POS0894 COMPARISON OF PULMONARY AND SMALL AIRWAYS FUNCTION BETWEEN IDIOPATHIC INFLAMMATORY MYOPATHIES PATIENTS WITH AND WITHOUT INTERSTITIAL LUNG DISEASE

Background

Pulmonary manifestations of idiopathic inflammatory myopathies (IIM) include interstitial lung disease (ILD) and respiratory muscle weakness, but function of small airways has not been studied in these patients (1). Spirometry, impulse oscillometry and measurement of respiratory resistance by the interrupter technique (Rocc) are tools to evaluate function of small airways. In addition, body plethysmography is the gold standard for measuring lung volumes, whereas nitrogen washout seems impaired, “underestimating” lung volumes in patients with small airways obstruction due to gas trapping (2). Thus, discrepancies between lung volumes measured by those two techniques may be an indication of early small airways dysfunction.

Objectives

To compare pulmonary and small airways function between IIM patients with and without ILD.

Methods

This prospective observational study included 13 IIM patients with ILD (8 patients with dermatomyositis and 5 with polymyositis) and 13 IIM patients without ILD (9 patients with dermatomyositis and 4 with polymyositis) who were diagnosed and followed up in the outpatient rheumatology clinic of the Department of Pathophysiology between June and December 2021. All IIM patients fulfilled the 2017 EULAR/ACR classification criteria (3). The presence of ILD was determined by high resolution computed tomography of the lungs that was performed as baseline standard of care at the time of diagnosis and was evaluated by a special radiologist blindly, according to Fleischner Society definitions for ILD (4). Clinical, laboratory and immunological data were recorded at the time of diagnosis and pulmonary function was assessed by spirometry, body plethysmography, single and multiple breath nitrogen washout, impulse oscillometry and measurement of Rocc, diffusing capacity for carbon monoxide (DLco) and maximal inspiratory and expiratory pressures. Statistical analysis for categorical data was performed by Fisher exact test or χ2 square test accordingly and numerical data with Man-Whitney test or t test.

Results

IIM-ILD patients presented more frequently with dyspnea (53.8% vs 0%, p<0.01), fever (61.5% vs 7.7%, p<0.05) and arthralgias (76.9% vs 23%, p<0.05), compared to IIM patients without ILD. Inflammatory markers, serum muscle enzymes, myositis specific autoantibodies and classic spirometric parameters did not differ between the two groups. IIM-ILD patients had markedly lower predicted DLco compared to those without (mean: 56.3% vs 78.2%, p<0.01). Predicted total lung capacity and residual volume (TLCN2WO%, RVN2WO%) measured by nitrogen washout and the TLC nitrogen washout: TLC body plethysmography ratio (TLCN2WO/TLCpleth) were significantly lower in IIM-ILD patients compared to those without ILD (mean: 111.1% vs 153.4%, p<0.05, median: 171% vs 210%, p<0.05 and median: 1.28 vs 1.45, p<0.05, respectively). Similarly, ΔΝ2(%) was found significantly higher among non-ILD than ILD-IIM patients [5.4 vs 2.8%, p=0.013]. Predicted normal value of Rocc tended to be higher in IIM-ILD patients, although not statistically significantly.

Conclusion

Abnormal single breath nitrogen washout and discrepancies between lung volumes measured by body plethysmography and nitrogen washout in IIM-ILD patients, indicate an early small airways dysfunction in these patients.

References

[1]Selva-O’Callaghan et al. PMID 16130510

[2]Bell et al. PMID 30022817

[3]Lundberg et al. PMID 29079590

[4]Hatabu et al. PMID 32649920

Table 1.

Comparison of pulmonary and small airways function variables between IIM patients with and without ILD.

