Genetic mutations or polymorphism, aneuploidy (abnormal number of chromosomes) and copy number variations are events that can cause or contribute to disease, while allowing for phenotypic variation in human population and (at least partially) explain complex inheritance.
Gene Mutations and Monogenic Disease
As briefly mentioned above, familial clustering of SLE patients, (relatively) high disease concordance in monozygotic twins (40–60%), and increased risk and poor prognosis of individuals of African or Asian descent suggest that genetic factors play a critical role in the pathogenesis of SLE [
5,
33]. However, especially based on the observation that disease penetrance is limited (e.g. concordance rates in genetically identical twins), SLE has been identified as a pathophysiologically highly complex condition in which gene mutations, polymorphisms and additional factors may be involved.
Indeed, only a relatively small number of patients diagnosed with SLE (estimated 1–4% across all age groups) carry highly penetrant mutations in single genes that are strong enough to cause disease. So-called monogenic SLE is caused by mutations in genes involved in the complement pathway, nucleic acid sensing and processing, apoptosis, and/or lymphocyte activation [
2].
While the exact molecular pathophysiology is not known for all, mutations affecting the early the
complement pathway (
C1q, C1r, C1s, C2, C4A and
C4B) [
34‐
39] result in inflammation and immune activation through incompletely understood mechanisms. Defective clearance of immune complexes results in their deposition in peripheral tissues, local inflammation, cytokine expression (including type I interferons) and immune cell infiltration which amplifies the above. Another mechanism may be the altered negative selection of self-reactive B lymphocytes in complement C4 deficiency. Indeed, insufficient clearance of cellular debris, which is dependent on complement activation, is a key mechanism not only in primary complement deficiencies but also in more common ‘classical’ forms of SLE [
2,
4,
30,
40]. Recently, a genome-wide analysis on a large British-French jSLE cohort investigated rare mono-allelic variants, further highlighting the importance of the complement pathway [
41•].
Disturbed apoptosis may be involved in SLE and other autoimmune/inflammatory conditions, and mutations in the
FAS (Fas cell surface death receptor) or
FASL (Fas ligand) [
42,
43] genes, regulators of activation-induced cell death, result in autoimmune lymphoproliferative syndrome (ALPS). Mice deficient of Fas (MRL.
lpr mice) are prone to SLE-like disease and generalised lymphoproliferation. In both humans with gene mutations and genetically modified mice, ineffective elimination of T lymphocytes results in lupus-like disease, systemic inflammation, and tissue and organ damage [
2,
4,
30,
40,
44,
45].
A number of genes affecting
nucleic acid metabolism and sensing have been linked with
increased type I interferon expression, the resulting presence of a so-called interferon signature, systemic inflammation and clinical pictures that (more or less) resemble SLE [
2,
4,
40]. Impaired processing and removal of chromatin components (including DNA) contribute to autoantibody production and tissue damage (as also happens in aforementioned complement deficiencies). In humans and mice deficient in DNAse1, accumulation of extracellular chromatin contributes to immune activation, type I interferon expression, autoantibody production and subsequently lupus-like disease. Rare familial cases of SLE segregate with autosomal recessive mutations in DNase1 (deoxyribonuclease 1) or DNASE1L3 (deoxyribonuclease 1 like 3
, a homologue of DNAse1), extracellular accumulation of DNA, autoantibody production, complement consumption and early-onset SLE [
44,
45]. Loss-of-function mutations in the gene encoding for the repair exonuclease TREX1 (three prime repair exonuclease 1) result in uncontrolled type I interferon expression and the clinical phenotype described as familial chilblain lupus that is characterised by painful and sometimes ulcerating chilblain lesions. Loss of TREX1 results in cytoplasmic accumulation of single-stranded DNA, which is detected by the nucleic acid sensing machinery resulting in type I interferon release. Thus,
DNASE1,
DNASE1L3 and
TREX1 mutations are key representatives of primary type I interferonopathies, some of which share clinical characteristics with SLE [
2,
4].
