Systemic lupus erythematosus: year in review 2019

scRNA-seq reveals involvement of monocytes in immune response in SLE patients

BACKGROUND

Systemic Lupus Erythematosus (SLE) is a typical autoimmune disease characterized by a complex pathogenesis and a strong genetic predisposition. The study of inflammatory response in SLE monocytes is not very clear, and exploring the inflammatory factors of monocytes is beneficial to discover new diagnostic targets.

RESULTS

Using scRNA-seq technology, we obtained the quantitative changes in circulating immune cells and various cellular immune metabolic profiles between SLE patients and healthy volunteers. A significant increase in monocytes was observed in peripheral blood of SLE patients. Flow cytometry was employed to validate the types and quantities of circulating immune cells in SLE, corroborating the scRNA-seq results. Monocyte highly expressed IRF1 (interferon regulatory factor 1) in SLE. Previous research proves that IRF1 is widely involved in immune regulation and inflammatory response, and can promote the transcription of a variety of pro-inflammatory cytokines. Additionally, Inflammatory factors secreted by monocytes in serum were measured. The results demonstrated a significant upregulation of IFN-γ, TNF-α, IL-2, IL-6, IL-8, IL-10, IL-1β in the sera of SLE patients compared to healthy controls.

CONCLUSION

Our results demonstrate upregulation of monocyte inflammation in circulating immune cells in SLE patients and expands the current understanding of circulating immune cells in SLE. Our study provides a blueprint for future exploration of SLE monocytes, revealing the pathogenesis and inventing new immunotherapies.

Comparative efficacy and safety of different recommended doses of telitacicept in patients with systemic lupus erythematosus in China: a systematic review and meta-analysis

Background

Telitacicept, a new biological agent, was approved in China for treating systemic lupus erythematosus (SLE) in 2021. Its optimal dosing for treating SLE remains unclear. Therefore, the aim of this meta-analysis is to evaluate the efficacy and safety of various telitacicept doses in SLE treatment.

Methods

PubMed, EMBASE, Cochrane libraries, Web of science, China National Knowledge Infrastructure (CNKI), VIP, Wanfang, and Sinomed were searched for the controlled trials that studied the efficacy and safety of telitacicept on SLE patients from their initiation to April 30, 2024. The analysis included three randomized controlled trials (RCT) with 606 participants. We used fixed-effects models for meta-analyses and the risk ratios (RRs) and corresponding 95% confidence intervals (CIs) to evaluate the effectiveness and safety. Heterogeneity was assessed and quantified using I2.

Results

All telitacicept dosages (80 mg, 160 mg, 240 mg) significantly improved SLE Responder Index 4 (SRI4) responses compared to the control group (RR = 2.20, 95%CI:1.50-3.21, p < 0.0001; RR = 2.18, 95%CI: 1.82-2.62, p < 0.00001; RR = 2.44, 95%CI: 1.67-3.56, p < 0.00001, respectively). The 80 mg, 160 mg, and 240 mg groups also showed better improvement on SELENA-SLE Disease Activity Index (SELENA-SLEDAI) scores (RR = 1.63, 95%CI: 1.23-2.17, p = 0.0008; RR = 1.72, 95%CI: 1.45-2.04, p < 0.00001; RR = 1.73, 95%CI: 1.30-2.30, p = 0.0002, respectively) and Physician Global Assessment (PGA) scores (RR = 1.25, 95%CI: 1.09-1.44, p = 0.002; RR = 1.39, 95%CI: 1.25-1.55, p < 0.00001; RR = 1.24, 95%CI: 1.09-1.42, p = 0.002, respectively). Furthermore, 160 mg group exhibited higher British Isles Lupus Assessment Group (BILAG) score than the control group (RR = 1.11, 95%CI: 1.01-1.22, p = 0.03). As for security, 160 mg telitacicept group had higher incidence of adverse events (AEs) than the control group (RR = 1.10, 95%CI: 1.03-1.18, p = 0.007).

Conclusion

Telitacicept combined with standard therapy presents potential benefits but there are certain safety concerns with certain dosages of telitacicept, warranting further investigation for optimal dosing strategies in SLE management.

Systematic review registration

INPLASY.COM, identifier INPLASY202440101.

Chemokines and chemokine receptors: Potential therapeutic targets in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects connective tissue and can lead to multisystem organ damage. Chemokines are a class of small proteins that interact with receptors and participate in a variety of physiological functions, including cell growth, differentiation, apoptosis and distribution. They also play important roles in pathological processes, such as the inflammatory response, wound repair, tumor formation and metastasis. Previous studies have shown that the levels of chemokines and their receptors are elevated in the blood and inflamed tissues of SLE patients. In addition, chemokine ligand-receptor interactions control the recruitment of leukocytes into tissues, suggesting that chemokines and their receptors may be biomarkers and therapeutic targets for SLE. This review summarizes the causative role of chemokines and their receptors in SLE, as well as their clinical values and challenges as potential biomarkers and therapeutic targets.

