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C 2007) Journal of Clinical Immunology, Vol. 27, No. 3, May 2007 ( DOI: 10.1007/s10875-007-9083-1

Vascular Endothelial Growth Factor (VEGF) in Autoimmune Diseases ´ JOZELIO FREIRE CARVALHO,1,2 MIRI BLANK,2 and YEHUDA SHOENFELD2,3,4

INTRODUCTION

Received February 5, 2007; accepted February 7, 2007 Published online: 6 March 2007

Vascular endothelial growth factor (VEGF) is a potent angiogenic, vasoactive molecule which increases vascular permeability (1–3). It is a specific mitogen for vascular endothelial cells. It was firstly described by Senger et al. in 1983 (4), as a homodimeric 34–42 kDa protein that increased vascular permeability in the skin. This protein was called vascular permeability factor (VPF) and was isolated from ascitic fluid and cell culture supernatants of a guinea-pig hepatocarcinoma cell line. In 1989, other researchers identified an endothelial growth substance that received the name of VEGF (5). In subsequent works it was established that VEGF is identical to VPF (6). VEGF is produced by endothelial cells, fibroblasts, smooth muscle cells, and macrophages (7). The VEGF family comprises seven members: VEGFA, VEGF-B, VEGF-C, VEGF-D, VEGF-E, VEGF-F, and placenta growth factor (PIGF). All of them have a common structure of eight cysteine residues in a VEGF homology domain. In addition, in relation a VEGF-A, there are six different isoforms of it, and VEGF-A165 is the main isoform. All these isoforms have distinct and overlapping functions in angiogenesis. The VEGF gene is located on chromosome 6p.21. The members of VEGF family have different physical and biological properties and they act through specific tyrosine kinase receptors (VEGFR-1, VEGFR-2, and VEGFR-3). The VEGFR-3 receptor and its ligands, VEGF-C and VEGF-D, are associated with lymphangiogenesis, while PIGF is linked to arteriogenesis (Fig. 1). Angiogenesis is a physiological process with a coordinated sequence of endothelial cell division, selective degradation of vascular basement membranes, and surrounding extracellular matrix with migration of theses cells that result in a new capillary growth from preexisting vessels (8). VEGF participates in many different steps of

Vascular endothelial growth factor (VEGF) is a potent stimulating factor for angiogenesis and vascular permeability. There are eight isoforms with different and sometimes overlapping functions. The mechanisms of action are under investigation with emerging insights into overlapping pathways and cross-talk between other receptors such as the neuropilins, which were not previously associated to angiogenesis. VEGF has important physiological actions on embryonic development, healing, and menstrual cycle. It also has a great role in pathological conditions that are associated to autoimmune diseases. There is considerable evidence in various autoimmune diseases such as in systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis of an interrelationship between the VEGF system and theses disorders. Serum levels of VEGF correlate with disease activity in a large number of autoimmune diseases and fall with the use of standard therapy. We raised the possible future therapeutic strategies in autoimmune diseases with the anti-VEGF or anti-VEGFR (receptor). So far, this therapy has been used in cancer and macular ocular degeneration in diabetes. This review outlines the evidence for VEGF participation in various autoimmune diseases and proposes lines for future research in this field. KEY WORDS: Vascular endothelial growth factor (VEGF); angiogenesis; autoimmune diseases; neovascularization.

1 Rheumatology

Division, S˜ao Paulo University, School of Medicine, S˜ao Paulo 01246-903, Brazil. 2 Department of Medicine B, Center for Autoimmune Diseases, TelAviv University Sackler Faculty of Medicine, Sheba Medical Center, Tel-Hashomer, Israel. 3 Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, 52621 Israel. 4 To whom correspondence should be addressed to Department of Medicine B, Center for Autoimmune Diseases, The Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel; e-mail: shoenfel@post. tau.ac.il.

