REVIEW PAPER
HE4: a potential diagnostic biomarker in autoimmune diseases
More details
Hide details
1
Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan, PR China
2
Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan, PR China
Submission date: 2025-01-22
Final revision date: 2025-05-20
Acceptance date: 2025-07-27
Online publication date: 2026-05-27
Corresponding author
Qinni Yang
Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan, PR China.
KEYWORDS
ABSTRACT
Human epididymal protein 4 (HE4), also known as protein four-disulfide core domain 2, is a secretory protein that is highly expressed in epithelial ovarian cancer. HE4 has higher specificity and sensitivity than traditional biomarkers in ovarian cancer, making it an effective marker for monitoring the progression of ovarian cancer. Given the similarities between the pathological processes in cancer and autoimmune diseases (ADs), namely overactivation of immune cells and involvement of inflammatory responses, patients with ADs may have an increased risk of cancer. Accumulating evidence suggests that HE4 is strongly associated with ADs such as systemic lupus erythematosus, Sjögren’s syndrome, rheumatoid arthritis-associated interstitial lung disease, and immunoglobulin A nephropathy. Several studies have reported that HE4 reflects disease severity and has excellent potential as a biomarker for the diagnosis and progression monitoring of ADs. In this article, we provide a detailed overview of the research on the biological function of HE4 in ADs and provide insights into whether HE4 has the potential to serve as a candidate biomarker for chronic inflammatory ADs.
REFERENCES (104)
1.
Fang Y, Ni J, Wang YS, et al. (2023): Exosomes as biomarkers and therapeutic delivery for autoimmune diseases: opportunities and challenges. Autoimmun Rev 22: 103260.
2.
Gutierrez-Arcelus M, Rich SS, Raychaudhuri S (2016): Autoimmune diseases - connecting risk alleles with molecular traits of the immune system. Nat Rev Genet 17: 160-174.
3.
Rose NR (2016): Prediction and prevention of autoimmune disease in the 21st century: a review and preview. Am J Epidemiol 183: 403-406.
4.
Miller FW (2023): The increasing prevalence of autoimmunity and autoimmune diseases: an urgent call to action for improved understanding, diagnosis, treatment, and prevention. Curr Opin Immunol 80: 102266.
5.
Getts DR, Chastain EM, Terry RL, et al. (2013): Virus infection, antiviral immunity, and autoimmunity. Immunol Rev 255: 197-209.
6.
Xiao Y, Hong X, Neelagar R, Mo H (2025): Age-standardized incidence, prevalence, mortality rates and future projections of autoimmune diseases in China: a systematic analysis based on GBD 2021. Immunol Res 2025; 73: 26.
7.
Li M, Li C, Cao M, et al. (2024): Incidence and prevalence of systemic lupus erythematosus in urban China, 2013-2017: A nationwide population-based study. Sci Bull (Beijing) 69: 3089-3097.
8.
Bieber K, Hundt JE, Yu X, et al. (2023): Autoimmune pre-disease. Autoimmun Rev 22: 103236.
9.
Floreani A, Leung PS, Gershwin ME (2016): Environmental basis of autoimmunity. Clin Rev Allergy Immunol 50: 287-300.
10.
Touil H, Mounts K, De Jager PL (2023): Differential impact of environmental factors on systemic and localized autoimmunity. Front Immunol 14: 1147447.
11.
Wang L, Wang FS, Gershwin ME (2015): Human autoimmune diseases: a comprehensive update. J Intern Med 278: 369-395.
12.
Wang W, Huang M, Ge W, et al. (2024): Identifying serum metabolite biomarkers for autoimmune diseases: a two-sample mendelian randomization and meta-analysis. Front Immunol 15: 1300457.
13.
Yuan X, Yang P, Hu J, et al. (2024): Causal association between plasma metabolites and diverse autoimmune diseases: a two-sample bidirectional mendelian randomization study. Front Immunol 15: 1437688.
14.
Jones BE, Maerz MD, Buckner JH (2018): IL-6: a cytokine at the crossroads of autoimmunity. Curr Opin Immunol 55: 9-14.
15.
Hirano T, Matsuda T, Turner M, et al. (1988): Excessive production of interleukin 6/b cell stimulatory factor-2 in rheumatoid arthritis. Eur J Immunol 18: 1797-1801.
16.
Linker-Israeli M, Deans RJ, Wallace DJ, et al. (1991): Elevated levels of endogenous il-6 in systemic lupus erythematosus. A putative role in pathogenesis. J Immunol 147: 117-123.