Pulmonary function variablesIIM-ILD patients (n=13)IIM patients without ILD (n=13)p valueFVC%88.2104.10.09FEV1%85.8101.90.07FEV1/FVC82.780.90.57FEF25-75%85.790.40.74TLCpleth%82.689.90.32RVpleth %83.976.10.40TLCN2WO%111.1153.40.03RVN2WO%1712100.039TLCN2WO/TLCpleth1.281.450.039DLco%56.378.20.005MEP%6962.40.57MIP%93.472.50.06ΔN2(%)2.85.40.013Rocc Exp %100.576.60.053R(20)%99.4123.40.09

Disclosure of Interests

None declared

POS0493 1H-NMR BASED METABOLOMIC PROFILE OF PATIENTS WITH GIANT CELL ARTERITIS AND POLYMYALGIA RHEUMATICA IN ACTIVE AND INACTIVE DISEASE STATE

Background

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in the elderly. The disease is characterized by a remarkable heterogeneity in terms of clinical picture, histologic pattern of the affected vessels, pathogenetic mechanisms and treatment selection strategies. Approximately half of GCA patients present with polymyalgia rheumatica (PMR), while 20% of PMR patients will develop GCA during follow-up. Organ or life-threatening complications of GCA, include vision loss, strokes, aneurysm formation and accelerated atherosclerosis. The clinical heterogeneity along with the increased relapse rate, even under treatment and the fact that ESR and C-Reactive Protein are the only laboratory tools for the assessment of active disease suggest that the definition of new biomarkers with diagnostic, prognostic and predictive value is an unmet need (1). Among the high throughput approaches towards this direction,1H NMR spectra of serum samples provides a direct, untargeted, and holistic metabolic profile offering a wealth of information that could be proved useful to discover outcome tools for the management of the disease (2).

Objectives

1. To characterize and compare the metabolic profile of GCA/PMR serum samples, as captured in 1H NMR spectra, in 3-time points: diagnosis, 1 and 6 months of treatment with steroids (remission), 2. evaluate whether 1H NMR-based metabolomics in serum from patients with GCA/PMR associate with response to treatment and 3. identify potential discriminatory serum metabolic profiles correlating with disease activity.

Methods

One-hundred and ten serum samples from 50 consecutive patients (33-GCA and 17-PMR) were evaluated in the study. GCA serum samples consisted of 33 naïve, 22 in 1 and 21 after 6 months of treatment (25 females, mean age 73.0 ± 7.6 years and 8 males, mean age 69.5 ± 4.9 years), while PMR of 15 naive, 10 in 1st and 8 respectively (9 females, mean age 65.0 ± 5.3 years and 8 males, mean age 77.0 ± 6.6 years). The serum metabolic profiles of patients were obtained at a 600 MHz NMR spectrometer and analysed by means of uni- and multivariate statistical methods.

Results

Multivariate analysis showed metabolic differences between GCA/PMR patients in activity and in remission using unsupervised principal component analysis (PCA: R2X= 0.698, Q2= 0.561) and supervised partial least squares discriminant analysis (PLS-DA: R2X= 0.596, Q2= 0.219) (Figure 1). In accordance with univariate analysis (p<0.05), the following discriminatory metabolites were identified: N-acetyl glycoproteins, 3-hydroxybutyric acid and phenylalanine were increased in inflammation, while cholines, lipoproteins, and lipids were decreased in these patients.

Figure 1.

(A) PLS-DA scores plot and (B) S-plot from OPLS-DA of 1H NMR profiling of GCA/PMR serum samples before treatment (green dots) and after 1 (red dots) and 6 months (black dots) of treatment. Characteristic metabolites in inflammation and remission are annotated and the corresponding p-values are given. PLS-DA: partial least square discriminant analysis, OPLS-DA: orthogonal partial least squares discriminant analysis.

Conclusion

1H NMR-based serum metabolomics revealed a clear discrimination of GCA/PMR metabolic profiles before (active inflammation) and after treatment with steroids (remission), suggesting that the metabolomic analysis may serve as a useful tool to identify potential biomarkers related to disease activity in both GCA and PMR, as well as give further insights into pathogenetic mechanisms mediating the inflammatory response. Further validation studies to dissect the clinical value of specific metabolites are ongoing in our laboratory.

References

[1]Robinette ML et al. Front Immunol 2021

[2]Emwas A-M et al., Metabolites 2019

Disclosure of Interests

None declared.