Safety and efficacy of telitacicept in refractory systemic lupus erythematosus patients who failed treatment with belimumab : A case series

OBJECTIVE

This study aimed to determine the effect and safety of telitacicept, an antagonist of BLyS/APRIL-mediated B cell activation, in patients with systemic lupus erythematosus (SLE) who failed treatment with belimumab and in whom telitacicept was administered combined with conventional therapy. A review of published reports on telitacicept for SLE was also performed.

METHODS

A retrospective review was performed of the records of patients seen in the Department of Rheumatology at the Wuhan Hospital of Chinese and Western Medicine, Wuhan, China, with refractory SLE who had failed treatment with belimumab. The terms "systemic lupus erythematosus" and "telitacicept" were used to identify patients reported in the English medical literature.

RESULTS

Identified were 14 refractory SLE patients, 3 males (21%) and 11 females (79%). The median age was 32.9 years. The median disease duration was 8.9 years. Patients in this cohort received telitacicept for an average of 34.1 weeks (17-62 weeks) and the total SLE responder index 4 (SRI-4) response rate was 78.9% (n = 11). The mean SLE Disease Activity Index (SLEDAI) score declined from 8.6 at baseline (95% confidence interval [CI] 7.87-9.28) to 4.29 at the endpoint (95% CI 3.4-5.16). All cases (100%) had hypocomplementemia at baseline, and 7 cases (50%) reported normal C3 and C4 levels at the follow-up endpoint. At the observation endpoint, the 24‑h urinary protein value of the 13 cases with proteinuria (baseline 24‑h urinary protein > 0.5 g/d) displayed a reduction, and 3 values turned negative. Although some patients had low serum total immunoglobulin (Ig) levels, subnormal IgG levels, and absolute counts of peripheral blood lymphocytes after treatment, no serious infection was reported. One case was refractory lupus hepatitis confirmed by liver pathology, and upon change to change to telitacicept treatment, liver function returned to normal.

CONCLUSION

This is the first case series in SLE patients who accepted telitacicept treatment after failed treatment with belimumab. Our case series and review of the literature show that telitacicept combined with the original standard treatment may significantly improve disease activity while reducing prednisone use. No major safety issues were seen in this group of patients. Telitacicept may be a promising drug for the treatment of refractory lupus hepatitis.

Quality of Life in Systemic Lupus Erythematosus and Other Chronic Diseases: Highlighting the Amplified Impact of Depressive Episodes

BACKGROUND

Extensive research has explored SLE's impact on health-related quality of life (H-QoL), especially its connection with mental wellbeing. Recent evidence indicates that depressive syndromes significantly affect H-QoL in SLE. This study aims to quantify SLE's impact on H-QoL, accounting for comorbid depressive episodes through case-control studies.

METHODS

A case-control study was conducted with SLE patients (meeting the ACR/EULAR 2019 criteria of age ≥ 18). The control group was chosen from a community database. H-QoL was measured with the SF-12 questionnaire, and PHQ-9 was used to assess depressive episodes.

RESULTS

SLE significantly worsened H-QoL with an attributable burden of 5.37 ± 4.46. When compared to other chronic diseases, only multiple sclerosis had a worse impact on H-QoL. Major depressive episodes had a significant impact on SLE patients' H-QoL, with an attributable burden of 9.43 ± 5.10, similar to its impact on solid cancers but greater than its impact on other diseases.

CONCLUSIONS

SLE has a comparable impact on QoL to serious chronic disorders. Concomitant depressive episodes notably worsened SLE patients' QoL, exceeding other conditions, similar to solid tumors. This underscores the significance of addressing mood disorders in SLE patients. Given the influence of mood disorders on SLE outcomes, early identification and treatment are crucial.

Development and validation of the systemic lupus erythematous scale amongst the system of quality of life instruments for chronic diseases QLICD-SLE (V2.0)

OBJECTIVE

The present study is aimed to develop and validate a quality of life scale for systemic lupus erythematosus (SLE) patients with Chinese cultural background, QLICD-SLE (V2.0).

METHODS

The QLICD-SLE (V2.0) was developed using a systematic approach that involved focus groups, nominal discussions, and pilot testing. A total of 428 SLE patients participated in the scale's assessment. Validity was examined through qualitative analysis, item domain correlation, multidimensional scaling, and factor analysis. Reliability was assessed using Pearson's correlation and Cronbach's alpha coefficients. To evaluate responsiveness, paired T-tests were conducted to compare pre- and post-treatment measurements with the standardised response mean (SRM) being calculated.