17.
Plebani M (2023): Why c-reactive protein is one of the most requested tests in clinical laboratories? Clin Chem Lab Med 61: 1540-1545.
18.
Sproston NR, Ashworth JJ (2018): Role of c-reactive protein at sites of inflammation and infection. Front Immunol 9: 754.
19.
Kay J, Upchurch KS (2012): Acr/eular 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford) 51 Suppl 6: vi5-9.
20.
Xiao ZX, Miller JS, Zheng SG (2021): An updated advance of autoantibodies in autoimmune diseases. Autoimmun Rev 20: 102743.
21.
Stinton LM, Fritzler MJ (2007): A clinical approach to autoantibody testing in systemic autoimmune rheumatic disorders. Autoimmun Rev 7: 77-84.
22.
Satoh M, Ceribelli A, Hasegawa T, et al. (2022): Clinical significance of antinucleolar antibodies: biomarkers for autoimmune diseases, malignancies, and others. Clin Rev Allergy Immunol 63: 210-239.
23.
Bossuyt X, De Langhe E, Borghi MO, et al. (2020): Understanding and interpreting antinuclear antibody tests in systemic rheumatic diseases. Nat Rev Rheumatol 16: 715-726.
24.
Anastasi E, Farina A, Granato T, et al. (2023): Recent insight about he4 role in ovarian cancer oncogenesis. Int J Mol Sci 24: 10479.
25.
Hamed EO, Ahmed H, Sedeek OB, et al. (2013): Significance of he4 estimation in comparison with ca125 in diagnosis of ovarian cancer and assessment of treatment response. Diagn Pathol 8: 11.
26.
Hellstrom I, Raycraft J, Hayden-Ledbetter M, et al. (2003): The he4 (wfdc2) protein is a biomarker for ovarian carcinoma. Cancer Res 63: 3695-3700.
27.
Moore RG, McMeekin DS, Brown AK, et al. (2009): A novel multiple marker bioassay utilizing he4 and ca125 for the prediction of ovarian cancer in patients with a pelvic mass. Gynecol Oncol 112: 40-46.
28.
Ghose A, McCann L, Makker S, et al. (2024): Diagnostic biomarkers in ovarian cancer: advances beyond ca125 and he4. Ther Adv Med Oncol 16: 12677961.
29.
Iwahori K, Suzuki H, Kishi Y, et al. (2012): Serum he4 as a diagnostic and prognostic marker for lung cancer. Tumour Biol 33: 1141-1149.
30.
LeBleu VS, Teng Y, O’Connell JT, et al. (2013): Identification of human epididymis protein-4 as a fibroblast-derived mediator of fibrosis. Nat Med 19: 227-231.
31.
Degez M, Caillon H, Chauvire-Drouard A, et al. (2021): Endometrial cancer: a systematic review of he4, rem and rem-b. Clin Chim Acta 515: 27-36.
32.
Furman D, Campisi J, Verdin E, et al. (2019): Chronic inflammation in the etiology of disease across the life span. Nat Med 25: 1822-1832.
33.
Masetti R, Tiri A, Tignanelli A, et al. (2021): Autoimmunity and cancer. Autoimmun Rev 20: 102882.
34.
Shah AA, Casciola-Rosen L, Rosen A (2015): Review: cancer-induced autoimmunity in the rheumatic diseases. Arthritis Rheumatol 67: 317-326.
35.
Roberts J, Ennis D, Hudson M, et al. (2020): Rheumatic immune-related adverse events associated with cancer immunothern apy: a nationwide multi-center cohort. Autoimmun Rev 19: 102595.
36.
Damania B, Kenney SC, Raab-Traub N (2022): Epstein-Barr virus: biology and clinical disease. Cell 185: 3652-3670.
37.
Kirchhoff C, Habben I, Ivell R, et al. (1991): A major human epididymis-specific cdna encodes a protein with sequence homology to extracellular proteinase inhibitors. Biol Reprod 45: 350-357.
38.
Bingle L, Singleton V, Bingle CD (2002): The putative ovarian tumour marker gene he4 (wfdc2), is expressed in normal tissues and undergoes complex alternative splicing to yield multiple protein isoforms. Oncogene 21: 2768-2773.
39.
Galgano MT, Hampton GM, Frierson HJ (2006): Comprehensive analysis of he4 expression in normal and malignant human tissues. Mod Pathol 19: 847-853.
40.
