and 2 μM, and the toxic concentration was greater than 5 μM) (Kurata H. 1999, Zhu J. 2001). Purified naive T cells were activated and infected with RV-Stat6:ER. The cells were cultured and expanded under Th culture conditions in the presence or absence of 0.3 μM 4-HT (Research Biochemicals Institute) for 2 weeks starting from days 1, 7, 14, or 21 and the cells were analyzed for cytokine (IL-4) expression by flow cytometer analysis of intracellular cytokine production or cytokine ELISA (Kurata H. 1999, Zhu J. 2001). CD4 T cells from Stat6-knockout mice are not able to drive Th2 differentiation and cell expansion under null Th cell (ThN) conditions with added with IL-4 (Zhu J. 2001).</p>
<p>Th2 differentiation is completely abolished both in vitro and in vivo when GATA3 is conditionally deleted in peripheral CD4 T cells from GATA-3-deficient (FF and FF cre) mice (Sung-Yun. 2004, Zhu J. 2004). Antigen-specific immune response is evaluated with lymphocyte from FF and FF cre mice injected with KLH, and cytokine production was measured by sandwich ELISA (Sung-Yun. 2004). </p>
<h4>Quantitative Understanding of the Linkage</h4>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Cunningham M. 2011). When estrogen levels are low, T cell expansion shift toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ.</p>
<h4>Quantitative Understanding of the Linkage</h4>
<p>When estrogen levels are low, T cell expansion shift toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ. This response results in cellular immunity inducing inflammation and exacerbating cellular type autoimmune disease such as multiple sclerosis (MS) and EAE rather than SLE.</p>
<strong>Response-response relationship</strong>
<p>MIE:</p>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Cunningham and Gilkeson, 2011). Treatment with low serum levels (60–100 pg/mL or 0.26–0.43 nM) of estradiol increased Th1 T-cell development in vitro by acting through an ERα mediated mechanism (Maret et al. 2003). Treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated disease, while high dose levels (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset and polarized T-cells to a Th2 phenotype in the EAE. (Bebo et al. 2001). High levels of estrogen during pregnancy have been reported to ameliorate T cell mediated diseases such as multiple sclerosis (Korn-Lubetzki et al. 1984).</p>
<p>XXXX</p>
<p>IL-4 may serve multiple roles in the development of lupus: it may enhance autoantibody production via its direct B-cell effects, protect against autoimmunity via its T-cell suppressor effect, or perpetuate tissue damage via its direct effects on target organs (Ram Raj Singh 2003).</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during gestation. This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria et al. 2006).</p>
<p>KE XX:</p>
<p>XXXX</p>
<strong>Time-scale</strong>
<p>XXXX</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during gestation. This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria et al. 2006).</p>
<strong>Known Feedforward/Feedback loops influencing this KER</strong>
<p>XXXX</p>
<h4>References</h4>
<ol>
<li>Aste-Amezaga M, Ma X, Sartori A, Trinchieri G. Molecular mechanisms of the induction of IL-12 and its inhibition by IL-10. J Immunol. 1998. 15;160(12):5936-44.</li>
<h4>References</h4>
<ol>
<li><a href="https://www.nature.com/articles/ni1115#auth-1">Spilianakis</a> CG & <a href="https://www.nature.com/articles/ni1115#auth-2">Flavell</a> RA, Long-range intrachromosomal interactions in the T helper type 2 cytokine locus. <a href="https://www.nature.com/ni">Nature Immunology</a>. 2004; 5: 1017-1027.</li>
<li>Ansel KM, Djuretic I, Tanasa B, RaoA. 2006. Regulation ofTh2 differentiation and <em>Il4 </em>locus accessibility. <em>Annu. Rev. Immunol. </em>24:607-56.</li>
<li>Horiuchi S, Onodera A, Hosokawa H, Watanabe Y, Tanaka T, et al. 2011. Genome-wide analysis reveals unique regulation of transcription of Th2-specific genes by GATA3. <em>J. Immunol. </em>186:6378-89.</li>
<li>Zhu J, Min B, Paul WE, et al. Conditional deletion of Gata3 shows its essential function in T(H)1-T(H)2 responses. Nat Immunol. 2004;5(11):1157-65.</li>
<li>Pai SY, Truitt ML, Ho IC. GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proc Natl Acad Sci U S A. 2004 Feb 17;101(7):1993-8.</li>
<li>Guo H, Liu T, Ling F, et al. Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity. Cell Mol Immunol. 2010;7(3):227-34.</li>
<li>Uemura Y, Liu TY, Narita Y, Suzuki M, Matsushita S. 17 Beta-estradiol (E2) plus tumor necrosis factor-alpha induces a distorted maturation of human monocyte derived dendritic cells and promotes their capacity to initiate T-helper 2 responses. Hum Immunol. 2008;69(3):149-57.</li>