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VEGF IN AUTOIMMUNE DISEASES

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VEGF VEGFR-2 (Flk/KDR) VEGFR-3 (Flt-4)

VEGFR-1 (Flt)

Raf

Lymphangiogenesis MEK

P13K

p38MAPK

ERK AKt/PKB

Endothelial cell migration

Endothelial cell proliferation Vascular permeability

Survival

Fig. 1. VEGF, VEGF receptors, and signal transduction.

angiogenesis including initial vasodilatation, endothelial cell permeability, remodeling of the perivascular matrix by induction of metalloproteinase 1 and plasminogen activators, and lastly induction of proliferation and migration of endothelial cells (9). It regulates theses functions via tyrosine kinase receptors and transmits signals to various downstream proteins. VEGFs have an important role in embryonic development and other physiological and pathological conditions, including wound healing, formation of the endometrium, corpus luteum and placenta, ocular neovascularization, tumor progression, endometriosis, cardiovascular diseases, and a significant impact in autoimmune disease. In this paper, we review the importance of VEGF in autoimmune disorders.

VEGF IN MULTISYSTEMIC AUTOIMMUNE DISEASES

Systemic Lupus Erythematosus High levels of VEGF have been correlated to lupus activity (10) and specifically to nephritis (11). The VEGF levels were higher in systemic lupus erythematosus (SLE) patients with renal dysfunction compared to SLE without renal damage, primary antiphospholipid syndrome, and normal controls. In addition, overexpression of VEGF in epithelial cells and podocyte on renal tissue was demonstrated (11). In a recent study that evaluated the levels of VEGF and its receptors in SLE patients, the author could demonstrate

Journal of Clinical Immunology, Vol. 27, No. 3, 2007

that VEGF and the soluble VEGFR-1 concentrations were higher in patients with active lupus than in inactive disease or healthy people. On the other hand, soluble VEGFR-2 was lower in this group of active lupus patients than in inactive group. They concluded that the imbalance between VEGF and its soluble receptors might have a role in SLE pathogenesis (12). Nishitani et al. (13) measured VEGF mRNA in peripheral blood mononuclear cells of 34 patients with lupus nephritis, but they did not find any difference between lupus and healthy populations. The measurement of urinary VEGF mRNA by quantitative real-time PCR could predict class IV of lupus nephritis from others classes in patients with high levels of this substance. Additionally, a significant reduction of VEGF mRNA levels was observed in patients who responded to therapy. It brings a possible additional noninvasive tool for monitoring lupus nephritis (14). NZBxNZW mice were treated every 3 days with intraperitonial injections of anti-VEGFR-2 during 24 weeks. Contrary to the initial hypothesis, the mice that received anti-VEGFR-2 had a higher mortality and an accelerated renal disease compared to controls. AntiVEGFR-2 might exacerbate renal disease by disrupting glomerular endothelial functioning or facilitating immune complex deposition (15). Rheumatoid Arthritis Angiogenesis is recognized as playing an important role in the maintenance and progression of rheumatoid

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arthritis (RA). This vascular process is present in early events of synovial proliferation, which can promote cartilage and bone destruction in later stages of RA. Angiogenesis brings inflammatory cells and mediators inside the joint. However, the neovascular network in RA would be dysfunctional and the joint would be hypoxic. In addition, VEGF is upregulated by inflammatory cytokines and hypoxia in RA (16). Endothelial proliferation is higher in synovial fluid of RA patients than normal population (17). Radiographic studies demonstrated that VEGF serum levels are correlated to joint damage (18). Specifically, VEGF-A121 and VEGF-A165 , and their receptors VEGFR-1, VEGFR-2, and neuropilin-1 receptor are increased in RA synovial tissue compared to normal controls (19). Serum VEGF levels are elevated in patients with RA than in patients with osteoarthritis (20, 21). Importantly, raised serum levels of VEGF in individuals with RA are correlated with disease activity (22) as well as in polyarticular juvenile rheumatoid arthritis (23). In patients with inflammatory arthritis, more specifically early RA, raised serum VEGF levels are associated with destructive lesions (24). Anti-angiogenic therapy may be a potential strategy in RA, and the use of bevacizumab, a neutralizing monoclonal antibody against VEGF, could be a promise (25). An interesting study of murine collagen-induced arthritis, using soluble VEGFR-1 receptor, which inhibits VEGF, significantly decreased inflammation and bone and cartilage destruction (26). Interestingly, the treatment with anti-TNF-alpha in RA led to significant improvements in clinical and laboratorial parameters and also reduced serum VEGF levels (27, 28).