Simmons AR, Baggerly K, Bast RJ (2013): The emerging role of he4 in the evaluation of epithelial ovarian and endometrial carcinomas. Oncology (Williston Park) 27: 548-556.
41.
Bolstad N, Oijordsbakken M, Nustad K, Bjerner J (2012): Human epididymis protein 4 reference limits and natural variation in a nordic reference population. Tumour Biol 33: 141-148.
42.
Urban N, Thorpe J, Karlan BY, et al. (2012): Interpretation of single and serial measures of he4 and ca125 in asymptomatic women at high risk for ovarian cancer. Cancer Epidemiol Biomarkers Prev 21: 2087-2094.
43.
Mokhtar N, Thevarajah M, Ma N, M I (2012): Human epididymis protein 4 reference intervals in a multiethnic asian women population. Asian Pac J Cancer Prev 13: 6391-6395.
44.
Dochez V, Caillon H, Vaucel E, et al. (2019): Biomarkers and algorithms for diagnosis of ovarian cancer: CA125, HE4, RMI and ROMA, a review. J Ovarian Res 12: 28.
45.
Hertlein L, Stieber P, Kirschenhofer A, et al. (2012): Human epididymis protein 4 (HE4) in benign and malignant diseases. Clin Chem Lab Med 50: 2181-2188.
46.
Lu R, Sun X, Xiao R, et al. (2012): Human epididymis protein 4 (he4) plays a key role in ovarian cancer cell adhesion and motility. Biochem Biophys Res Commun 419: 274-280.
47.
Zhu L, Zhuang H, Wang H, et al. (2016): Overexpression of he4 (human epididymis protein 4) enhances proliferation, invasion and metastasis of ovarian cancer. Oncotarget 7: 729-744.
48.
Ten BG, Bolk J, T HB, Laman JD (2021): Multiple sclerosis is linked to MAPKERK overactivity in microglia. J Mol Med (Berl) 99: 1033-1042.
49.
Wang Y, Han D, Huang Y, et al. (2024): Oral administration of punicalagin attenuates imiquimod-induced psoriasis by reducing ROS generation and inflammation via MAPK/ERK and NF-B signaling pathways. Phytother Res 38: 713-726.
50.
Yu H, Lin L, Zhang Z, et al. (2020): Targeting NF-B pathway for the therapy of diseases: mechanism and clinical study. Signal Transduct Target Ther 5: 209.
51.
Barnabei L, Laplantine E, Mbongo W, et al. (2021): NF-B: at the borders of autoimmunity and inflammation. Front Immunol 12: 716469.
52.
Kim K, Khazan N, McDowell JL, et al. (2024): The nf-kappab-he4 axis: a novel regulator of he4 secretion in ovarian cancer. PLoS One 19: e314564.
53.
Zhang L, Liu L, Bai M, et al. (2020): Hypoxia-induced he4 in tubular epithelial cells promotes extracellular matrix accumulation and renal fibrosis via NF-B. Faseb J 34: 2554-2567.
54.
Ramasamy A, Mohan C (2025): Molecular and cellular mediators of renal fibrosis in lupus nephritis. Int J Mol Sci 26: 2621.
55.
Allen ME, Rus V, Szeto GL (2021): Leveraging heterogeneity in systemic lupus erythematosus for new therapies. Trends Mol Med 27: 152-171.
56.
Barber M, Drenkard C, Falasinnu T, et al. (2021): Global epidemiology of systemic lupus erythematosus. Nat Rev Rheumatol 17: 515-532.
57.
Li S, Gong T, Peng Y, et al. (2020): Prevalence and incidence of systemic lupus erythematosus and associated outcomes in the 2009-2016 us medicare population. Lupus 29: 15-26.
58.
Rees F, Doherty M, Grainge M, et al. (2016): The incidence and prevalence of systemic lupus erythematosus in the UK, 1999-2012. Ann Rheum Dis 75: 136-141.
59.
Liu C, Yan L, Zhang M, et al. (2024): Increased serum human epididymis protein 4 is associated with disease activity and systemic involvement in pediatric-onset systemic lupus erythematosus. Front Immunol 15: 1461987.
60.
Julkunen H, Ekblom-Kullberg S, Miettinen A (2012): Nonrenal and renal activity of systemic lupus erythematosus: a comparison of two anti-C1q and five anti-dsDNA assays and complement C3 and C4. Rheumatol Int 32: 2445-2451.
61.