<li>Ram Raj Singh (2003). IL-4 and many roads to lupuslike autoimmunity. Clinical Immunology 108: 73-79.</li>
<li>Kurata, H., Lee, H. J., O’Garra, A. and Arai, N. (1999). Ectopic expression of activated STAT6 induces the expression of Th2-specific cytokines and transcription factors in developing Th1 cells. Immunity 11: 677-688.</li>
<li>Zhu, J., Guo, L., Watson, C. J., Hu-Li, J. and Paul, W. E. (2001). STAT6 is necessary and sufficient for IL-4's role in Th2 differentiation and cell expansion. The Journal of Immunology 166(12): 7276-7281.</li>
<li>Sung-Yun, Morgan L. T. I-Cheng H. (2004). GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proceedings of the National Academy of Sciences. 101 (7): 1993-1998.</li>
<li>Zhu J, Min B, Paul WE, et al. Conditional deletion of Gata3 shows its essential function in T(H)1-T(H)2 responses. Nat Immunol. 2004;5(11):1157-65.</li>
<li>Melissa, C. and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40: 66-73.</li>
<li>Lee, M. H., Chung, S. W., Kang, B. Y., Park, J., Lee, C. H., Hwang, S. Y. and Kim, T. S. (2003). Enhanced interleukin-4 production in CD4+ T cells and elevated immunoglobulin E levels in antigen-primed mice by bisphenol A and nonylphenol, endocrine disruptors: involvement of nuclear factor-AT and Ca2+. Immunology 109(1): 76-86.</li>
<li>Huimin, Y., Masaya, T. and Kazuo, S. (2008). Exposure to Bisphenol A Prenatally or in Adulthood Promotes TH2 Cytokine Production Associated with Reduction of CD4+CD25+ Regulatory T Cells. Environmental Health Perspective 116(4): 514-519.</li>
<li>Cunningham, M., Gilkeson, G., 2011. Estrogen receptors in immunity and autoimmunity. Clinical Reviews in Allergy and Immunology 40, 66-73.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512-521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology 166: 2080-2089.</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231.</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256.</li>
<li>Kaplan MH, Schindler U, Smiley ST, Grusby MJ. Stat6 is required for mediating responses to IL-4 and for development of Th2 cells. Immunity. 1996;4(3):313-9.</li>
<li>Shimoda K, van Deursen J, Ihle JN, et al. Lack of IL-4-induced Th2 response and IgE class switching in mice with disrupted Stat6 gene. Nature. 1996. 18;380(6575):630-3.</li>
<li>Takeda K, Tanaka T, Akira S, et al. Essential role of Stat6 in IL-4 signalling. Nature. 1996. 18;380(6575):627-30.</li>
<li>Zhu, J., Guo, L., Watson, C. J., Hu-Li, J. and Paul, W. E. (2001). STAT6 is necessary and sufficient for IL-4's role in Th2 differentiation and cell expansion. The Journal of Immunology 166(12): 7276-7281.</li>
<li>Lee, J. and Lim K. T. (2010). Plant-originated glycoprotein (36kDa) suppresses interleukin-4 and -10 in bisphenol A-stimulated primary cultured mouse lymphocytes. Drug and Chemical Toxicology. 33(4): 421-429.</li>
<li>Ram Raj Singh (2003). IL-4 and many roads to lupuslike autoimmunity. Clinical Immunology 108: 73–79</li>
</ol>
</div>
<br>
<div>
<h4><a href="/relationships/2022">Relationship: 2022: Overproduction of IL-4 leads to Increase of autoantibody production</a></h4>
<div>
<h4><a href="/relationships/2022">Relationship: 2022: Increase of Th2 cells producing IL-4 leads to Increase of autoantibody production</a></h4>
<td><a href="/aops/314">Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<td>adjacent</td>
<td>Moderate</td>
<td>Moderate</td>
</tr>
</thead>
<tbody>
<tr>
<th><a href="/aops/314">Activation of estrogen receptor in immune cells leading to exacerbation of systemic lupus erythematosus</a></th>
<th>adjacent</th>
<th>Moderate </th>
<th>Moderate</th>
</tr>
</tbody>
</table>
</div>
<h4>Key Event Relationship Description</h4>
<p>The receptor for IL-4 is IL-4Rα, which expresses in B cells. Th2 cells secrete cytokines IL-4 that upregulate antibody formation via B cells. Naive B cells that have not yet encountered antigen express immunoglobulin M and immunoglobulin D on their surface. During an immune response, B cells can express different immunoglobulin heavy chain isotypes sharing the same variable–diversity–joining (VDJ) region. This isotype-switching recombination allows a B-cell clone to produce antibodies with the same specificity for antigens but with different effector functions. To switch to a particular isotype, a B cell needs two signals, one cytokine-dependent and the other CD40-dependent. In B cells, estrogen-mediated events could occur through the CD40/CD40L costimulatory pathway. Estrogen can also enhance differentiation of immature DCs into mature functional DCs and regulate the expression of cytokines and chemokines such as IL-6, IL-10, CXCL8, and CCL2 (Liu Y. 2009, Guo H. 2010). This increase the number of B cells producing autoantibodies.</p>