AB0565 PREVALENCE OF LIVER FIBROSIS ASSESSED BY TRANSIENT ELASTOGRAPHY IN PATIENTS WITH SJÖGREN’S SYNDROME

Background

Liver is considered one of the most commonly involved extra-glandular organs in patients with Sjögren’s syndrome (SS). Primary biliary cholangitis, hepatitis C virus infection, non-alcoholic fatty liver disease (NAFLD) and drug hepatotoxicity are the major contributors of liver disease among SS patients. Especially, NAFLD comprises a major health problem worldwide with a rapidly rising incidence and a prevalence of approximately 25% in the general population. In both NAFLD and SS, inflammatory and apoptotic pathways are implicated in pathogenesis, pathways that are also linked to fibrogenesis. No studies so far have investigated the net effect of SS in liver fibrosis.

Objectives

To assess whether SS is associated with advanced liver fibrosis (LF) in the absence of viral, alcohol-related, autoimmune hepatitis or primary cholangitis.

Methods

In this prospective study, consecutive SS patients from the rheumatology outpatient clinic of the Department of Pathophysiology, “Laiko” General Hospital, Athens, Greece between June 1st and December 31st, 2021, underwent transient elastography (TE) with measurement of liver stiffness and controlled attenuation parameter, assessing LF and liver steatosis (LS), respectively. For LF the following cut-offs were used: F0-1: 2-7 kPa, F2: 7-10 kPa, F3: 10-14 kPa, and F4: >14 kPa. F0-F1 stages were considered as clinically insignificant and F2-F4 as advanced. For LS the following cut-offs were used: S0-S1: 100-260 dB/m, S2: 260-290 dB/m, and S3: >290 dB/m. LS stage S0-S1 was classified as low and S2-S3 as high. Individuals who were evaluated in the hepatology outpatient clinic for possible NAFLD/LS based on ultrasonographic criteria (higher echogenicity than renal cortex and/or splenic parenchyma) served as a comparator group. In all participants, those with viral or alcoholic hepatitis, autoimmune liver diseases, transaminasemia or liver disease attributed to drug hepatotoxicity were excluded. Clinical, demographic and laboratory data were collected from all participants at the time of TE.

Results

Fifty-two patients with SS (49 females, 94.2%) with a median disease duration (range) of 8 (1-46) years and 198 comparators (104 females, 52.5%) were included in this study. The median age (range) of SS and comparators was 62.5 (30-81) and 55 (19-86) years, respectively. Comparators and SS patients had comparable prevalence regarding type 2 diabetes mellitus (T2DM), hyperlipidemia and body-mass index (BMI). Patients with SS had less frequently high LS (27% vs 62%, p<0.001) and advanced LF [2 (3.8%) vs 34 (17.2%), p=0.014], compared to comparator group. The 2 SS patients with advanced LF had also high LS. Univariable analysis in terms of T2DM, hyperlipidemia, BMI, age, gender, steatosis, and disease status (SS or comparators) between individuals with insignificant and advanced LF revealed age, liver steatosis, BMI, and disease status as the only statistically significant parameters; of these, only age was finally identified as independent risk factor in the multivariable logistic regression analysis (Table 1).

Table 1.

Multivariable logistic regression analysis for risk factors associated with advanced liver fibrosis among patients with Sjögren’s Syndrome and comparators.

VariablesCoefficientOdds ratiop-valueCI lowCI upperAge0.0571.0590.0231.0191.1Body Mass Index0.0991.1050.1211.0121.207Presence of Sjögren’s syndrome-0.9410.4190.3460.0672.826High Liver Steatosis0.3441.4730.620.3556.167

Conclusion

Sjögren’s syndrome per se is not associated with advanced liver fibrosis.

References

[1]Kaplan, M.J., et al. The liver is a common non-exocrine target in primary Sjögren’s syndrome: a retrospective review. BMC Gastroenterol2002, 2, 21, doi:10.1186/1471-230x-2-21.

[2]Montaño-Loza, A.J., et al. Abnormal hepatic biochemistries and clinical liver disease in patients with primary Sjögren’s syndrome. Ann Hepatol2007, 6, 150-155.