Yang Z, Zhang Z, Qin B, et al. (2016): Human epididymis protein 4: a novel biomarker for lupus nephritis and chronic kidney disease in systemic lupus erythematosus. J Clin Lab Anal 30: 897-904.
62.
Seshan SV, Jennette JC (2009): Renal disease in systemic lupus erythematosus with emphasis on classification of lupus glomerulonephritis: advances and implications. Arch Pathol Lab Med 133: 233-248.
63.
Danila MI, Pons-Estel GJ, Zhang J, et al. (2009): Renal damage is the most important predictor of mortality within the damage index: data from lumina lxiv, a multiethnic us cohort. Rheumatology (Oxford) 48: 542-545.
64.
Ren Y, Xie J, Lin F, et al. (2018): Serum human epididymis protein 4 is a predictor for developing nephritis in patients with systemic lupus erythematosus: a prospective cohort study. Int Immunopharmacol 60: 189-193.
65.
Li L, Xu H, Le Y, et al. (2023): Elevated serum levels of human epididymis protein 4 in adult patients with proliferative lupus nephritis. Front Immunol 14: 1179986.
66.
Fanouriakis A, Kostopoulou M, Cheema K, et al. (2020): 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis 79: 713-723.
67.
Gargiulo M, Khoury M, Gomez G, et al. (2018): Cut-off values of immunological tests to identify patients at high risk of severe lupus nephritis. Medicina (B Aires) 78: 329-335.
68.
Alduraibi FK, Tsokos GC (2024): Lupus nephritis biomarkers: a critical review. Int J Mol Sci 25: 805.
69.
Jonsson R, Brokstad KA, Jonsson MV, et al. (2018): Current concepts on Sjogren’s syndrome – classification criteria and biomarkers. Eur J Oral Sci 126 Suppl 1: 37-48.
70.
Mavragani CP, Moutsopoulos HM (2020): Sjogren’s syndrome: old and new therapeutic targets. J Autoimmun 110: 102364.
71.
Chen J, Sun F, Bao H, et al. (2021): Elevated serum human epididymis protein 4 is associated with disease activity and systemic involvements in primary Sjogren’s syndrome. Front Immunol 12: 670642.
72.
Shiboski SC, Shiboski CH, Criswell L, et al. (2012): American college of rheumatology classification criteria for Sjogren’s syndrome: a data-driven, expert consensus approach in the Sjogren’s international collaborative clinical alliance cohort. Arthritis Care Res (Hoboken) 64: 475-487.
73.
Shiboski CH, Shiboski SC, Seror R, et al. (2017): 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjogren’s syndrome: a consensus and data-driven methodology involving three international patient cohorts. Ann Rheum Dis 76: 9-16.
74.
Chen J, He Q, Yang J, et al. (2023): Anti-SSA/SSB-negative primary Sjogren’s syndrome showing different clinical phenotypes: a retrospective study of 934 cases. Adv Rheumatol 63: 21.
75.
Smolen JS, Aletaha D, McInnes IB (2016): Rheumatoid arthritis. Lancet 388: 2023-2038.
76.
Tyker A, Ventura IB, Lee CT, et al. (2021): High-titer rheumatoid factor seropositivity predicts mediastinal lymphadenopathy and mortality in rheumatoid arthritis-related interstitial lung disease. Sci Rep 11: 22821.
77.
Matson SM, Baqir M, Moua T, et al. (2023): Treatment outcomes for rheumatoid arthritis-associated interstitial lung disease: a real-world, multisite study of the impact of immunosuppression on pulmonary function trajectory. Chest 163: 861-869.
78.
Sullivan DI, Ascherman DP (2024): Rheumatoid arthritis-associated interstitial lung disease (RA-ILD): update on prevalence, risk factors, pathogenesis, and therapy. Curr Rheumatol Rep 26: 431-449.
79.
Zamora-Legoff JA, Krause ML, Crowson CS, et al. (2017): Patterns of interstitial lung disease and mortality in rheumatoid arthritis. Rheumatology (Oxford) 56: 344-350.
80.
Lin T, Xu S, Wang Y, et al. (2022): Human epididymis protein 4 as a new diagnostic biomarker for rheumatoid arthritis-associated interstitial lung disease. Clin Exp Rheumatol 40: 2167-2174.
81.
Guo L, Wang J, Li J, et al. (2024): Biomarkers of rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis. Front Immunol 15: 1455346.
82.
