Clin Exp Immunol 2000; 119:189–195

Serum thrombomodulin—a reliable marker of disease activity in systemic lupus

erythematosus (SLE): advantage over established serological parameters to indicate
disease activity

M. W. J. BOEHME, U. RAETH, P. R. GALLE*, W. STREMMEL & W. A. SCHERBAUM†

Department of Internal Medicine IV, University of Heidelberg, Heidelberg, *Departrment of Internal Medicine I,
University of Mainz, Mainz, and †Department of Endocrinology, University of Düsseldorf, Düsseldorf, Germany

(Accepted for publication 16 August 1999)

SUMMARY
To date no specific serological parameter is available to assess disease activity in SLE. Soluble serum
thrombomodulin is a new marker of endothelial cell injury and vasculitis. The objective of this study
was to compare in vivo soluble thrombomodulin as marker of disease activity in SLE with established
and recent serological parameters. One hundred and twenty-four sera of 30 patients with proven SLE
with different disease activities were tested for serum levels of thrombomodulin, intercellular adhesion
molecule-1 (ICAM-1), E-selectin, vascular cell adhesion molecule-1 (VCAM-1), IL-2R, IL-6, IL-10,
dsDNA by ELISA and dsDNA additionally by radioimmunoassay (RIA). C-reactive protein (CRP),
complement component C3, IgG, creatinine, anti-nuclear antibodies (ANA) and intermediate filament
antibodies were measured by standard laboratory tests. The clinical disease activity was evaluated by
the Systemic Lupus Activity Measure (SLAM). Correlations of the different serological SLE disease
activity parameters with the SLAM scores revealed the highest significance for serum thrombomodulin
(correlation coefficient 0·82). This was further confirmed by the intra-individual analysis of follow-up
sera. In addition, a moderate correlation could be found for IL-6, IL-10, ICAM-1, CRP and erythrocyte
sedimentation rate (ESR). In summary, soluble thrombomodulin is the most important serological
parameter of disease activity in SLE currently available, as shown by the in vivo studies. Soluble
thrombomodulin might be a valuable serological parameter for therapeutical considerations.