Disclosure of Interests

None declared

AB0172 METABOLIC AND LIPOPROTEIN PROFILING IN RHEUMATOID ARTHRITIS WITH THE USE OF NMR-BASED METABOLOMICS

Background

Rheumatoid arthritis (RA) remains a disease with high morbidity, due to the greater prevalence of cardiovascular disease. In contrast to the general population, systemic inflammation in RA lowers the circulating levels of lipids, a phenomenon called “the lipid paradox”. In addition to that, therapy is withdrawn in 50% of patients within 5 years, due to loss of efficacy or side effects. Momentarily predictive biomarkers for drug efficacy or side effects are missing, while a personalized approach in RA therapy is imperative. Several reports support the notion that specific metabolomic profiles are good predictors for response to MTX and anti-TNF therapy.

Objectives

The aim of this work is to depict in detail the metabolic profile of RA patients at different time-points of therapy DMARDs/bDMARDs in order to retrieve biomarkers related to their response to a given therapy, to monitor the disease progression and to predict the optimal disease management approaches.

Methods

Plasma was collected from fasted RA patients according to their therapy timepoint and organized in the following groups: a) newly diagnosed, without therapy (Naïve, n=15); b) patients having received therapies previously, with unstable disease, who were evaluated before receiving a new therapy (RAb, n=23); c) patients after having received a new therapy (RAa, n=14); and d) patients receiving any standard therapy (RAs, n=54), either DMARD or bDMARD, being in a stable condition. Finally, healthy subjects were enrolled as controls (n=33). Metabolomic profiling was carried out firstly with untargeted 1H NMR spectroscopy, and secondly with in vitro diagnostic (IVDr) NMR spectroscopy with the lipoprotein subclass analysis (B.I.LISA), to quantify absolute concentrations of metabolites and lipoproteins. The acquired data were subjected to univariate and multivariate statistical analysis to investigate clustering of the groups and define the responsible molecules. Clinical parameters, including inflammation markers, DAS28, and comorbidities, were also included in the analysis, and Spearman correlation coefficient was calculated.

Results

Untargeted NMR data were analyzed with multivariate supervised approach (PLS-DA) revealing distinct metabolic signatures for the 6 groups under investigation. The most defined groups being RAb and RAs, compared to controls, which indicated changes in alanine, tyrosine, lactate and acetone. Besides small molecule, significant changes were also observed in various plasma lipoproteins. For the thorough investigation of these findings, a targeted lipoprotein subclass analysis was conducted and highlighted significantly higher lipoprotein subclass concentrations, including free cholesterol (FC), cholesterol (CH), phospholipids (PL) and apolipoprotein A1 subfractions in RAs compared to controls and Naïve. Concerning metabolite differentiations, RAs patients exhibited reduced ketone bodies and organic acids compared to RAb and control individuals, respectively. All RA groups had lower concentrations of sarcosine. Correlation analysis highlighted the association of DAS28, ESR and CRP with ketone body acetoacetate (p<10-4) and sarcosine (p<10-2). VAS correlated with HDL triglyceride subfractions (H1TG and H2TG, p<10-5) and sarcosine (p=1.8x10-4). All therapies were found to correlate with lipoproteins; MTX with LDL-2 subfractions (p=5x10-4), intermediate-density lipoprotein (p=2.7x10-5) and acetate (p=5.9x10-6), Anti-IL-6R with VLDL cholesterol subfraction V1CH, (p=1.9x10-3) and V2CH (p=1.5x10-3), and Anti-CD20 with triglyceride fractions, IDTG and TPTG (p<10-3).

Conclusion

Overall, these data reveal that RA patients have a distinct metabolic signature depending on the time-point of therapy. Clinical parameters correlated with changes in ketone bodies, amino and organic acids, while therapies correlated with lipoproteins. The above analysis indicates that biomarkers revealed by metabolomic profiling can be useful in RA therapy monitoring.