Systemic Sclerosis The pathogenesis of systemic sclerosis (SSc) is unknown, but vascular alterations have been suggested to play an important role in this condition (29). There was an attractive hypothesis that the lack of sufficient angiogenesis in SSc could be mediated by a downregulation of the VEGF system. Conversely, diverse studies have shown the opposite: the VEGF/VEGFR system is increased in SSc. In this line, dermal fibroblasts activated by transforming growth factor-beta, release large amounts of VEGF (30). In this line, another study demonstrated that VEGFR-1, VEGFR-2, and VEGFR-3 receptors were studied in the skin of SSc and were overexpressed, in contrast to VEGF that was only slightly upregulated. This imbalanced situation suggests that the compensatory efforts toward an-

CARVALHO, BLANK, AND SHOENFELD

giogenesis fail in SSc, partly due to insufficient local production of VEGF compared to VEGFR expression (31). High levels of VEGF were reported in SSc (32, 33) and additionally, were significantly higher in diffused SSc than in limited SSc (33). A positive correlation was found between VEGF and the severity of nailfold capillary loss as well as with the extent of skin sclerosis measured by Rodnan score (33). In contrast, Viac et al. (34) confirmed that patients with SSc have increased levels of VEGF, but they did not find a correlation with disease activity in this population studied. A positive correlation was found between higher levels of VEGF and anti-Scl-70 antibodies and also with diffuse disease. In addition, patients with short disease duration showed significant increased levels of VEGF, indicating that elevated serum levels of VEGF are a feature of the earliest disease stages. More importantly, this study brings the knowledge that VEGF at high concentrations maybe protective against ischemic manifestations when concentrations of VEGF are high (35). In a study of skin specimens of SSc patients, VEGF and its receptors VEGFR-1 and VEGFR-2 were dramatically increased. An attractive hypothesis for the insufficient angiogenesis in SSc is that despite upregulated VEGF/VEGFR system, perhaps an upregulation of other factors that block the angiogenesis (angiostatic factors) could be higher than those of VEGF and thereby outweighs its proangiogenic effects (36). The relationship between VEGF levels and organ systemic involvement in SSc was addressed by KuryliszynMoskal et al. (37), and they found significant elevated concentrations of VEGF in the sera of SSc patients with organ systemic damage compared to those without systemic manifestations. An association was reported between the ratios of VEGF to endostatin in relation to healthy controls, despite the fact that VEGF levels did not differ among them. Moreover, negative correlations were found between diffusing capacity of the lung for carbon monoxide (DLCO) and VEGF and also DLCO, and the ratio of VEGF to endostatin in patients with limited SSc with interstitial lung disease (38). Three polymorphism in VEGF (634 C/T, 936 C/G mutations, and an 18 base pair insertion/deletion at 2549) gene were studied in a large population of SSc, but the allele and genotype frequencies of these polymorphisms did not differ between SSc patients and controls (39). The use of calcium blockers in SSc and their relationship with VEGF was assessed in a clinical trial. The drug reduced soluble vascular cell adhesion molecule-1 (sVCAM-1) levels and oxidative stress indexes, but did not decrease the concentrations of VEGF and its receptor