Keywords systemic lupus erythematosus disease activity thrombomodulin

endothelial cell damage

INTRODUCTION Pathophysiologically, SLE is characterized by complex altera-

tions of the immune system (e.g. polyclonal B cell activation,
SLE is a systemic autoimmune disease of unknown aetiology,
autoantibodies, and T cell defects) and an immune complex
which involves different organ systems to a variable degree [1].
vasculitis with endothelial cell damage [1,9,13]. Therefore, factors
Clinically, a reliable serological parameter of the inflammatory
of endothelial cell activation or damage are of considerable
activity of the disease is required due to considerable variation in
interest. However, the levels of soluble endothelial adhesion
disease manifestations. However, a pathophysiologically deter-
molecules such as intercellular adhesion molecule-1 (sICAM-1;
mined, specific serological marker of disease activity is currently
CD54) [10,14,15], vascular cell adhesion molecule-1 (sVCAM-1;
missing. At present the erythrocyte sedimentation rate (ESR) [2,3],
CD106) [14,15], and sE-selectin (CD62E) [15,16] did not show a
products of complement activation [3–5], and levels of C-reactive
close correlation with disease activity in SLE.
protein (CRP) [2,3,6], autoantibodies (e.g. dsDNA antibodies)
In contrast, soluble serum thrombomodulin (sTM) was recently
[2,3,5,7,8], or cytokines such as IL-2/IL-2 receptor [8–10], IL-6
established as a valuable new serological marker with good
[7,11] and IL-10 [12] are used as indirect serological markers with
correlation to disease activity in SLE [17–20]. TM is the endo-
variable degrees of significance. In general, these factors do not
thelial cell transmembrane receptor for thrombin [21,22]. Soluble
correlate closely enough with disease activity.
TM is an established marker of endothelial cell damage [23,24].
Correspondence: PD Dr M. W. J. Boehme, Hospital of Internal Medi- However, a direct comparison of sTM and other serological
cine and Rheumatology, Aukammallee 39, D-65191 Wiesbaden, Germany. markers of disease activity in SLE is still lacking. Here we present
q 2000 Blackwell Science 189
190 M. W. J. Boehme et al.
in vivo data, comparing different serological disease activity para-
meters in patients with SLE and different disease activities.
PATIENTS AND METHODS
Patients
A total of 124 serum samples from 30 patients (26 female, four
male; mean age 34 6 6 years; range 16–65 years) with proven SLE
were investigated in a retrospective study. At the time of diagnosis
all patients fulfilled the 1982 revised American College of Rheu-
matology (ACR; formerly American Rheumatism Association
(ARA)) criteria for the diagnosis of SLE [25]. Two to six serum
samples were tested from each patient taken at times of different
disease activities. The serum samples included at least one taken at
the time of high active and one taken at the time of low active/
inactive disease. Serum samples of 20 healthy volunteers (staff
members; 14 female, six male; mean age 34 6 9 years; range 18–
41 years) were used as normal controls. Aliquots of the sera had
been stored at ¹208C until tested.
All patients were seen as in- or out-patients by an interdisci-
plinary team of specialists. At the time of sample collection the
patients were treated as follows with several patients receiving
combination therapy: no therapy, 14 times; 5–20 mg prednisolone
daily, 75 times; > 20 mg prednisolone daily, 19 times; 50–100 mg
azathioprine daily, 34 times; and cyclophosphamide pulse therapy
(1000 mg), nine times.
Evaluation of SLE disease activity
The disease activity was retrospectively determined for each
collected sample. The Systemic Lupus Activity Measure
(SLAM) score [26] was used as established SLE disease activity
scoring system. The SLAM score consists of 32 different labora-
tory or clinical parameters, which are divided into 12 subgroups:
constitutional, integumentum, eye, reticulo-endothelial, pulmon-
ary, cardiovascular, gastrointestinal, neurological, joint, nephro-
logical/laboratory manifestations, and ad hoc observations. Each
parameter is scored as 0, 1, 2, or 3 points. For some statistical
evaluations the patients were divided into three subgroups with a
SLAM score of 0–5 (low activity), 6–10 (moderate activity), and
> 10 (high activity).
Laboratory parameter and kidney dysfunction
Marked kidney dysfunction is known to result in accumulation
of different serological disease activity markers including
thrombomodulin, which is difficult to distinguish from disease