Disclosure of Interests

None declared

POS1240 HIGH PREVALENCE OF SERUM AUTOANTIBODIES IN SEVERELY ILL COVID-19 PATIENTS HOSPITALIZED IN THE INTENSIVE CARE UNIT

Background

Coronavirus Disease-19 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is characterized by a wide range of clinical manifestations 1. Although COVID-19 was initially considered a respiratory infection, it was shortly recognized as a multisystemic disorder associated with heightened inflammatory responses, including autoimmune phenomena 1. The presence of autoantibodies (AAbs) has been described in COVID-19 patients, highlighting the state of immune dysregulation in COVID-19 1. The clinical significance of AAbs, however, is still elusive.

Objectives

To assess the prevalence of AAbs in critically ill, mechanically ventilated COVID-19 patients admitted to the intensive care unit (ICU) and investigate whether AAbs influence the clinical outcome of these patients.

Methods

The current study evaluated prospectively from March 8th, 2021 to May 10th, 2021 the presence of AAbs against nuclear antigens (ANA), extractable nuclear antigens (ENA), neutrophil cytoplasmic antigens (ANCA), cyclic citrullinated peptides (anti-CCP), double stranded-DNA (anti-dsDNA), cardiolipin (anti-CL), β2-glycoprotein-I (anti-β2-GPI), thyroid peroxidase (anti-TPO), and thyroglobulin (anti-TG) in critically ill COVID-19 patients upon admission in the ICU (n=217). Samples from 60 COVID-19 patients that were available 15 days after ICU admission were further analyzed for the evaluation of de novo AAbs production. Serum samples of age and sex matched healthy individuals before the COVID-19 pandemic were used as a control group (n=117).

Results

COVID-19 patients treated in ICU had more commonly at least one AAb compared to age and sex matched controls (174/217, 80.2% vs 73/217, 62,4%, p< 0,001). More specifically, COVID-19 patients expressed more frequently ANAs (48.4% vs 21.4%, p<0.001), anti-dsDNA (5.1% vs 0%, p=0.01), anti-CCP (8.3% vs 1.7%, p=0.014) and anti-CL IgM AAbs (21.7% vs 9.4%, p=0.005) than controls. The majority of critical COVID-19 patients who were positive for AAbs (144, 82.8%) expressed reactivity in up to three autoantigens with the most prominent being ANA, anti-phospholipid, ANCA and anti-TPO AAbs. AAbs-positive patients demonstrated more robust anti-SARS-CoV-2 humoral responses compared to AAbs-negative patients [detectable anti-SARS-CoV-2 S1-protein IgG antibodies: 150 (86.2%) vs 28 (65.1%), p=0.001; adequate neutralizing activity: 159 (91.4%) vs. 33 (76.7%), p=0.007]. The two groups, however, did not differ in terms of clinicoepidemiologic characteristics or the incidence of death in the ICU. Convalescent COVID-19 patients (n=111) compared to those who died (n=106), did not differ in the prevalence of serum AAbs or antibody responses against SARS-CoV-2. Differences were only shown in clinicolaboratory parameters including patients’ age, comorbidities, O2 saturation, inflammatory markers, and in-hospital prognostic scores as expected. Paired samples testing (n=60) revealed that 45 patients had at least one newly induced AAb, 28 patients lost at least one reactivity and only 6 patients didn’t show any seroconversion. The most common new-onset AAb reactivity was against anti-CL (IgG isotype) (n=21) followed by ANA (n=20), anti-β2-GPI (IgG isotype) (n=11), myositis-related antigens (n=13) and ENAs (n=9); nevertheless, no associations with clinicoepidemiologic features or COVID-19 outcome were revealed.

Conclusion

Patients with severe COVID-19 express AAbs more commonly than age and sex matched controls, suggesting that SARS-COV-2 infection may induce a hitherto unknown B-cell autoreactivity. The presence of autoantibodies does not play a role in the outcome of SARS-COV-2 infection. However, further studies are needed to define their role in future development of systemic autoimmune disorders or the long-COVID syndrome.

References

[1]Kaklamanos, A.; et al. COVID-19 Immunobiology: Lessons Learned, New Questions Arise. Front Immunol 2021, 12, 719023, doi:10.3389/fimmu.2021.719023.