<!-- if nothing shows up in any of these fields, then evidence supporting this KER will not be displayed -->
<h4>Evidence Supporting this KER</h4>
</tbody>
</table>
</div>
<h4>Key Event Relationship Description</h4>
<p>During process of B cell maturation, the autoreactive B cell which has high-affinity for DNA are normally silenced by anergy, and activated by stimulation with antigen independent CD40 ligand (CD154) or IL-4 from Th2 cells. The receptor for IL-4 is IL-4Rα, which expresses in B cells. In the development of T-cell dependent antibody producing cells, the interaction between IL-4 and its receptor stimulates B-cells to mature (proliferate, switch immunoglobulin classes). As a result, production of anti-DNA antibody from activated autoreactive B cells in increased.</p>
<strong>Biological Plausibility</strong>
<p>Lack of ERα, in either male or female mice, did not increase B cell precursors (Smithson G. 1998).</p>
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>Lack of ERα, in either male or female mice, did not increase B cell precursors (Smithson G. 1998). Restoration of estradiol in ovariectomized NZB/W F1 mice reestablished high numbers of autoantibody-producing (DNA-specific) B cells, and thereby suggests a pathogenic role of estrogen in lupus (Daniel P. 2011). </p>
<p>Estrogen upregulates CD40L on B and T cells from SLE patients (Desai-Mehta A. 1996, Li X. 2006), and CD40L expression on B cells is increased two-fold in SLE patients (Díaz-Alderete A. 2004). Whereas anti-CD40L antibodies downregulate CD86 expression on normal and SLE B lymphocytes, blockade of CD86 only diminishes anti-DNA antibody production by SLE B cells (Nagafuchi H. 2003). Moreover, mice overexpressing CD40L develop a lupus-like disease with high levels of antibodies to nuclear antigens, DNA, and histones, as well as glomerulonephritis (Higuchi T. 2002). It is possible that this estrogen modulated elevation in CD40/CD40L crosstalk as well as stimulation via CD86 synergizes in the exacerbation of SLE by promoting autoantibody secretion as well as activation of T cells (Karpuzoglu E. 2011). In a murine model of SLE, BPA increased the number of B cells producing autoantibodies, and IgM antibody secretion by B1 cells was augmented (Yurino et al. 2004).</p>
<p>Anergic B cells, dsDNA-specific models, can be stimulated by IL-4 specific antibody in vitro, suggesting that they are capable of responding to T-cell-derived signals (Acevedo-Suarez CA. 2005, Noorchashm H. 1999, Mandik-Nayak L. 2000, Eris JM. 1994).</p>
<p>Direct exposure of PBMCs from SLE patients to 17β-estradiol induces secretion of anti-dsDNA antibodies and enhances the secretion of Igs, in particular IgG (Kanda et al. 1999).</p>
<p>Transfer of either IL-4-stimulated splenocytes from 5-mo-old NZB/W F1 mice into NZB/W F1 mice of the same age enhanced the production of IgG anti-dsDNA Ab. Consistently, administration of mAb against IL-4 before the onset of lupus was effective in preventing the onset of lupus nephritis (Nakajima A. 1997).</p>
<strong>Empirical Evidence</strong>
<p>The administration of the estrogen antagonist tamoxifen diminishes anti-DNA antibody levels by ELISA as well as decreases percentages of total B cells and CD5+ B cells by FCM (Wu WM. 2000). Tamoxifen blocks estrogen-induced B cell maturation but not survival (Peeva E. 2005). ERα deficiency in (NZB×NZW) F1 female mice downregulated levels of anti-dsDNA IgG antibodies, and the absence of ERα In (NZB×NZW) F1 males resulted in decreased anti-dsDNA antibodies (Bynote KK. 2008).</p>
<strong>Empirical Evidence</strong>
<p>CD23 on M12.4.1 cells, transfected with the luciferase reporter gene by inserting three copies of human STAT6 binding site oligonucleotide, is up-regulated with treatment1 μM 4HT for 16 hr (Kamogawa et al. 1998).</p>
<strong>Uncertainties and Inconsistencies</strong>
<p>Estrogen upregulates CD40L (CD154) on T cells from SLE patients (Desai-Mehta A. 1996, Li X. 2006). Anti-CD40L antibodies downregulate CD86 expression on normal and SLE B lymphocytes, blockade of CD86 only diminishes anti-DNA antibody production by SLE B cells (Nagafuchi H. 2003). Moreover, mice overexpressing CD40L develop a lupus-like disease with high levels of antibodies to nuclear antigens, DNA, and histones, as well as glomerulonephritis (Higuchi T. 2002). Activation of autoreactive B cell may be involved in stimulation not only IL-4, but also CD40 ligand (CD154) of Th2 cell as well as the other immune cells.</p>