RESULTS

Correlation and factor analyses demonstrated strong construct validity. When using SF-36 as criteria, the correlation between various domains of QLICD-SLE and SF-36 ranged from 0.55 to 0.70. Test-retest correlation coefficients exceeded 0.71, and Cronbach's alpha coefficients for both measurements in each domain were greater than or equal to 0.75. T-test results showed that both the overall score and most facet scores within each domain showed statistically significant changes after treatment (P < 0.05), indicating reasonable responsiveness.

CONCLUSION

The QLICD-SLE (V2.0) appears to be a valid and reliable instrument for assessing the quality of life in patients with SLE.

Cardiac Abnormalities in Relation to the Disease Activity Index Among Systemic Lupus Erythematosus Patients in a Tertiary Hospital: A Cross-Sectional Study

BACKGROUND

 Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective tissue disorder involving multiple organs and systems. Cardiovascular involvement in SLE patients is a major cause of morbidity and mortality. Although subclinical cardiac abnormalities exist among SLE patients, they are rarely screened for. Echocardiography has been demonstrated to be a useful tool for the early diagnosis of cardiac abnormalities in SLE patients, many of which are clinically silent. Early recognition of cardiovascular abnormalities is vital for the prompt initiation of the appropriate management. This study aims to determine the prevalence of various structural and functional cardiac abnormalities among SLE patients and to determine its association with the modified SLE Disease Activity Index 2000 (modified SLEDAI-2K).

METHODS

 The study was a cross-sectional study of SLE patients at the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, from June to December 2021. The setting was the rheumatology outpatient clinic of the KBTH and included adult men and women, 18 years and above, diagnosed with SLE with no known cardiac abnormalities. The baseline demographic and clinical characteristics of the participants were determined. A detailed transthoracic echocardiogram was performed for all patients. The frequency of common cardiac pathologies was determined and compared between those with a high modified SLEDAI-2K and those with a low modified SLEDAI-2K.

RESULTS

 Ninety-nine SLE patients participated in the study with a mean age of 35.12 years. Females formed the majority (90.9%) of the participants. The mean age at diagnosis of SLE was 28.7 years and the mean disease duration was 4.6 years. All of the participants were on at least two disease-modifying medications. The mean modified SLEDAI-2K score was 9.1. Thirty-five percent (35%) of the patients had mild to moderately active disease and 39% had severely active disease. Sixty-six (66%) out of the severely active disease group had abnormal echocardiographic findings, while 28% of those with mild to moderate disease had abnormal echocardiographic findings. Echocardiographic abnormalities were found in 56 patients (47%), out of which 8.7% had valvular involvement, 15.7% had diastolic dysfunction, 5.2% had left ventricular hypertrophy (LVH), and 0.9% had left ventricular systolic dysfunction (LVSD). About 12% of the participants had pulmonary hypertension and 1% had pericardial involvement. The odds of echocardiographic abnormalities were 13.7 times higher in SLE patients with high disease activity compared to those with low disease activity (odds ratio (OR) = 13.714, 95% confidence interval (CI) = 3.804-49.442, p < 0.001). There was no significant association between cardiac abnormalities and SLE duration. No significant correlation between cardiac abnormalities and modified SLEDAI-2K score was found.  Conclusion: Cardiac abnormalities, especially left ventricular diastolic dysfunction (LVDD), valvular involvement, and pulmonary hypertension, are common in SLE patients. For SLE patients, especially those with active diseases, echocardiographic assessment should be considered in the management of SLE patients to enable early detection of cardiac abnormalities, early treatment, and thus a decrease in morbidity and mortality associated with cardiovascular involvement in SLE patients.

Melatonin and bone-related diseases: an updated mechanistic overview of current evidence and future prospects

PURPOSE

Bone diseases account for an enormous cost burden on health systems. Bone disorders are considered as age-dependent diseases. The aging of world population has encouraged scientists to further explore the most effective preventive modalities and therapeutic strategies to overcome and reduce the high cost of bone disorders. Herein, we review the current evidence of melatonin's therapeutic effects on bone-related diseases.

METHODS

This review summarized evidences from in vitro, in vivo, and clinical studies regarding the effects of melatonin on bone-related diseases, with a focus on the molecular mechanisms. Electronically, Scopus and MEDLINE®/PubMed databases were searched for articles published on melatonin and bone-related diseases from inception to June 2023.

RESULTS

The findings demonstrated that melatonin has beneficial effect in bone- and cartilage-related disorders such as osteoporosis, bone fracture healing, osteoarthritis, and rheumatoid arthritis, in addition to the control of sleep and circadian rhythms.

