This study found that the prevalence of the TNFSF13B BAFF-var among German and Swiss SLE patients was 9.2%. Patients with the BAFF-var genotype were more likely to exhibit signs of renal involvement, such as lupus nephritis, proteinuria, and hematuria. Compared to SLE patients who do not carry the BAFF-var allele, those carrying the allele displayed increased disease activity at the time of study entry and more frequently required intensive treatment with immunosuppressive agents.
Previous studies demonstrated that the frequency of the BAFF-var allele was higher among SLE patients from various European cohorts than among the corresponding control populations, a finding suggesting a relationship between the BAFF-var and SLE [17,19]. The frequency of BAFF-var allele carriers (9.2%) and the MAF of the BAFF-var allele (4.6%) identified in our SLE study cohort were in line with and support the findings of case-control studies performed by González-Serna et al. . We detected the BAFF-var allele in 7.1% of SLE patients in our German cohort and the corresponding MAF was 3.69%. In comparison, the frequency of the BAFF-var allele (4%) and the MAF (2.02%) among the healthy German population were markedly lower. Similarly, the prevalence of the BAFF-var allele among healthy control subjects from another northern country (the Netherlands) was 3.8%, and the MAF was 1.91%. Among healthy subjects from Spain, the frequency (8.8%) and MAF (4.2%) of the BAFF-var allele were increased; however, among the corresponding Spanish SLE cohort the prevalence and MAF of the BAFF-var allele were even higher than in healthy control subjects with 10.8% and 5.81%, respectively . These variations are mainly due to the previously described north-south gradient underlying the higher minor allele frequency of the BAFF-var allele observed for southern European countries (Spain, 4.2%; Italy, 5.9%) than for the northern European countries (United Kingdom, 1.8%; Netherlands, 1.9%; Germany, 2.02 %) [17,19]. No homozygous carries of the BAFF-var allele were identified in our SLE cohort. The finding is in line with observations of the group of González-Serna et al. who did not detect any homozygotes within the control cohorts from Germany and Netherlands and identified only one homozygous carrier of the BAFF-var allele among 427 German SLE patients . Related to the low allele frequency of BAFF-var in Northern Europe the appearance of carriers with homozygous genotype is very rare. It is noteworthy that our study population consisted predominantly of SLE patients from Switzerland rather than patients representing a central-European population influenced by migration. Hence, a low percentage of these SLE patients were of African or Asian ancestry. These facts should be considered when the results of our study are interpreted, because they may explain why the prevalence of the BAFF-var allele in our cohort is slightly higher compared to the German SLE cohort reported by González-Serna et al. . However, separate analysis of the prevalence of the BAFF-var allele among German SLE patients from the University of Essen and patients from the SSCS found that both subgroups exhibited the same MAF (4%) (data not shown). A limitation of our study is a missing second control population from Switzerland, however we assumed a comparable genetic Caucasian background in both study cohorts.
We focused primarily on analyzing the association of the BAFF-var genotype with several disease manifestations of SLE. Here, our data contradict the observations of Steri et al., who found no association between the BAFF-var allele and clinical manifestations of SLE in 302 patients from the Sardinian SLE population . In contrast, we demonstrated for the first time an association between the BAFF-var allele and SLE disease activity and renal involvement. However, the analysis of overall 362 Italian SLE patients performed by Steri et al. revealed a trend towards increased occurrence of renal disorders among SLE patients with the BAFF-var genotype compared to those without supporting our data . These findings are likely attributable to the fact that the presence of the BAFF-var allele led to an increased production of soluble BAFF, thereby resulting in sustained high levels of BAFF. Consistently, several studies have found that elevated BAFF levels are linked to lupus nephritis and exacerbation of SLE [11-14]. However, serum concentrations of BAFF are modulated by additional regulatory factors (e.g., current B-cell number, type of immunosuppressive treatment etc.) and may vary widely. In contrast, the BAFF-var allele is inherited and its expression does not depend on current therapies or other factors potentially influencing serum levels. Thus, the presence of BAFF-var allele constitutively impairs the downregulation of BAFF expression and results in a predisposition to higher levels of BAFF, which are implicated in the immunopathological pathway of SLE and influence the course of disease among carriers of the BAFF-var allele. A previous study of promoter and exon polymorphisms of the BAFF gene  failed to show causality with BAFF synthesis and demonstrated in general only a weak association with susceptibility to SLE. However, this study did not analyze the BAFF-var allele .
