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Fatigue in SLE: diagnostic and pathogenic impact of anti-N-methyl-D-aspartate receptor (NMDAR) autoantibodies
  1. Andreas Schwarting1,2,
  2. Tamara Möckel1,
  3. Freya Lütgendorf2,
  4. Konstantinos Triantafyllias2,
  5. Sophia Grella1,
  6. Simone Boedecker1,
  7. Arndt Weinmann1,
  8. Myriam Meineck1,
  9. Clemens Sommer3,
  10. Ingrid Schermuly4,
  11. Andreas Fellgiebel4,
  12. Felix Luessi5,
  13. Julia Weinmann-Menke1
  1. 1 Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
  2. 2 Acura Rheumatology Center Rhineland Palatinate, Bad Kreuznach, Germany
  3. 3 Institute of Neuropathology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
  4. 4 Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
  5. 5 Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
  1. Correspondence to Andreas Schwarting, Division of Rheumatology and Clinical Immunology, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz 55131, Germany; schwarting{at}


Objectives We explored the impact of circulating anti-N-methyl-D-aspartate receptor (NMDAR) antibodies on the severity of fatigue in patients with systemic lupus erythematosus (SLE).

Methods Serum samples of 426 patients with SLE were analysed for the presence of antibodies to the NR2 subunit of the NMDAR. In parallel, the severity of fatigue was determined according to the Fatigue Scale for Motor and Cognitive functions questionnaire. In a subgroup of patients with SLE, the hippocampal volume was correlated with the levels of anti-NR2 antibodies. Isolated immunoglobulin G from patients with anti-NR2 antibodies were used for murine immunohistochemical experiments and functional assays on neuronal cell lines. Treatment effects were studied in 86 patients with lupus under belimumab therapy.

Results We found a close correlation between the titre of anti-NR2 antibodies, the severity of fatigue, the clinical disease activity index (Systemic Lupus Erythematosus Disease Activity Index 2000) and anti-double stranded DNA antibodies—independently of the presence of neuropsychiatric lupus manifestations. Pathogenic effects could be demonstrated by (1) detection of anti-NR2 antibodies in the cerebrospinal fluid, (2) in situ binding of anti-NR2 antibodies to NMDAR of the hippocampus area and (3) distinct functional effects in vitro: downregulating the energy metabolism of neuronal cells without enhanced cytotoxicity. Treatment with belimumab for at least 6 months affected both the severity of fatigue and the levels of anti-NR2 antibodies.

Conclusion The presence of anti-NR2 antibodies in patients with SLE with fatigue is a helpful diagnostic tool and may offer a major approach in the therapeutic management of this important disabling symptom in patients with SLE.

  • fatigue
  • systemic lupus erythematosus
  • anti-nmda receptor antibodies
  • belimumab

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  • Handling editor Josef S Smolen

  • Contributors AS and JW conceived and supervised the study. AS, AW, JW, SG and MM maintained the SLE database. TM, MM, CS, AF, IS, SG and FL contributed to the acquisition of data. All authors have made substantial contributions to the analysis or interpretation of data and revised the manuscript critically for important intellectual content and approved the version for publication.

  • Funding The Investigator-initiated-study was supported by GSK (data acquisition) and the Deutsche Forschungsgemeinschaft.

  • Competing interests AS, TM, FL, KT, SG, SB, AW, FL, MM, CS, IS and AF have nothing to declare; AS has received speaker fees (less than US$10 000) and grant/research support by AbbVie, Novartis, Roche and GSK; KT has received speaker fees (less than US$10 000) and research support from Pfizer outside the submitted work.

  • Patient and public involvement statement Indirect Patient and Public Involvement. We did not directly include PPI in this study, but the initiative of the study was driven by lupus patients and their representatives.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was approved by the local ethics committee (Ethics Commission of the State Chamber of Medicine in Rheinland-Pfalz, Mainz, Germany) in adherence to the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data relevant to the study are included in the article or uploaded as supplementary information.