1. It is consistent with the idea that VEGF/VEGF axis could be defective in SSc (40). On the other hand, bucillamine, an immunosuppressive drug that was applied to SSc fibroblasts culture, induced the synthesis of VEGF in a dose-dependent manner. Consequently, bucillamine may have a positive role on the impaired angiogenesis of SSc patients (41). Dermatomyositis VEGF and its receptors were histochemically investigated on muscle biopsy of patients with dermatomyositis (DM) with the involvement of the peripheral nerve system. In this study, VEGF and VEGFRs were overexpressed in vasculitic regions in biopsied specimens of sural nerves, skeletal muscles, and skin of two patients with DM. This finding suggests that VEGF may be implicated in the vasculopathy of this disease. On the other hand, there was no remarkable elevation of VEGF in the sera of these patients suggesting a local reaction in the vascular lesion, not a systemic overproduction of this growth factor (42). Another case report showed that VEGF levels were increased in the plasma and expressed in biopsied specimens of muscle and salivary glands from patients with DM associated with Sjogren’s syndrome; both patients exhibited sensory polyneuropathy (43). Therefore, more studies without neurological impairment are still necessary in DM to confirm any role of VEGF in myositis. Antiphospholipid Syndrome Numerous procoagulant mechanisms have been implicated in antiphospholipid syndrome (APS), and one of them is the endothelial cell activation. Williams et al. (44) demonstrated significantly higher levels of VEGF in patients with primary APS compared to controls. In a recent study, purified monocytes from APS patients showed higher levels of VEGF and VEGFR than those derived from healthy donors, which further correlated with IgG anticardiolipin titers. Interestingly, monocyte VEGF and VEGFR levels were significantly higher in patients with thrombosis than in patients without it. Thus, VEGF might act as a regulatory factor in aPL-mediated monocyte activation, thereby contributing to the proinflammatoryprothrombotic phenotype of APS patients (45). Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is a disorder characterized by swelling of the hands with pitting edema. The presence of this impressive edema instigates some


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authors to investigate its possible relationship with VEGF levels; and indeed, a significant concentration of VEGF in three patients with this inflammatory condition was found, compared to RA, SLE, MCTD, myositis, and vasculitis (46). Rheumatic Fever Only in one study, VEGF in rheumatic fever was assessed. Studying calcified rheumatic valve using immunohistochemical methodology, the authors could show the presence of VEGF in areas of inflammation of theses valves. The VEGF can contribute to the angiogenic process on these rheumatic valves (47). Vasculitic Syndromes Polyarteritis Nodosa Only one study assessed serum VEGF levels in polyarteritis nodosa (PAN) and found that they were higher in comparison with healthy controls. Additionally, VEGF was significantly more elevated in systemic PAN than cutaneous PAN. Importantly, some fibroblast around the vasculitic lesion expressed VEGF in immunohistochemical studies (48). Churg–Strauss Syndrome With the objective to distinguish Churg–Strauss Syndrome (CSS) from asthma and acute bronchitis, only one study showed increased serum VEGF levels in the group of patients with this vasculitis. In addition, VEGF significantly correlated with peripheral eosinophil counts and decreased after immunosuppressive therapy (49). Wegener’s Granulomatosis Serum VEGF levels were markedly elevated in patients with Wegener’s granulomatosis (WG) compared to normals and patients with urinary infection and correlated with disease activity (50). Behcet’s Disease Behcet’s disease (BD) is a systemic vasculitis characterized by endothelial activation. The levels of VEGF were higher in patients with BD compared to healthy controls with no difference between active and nonactive BD groups (51). In another study, VEGF levels were increased and were associated with disease activity. Ocular BD patients had higher VEGF levels than BD patients without ocular involvement (52). Patients with BD were genotyped by polymerase chain reaction for +936 C/T and −634 C/G mutations and for an 18 base pair insertion/deletion of VEGF gene polymorphisms. The alleles I and −634C were more frequent in BD patients than in normal controls. Indicating that carriers of −634C and I alleles of VEGF gene are associated with susceptibility to develop BD (53). Kawasaki Disease Since Kawasaki disease (KD) is characterized by a marked edema in the skin as well as histological subendothelial edema in the vascular system,