CONCLUSION

A number of animal and clinical studies have indicated that various biological effects of melatonin may suggest this molecule as an effective therapeutic agent for controlling, diminishing, or suppressing bone-related disorders. Therefore, further clinical studies are required to clarify whether melatonin can be effective in patients with bone-related diseases.

Post-partum Fever of Unknown Origin: An Inaugural Flare of Severe Lupus With Multisystemic Involvement and Hemophagocytic Syndrome

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost every organ. Lupus protein-losing enteropathy (PLE) is one of the rarest manifestations of gastrointestinal involvement. Lupus flare as initial presentation is rare and the disease can act as a trigger to other pathologic immune syndromes like Hemophagocytic Lymphohistiocytosis (HLH), although this association is rare. We report the case of a previously healthy African 39-year-old female patient, with a recent history of cesarean section. Admitted to the Emergency Department (ED) with diffuse abdominal pain and fever, having completed a cycle of antibiotic therapy for initially suspected endometritis. The clinical picture progressed with sustained high fever, new-onset lymphadenopathies, systemic rash, acute pulmonary edema and seizures. Laboratory findings included hyperferritinemia, hypertriglyceridemia, proteinuria and hypoalbuminemia. The auto-immune panel was positive for antinuclear antibodies (ANA), anti-dsDNA, anti-SSA and anti-SSB, anti-PL7, anti-RNP, anti-U1-SnRNP, and anti-Pm-Scl75. She also presented hypocomplementemia. An inaugural flare of SLE with multisystemic involvement and concomitant secondary Hemophagocytic Syndrome was considered and therapy with methylprednisolone pulses, Anakinra and Cyclophosphamide was started. By the end of the first cycle of cyclophosphamide, the patient presented clinical worsening with abdominal pain recrudescence and profuse diarrhea. After the exclusion of an infectious process, a Lupus PLE was assumed and Cyclophosphamide protocol was resumed, with sustained clinical improvement after the induction protocol. Despite initially suspected gynecological infection, the clinical progression with multisystemic involvement together with the auto-immune panel made the diagnosis of SLE possible, with other laboratory findings raising the suspicion of HLH. This case represents a rare report of severe SLE with multiple organ involvement accompanied by HLH. Gastrointestinal involvement with PLE added rarity and morbidity to the clinical picture. The case reinforces the idea that when organ dysfunction is due to a severe autoimmune response, supportive treatment can be lifesaving until immunosuppressive drugs reach their full effect.

Telitacicept: First Approval

Telitacicept (Tai'ai^®) is fusion protein comprising a recombinant transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI) receptor fused to the fragment crystallizable (Fc) domain of human immunoglobulin G (IgG). Telitacicept is being developed by Yantai Rongchang Pharmaceutical through its subsidiary RemeGen for the treatment of B cell-mediated autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and multiple sclerosis (MS). Telitacicept binds to and neutralizes the activity of two cell-signalling molecules, B-lymphocyte stimulator (BLyS) and a proliferation-inducing ligand (APRIL), thereby suppressing the development and survival of plasma cells and mature B cells. In March 2021, telitacicept received its first approval in China for the treatment of patients with active SLE. Clinical studies of telitacicept in several other indications, including IgA nephropathy, MS, myasthenia gravis, neuromyelitis optica spectrum disorders, RA and Sjögren's syndrome are underway in China. This article summarizes the milestones in the development of telitacicept leading to this first approval for SLE.

Systemic Lupus Erythematosus Presenting as Pulmonary Embolism After Liposuction: A Clinical Conundrum

Systemic lupus erythematosus (SLE) is an autoimmune disorder with a wide array of presentations and a predilection to affect women of certain ethnic backgrounds. The hallmark of the disease is multisystem involvement, dispersed in time and severity. Usual pulmonary involvement includes pleuritis, pleural effusions, pneumonitis, shrinking lung syndrome, pulmonary hypertension, and alveolar hemorrhage. Pulmonary embolism (PE) is a relatively unusual presentation of SLE. We present the case of a 28-year-old Hispanic female who presented with shortness of breath and chest pain after liposuction and was found to have a PE. Fat embolism was ruled out. The absence of overt signs and symptoms and traditional risk factors prompted a fragmentary workup. This led to the detection of antibodies sensitive and specific for SLE, in the absence of overt signs and symptoms. We revive the concept of latent lupus, a condition construed as early lupus. Since our patient was lost to follow up, we were unable to complete workup for SLE, but firmly suspect direct causation between SLE and PE. Further studies are needed to establish pathogenesis in order to facilitate early diagnosis and prevent morbidity and mortality from PE.