Acknowledgements

The experimental arm of the current study was financially supported by donation grants from SYN-ENOSIS (Greece)

Disclosure of Interests

None declared

POS0764 CLINICAL AND LABORATORY FINDINGS IN PRIMARY SJOGREN’S SYNDROME PATIENTS WITHOUT SUBJECTIVE SICCA SYMPTOMS

Background

Sjogren’s syndrome (SS) is a systemic autoimmune rheumatic disease characterized by symptoms of dryness. In fact, subjective manifestations of dry eyes or dry mouth are part of the inclusion criteria of the 2016 ACR-EULAR Classification Criteria for primary SS (pSS). However, some patients with SS diagnosis may present without subjective dryness, meeting the inclusion criteria based on the EULAR SS disease activity index (ESSDAI) questionnaire (1). Studies on non-dryness SS patients are missing.

Objectives

To describe the clinical phenotype of pSS patients who lack subjective dryness symptoms.

Methods

From 1738 consecutive pSS patients who fulfill the 2016 ACR-EULAR Classification Criteria for primary SS and were followed up in 4 centers from Greece and Italy (Universities of Athens, Pisa, Harokopio and Ioannina) (PAHI group), those without sicca symptoms were identified (non-Dryness Group) (1). Cumulative, clinical, laboratory, immunologic and histologic data were collected and compared with age, gender and disease duration-matched SS patients with both oral and eye dryness in 1:2 ratio (Dryness Group) (Table 1). Statistical analysis for categorical data was performed by Fisher exact test or χ2 square test accordingly and numerical data with Mann-Whitney test or t test.

Table 1.

Comparison of clinical and laboratory features of pSS patients with (Dryness Group) and without sicca manifestations (Non-dryness Group)

Clinical and Laboratory featuresNon-Dryness Group, %, n=38Dryness Group, %, n=76p-valueANA positivity %10095.90.55RF positivity %58.364.30.7Anti-Ro positivity %10090.80.09Anti-La positivity %54.150.70.89Salivary gland biopsy positivity %93.989.80.71Focus score2.122.190.97Ocular tests positivity %55.693.9<0.001Salivary gland enlargement %26.330.30.83Arthralgias %52.656.60.84Arthritis %25.717.60.48Raynaud’s phenomenon %23.727.60.82Palpable purpura %7.918.40.17Lymphadenopathy %22.620.30.99Leukopenia %20.726.10.76Lymphopenia %017.30.049Neutropenia %20.85.80.1Thrombocytopenia %13.83.10.07Low C4 %23.330.30.65Cryoglobulinemia %10.53.90.3Lymphoma %10.86.70.47

Results

Thirty-eight SS patients were found without sicca manifestations (2.19%). The most common presenting clinical manifestation of non-dryness pSS patients were arthralgias (47.4%), followed by parotid gland enlargement (23.6%), Raynaud’s phenomenon (10.5%), generalized lymphadenopathy (10.5%), fatigue (10.5%), palpable purpura (5.3%) and pulmonary symptomatology of dry cough or exertional dyspnea (5.3%). Despite the lack of ocular dryness, non-dryness group had positive ocular tests but statistically lower compared to those with sicca symptoms (55.6% vs 93.9%, p<0.001), and displayed lymphopenia less frequently (0 vs 17.3%, p=0.049). No statistical differences were found in terms of salivary gland enlargement (SGE), focus score (FS), cryoglobulinemia and autoantibody profile between the 2 groups.

Conclusion

SS patients without subjective dryness are characterized by similar underlying immunopathologic processes as typical SS sicca patients.

References

[1]Shiboski CH, Shiboski SC, Seror R, Criswell LA, Labetoulle M, Lietman TM, et al. 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. Arthritis Rheumatol. 2017;69(1):35-45.

Disclosure of Interests

None declared

POS0807 RETINAL VESSEL CALIBERS AS A NON-INVASIVE BIOMARKER OF INFLAMMATORY BURDEN IN PRIMARY SYSTEMIC VASCULITIS

Background:

Primary Systemic Vasculitides (PSV) constitute a heterogeneous group of rare and potentially life-threatening autoimmune diseases, characterized by a varying degree of inflammatory response, leading to local or generalized vascular disease. Vessel involvement accounts for the micro- and macrovascular complications of the disease, along with the classic risk factors including, among others age and chronic use of steroids (1). Early identification of high-risk patients for cardiovascular disease (CVD) development and the contribution of inflammation towards this adverse outcome are still unmet needs. Alterations of retinal microcirculation have been independently associated with increased CVD risk in the general population (2). The potential changes of retinal vasculature and their association with disease activity and the magnitude of inflammation have not been studied in PSV so far.