<p>The production of IgA and IgG2a was increased in B cells from mice fed BPA (Goto et al. 2007). Similarly, in mice exposed prenatally to BPA and then immunized in adulthood with hen egg lysozyme (HEL), the anti-HEL IgG2a measured three weeks later was elevated (Yoshino et al. 2004). These Ig can be measured by ELISA. The administration of the estrogen antagonist tamoxifen diminishes anti-DNA antibody levels by ELISA as well as decreases percentages of total B cells and CD5+ B cells by FCM (Wu et al. 2000). Tamoxifen Blocks Estrogen-Induced B Cell Maturation but not survival (Peeva et al. 2005). ERα deficiency in (NZB×NZW) F1 female mice downregulated levels of anti-dsDNA IgG antibodies, and the absence of ERα In (NZB×NZW) F1 males resulted in decreased anti-dsDNA antibodies (Bynote et al. 2008).</p>
<p>B1 cells from aged mice exhibited increased expression of ERα mRNA compared to young mice (Yurino H. 2004). Since the ER of B cell is also expressed, there may be a direct route that does not go through Th2.</p>
<h4>Quantitative Understanding of the Linkage</h4>
<strong>Response-response relationship</strong>
<p>When estrogen levels are low, T cell expansion shift toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ. This response results in cellular immunity inducing inflammation and exacerbating cellular type autoimmune disease such as multiple sclerosis (MS) and EAE rather than SLE.</p>
<h4>Quantitative Understanding of the Linkage</h4>
<strong>Response-response relationship</strong>
<p>MIE:</p>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Cunningham and Gilkeson, 2011). Treatment with low serum levels (60–100 pg/mL or 0.26–0.43 nM) of estradiol increased Th1 T-cell development in vitro by acting through an ERα mediated mechanism (Maret et al. 2003). Treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated disease, while high dose levels (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset and polarized T-cells to a Th2 phenotype in the EAE. (Bebo et al. 2001). High levels of estrogen during pregnancy have been reported to ameliorate T cell mediated diseases such as multiple sclerosis (Korn-Lubetzki et al. 1984).</p>
<strong>Time-scale</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during gestation. This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria et al. 2006).</p>
<strong>Known Feedforward/Feedback loops influencing this KER</strong>
<p>XXXX</p>
<h4>References</h4>
<ol>
<li>Liu Y, Shi J, Ding B. Activation of peroxisome proliferator-activated receptor-gamma potentiates pro-inflammatory cytokine production, and adrenal and somatotropic changes of weaned pigs after Escherichia coli lipopolysaccharide challenge. Innate Immun. 2009;15(3):169-78.</li>
<li>Guo H, Liu T, Ling F, et al. Bisphenol A in combination with TNF-alpha selectively induces Th2 cell-promoting dendritic cells in vitro with an estrogen-like activity. Cell Mol Immunol. 2010;7(3):227-34.</li>
<h4>References</h4>
<ol>
<li>Smithson G, Couse JF, Lubahn DB, Korach KS, Kincade PW. The role of estrogen receptors and androgen receptors in sex steroid regulation of B lymphopoiesis. J Immunol. 1998;161(1):27-34.</li>
<li>Daniel, P., Allison, S., Yiming, Y., Ying-Yi, Z. and Laurence, M. Murine Models of Systemic Lupus erythematosus. Journal of Biomedicine and Biotechnology 2011: ArticleID 271694</li>
<li>Acevedo-Suarez CA, Hulbert C, Woodward EJ, Thomas JW. Uncoupling of anergy from developmental arrest in anti-insulin B cells supports the development of autoimmune diabetes. J. Immunol. 2005; 174:827-833.</li>
<li>Noorchashm H, et al. Characterization of anergic anti-DNA B cells: B cell anergy is a T cellindependent and potentially reversible process. Int. Immunol. 1999; 11:765-776.</li>
<li>Mandik-Nayak L, et al. Functional consequences of the developmental arrest and follicular exclusion of anti-double-stranded DNA B cells. J. Immunol. 2000; 164:1161-1168.</li>
<li>Eris JM, et al. Anergic self-reactive B cells present self-antigen and respond normally to CD40-dependent T-cell signals but are defective in antigen-receptor-mediated functions. Proc. Natl Acad. Sci. USA. 1994; 91:4392-4396.</li>
<li>Nakajima A, Hirose S, Yagita H and Okumura K, Roles of IL-4 and IL-12 in the development of lupus in NZB/W F1 mice. J Immunol 1997; 158 (3) 1466-1472.</li>
<li>Wu WM., Lin, B.-F., Su, Y.-C., Suen, J.-L. and Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<li>Peeva, E., Venkatesh, J. and Diamond, B. (2005). Tamoxifen Blocks Estrogen-Induced B Cell Maturation but Not Survival. The Journal of Immunology 175: 1415-1423.</li>
