Article Text

Download PDFPDF

Measuring plasma C4D to monitor immune complexes in lupus nephritis
  1. Tineke Kraaij1,
  2. Sara C. Nilsson2,
  3. Cees van Kooten1,
  4. Marcin Okrój3,
  5. Anna M Blom2 and
  6. YK Onno Teng1
  1. 1Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Department of Translational Medicine, Section of Medical Protein Chemistry, Lund University, Malmö, Sweden
  3. 3Department of Medical Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Gdańsk, Poland
  1. Correspondence to Tineke Kraaij; t.kraaij{at}


Objective Because currently available assays that measure circulating immune complexes (ICx) are suboptimal, a novel assay was recently developed measuring C4d, a stable product of activation of the classical complement pathway. The present study aimed to establish the value of measuring plasma C4d levels in a longitudinal cohort of patients with severe refractory SLE who were treated with a combination therapy of rituximab with belimumab (RTX+BLM).

Methods Fifteen patients with SLE who were treated with RTX+BLM in a phase 2A, open label study were included to sequentially measure plasma C4d levels and correlated to well-established markers of ICx-formation, that is, autoantibodies against double-stranded (ds) DNA, autoantibodies against C1q and proteinuria. The performance of plasma C4d measurements, C4 measurements and the ratio of C4d over C4 (C4d:C4) was evaluated.

Results After establishing that on RTX+BLM treatment kinetics of C4d levels was distinct from traditional C3 and C4 levels, we found strong correlation of C4d:C4 with anti-dsDNA (R=0.76, p<0.001) and anti-C1q (R=0.65, p<0.001) autoantibody levels, which outperformed both stand-alone C4 and C4d levels. Additionally, changes in C4d:C4 over time correlated strongly with changes in proteinuria (R=0.59, p<0.001) as well as anti-dsDNA (R=0.46, p=0.003) and anti-C1q (R=0.47, p=0.002).

Conclusion In patients with severe SLE, plasma C4d levels in relation to C4 levels is useful for longitudinal monitoring after RTX+BLM treatment to reflect amelioration of classical complement activation by ICx as well as proteinuria.

  • systemic lupus erythematosus
  • lupus nephritis
  • immunoglobulin-mediated membranoproliferative glomerulonephritis
  • complement
  • C4d

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors TK, SN, CVK, AMB and YKOT contributed to the ideas for the article. TK, CVK, AMB and YKOT analysed the data, participated in the interpretation of the data and wrote and revised the manuscript. AMB and MO were involved in developing the assay for C4d measurement. All authors approved of the final version.

  • Funding The study was funded by the Swedish Research Council (2016-01142), King Gustav V’s 80th Anniversary Foundation, Swedish Rheumatism Association, and grants for clinical research (ALF and from the Skåne University Hospital). Dr Kraaij and Dr Teng’s work is supported by the Dutch Kidney Foundation (KJPB12.028 and 17OKG04), Clinical Fellowship from the Netherlands Organization for Scientific Research (90713460). Marcin Okrój’s work is supported by the National Science Centre Poland, grant no. 2014/14/E/NZ6/00182. GlaxoSmithKline (GSK) provided belimumab and an unrestricted grant for the clinical study described in this manuscript.

  • Competing interests AMB and MO are named as inventors in a patent application including claims to use of C4d as biomarker.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the LUMC medical ethics committee (Commissie Medische Ethiek LUMC, P14.065).

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

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.