Objectives:

To explore the effect of disease activity and inflammation on retinal microcirculation in PSV, classified according to vessel size as large, medium or small vessel vasculitides (LVV, MVV or SVV respectively), and polymyalgia rheumatica (PMR) without vasculitis.

Methods:

Fifty-nine patients, 43 with active disease [30 active vasculitis (12 LVV, 4 MVV, 14 SVV) and 13 PMR] and 16 with chronic inactive disease (13 vasculitis, 3 PMR) were studied. All patients were matched at 1:1 ratio with 59 controls, without underlying autoimmune/autoinflammatory disorder, neoplasia or infection, according to age, gender, CVD history, BMI, smoking, arterial hypertension, dyslipidemia, diabetes mellitus and treatment related to comorbidities. A total of 32 rheumatoid arthritis (RA) patients with mild to moderate inflammatory component as defined by standard of care acute phase reactants (ESR and CRP) and 16 chronic RA patients with normal ESR and CRP levels, matched 1:1 according to all the above parameters with 32 active and 16 inactive vasculitis/PMR patients respectively, served as disease controls. Digital retinal images were obtained and retinal vessel calibers were measured with a validated software to determine central retinal arteriolar and venular equivalents ratio (CRAE and CRVE respectively). For 16 patients with active vasculitis/PMR, retinal examination was performed in two time points (baseline and ≤ 6 months later).

Results:

In the overall population, patients with active Vasculitis/PMR had increased CRVE (213.8±21.7 vs 201.3±17.1, p<0.001) and CRAE (180.0±19.2 vs 164.1±17.5 p<0.001) compared to healthy controls. Separating patients according to disease type, we found that in LVV, MVV and PMR, CRAE (p≤0.05) and CRVE (p<0.05) were increased compared to control group, while in SVV only CRAE was increased (p<0.001). Interestingly, chronic patients with disease in remission displayed higher CRAE compared to matched controls (179.8±17.2 vs 169.1±11.1, p=0.006). After immunosuppressive treatment for ≤ 6 months CRVE and to a lesser extent CRAE were reduced (p=0.048 and 0.149 respectively) with a stronger statistical significance found in the Vasculitis group (p=0.026 and 0.069 respectively). Pearson’s linear correlation coefficient in active disease state (at baseline examination) revealed positive bivariate correlation only between CRVE with ESR and CRP. Patients with Vasculitis/PMR had also increased CRAE when compared to RA patients in both active and inactive disease status (182.8±19.4 vs 170.1±18.4, p<0.001 and 179.8±17.2 vs 166.3±17.9, p=0.005 respectively).

Conclusion:

Systemic inflammation alters retinal microcirculation in both a reversible (venules) and irreversible (arterioles) way, independently of PSV form. Thus, common disease specific pathogenetic mechanisms related to inflammation may be implicated in vascular remodeling. Sequential follow-up of PSV patients will address whether retinal vessel calibers may serve as a biomarker of disease activity and CVD development.

References:

[1]Argyropoulou OD et al. Curr Opin Rheumatol 2017.

[2]Shaohua G et al. Current Atherosclerosis reports 2020.

Disclosure of Interests:

None declared

POS0290 PREDICTING RISK FACTORS OF MALT LYMPHOMA IN SJÖGREN’S SYNDROME

Background:

Primary Sjögren Syndrome (SS) is a slowly progressive systemic autoimmune disease complicated by lymphoma, with mucosa associated lymphoid tissue (MALT) type being the most common lymphoma form. Several predictors related to pSS associated lymphomas have been described, but there are no studies focusing on specific risk factors for the MALT histologic subtype.

Objectives:

To identify predictors at SS diagnosis for MALT lymphoma development in pSS patients using simple clinical features.