<li>Bynote, KK. Hackenberg, JM., Korach, KS, Lubahn, DB., Lane, PH.and Gould, KA. (2008). Estrogen receptor-alpha deficiency attenuates autoimmune disease in (NZB xNZW) F1 mice. Genes and Immunity. 9: 137-152.</li>
<li>Desai-Mehta A, Lu L, Ramsey-Goldman R, Datta SK. Hyperexpression of CD40 ligand by B and T cells in human lupus and its role in pathogenic autoantibody production. J Clin Invest. 1996. 1;97(9):2063-73.</li>
<li>Li X, Rider V, Kimler BF, Abdou NI. Estrogen does not regulate CD154 mRNA stability in systemic lupus erythematosus T cells. Lupus. 2006;15(12):852-7.</li>
<li>Díaz-Alderete A, Crispin JC, Vargas-Rojas MI, Alcocer-Varela J. IL-10 production in B cells is confined to CD154+ cells in patients with systemic lupus erythematosus. J Autoimmun. 2004;23(4):379-83.</li>
<li>Nagafuchi H, Shimoyama Y, Suzuki N, et al. Preferential expression of B7.2 (CD86), but not B7.1 (CD80), on B cells induced by CD40/CD40L interaction is essential for anti-DNA autoantibody production in patients with systemic lupus erythematosus. Clin Exp Rheumatol. 2003;21(1):71-7.</li>
<li>Higuchi T, Aiba Y, Tsubata T. Cutting Edge: ectopic expression of CD40 ligand on B cells induces lupus-like autoimmune disease. J Immunol. 2002. 1;168(1):9-12.</li>
<li>Karpuzoglu E, Zouali M. The Multi-faceted Influences of Estrogen on Lymphocytes: Toward Novel Immuno-interventions Strategies for Autoimmunity Management. Clin Rev Allergy Immunol. 2011;40(1):16-26.</li>
<li>Wu WM., Lin, B.-F., Su, Y.-C., Suen, J.-L. and Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<li>Peeva, E., Venkatesh, J. and Diamond, B. (2005). Tamoxifen Blocks Estrogen-Induced B Cell Maturation but Not Survival. The Journal of Immunology 175: 1415-1423.</li>
<li>Bynote, K. K., Hackenberg, J. M., Korach, K.S., Lubahn, D. B., Lane, P. H.and Gould, K. A. (2008). Estrogen receptor-alpha deficiency attenuates autoimmune disease in (NZB xNZW) F1 mice. Genes and Immunity. 9: 137-152.</li>
<li>Kanda N. and Tamaki, K. (1999). Estrogen enhances immunoglobulin production by human PBMCs. The Journal of Allergy and Clinical Immunology 103(2): 282-288.</li>
<li>Yurino, H., Ishikawa, S., Sato, T., Akadegawa, K., Ito, T., Ueha, S., Inadera, H. and Matsushima, K. (2004). Endocrine disruptors (environmental estrogens) enhance autoantibody production by B1 cells. Toxicological Sciences 81(1): 139-147.</li>
<li>Goto, M., Takano-Ishikawa, Y., Ono, H., Yoshida, M., Yamaki, K. and Shinmoto, H. (2007). Orally Administered Bisphenol A Disturbed Antigen Specific Immunoresponses in the Naive Condition. Bioscience, Biotechnology, and Biochemistry 71(9): 2136–2143.</li>
<li>Yoshino S., Yamaki, K., Li, X., Sai, T., Yanagisawa, R., Takano, H., Taneda, S., Hayashi, H. and Mori, Y. (2004). Prenatal exposure to bisphenol A up-regulates immune responses, including T helper 1 and T helper 2 responses, in mice. Immunology 112: 489–495.</li>
<li>Melissa, C. and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40: 66–7</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512–521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology. 166: 2080-2089.</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231.</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256</li>
<li>Kamogawa, Y., Lee, H.J., Johnston, J.A., McMahon, M., O’Garra, A., and Arai, N. (1998). Cutting Edge: A conditionally active form of STAT6 can mimic certain effects of IL-4. J. Immunol. 161, 1074–1077.</li>
</ol>
</div>
<br>
<div>
<div>
<h4><a href="/relationships/2023">Relationship: 2023: Increase of autoantibody production leads to Exacerbation of SLE</a></h4>
<td><a href="/aops/314">Binding to estrogen receptor (ER)-α in immune cells leading to exacerbation of systemic lupus erythematosus (SLE)</a></td>
<td>adjacent</td>
<td>Moderate</td>
<td>Moderate</td>
</tr>
</thead>
<tbody>
<tr>
<th><a href="/aops/314">Activation of estrogen receptor in immune cells leading to exacerbation of systemic lupus erythematosus</a></th>
<th>adjacent</th>
<th>Moderate </th>
<th>Moderate</th>
</tr>
</tbody>
</table>
</div>
<h4>Key Event Relationship Description</h4>
<p>SLE patients appear to produce significant amounts of the anti-double-stranded DNA (anti-dsDNA) autoantibodies that cause the disease. Activation of autoantibody-producing B cells only serves to exacerbate that condition.</p>
<!-- if nothing shows up in any of these fields, then evidence supporting this KER will not be displayed -->
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>SLE has been seen to flare up during pregnancy (Petri et al., 1991). Female MRL/lpr mice that developed lymphadenopathy and a lupus-like disease also exhibited a 50% higher mortality rate than males at 5 months of age (Carlsten H. 1992).</p>