Van Kalsbeek D, Brooks R, Shaver D, et al. (2023): Peripheral blood biomarkers for rheumatoid arthritis-associated interstitial lung disease: a systematic review. Acr Open Rheumatol 5: 201-226.
83.
Bauer Y, White ES, de Bernard S, et al. (2017): MMP-7 is a predictive biomarker of disease progression in patients with idiopathic pulmonary fibrosis. ERJ Open Res 3: 00074-2016.
84.
Lee JS, Lee EY, Ha YJ, et al. (2019): Serum KL-6 levels reflect the severity of interstitial lung disease associated with connective tissue disease. Arthritis Res Ther 21: 58.
85.
Stamellou E, Seikrit C, Tang S, et al. (2023): IgA nephropathy. Nat Rev Dis Primers 9: 67.
86.
Gleeson PJ, O’Shaughnessy MM, Barratt J (2023): IgA nephropathy in adults-treatment standard. Nephrol Dial Transplant 38: 2464-2473.
87.
Luo HL, He C, Xue H, et al. (2024): Serum human epididymis protein 4 is associated with disease severity in patients with IgA nephropathy. Clin Biochem 123: 110701.
88.
Shiffman ML (2024): Autoimmune hepatitis: epidemiology, subtypes, and presentation. Clin Liver Dis 28: 1-14.
89.
Muratori L, Lohse AW, Lenzi M (2023): Diagnosis and management of autoimmune hepatitis. BMJ 380: e70201.
90.
Komori A (2021): Recent updates on the management of autoimmune hepatitis. Clin Mol Hepatol 27: 58-69.
91.
Yu Z, Nian C, Sun W, et al. (2024): Elevated serum he4 levels as a novel biomarker of disease severity and hepatic fibrosis in autoimmune hepatitis. Clin Chim Acta 559: 119682.
92.
Ilchovska DD, Barrow DM (2021): An overview of the NF-kB mechanism of pathophysiology in rheumatoid arthritis, investigation of the NF-kB ligand RANKL and related nutritional interventions. Autoimmun Rev 20: 102741.
93.
Zubair A, Frieri M (2013): NF-B and systemic lupus erythematosus: examining the link. J Nephrol 26: 953-959.
94.
Chen X, Liu G, Yuan Y, et al. (2019): Nek7 interacts with nlrp3 to modulate the pyroptosis in inflammatory bowel disease via NF-B signaling. Cell Death Dis 10: 906.
95.
Mc GC, Prinz M, Beyaert R, van Loo G (2013): Nuclear factor kappa B (NF-B) in multiple sclerosis pathology. Trends Mol Med 19: 604-613.
96.
Mavropoulos A, Rigopoulou EI, Liaskos C, et al. (2013): The role of p38 MAPK in the aetiopathogenesis of psoriasis and psoriatic arthritis. Clin Dev Immunol 2013: 569751.
97.
Zhao L, Lan Z, Peng L, et al. (2022): Triptolide promotes autophagy to inhibit mesangial cell proliferation in IgA nephropathy via the card9/p38 MAPK pathway. Cell Prolif 55: e13278.
98.
Wang J, Mizui M, Zeng LF, et al. (2016): Inhibition of shp2 ameliorates the pathogenesis of systemic lupus erythematosus. J Clin Invest 126: 2077-2092.
99.
Liu C, He L, Wang J, et al. (2020): Anti-angiogenic effect of Shikonin in rheumatoid arthritis by downregulating PI3K/AKT and MAPKs signaling pathways. J Ethnopharmacol 260: 113039.
100.
Zhang F, Meng T, Feng R, et al. (2024): MIF aggravates experimental autoimmune prostatitis through activation of the NLRP3 inflammasome via the PI3K/AKT pathway. Int Immunopharmacol 141: 112891.
101.
He C, Li Y, Gan L, et al. (2024): Notch signaling regulates Th17 cells differentiation through PI3K/AKT/mTORC1 pathway and involves in the thyroid injury of autoimmune thyroiditis. J Endocrinol Invest 47: 1971-1986.
102.
Zhao C, Gu Y, Chen L, Su X (2020): Upregulation ofFoxO3a expression through PI3K/AKT pathway attenuates the progression of lupus nephritis in MRL/lpr mice. Int Immunopharmacol 89: 107027.
103.
Sun SC (2017): The non-canonical NF-B pathway in immunity and inflammation. Nat Rev Immunol 17: 545-558.
104.
Chi H, Pepper M, Thomas PG (2024): Principles and therapeutic applications of adaptive immunity. Cell 187: 2052-2078.