activity-related elevation of the respective serum levels. Therefore,
in agreement with other publications, only patients were included
in the study who had a serum creatinine < 2·5 mg/100 ml
(¼< 225 mmol/l) at the time of serum collection [19,27].
Immunological assays
A prototype two-site ELISA was used for the determination of
thrombomodulin in serum samples (Thrombomodulin VarElisa,
charge no. 17067; ELIAS/Pharmacia & Upjohn, Freiburg, Ger-
many). The test was performed according to the manufacturer’s
instructions. Briefly, the precoated 96-well plates were washed
with buffer once and than incubated with diluted samples or
provided standards (25 ml serum sample and 100 ml sample buffer
per well). After 1 h of incubation at room temperature the plates
were washed three times and further incubated with the perox-
idase-conjugated secondary anti-TM antibody (100 ml/well) for 1 h.
q 2000 Blackwell Science Ltd, Clinical and Experimental Immunology, 119:189–195
Subsequently, the plates were washed again and incubated with the
substrate solution (tetramethylbenzidine (TMB)) at room tempera-
ture in the dark. After 10 min the stop solution (2 N H2SO4) was
added and the optical density (OD) measured after colour stabili-
zation (30 min) by an automated ELISA plate reader at 450 nm
(Titertek Multiscan Plus MKII; ICN/Flow, Meckenheim, Ger-
many). The respective sample concentrations of TM were calcu-
lated in relation to the reference standard curve. The samples were
tested in duplicates and the mean taken for further calculations.
Commercially available two-site ELISAs were used to deter-
mine the serum levels of dsDNA (ELIAS/Pharmacia & Upjohn),
soluble IL-2 receptor (sIL-2R; Coulter-Immunotech Diagnostics,
Hamburg, Germany), sIL-6 (Quantikine human IL-6; R&D Sys-
tems GmbH, Wiesbaden, Germany), sIL-10 (Quantikine human
IL-10; R&D Systems GmbH), sICAM-1 (Parameter human soluble
ICAM-1; R&D Systems GmbH), sE-selectin (Parameter human
soluble E-selectin; R&D Systems GmbH), and sVCAM-1 (Parameter
human soluble VCAM-1; R&D Systems GmbH). In addition, the
levels of dsDNA were measured by radioimmunoassay (RIA;
dsDNA radioimmunoassay; Amersham Buchler, Braunschweig,
Germany). The assays were performed according to the manufac-
turers’ instructions with the reagents provided. As for TM, the
mean of duplicates was taken for further calculations.
Standard laboratory tests were used to measure the serum
levels of CRP, ESR (at 1 h), complement component C3, creati-
nine, and IgG. The titre of anti-nuclear antibodies (ANA) and anti-
intermediate-filament antibodies to vimentin (vim) and keratine
(ker) (INFIL-ab) were determined by standard indirect immuno-
fluorescence (IIF) technique on Hep-2 cells as described previously
[28]. Fluorescein-conjugated mouse anti-human IgG antibodies
(Dianova GmbH, Hamburg, Germany) were used as secondary
antibodies.
Statistical analysis
If not otherwise stated the mean and s.e.m. are given. The x2 test
was used to determine the differences of disease and control groups
for ANA and INFIL-ab titre. For the remaining serological para-
meters the non-parametric Wilcoxon–Mann–Whitney U-test was
used. P # 0·05 was considered significant. The same test was used
to determine the significance of the different experimental groups
in the in vitro tests. The multiple range Duncan’s test [29] was used
as multiple stage test to assess the significance of the different
disease activity groups for the distinct serological disease activity
parameters (Statistical Analysis System for Windows, Version 6.1;
SAS Institute Inc., Cary, NC). The regression and correlation
analysis (Pearson’s correlation) was perfomed with WinSTAT 3.1
(Kalmia Co. Inc., Cambridge, MA). The significance of the
Pearson’s correlation was graded into five groups according to
Landis & Kock [30]: ¹ ¹, slight (0·00–0·20); ¹, fair (0·21–0·40);
þ/¹, moderate (0·41–0·60); þ, substantial (0·61–0·80); and þþ,
perfect (0·81–1·00).
RESULTS
Serological disease activity parameters
Fifty-six serum samples were collected at time of low disease
activity (SLAM score 0–5), 38 serum samples at moderate
disease activity (SLAM score 6–10), and 30 serum samples at
high disease activity (SLAM score > 10). Table 1 summarizes the
results of the different disease activity parameters. Differences
with variable degrees of significance were found between the three
 Serological parameters of SLE disease activity 191
Table 1. Serological disease activity parameters in patients with SLE classified in five main groups according to historical developments