<p>In (NZB×NZW) F1 mice too, females develop signs of SLE several months before males, with severe autoimmune hemolytic anemia, glomerulonephritis, and autoantibodies to single-stranded DNA, doublestranded DNA, and histones. In both (NZB×NZW) F1 and MRL/lpr mice, estrogen treatment exacerbates the lupus disease, with augmented levels of autoantibodies against dsDNA and phospholipids as well as formation of circulating immune complexes (Grimaldi CM. 2002, Peeva E. 2000).</p>
<p>Murine lupus models such as NZB×NZW F1 (NZB/W F1), NZB.H-2bm12, NZB×SWR F1 (SNF1), MRL.lpr/lpr, and BXSB mice have led to a better understanding of the pathogenic mechanisms of lupus (Zhang DH. 1997, Pai SY. 2004). All of these species of mice develop immunoglobulin G (IgG) anti-dsDNA antibody, which is a characteristic of lupus, and die of uremia in early life. Among these murine lupus models, the natural course of NZB/W F1 mice is closer to human lupus than MRL.lpr/lpr and BXSB mice. The administration of the estrogen antagonist tamoxifen diminishes immune complex deposition in the kidneys and increases survival. Renal disease was evaluated by the development of albuminuria and histological changes in the kidney (Wu et al. 2000).</p>
<p>In NZM female mice, ERα inactivation markedly prolonged life-span, lowered proteinuria, and ameliorated glomerulonephritis but resulted in higher serum anti-dsDNA antibody levels (Svenson JL. 2008).</p>
<strong>Empirical Evidence</strong>
<p>Estrogen enhances anti-double-stranded DNA antibody and IgG, IgM production by PBMCs. PBMCs or B cells were cultured for 7 days with E2 (10<sup>–8</sup> mol/L). Theamounts of total IgG and IgM in the supernatants were measured by ELISA. Proliferative responses PBMCs or B cells were measured by [3H]-thymidine (Kanda N. 1999).</p>
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<h4>Evidence Supporting Applicability of this Relationship</h4>
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<p>XXXX</p>
<h4>Quantitative Understanding of the Linkage</h4>
<h4>Key Event Relationship Description</h4>
<p>The presence of many autoantibodies is a hallmark of SLE. In particular, autoantibodies directed to double-stranded DNA (dsDNA) are characteristic (Isenberg DA. 2007). SLE patients appear to produce significant amounts of the anti-dsDNA autoantibodies that cause the disease. Anti-dsDNA antibody exists even in healthy people, but in SLE patients, an increase in anti-dsDNA antibody has been observed and is also used for definitive diagnosis of SLE. Activation of autoantibody-producing B cells only serves to exacerbate that condition.</p>
<strong>Response-response relationship</strong>
<p>When estrogen levels are low, T cell expansion shift toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ. This response results in cellular immunity inducing inflammation and exacerbating cellular type autoimmune disease such as multiple sclerosis (MS) and EAE rather than SLE.</p>
<h4>Evidence Supporting this KER</h4>
<strong>Biological Plausibility</strong>
<p>SLE has been seen to flare up during pregnancy (Petri M. 1991). The aberrant T cell dysfunction in SLE is also associated with high levels of autoantibodies (Crispin JC. 2010).</p>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Cunningham and Gilkeson, 2011). Treatment with low serum levels (60–100 pg/mL or 0.26–0.43 nM) of estradiol increased Th1 T-cell development in vitro by acting through an ERα mediated mechanism (Maret et al. 2003). Treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated disease, while high dose levels (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset and polarized T-cells to a Th2 phenotype in the EAE. (Bebo et al. 2001). High levels of estrogen during pregnancy have been reported to ameliorate T cell mediated diseases such as multiple sclerosis (Korn-Lubetzki et al. 1984).</p>
<p>Premenopausal women receiving low estrogen containing birth control pills did not have an increased flare rate compared to women receiving placebo suggesting that adding estrogen to an already high estrogen state had no effect on disease (Buyon JP. 1996).</p>
<strong>Empirical Evidence</strong>
<p>In a study to investigate a novel subpopulation of B-1 cells and its roles in murine lupus, anti-double-stranded DNA (anti-dsDNA) autoantibodies were preferentially secreted by a subpopulation of CD5+ B-1 cells that expressed programmed death ligand 2 (L2pB1 cells) (Xuemei Z. 2009). A substantial proportion of hybridoma clones generated from L2pB1 cells reacted to dsDNA. L2pB1 cells are potent antigen-presenting cells and a dramatic increase of circulating L2pB1 cells in lupus-prone BXSB mice correlates with elevated serum titers of anti-dsDNA antibodies (Xuemei Z. 2009).</p>