All of the aforementioned (and additional) monogenic SLE-like diseases following Mendelian inheritance are usually characterised by
disturbed apoptosis, with mutations in the
FAS (Fas cell surface death receptor) or
FASL (Fas ligand) [
42,
43] genes, regulators of activation-induced cell death, resulting in autoimmune lymphoproliferative syndrome (ALPS). Mice deficient of Fas (MRL.
lpr mice) are prone to SLE-like disease and generalised lymphoproliferation. In both humans with gene mutations and genetically modified mice, ineffective elimination of T lymphocytes results in lupus-like disease, systemic inflammation, and tissue and organ damage [
2,
4,
30,
40,
44,
45].
Relatively recently discovered and explored mutations in
PKCD (protein kinase C delta), which plays a role in cell apoptosis and proliferation, but is also involved in B-cell negative selection, segregate with SLE-like disease likely affecting the same or closely related pathways as the above [
46‐
49].
Taken together, rare gene mutations affecting innate or adaptive immune signalling can result in SLE-like clinical phenotypes. Genetic forms of SLE/SLE-like disease may be over-represented in patients with ‘early-onset SLE’, which is characterised by disease expression within the first years of life [
19]. Characteristically, early-onset SLE patients present with severe and sometimes ‘not classical’ symptoms of SLE (such as lack of autoantibodies), and can show poor response to routine treatment [
2,
5,
19,
40]. In addition to aforementioned genes, genome-wide association studies (GWAS) and targeted approaches have revealed associations between mutations in one of more than 40 genes and monogenic SLE-like conditions [
2,
4].
Aneuploidy as a Genetic Risk Factor for SLE
Aneuploidy is defined as an abnormal number of (entire or parts of) chromosomes in a cell, tissue or entire organism due to abnormal meiosis [
81].
The X chromosome contains a number of genes involved in the regulation of innate and adaptive immune responses, including TLR7, TLR8, IRAK1, IL2RG, FOXP3 and CD40L. Studies targeting sex-related differences of immune responses investigated effects mediated by the number of X chromosomes and delivered an increased risk for the development of SLE with growing numbers of X chromosomes.
In males (physiologically having one X and one Y chromosome), the presence of an additional X chromosome, such as 46, XX in la Chapelle’s syndrome or 47, XXY in Klinefelter’s syndrome, is associated with an increased risk of SLE. This risk is similar to euploid women (46, XX); and no differences in SLE disease phenotypes between aneuploid men with an additional X chromosome and euploid women were observed [
82,
83]. The prevalence of SLE in males with Klinefelter’s syndrome is nearly 14-fold higher when compared to boys/men with 46, XY karyotypes [
84]. In 2016, Liu et al. reported an increased prevalence (~ 2.5 times higher than in women 46, XX and ~ 25 times higher than in men 46, XY) of SLE in a cohort of females with an additional X chromosome (47, XXX karyotype) [
85]. Conversely, the prevalence of SLE in females with Turner’s syndrome (45, X0 karyotype) is lower when compared to women with 46, XX karyotypes [
83]. Recently, Webb et al. reported that the presence of two X chromosomes, independent of serum sex hormones, may be responsible for increased production of type 1 interferons by plasmacytoid dendritic cell as a result of TLR7 stimulation, which may centrally contribute to the increased prevalence of SLE in females [
86]. However, additional laboratory investigation is needed to sufficiently understand the involvement of X chromosomes and X chromosome gene dose effects in SLE.
In addition to aneuploidy of the X chromosome, also aneuploidy and mosaicism of chromosome 9 has been reported in SLE patients. Zuang et al. described a familial cluster of SLE patients with a chromosomal translocation involving chromosome 9. The authors concluded that patients’ autoimmune phenomena relate to having three copies of the type 1
IFN (Interferon) cluster located on the p (short) arm of chromosome 9, as they also observed increased IFN-α/β and IFN receptor signalling in patients [
87]. A mosaic tetrasomy affecting a 42-Mb spanning region on chromosome 9p24.3q12 was observed in a 6-year-old girl with myositis and lupus-like features. This 42-Mb region includes 495 genes, among them 26 encoding for interferon (IFN) pathway related genes [
88]. Overall, these reports support the hypothesis that abnormal regulation of type I IFN production is involved in the pathogenesis of SLE, especially in children.
Increased DNA damage and genomic instability are possible outcomes of chromosome gain that can trigger inflammation and result in SLE-like phenotypes. The exact underlying mechanisms, however, remain to be addressed in future studies [
81].