SLE disease activity (n ¼ 124)

Pearson correlation
Low activity Moderate activity High activity coefficient to disease
Serological disease Normal SLAM # 5 SLAM 6–10 SLAM $ 11 activity
Main groups activity markers values (n ¼ 56) (n ¼ 38) (n ¼ 30) (SLAM score)

1 General ESR (1.h) 8 6 4 mm NW 23 6 16*** 33 6 20*** 56 6 32*** 0·545

serological CRP 0·3 6 0·1 mg/dl 0·3 6 0·3 0·7 6 1·2* 1·6 6 1·3*** 0·504
markers Complement (C3) 79 6 15 mg/dl 67 6 21* 60 6 20*** 50 6 20*** ¹0·285
IgG 13 6 3 g/l 16 6 5* 16 6 5* 14 6 6 0·165
2 Autoantibodies ANA # 1 : 40 640 (160–640)† 480 (160–2560)† 640 (320–3584)† ¹0·026
dsDNA (ELISA) 21 6 9 U/ml 140 6 145*** 190 6 195*** 203 6 152*** 0·146
dsDNA (RIA) 13 6 6 U/ml 38 6 39*** 67 6 63*** 77 6 61*** 0·252
INFIL (vim & ker) neg. (# 1:10) 35% positive† 37% positive† 40% positive† ND
3 Cytokines sIL-2R 2·7 6 1·4 ng/ml 4·5 6 3·5* 4·5 6 3·0* 11·9 6 10·1*** ¹0·129
sIL-6 2·5 6 0·9 pg/ml 2·9 6 4·6 4·5 6 4·0** 13·6 6 14·5*** 0·435
sIL-10 3·4 6 2·0 pg/ml 3·1 6 1·9 5·3 6 3·3* 10·1 6 9·0*** 0·516
4 Adhesion sICAM-1 275 6 52 ng/ml 379 6 135*** 414 6 136*** 547 6 249*** 0·406
molecules sE-selectin 50 6 18 ng/ml 60 6 23*** 64 6 26* 69 6 37* 0·197
sVCAM-1 656 6 99 ng/ml 1111 6 546 1363 6 729*** 1525 6 913*** 0·254
5 Markers of sThrombomodulin 3·8 6 1·3 ng/ml 3·4 6 1·1 9·2 6 3·6*** 14·7 6 5·5*** 0·819
endothelial
damage