Interestingly, the effect of the BAFF-var allele was restricted to the lupus nephritis without heightening the frequency of other organ involvements. We hypothesize that occurrence of the BAFF-var allele might induce the intrarenal overexpression of BAFF besides increasing the levels of soluble BAFF in peripheral circulation. In respect to latter studies, release of BAFF by renal tubular epithelial cells was described to contribute to the pathogenesis of lupus nephritis in mice and humans [24-26]. Schwarting et al. showed that BAFF derived from renal tubular epithelial cells activates production of colony forming factor 1 via autocrine loop by binding to the BAFF receptors located on tubular epithelial cells resulting in macrophage influx and creating an inflammatory microenvironment in the affected kidneys . Additionally, local constitutive expression of BAFF within the kidney promotes formation of large organized tertiary lymphoid organs in lupus nephritis leading to expansion of activated B cells and plasmablasts reactive to renal antigens [25-26]. Otherwise, elevated intrarenal BAFF production mediates glomerular damage in case of lupus nephritis by inducing invasion of T cells secreting proinflammatory cytokines as well as attracting Th17 cells . Moreover, local production of BAFF by infiltrating immune cells retains a proliferative effect on glomerular mesangial cells through interaction with its receptor BAFF-R following activation of protein kinase B and consequently stimulating the development of lupus nephritis .
Our results imply that it may be reasonable to stratify SLE patients according to their BAFF-var allele status as a genetic risk factor. On the other hand, we are aware of the BAFF-var allele being a rare genetic variant and occurring at a relatively low allele frequency. Moreover, besides the presence of the BAFF-var allele and high serum levels of BAFF, a range of other factors exert an effect on the course of SLE [5-6]. However, we believe that the BAFF-var allele is of high clinical significance as a promising candidate for a genetic risk marker that can determine which SLE patients may require extended follow-up care and intensive immunosuppressive therapy because of the relationship between this allele and the risk of severe SLE with renal manifestations.
Moreover, with respect to individualized therapeutic approaches for SLE patients, we assume that knowledge of the patient’s BAFF-var status and subsequent discrimination between patients carrying this allele and those not carrying it may be useful for making the decision about whether to use therapeutic strategies based on anti-BAFF. B-cell depletion therapies, such as rituximab, may not be appropriate for carriers of the BAFF-var allelic variation because of the potentially rapid restitution of B-cells as a result of high levels of circulating BAFF [28-29]. Furthermore, the effects of belimumab on SLE patients carrying the BAFF-var allele are controversial. On the one hand, patients with the BAFF-var allele may benefit from early treatment with belimumab, which targets BAFF overexpression. On the other hand, the presence of the BAFF-var allele may lead to a weaker response or even resistance to belimumab, so that higher dosages would be necessary for overcoming the overproduction of BAFF. Therefore, we assume that the response to belimumab among carriers of the BAFF-var allele and appropriate control subjects, as well as the detection of the BAFF-var allele among patients who do not respond to belimumab, warrants investigation in future studies.
Of importance, there are some limitations to our study. Our cohort was small in comparison to those involved in previously reported studies of the rare BAFF-var allele and SLE. Also, we did not include a control population from Switzerland; however, we anticipated that both study cohorts would exhibit a comparable genetic (white) background. We analyzed the association between BAFF-var allele status and disease activity scores (SLEDAI and PGA) as unstable variables that changed, in particular with regard to dependence on therapy. To avoid bias, we decided to use exclusively the SLEDAI and PGA scores captured at the time of entry into the SSCS or into the SLE cohort from the University Hospital Essen. The time points of diagnosis and study entry were congruent at least in one third of the 195 SLE patients in our cohort. Otherwise, in consistence with data on the association between the BAFF-var allele and disease activity at study entry, patients with the BAFF-var allele received more-intensive treatment for SLE, with a significantly higher frequency of immunosuppressant administration.