<strong>Uncertainties and Inconsistencies</strong>
<p>Stat6-deficient New Zealand Mixed (NZM) 2328 mice display a significant reduction in incidence of kidney disease, with a dramatic increase in survival, despite the presence of high levels of anti-dsDNA Abs same like the wild-type NZM 2328 animals (Chaim O. 2003). In NZM 2410 mice, STAT6 deficiency or anti-IL-4 Ab treatment decreases type 2 cytokine responses and ameliorates kidney disease, particularly glomerulosclerosis, despite the presence of high levels of IgG anti-dsDNA Abs same like the wild-type littermates or PBS-treated controls (Ram RS. 2003). Anti-dsDNA antibodies are not what we think they are, as they may be antibodies operational in quite different biological contexts, although they bind dsDNA by chance. This may not mean that these antibodies are not pathogenic but they do not inform how they are so (Ole PR. 2019). In other words, might be that the high levels of anti-dsDNA Abs does not always exacerbate SLE.</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during the menstrual cycle and gestation. Immune activity shifts across the menstrual cycle, with higher follicular-phase Th1 cell activity and higher luteal-phase Th2 cell activity (Tierney et al. 2015). This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria, A., et al. 2006).</p>
<h4>Quantitative Understanding of the Linkage</h4>
<strong>Response-response relationship</strong>
<p>The effects of estrogen receptor signaling on T cells also appear to be dose dependent (Cunningham M. 2011). When estrogen levels are low, T cell expansion shift toward a Th1 phenotype that produces IL-12, TNF-α, and IFN-γ. This response results in cellular immunity inducing inflammation and exacerbating cellular type autoimmune diseases (multiple sclerosis; MS, rheumatoid arthritis; RA, and experimental autoimmune encephalomyelitis; EAE, etc.) caused by Th1 rather than SLE. Treatment with low serum levels (60-100 pg/mL or 0.26-0.43 nM) of estradiol increased Th1 T-cell development in vitro by acting through an ERα mediated mechanism (Maret A. 2003). Treatment with low doses of estrogen (25 pg/ml or 0.1 nM) ameliorated autoimmune diseases caused by Th1, while high dose levels (>1000 pg/ml or 4.3 nM), which mimic pregnancy levels, prevented EAE onset and polarized T-cells to a Th2 phenotype in the EAE. (Bebo BF. 2001, Korn-Lubetzki I. 1984).</p>
<strong>Time-scale</strong>
<p>XXXX</p>
<strong>Known modulating factors</strong>
<p>The Th1/Th2 shift is one of the most important immunologic changes during the menstrual cycle and gestation. Immune activity shifts across the menstrual cycle, with higher follicular-phase Th1 cell activity and higher luteal-phase Th2 cell activity (Tierney KL. 2015). This is due to the progressive increase of estrogens, which reach peak level in the third trimester of pregnancy. At these high levels, estrogens suppress the Th1-mediated responses and stimulate Th2-mediated immunologic responses (Doria A. 2006). Incidence of flare in patients with SLE is increased during pregnancy and within the 3-months postpartum (Amanda E. 2018). </p>
<strong>Known Feedforward/Feedback loops influencing this KER</strong>
<p>XXXX</p>
<h4>References</h4>
<ol>
<li>Petri, M. Howard, D. and Repke, J. (1991). Frequency of lupus flare in pregnancy. The Hopkins Lupus Pregnancy Center experience. Arthritis & Rheumatology. 34(12): 1538-1545.</li>
<li>Estrogen accelerates immune complex glomerulonephritis but ameliorates T cell-mediated vasculitis and sialadenitis in autoimmune MRL lpr/lpr mice Estrogen alters thresholds for B cell apoptosis and activation.</li>
<li>Carlsten H, Nilsson N, Tarkowski A, et al. Estrogen accelerates immune complex glomerulonephritis but ameliorates T cell-mediated vasculitis and sialadenitis in autoimmune MRL lpr/lpr mice. Cell Immunol. 1992;144(1):190-202.</li>
<li>Grimaldi CM, Cleary J, Dagtas AS, Moussai D, Diamond B. Estrogen alters thresholds for B cell apoptosis and activation. J Clin Invest. 2002;109(12):1625-33.</li>
<li>Peeva E, Grimaldi C, Spatz L, Diamond B. Bromocriptine restores tolerance in estrogen-treated mice. J Clin Invest. 2000;106(11):1373-9.</li>
<li>Zhang DH, Cohn L, Ray P, Bottomly K, Ray A. Transcription factor GATA-3 is differentially expressed in murine Th1 and Th2 cells and controls Th2-specific expression of the interleukin-5 gene. J Biol Chem. 1997. 22;272(34):21597-603.</li>