Medium 6 s.d. (mean 6 s.d.); italics, median (25% and 75% percentile).
*P < 0·05; **P < 0·01; ***P < 0001 (correlation to control values; Wilcoxon–Mann–Whitney U-test).
†P < 0·05 (difference from control values, x2 test).

disease activity groups of patients for all parameters tested with the the Pearson correlation gave the highest level of significance for
exception of ANA and INFIL-ab titre, E-selectin and IgG values. sTM, pointing to an advantage of sTM as serological disease
The respective degrees of significance as well as the data in detail activity parameter in SLE (Tables 1 and 2). Furthermore, a cross
are presented in Table 1. The multiple stage correlation as well as correlation amongst all serological disease activity parameters

Table 2. Pearson’s correlation and Duncan’s multiple range test between serological disease activity parameters and disease activity in patients with SLE

Disease activity (SLAM)

(independent variable) Pearson correlation
Dependent variable Duncan’s multiple rank test (grading of the correlation coefficient
(n ¼ 124) (significance to SLAM 0–5) due to Landis & Kock 1977 [30])

Parameter Dimension SLAM 6–10 SLAM > 10 r Significance

Thrombomodulin ng/ml Yes Yes 0·82 þþ

sIL-2R ng/ml No Yes ¹0·13 ¹¹
IL-6 pg/ml No Yes 0·44 þ/¹
IL-10 pg/ml No Yes 0·52 þ/¹
sICAM-1 ng/ml No Yes 0·41 þ/¹
E-selectin ng/ml No No 0·20 ¹¹
sVCAM ng/ml No Yes 0·25 ¹
dsDNA-ELISA U/ml No No 0·15 ¹¹
dsDNA-RIA U/ml Yes Yes 0·25 ¹
ANA Titre No No ¹0·03 ¹¹
Creatinine mmol/l No Yes 0·63 þ
CRP mg/100 ml Yes Yes 0·50 þ/¹
ESR 1 h (mm) Yes Yes 0·54 þ/¹
Complement (C3) mg/ml No Yes ¹0·29 ¹
IgG g/l No No ¹0·17 ¹¹

The significance of the Pearson’s correlation was graded into five groups according to Landis & Kock [30]: ¹ ¹, slight (0·00–0·20); ¹, fair (0·21–
0·40); þ/¹, moderate (0·41–0·60); þ, substantial (0·61–0·80); and þ þ, perfect (0·81–1·00).
q 2000 Blackwell Science Ltd, Clinical and Experimental Immunology, 119:189–195
192 M. W. J. Boehme et al.
Table 3. Cross-correlation of the different serological disease activity parameters in patients with SLE