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it is reasonable to link VEGF to this disease. In concordance with this idea, Ohno et al. (54) showed that serum VEGF levels were higher in patients with KD compared to afebrile controls and patients with active infections. Prospectively, the VEGF levels decreased to undetectable or low levels during the recovery phase. And importantly, serum VEGF levels were associated with the occurrence of coronary artery lesions in these patients. Additionally, there is immunohistological data that show an abundant expression of VEGF and VEGFR-1 in many organs from acute KD, including the heart and the lung. The high serum VEGF levels were correlated with low serum albumin in acute KD (55). Giant Cell Arteritis A study of polymorphisms demonstrated an association between VEGF − 634 G allele in patients with severe ischemic complications of giant cell arteritis compared with patients without ischemic complications or healthy controls (56). Spondyloarthropathy The vasculature is involved in the pathogenesis of spondyloarthropathy with increased vascularity being a feature of ankylosing spondylitis synovitis (57). In this line, VEGF levels were studied in patients with spondyloarthropathy, and they were higher in this group compared with controls. Moreover, serum VEGF levels correlated to disease activity indices as BASDAI score, ESR, and CRP in this population (58). Influence of VEGF polymorphisms on the severity of ankylosing spondylitis was assessed. Patients that carry the AGG haplotype had a more severe disease, characterized by higher frequency of cervical spine involvement and radiological score >6, measured by BASRI, compared to healthy controls (59).

INFLAMMATORY BOWEL DISEASE

Since ulceration and regeneration of the intestinal epithelium occurs during the course of inflammatory bowel disease (IBD), angiogenesis is undoubtedly an integral part of the IBD pathophysiology. Many studies have shown increased VEGF levels in patients with IBD compared to healthy controls (60, 61). In majority of theses studies, the VEGF levels correlated with disease activity (60, 61). Low significant plasma levels of VEGF were found in active and quiescent Crohn’s disease than in healthy controls (62). Despite the lower plasma VEGF levels, noted also for patients with ulcerative colitis, difference was not significant. Moreover, on immunohistochemical studies,


VEGF was not expressed in lymphocytes, macrophages, fibroblasts, or muscular layer of the intestinal wall. Magro et al. (63) also found a similar lower level of VEGF in patients with IBD compared to controls. Corticosteroids were found to suppress nonstimulated VEGF production in patients with IBD (64). As in RA, the administration of anti-TNF-alpha antibody seemed to interfere with VEGF production (65). For a summary of the studies reported herein, see Tables I and III. In some autoimmune diseases, VEGF was not yet studied (Table II).

VEGF IN ORGAN-SPECIFIC AUTOIMMUNE DISEASES

VEGF and Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune demyelinating disorder of the central nervous system, and many factors already implicated in the pathogenesis of this disorder have been shown to act either directly or indirectly to promote angiogenesis. Further evidence for the possible presence of neovascularization in MS is observed with contrast-enhanced MRI in the appearance of “ring enhancement” at the periphery, but not at the center of chronic lesions (66). A study using MRI data and the measurement of VEGF levels showed a significant positive correlation between VEGF and the length of spinal cord lesions, suggesting that VEGF might be involved in the formation of longitudinal extensive spinal cord lesions of MS (67). Histopathologically, plaques of MS have a multiple perivenular distribution. In addition, immunohistochemical studies have shown a damage of vessel wall in the acute plaques (68) and also an evidence for serum protein leakage into the white matter in 50% of the inactive plaques (69). Previous study had demonstrated that chronic overexpression of VEGF in rat brain caused blood–brain barrier breakdown, increases expression of major histocompatibility complex class I and II molecules and intercellular adhesion molecule-1 (70). Substantiating these data, Proescholdt et al. (71) showed that VEGF expression in MS plaques was consistently upregulated in both acute and chronic lesions. Furthermore, intracerebral infusion of VEGF in animals previously immunized with myelin basic protein induced an inflammatory response in the brain (71). Taken together, theses data suggest that overexpression of VEGF may exacerbate the inflammatory response in autoimmune diseases of the central nervous system. On the other hand, in an experimental model of an autoimmune encephalomyelitis in LEW rats, no association



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Table I.