<li>Pai SY, Truitt ML, Ho IC. GATA-3 deficiency abrogates the development and maintenance of T helper type 2 cells. Proc Natl Acad Sci U S A. 2004 Feb 17;101(7):1993-8.</li>
<li>Wu, W.-M., Lin, B.-F., Su, Y.-C., Suen, J.-L. and Chiang, B.-L. (2000). Tamoxifen decreases renal inflammation and alleviates disease severity in autoimmune NZB/W F1 mice. Scandinavian Journal of Immunology 52(4): 393-400.</li>
<li>Svenson JL, EuDaly J, Ruiz P, Korach KS, Gilkeson GS. Impact of estrogen receptor deficiency on disease expression in the NZM2410 lupus prone mouse. Clin Immunol. 2008;128(2):259-68.</li>
<li>Kanda N. and Tamaki, K. (1999). Estrogen enhances immunoglobulin production by human PBMCs. The Journal of Allergy and Clinical Immunology 103(2): 282-288.</li>
<li>Melissa, C. and Gary, G (2011). Estrogen Receptors in Immunity and Autoimmunity. Clinical Reviews in Allergy & Immunology 40: 66–73.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512–521.</li>
<h4>References</h4>
<ol>
<li>Isenberg, DA., Manson, JJ., Ehrenstein, MR. and Rahman, A. (2007). Fifty years of anti-ds DNA antibodies: are we approaching journey’s end? Rheumatology 46:1052-6.</li>
<li>Petri, M. Howard, D. and Repke, J. (1991). Frequency of lupus flare in pregnancy. The Hopkins Lupus Pregnancy Center experience. Arthritis & Rheumatology. 34(12): 1538-1545.</li>
<li>Crispin, JC. Liossis, SN. (2010). Pathogenesis of human systemic lupus erythematosus: recent advances. Trends in Molecular Medicine. 16: 47-57.</li>
<li>Buyon JP. Oral contraceptives in women with systemic lupus erythematosus. Ann Med Interne (Paris) (1996) 147(4):259-264.</li>
<li>Xuemei, Z., Stanley, L., et al. (2009). A Novel Subpopulation of B-1 Cells Is Enriched with Autoreactivity in Normal and Lupus-Prone Mice. Arthritis & Rheumatology 60 (12):3734-3743.</li>
<li>Chaim O. Jacob, Song Zang, Lily Li, Voicu Ciobanu, Frank Quismorio, Akiei Mizutani, Minoru Satoh and Michael Koss (2003). Pivotal Role of Stat4 and Stat6 in the Pathogenesis of the Lupus-Like Disease in the New Zealand Mixed 2328 Mice. J Immunol. 171 (3): 1564-1571.</li>
<li>Ram Raj Singh, Vijay Saxena, Song Zang, Lily Li, Fred D. Finkelman, David P. Witte and Chaim O. Jacob (2003). Differential Contribution of IL-4 and STAT6 vs STAT4 to the Development of Lupus Nephritis. J Immunol, 170 (9): 4818-4825</li>
<li>Ole Petter Rekvig (2019), The dsDNA, Anti-dsDNA Antibody, and Lupus Nephritis: What We Agree on, What Must Be Done, and What the Best Strategy Forward Could Be, Front. Immunol. 10: 1-17.</li>
<li>Cunningham, M., Gilkeson, G., 2011. Estrogen receptors in immunity and autoimmunity. Clinical Reviews in Allergy and Immunology 40, 66-73.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512-521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology. 166: 2080-2089.</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231</li>
<li>Tierney, K. L., Julia, R. H. and Gregory, E. D. (2015). Sexual activity modulates shifts in Th1/Th2 cytokine profile across the menstrual cycle: An observational study. Fertility and Sterility 104 (6): 1513–1521.</li>
<li>Doria, A., Iaccarino, L., Sarzi-Puttini, P., Ghirardello, A., Zampieri, S., Arienti, S., Cutolo, M. and Todesco, S. (2006). Estrogens in pregnancy and systemic lupus erythematosus. Annals of the New York Academy of Sciences 1069: 247-256.</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231.</li>
<li>Maret, A., Coudert, J. D., Garidou, L., Foucras, G., Gourdy, P., Krust, A., Dupont, S., Chambon, P., Druet, P., Bayard, F. and Guéry, J. C. (2003). Estradiol enhances primary antigen-specific CD4 T cell responses and Th1 development in vivo. Essential role of estrogen receptor α expression in hematopoietic cells. The European Journal of Immunology 33: 512-521.</li>
<li>Bebo, B. F. Jr., Fyfe-Johnson, A., Adlard, K., Beam, A. G., Vandenbark, A. A.and Offner, H. Low-Dose Estrogen Therapy Ameliorates Experimental Autoimmune Encephalomyelitis in Two Different Inbred Mouse Strains. (2001). The Journal of Immunology. 166: 2080-2089.</li>
<li>Korn-Lubetzki, I., Kahana, E., Cooper, G. and Abramsky, O. (1984). Activity of multiple sclerosis during pregnancy and puerperium. Annals of Neurology 16(2): 229-231.</li>
<li>Tierney, K. L., Julia, R. H. and Gregory, E. D. (2015). Sexual activity modulates shifts in Th1/Th2 cytokine profile across the menstrual cycle: An observational study. Fertility and Sterility 104 (6): 1513-1521.</li>
<li>Amanda E, Anna Maria SR, Michelle P, et al. Effect of pregnancy on disease flares in patients with systemic lupus erythematosus. Ann Rheum Dis. 2018; 77(6): 855-860.</li>