Pearson correlation coefficient

sE- ds-DNA ds-DNA

TM sIL-2R IL-6 IL-10 sICAM-1 selectin sVCAM-1 ELISA RIA ANA CRP ESR C3 IgG

Thrombomodulin 0·29 0·35 0·48 0·28 0·13 0·26 0·12 0·25 0·01 0·39 0·44 ¹0·16 ¹0·26
sIL-2R ¹ 0·36 0·09 0·31 ¹0·17 0·27 0·25 0·26 0·12 0·16 0·23 ¹0·32 ¹0·14
IL-6 ¹ ¹ 0·59 0·35 ¹0·20 0·29 ¹0·11 0·01 0·22 0·18 0·16 ¹0·23 ¹0·37
IL-10 þ/¹ ¹ ¹ þ/¹ 0·47 0·18 0·09 ¹0·04 ¹0·04 0·06 0·22 0·08 ¹0·11 ¹0·19
sICAM-1 ¹ ¹ ¹ þ/¹ 0·30 0·19 0·17 0·08 0·14 0·30 0·11 ¹0·12 0·40
sE-selectin ¹¹ ¹¹ ¹¹ ¹¹ ¹ ¹0·13 ¹0·02 0·06 0·01 0·07 ¹0·03 ¹0·07 0·26
sVCAM-1 ¹ ¹ ¹ ¹¹ ¹¹ ¹¹ 0·11 0·15 0·18 0·16 0·28 0·02 0·18
dsDNA ELISA ¹– ¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹¹ 0·55 0·20 0·25 0·14 ¹0·35 0·08
dsDNA RIA ¹ ¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹¹ þ/¹ 0·17 0·19 0·29 ¹0·48 ¹0·04
ANA ¹¹ ¹¹ ¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹¹ 0·12 0·05 ¹0·12 0·13
CRP ¹ ¹¹ ¹¹ ¹ ¹ ¹¹ ¹¹ ¹ ¹¹ ¹¹ 0·50 ¹0·19 0·18
ESR þ/¹ ¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹ ¹¹ ¹ ¹¹ þ/¹ ¹0·01 ¹0·11
C3 ¹¹ ¹ ¹ ¹¹ ¹¹ ¹¹ ¹¹ ¹ þ/¹ ¹ ¹¹ ¹¹ ¹0·05
IgG ¹ ¹¹ ¹ ¹¹ ¹ ¹ ¹ ¹¹ ¹¹ ¹ ¹¹ ¹¹ ¹¹
Grading of the correlation coefficient (due to Landis & Kock 1977 [30])

The significance of the Pearson’s correlation was graded into five groups according to Landis & Kock [30]: ¹ ¹, slight (0·00–0·20); ¹, fair (0·21–
0·40); þ/¹, moderate (0·41–0·60); þ, substantial (0·61–0·80); and þ þ, perfect (0·81–1·00).

Soluble serum TM (sTM) Soluble ICAM-1

30 r = 0.82 1200 r = 0.41

Soluble sTM (ng/ml)

25 1000
sICAM-1 (ng/ml)

20 800

15 600

10 400

5 200

0 0
0 5 10 15 20 25 0 5 10 15 20 25

Soluble VCAM-1 Soluble E-selectin

4000 r = 0.25 180 r = 0.20

160
sE-selectin (ng/ml)
sVCAM-1 (ng/ml)

3000 140
120
100
2000
80
60
1000 40
20
0 0
0 5 10 15 20 25 0 5 10 15 20 25
SLE disease activity : SLAM score SLE disease activity : SLAM score

Fig. 1. The serological values and correlations with SLE disease activity are shown for thrombomodulin (TM) as well as for the adhesion
molecules intercellular adhesion molecule-1 (ICAM-1), E-selectin, and vascular cell adhesion molecule-1 (VCAM-1). The SLE disease
activity was determined by the SLAM score.
q 2000 Blackwell Science Ltd, Clinical and Experimental Immunology, 119:189–195
 Serological parameters of SLE disease activity 193

25 1200 4000 140

120
1000
20
3000
100
800
Soluble sTM (ng/ml)

sE-selectin (ng/ml)
sVCAM-1 (ng/ml)
sICAM-1 (ng/ml)

15
80

600 2000

60
10

400
40
1000
5
200
20

n = 30 n = 30 n = 30 n = 30
0 0 0 0
High-active SLE Low-/inactive SLE High-active SLE Low-/inactive SLE High-active SLE Low-/inactive SLE High-active SLE Low-/inactive SLE
SLAM score > 5 SLAM score 0.5 SLAM score > 5 SLAM score 0.5 SLAM score > 5 SLAM score 0.5 SLAM score > 5 SLAM score 0.5