VEGF levels in Autoimmune Diseases

Autoimmune diseases

Human studies

Systemic lupus erythematosus Robak et al., 2001 Navarro et al., 2002 Avihingsanon et al., 2006

Correlated with activity Correlated with nephritis Urinary mRNA VEGF is associated with nephritis

Rheumatoid arthritis Lee et al., 2001 Sone et al., 2001 Maeno et al., 1999 Paleolog et al., 2002 Ballara et al., 2001 Strunk et al., 2006

Higher in RA than osteoarthritis Correlated with activity Polyarticular Juvenile RA Associated with radiographic damage Associated with joint damage in early RA Anti-TNF therapy decreased serum VEGF levels

Systemic sclerosis Kikuchi et al., 1998 Choi et al., 2003 Viac et al., 2000 Distler et al., 2002 Kuryliszyn-Moskal et al., 2005 Dziankowska-Bartkowiak et al., 2006

High levels Correlated with diffuse disease and nailfold capillary loss High levels, no association with activity Associated with diffuse disease and anti-Scl-70 Negative association with ischemia Associated with systemic involvement Negative correlations between DLCO and VEGF and also DLCO and the ratio VEGF/endostatin in limited SSc with interstitial lung disease

Antiphospholipid syndrome Williams et al., 2000

High levels

RS3PE Arima et al., 2005

Higher levels compared with RA, SLE, MCTD, myositis, and vasculitis

Polyarteritis nodosa Kikuchi et al., 2005

Systemic PAN has higher levels than cutaneous PAN

Churg–Strauss Syndrome Mitsuyama et al., 2006

Associated with peripheral eosinophil count

Wegener’s granulomatosis Li et al., 1998

Correlated with disease activity

Behcet’s disease Cekmen et al., 2003 Erdem et al., 2005

Associated with activity Not associated with activity

Kawasaki’s disease Ohno et al., 2000

Decreases with the inactivity and is associated with coronary lesions

Giant cell arteritis Rueda et al., 2005

VEGF polymorphism is associated with severe ischemia

Spondyloarthropathy Drouart et al., 2003 Seo et al., 2005

Associated with BASDAI score, ESR and CRP AGG haplotype is associated with cervical involvement and BASRI score > 6

Inflammatory bowel disease Griga et al., 1998 Magro et al., 2004 Beddy et al., 2004 Di Sabatino et al., 2004

Associated with activity Not associated with activity Corticosteroid suppress VEGF production Anti-TNF reduces serum VEGF

Multiple sclerosis Sue et al., 2006

Associated with the length of spinal cord lesions

Pemphigoid and pemphigus vulgaris Ameglio et al., 1997

Associated with the number of skin lesions

Psoriasis Creamer et al., 2002 Nielsen et al., 2002

Associated with activity and severity Associated with arthritis

Thyroid autoimmune diseases Iitaka et al., 1998 Viglietto et al., 1997 Klein et al., 1999

Associated with thyroid vascularization on Doppler High levels of VEGF in Graves’ disease High levels of VEGF in thyroiditis

Primary biliary cirrhosis Akiyoshi et al., 1998

High levels of VEGF


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Table II.