Fig. 2. The serological levels of thrombomodulin (TM) and adhesion molecules (intercellular adhesion molecule-1 (ICAM-1), E-selectin, and
vascular cell adhesion molecule-1 (VCAM-1)) are compared in 30 patients with proven SLE at active (SLAM score > 5) and low active/
inactive (SLAM score 0–5) stage of disease (more details in Patients and Methods). The best correlation of the intra-individual kinetics with
the course of disease is found for the serum TM levels.

tested confirmed these results. In addition, these correlations values decreased only in 73%, 70%, and 53% of patients, respec-
demonstrated the independence of sTM and the other serological tively (Fig. 2).
parameters of disease activity and in particular the parameters of
the immunological system (Table 3). A subanalysis between the
DISCUSSION
different disease manifestations and the values of sTM revealed
that the involvement of several organ systems contributed together Our data provide in vivo evidence for sTM as an excellent serolo-
to the sTM increase. In addition, a special subanalysis showed that gical parameter of disease activity in patients with SLE. sTM
nephritis was not only correlated with a significant increase of sTM shows the best correlation to disease activity by comparing
but also with a significant increase of DNA antibody titre established and recent serological parameters. The serological
(P < 0·003) and decrease of C3 (P < 0·03). parameters of disease activity in SLE can be divided into the
Next we investigated sTM as well as the adhesion molecules following groups according to the historical development: general
sICAM-1, sE-selectin, and sVCAM-1 as markers of disease indirect markers, autoantibodies, cytokines, adhesion molecules
activity in more detail due to their importance as parameters of and finally markers of endothelial cell damage.
endothelial cell activation and cell damage. The levels of sICAM- Initially, only general, unselective parameters of disease activ-
1, sVCAM-1, and to a minor extent sE-selectin were elevated in ity were available such as ESR, CRP, or levels of immunoglobulins
SLE patients compared with control values. However, there was and complement components. Overall, these parameters show a
only a weak correlation with disease activity due to a broad weak correlation to disease activity only and are influenced by a
variability amongst patients with similar disease activities (Table multiplicity of factors [2–6]. Furthermore, the CRP response of
1, Fig. 1). In contrast, sTM showed a much better correlation with patients with SLE was characterized in most cases by a weak
disease activity (r ¼ 0·82). In addition, the intra-individual kinetics increase only [6]. Finally, the levels of several complement
of these parameters further demonstrated the superiority of sTM. components have proved to be of special value in the subgroup
Serum samples were available for all 30 patients at low active or of patients with nephritis [4,5].
inactive (SLAM score 0–5) and active (SLAM score > 5) stages of A characteristic feature of SLE is the polyclonal B cell
disease activity. The mean of the respective serological values was activation and the occurence of a variety of autoantibodies.
taken if more than one sample at the same stage of disease activity Particularly, autoantibodies to dsDNA have proved to be of high
was available in individual patients. All 30 patients showed lower value for the diagnosis of SLE [7,8]. In contrast, the titre of dsDNA
sTM values at low active/inactive compared with high active stage antibodies is of limited value as a serological parameter of disease
of disease. In contrast, the sVCAM-1, sICAM-1 and sE-selectin activity [5,7,8,25]. Continuously elevated titres are found in a
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194 M. W. J. Boehme et al.
substantial subgroup of SLE patients independent of the clinical
disease activity or relapse [5,7,31]. In addition, several autoanti-
bodies occur of very restricted or minor clinical importance. Anti-
endothelial cell antibodies (AECA) and INFIL-ab are present in up
to 50% of the patients but they do not correlate well with the course
of disease. The titre of distinct autoantibodies may be of interest for
the definition of subgroups such as patients with kidney involve-
ment (AECA; [32]), joint involvement (INFIL-ab; [33]), or drug-
induced SLE (anti-histone antibodies; [3]).
Pro- and anti-inflammatory cytokines mediate cell–cell inter-
actions. They play an important role in the initiation and main-
tenance of inflammatory autoimmune processes. Soluble cytokine
levels are potential parameters to monitor disease activity in SLE
patients. However, the serological levels of different cytokines or
their respective receptors were shown to be of limited value. In
general, the levels of investigated cytokines such as IL-2/IL-2R (as
marker of T cell activation), IL-6 or IL-10 were higher in active
than in low active/inactive SLE, but did not correlate well with the
course of the disease. They might be useful in certain subgroups of
SLE patients only [3,8–12]. The limited value of serological
cytokine levels as activity parameters of SLE is probably due to
the established abnormalities of T cell function, the deficient
cytokine production, the altered Th1/Th2 cell relation in SLE,
and the substantial differences between local cytokine secretion
and systemic distribution [9,34].
The results of the present study confirm the restricted signifi-
cance of the general unselective markers, autoantibodies, and
cytokines as serological disease activity markers in SLE. Recently,
markers of endothelial cell activation or injury have gained
increasing importance. This is mainly due to the established
endothelial cell activation and damage as an important pathophy-
siological feature of SLE.
ICAM-1, E-selectin and VCAM-1 are important adhesion
molecules for the interaction of endothelial cells with leucocytes
in inflammation [35]. ICAM-1 is constitutively expressed on a
large variety of cells. The expression is induced by proinflamma-
tory cytokines. VCAM-1 is found on a limited number of activated
cells, including endothelial cells. E-selectin is mainly expressed on
cytokine-activated endothelial cells in a transient fashion [35,36].
In addition to the membrane-bound receptor, soluble forms of
adhesion molecules can be found in the supernatant of activated
endothelial cells in vitro or in serum in vivo, probably as a result of
active shedding or membrane injury [36–38]. However, the data of
this study as well as other studies show a weak correlation between
soluble adhesion molecule levels and disease activity of SLE only.
Therefore, levels of soluble adhesion molecules are of limited
value as disease activity parameters in SLE as well [10,14–16].
Pathophysiologically SLE is characterized by an immune
complex vasculitis and increased cytotoxicity of polymorphonuc-
lear neutrophils (PMN) to endothelial cells [1,39]. Recently, sTM
was established as marker of endothelial cell damage [23,24].
Thrombomodulin is the transmembranous glycoprotein receptor
for thrombin mainly expressed on endothelial cells and syncytio-
trophoblasts. The TM–thrombin complex acts as important anti-
coagulant resulting in accelerated activation of protein C [21,22].
After physiological activation and reaction the complex is inter-
nalized and degraded. In vitro studies including 51Cr-release assays
could confirm that soluble TM is a reliable marker of endothelial
cell damage independent of physiological activation [23,24].
In addition, cytokine stimulation of endothelial cells results
in decreased TM expression on the cell surface due to TM
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internalization with subsequent degradation and suppression of
TM transcription and translation [40,41]. Nevertheless, previously
we showed in endothelial cell cultures in vitro and in patients
receiving recombinant human tumour necrosis factor-alpha
(rhTNF-a) for therapy, that soluble TM is a reliable marker of
endothelial cell damage due to endothelial–leucocyte adhesion and
interaction after cytokine activation [42]. In summary, sTM is an
excellent and promising marker of endothelial cell damage in
vasculitides. The latter is highlighted by our present study compar-
ing in parallel established and recent serological markers of SLE
disease activity, including the intra-individual follow up at times of
different disease activity. The clinical importance of sTM has
further been documented recently in studies correlating sTM with
disease activity in patients with various diseases resulting in
vasculitides or vascular injury. These included patients with SLE
[17–22], ulcerative colitis [43], Wegener’s granulomatosis
[44,45], Takayasu’s arteritis [44], Behçet’s disease [44], giant
cell arteritis [44], panarteritis nodosa [46], microscopic polyangii-
tis [45], diabetic microangiopathy [46], sepsis [47,48], malaria
[49,50], and disseminated intravascular coagulation [48,51]. How-
ever, a marked variation of TM concentration (up to 10-fold) is
found comparing the different reports. This might be due to the
different standards used in the individual test kits, based on either
recombinate or purified TM from human placenta. Therefore, an
international standardization is required.
In conclusion, our in vivo data highlight sTM as the best
serological activity marker in SLE available at present. sTM
reflects closely endothelial cell damage due to vasculitis and
therefore is closely related to the immunopathophysiological
alterations in SLE. Our comparative study suggests that sTM
may also represent a promising serological parameter for thera-
peutical considerations and decisions.
ACKNOWLEDGMENT
The authors would like to thank Dr I. Zuna (German Cancer Research
Centre, Heidelberg, Germany) for statistical analysis.
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