Autoimmune Diseases not Analyzed for VEGF

Autoimmune diseases Takayasu arteritis Sjogren’s syndrome Vitiligo Eosinophilic fasciitis Pernicious anemia Addison’s disease Mixed connective tissue disease Autoimmune neutropenia Thrombocytopenic purpuras Myasthenia gravis Autoimmune haemolytic anemia Autoimmune polyglandular syndromes Goodpasture disease

was found with VEGF-B and VEGFR, and unexpectedly the VEGF-A was downregulated in glia of this model (72). These contradictory results demonstrate that a complex regulation of VEGF system exists during neuroinflammation process and more studies are necessary to clarify the role of VEGF in MS. Pemphigoid and Pemphigus Vulgaris Few studies showed that serum VEGF levels were found to be elevated in patients with bullous pemphigoid and pemphigus vulgaris when compared to healthy controls. Additionally, the cytokine levels also correlated with the number of skin lesions (73). These few data bring a possible endothelium involvement in these bullous dermatoses; however, more studies are necessary to confirm this association. Psoriasis Psoriasis is characterized by inflammatory cell infiltrate and proliferation of blood vessels on the skin. Previous study has demonstrated an overexpression of VEGF and its receptors in keratinocytes of psoriatic skin lesion, which can lead to neovascularization (74). In this line, a major role of VEGF in psoriasis was further corroborated by the phenotype of transgenic mouse with epidermisspecific overexpression of VEGF and enhanced skin vascularity and vascular permeability (75). At about 6 months of age, theses mice spontaneously develop chronic inflammatory lesions that histologically resemble human psoriasis, which was, importantly, reverted using a potent VEGF antagonist (76). Moreover, the Koebner’s phenomenon, a characteristic finding in psoriatic patients, was induced in these mice. Single-nucleotide polymorphisms of VEGF gene in the early onset of psoriasis could contribute to the raised VEGF levels observed in psoriatic patients (77). Several studies have demonstrated that serum circulat-

ing VEGF levels are elevated in patients with severe disease, also correlate to disease activity, and is especially increased in the presence of arthritis (78, 79). Thyroid Autoimmune Diseases There is accumulating evidence that VEGF and its receptors are important in Graves’ disease (80) and thyroiditis (81). It is known that there is a marked enlargement of blood vessels and flow in the thyroid of patients with Graves’ disease. It has been demonstrated that VEGF is produced in the thyroid follicular epithelial cells (82). In a study using Doppler ultrasonography in patients with Graves’ disease and Hashimoto’s thyroiditis, a significant increase in serum VEGF levels in autoimmune thyroid disease compared to normal subjects was detected. Interestingly, there was a positive correlation between serum VEGF levels and the ratio of intrathyroidal vascular area measured by Doppler in untreated Graves’ disease patients as well as a correlation between VEGF and thyroidstimulating hormone levels in Hashimoto’s patients. Additionally, VEGF levels were reduced after the thyroid treatment (83). Anti-Glomerular Basement Membrane Glomerulonephritis The VEGF administration in rats, with necrotizing and crescentic glomerulonephritis (GN) induced by injection of anti-rat glomerular basement membrane antibody, caused an improvement in the histological lesions and renal function. This finding suggests that VEGF infusion resolved glomerular inflammation and accelerated glomerular recovery in the progressive necrotizing and crescentic GN (84). For a summary of the studies reported herein, see Tables I and III. BLOCKING ANGIOGENESIS

Efforts are currently targeted at inhibiting VEGF-driven angiogenesis in cancer. Its success has lead to the translation of this treatment in autoimmune diseases. The effects of combinations of therapy with antirheumatic drugs in cultured synoviocytes from patients with rheumatoid arthritis were evaluated and Nagashima et al. (85) showed that corticosteroids associated with any of the drugs, i.e., gold salt, methotrexate, salazosulphapyridine, or bucillamine could inhibit VEGF production and also reduce the serum levels of VEGF in patients who received the combined therapy (85). As previously mentioned, the use of anti-TNF-alpha antibodies in RA led to significant improvements in



Table III.

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VEGF Determinations in Animal Models of Autoimmune Diseases or Histopathological Human Studies

Autoimmune diseases

Laboratorial studies

Systemic lupus erythematosus Navarro et al., 2002 Nishitani et al., 2001 Watanabe et al., 2005

VEGF expression on epithelial cells and podocytes on renal tissue VEGF mRNA in monocytes is equal to controls Rats treated with anti-VEGFR-2 had higher mortality and accelerated renal disease

Rheumatoid arthritis Walsh et al., 1998 Ikeda et al., 2000 Miotla et al., 2000

VEGF is high in synovial fluid VEGF121 , VEGF165 , VEGFR-1 to 3 are increased in RA synovial tissue. Anti-VEGFR-1 decreased inflammation and bone and cartilage destruction

Systemic sclerosis Pernet et al., 2000 Distler et al., 2004 Mackiewicz et al., 2002 Allanore et al., 2006 Distler et al., 2004

Dermal fibroblasts produces VEGF VEGFR-1 and 2 are expressed on skin VEGFR-1 to 3 are overexpressed in skin, but not VEGF 3 polymorphism in VEGF gene did not differ from normals Bucillamine induced VEGF synthesis dose-dependently in fibroblasts culture

Antiphospholipid syndrome Cuadrado et al., 2006

Monocyte VEGF and VEGFR levels

Dermatomyositis Matsui et al., 2003 Mitsui et al., 2004

Expressed in muscles cells and associated with nerve involvement Expressed in muscle and salivary cells

Rheumatic fever Rajamannan et al., 2005

Expression in rheumatic valves

Polyarteritis nodosa Kikuchi et al., 2005

Expression on fibroblasts around the vasculitic lesion

Behcet’s disease Salvarani et al., 2004

-634C and I alleles of VEGF gene are associated with susceptibility to developing BD

Kawasaki’s disease Yasukama et al., 2002

VEGF and VEGFR-1 expressed in heart and lung of acute KD

Multiple sclerosis Proescholdt et al., 2002 Tham et al., 2006

Expressed on the plaques and the VEGF infusion induces brain inflammation Model of autoimmune encephalomyelitis in LEW rats, no association was found with VEGF-B and VEGFR

Psoriasis Detmar et al., 1994 Detmar et al., 1998 Xia et al., 2003 Young et al., 2004

VEGF and VEGFR expressed in keratinocytes VEGF overexpression mice model presented enhanced skin vascularity and vascular permeability VEGF overexpression mice model presented skin lesion identical to human psoriasis Single-nucleotide VEGF gene polymorphisms in early psoriasis is associated to VEGF levels

Autoimmune uveitis Vinores et al., 1998

Expression of VEGF on retinal experimental autoimmune uveoretinitis

Anti-Glomerular basement membrane nephritis Shimizu et al., 2004

VEGF infusion resolved glomerular inflammation in necroziting and crescentic glomerulonephritis induced by anti-rat glomerular basement membrane antibody

clinical and laboratorial parameters and also a decrease in serum VEGF levels (27, 28). In addition to previous data, anti-interleukin-6 receptor antibody therapy reduced VEGF production in patients with RA. It is known that interleukin-6 is a pivotal cytokine that induces VEGF production in synergy with interleukin-1 beta or TNF-alpha, and this may be the underlying mechanism for the VEGF blocking when anti-Il6 receptor is employed (86).


The use of anti-VEGF antibodies in neoplastic diseases (87), ocular diseases (88, 89), and diabetic macular edema (90) allows a novel and important target therapy in autoimmune diseases. In an experimental study, using K/BxN mouse model of RA, De Bandt et al. (91) demonstrated that the treatment with anti-VEGFR strongly attenuated the intensity of disease, and prevented joint damage qualitative and semiquantitative histological analysis (91).

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CONCLUSION

The understanding of the role of VEGF in the pathogenesis of each one of the autoimmune diseases requires further studies. The additional efforts in VEGF research will certainly provide invaluable clues to facilitate the development of novel molecular targets for both diagnosis and therapy in many autoimmune conditions.

16.

17. 18. 19.

ACKNOWLEDGMENT 20.

JF Carvalho received a grant BEX 2367/06-8 awarded by CAPES.

21. 22.

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