Methods:

From 815 SS patients of a single center fulfilling the 2016 ACR/EULAR criteria, those with subsequent development of MALT lymphoma according to the 2016 WHO classification were identified and matched in 1:2 ratio, with non-lymphoma SS control patients according to age, disease duration from SS diagnosis and gender. Lymphoma patients diagnosed within a year from SS diagnosis were excluded from the current study. Clinical, laboratory, histologic data as well as the ESSDAI scores at the time of SS diagnosis were recorded and compared between lymphoma and non-lymphoma patients. Independent lymphoma predictors were identified by a data driven Fast Correlation Based Feature selection (FCBF)/Logistic Regression (LR) algorithm.

Results:

A unified dataset of 57 MALT lymphoma patients and 114 non lymphoma controls along with 39 features/variables was generated. The median age of SS diagnosis and the disease duration from SS diagnosis to lymphoma diagnosis (lymphoma group) or last follow up (control group) was 50,5 years old (range 25-77) and 7 years (range 0- 30) for the control group and 50 years old (range 24-70) and 8 years (range 1 -30) for the lymphoma group, respectively. MALT lymphoma patients presented more frequently with palpable purpura (23,2% vs 5,3% p=0,001), cryoglobulinemia (30,2% vs 1,6% p<0,0001), low C4 serum levels (62,9% vs 32,1% p=0,0003), rheumatoid factor (76,9% vs 56,1% p=0,01), anti La/SSB antibodies (33,9% vs 50,8% p=0,049) and higher median ESSDAI score (5 vs 2, p<0,0001). In contrast, autoimmune thyroiditis was more prevalent in controls (48,2% vs 18,6%, p=0,004). The FCBF/LR model revealed cryoglobulinemia (p=0,03) and ESSDAI at SS Diagnosis (p<0,001) as the only independent lymphoma predictors.

Conclusion:

MALT is the predominant pSS related lymphoproliferative histologic type, associated with systemic disease activity and vasculitic manifestations at SS diagnosis. Cryoglobulinemia and ESSDAI score were proven independent risk factors for MALT lymphoma development.

Table 1.

An FCBF-based multivariable logistic regression analysis results for investigating risk factors for MALT lymphoma development

Prominent featureRegression coefficientOdds ratiop-valueCI lowCI upperCryoglobulinemia1.675.3420.033*1.1824.327Total ESSDAI at diagnosis0.281.318<0.001*1.2081.439Kidney involvement0.071.0690.50.1010.351

•< 0.05 (95% confidence interval). The rest of the features that participated in the analysis include the following: Palpable purpura, Low C4, Salivary gland enlargement, Lacrimal gland enlargement, ANA Titers, RF, Focus score at Sjögren diagnosis, PNS involvement, Anti-La, Disease duration from SS onset to SS diagnosis, Neutrophils<1500, Autoimmune thyroiditis, Lung involvement – interstitial disease Type, Lymphocytes<1000, Lymphadenopathy fixed, Arthralgias, Dry eyes, Raynaud, Gender, Age at Sjögren diagnosis, Dry mouth, Aca, Hb<12.5 g/dL, ANA, Disease duration from SS Diagnosis to Lymphoma diagnosis or last follow up, Anti-Ro, Arthritis, WBC<4000/μL, Lung involvement bronchocentric disease, Interstitial renal disease, PLTs<100.000/μL, Liver involvement-PBC, Liver involvement–autoimmune hepatitis, CNS involvement.

•AUC=0.78

Disclosure of Interests:

None declared

OP0029 NEUTROPHIL EXTRACELLULAR TRAPS IN GIANT CELL ARTERITIS INFLAMED TEMPORAL ARTERIES: LOCALIZATION, CO-EXPRESSION OF INFLAMMATORY CYTOKINES AND ASSOCIATION WITH DISEASE EXTENSION

Background:

Giant cell arteritis (GCA) represents the most prevalent form of systemic vasculitis in elderly, characterized by a remarkable heterogeneity in terms of clinical and histological phenotype, the pathogenetic mechanisms and treatment selection (1). An interplay between cells of both innate and adaptive immunity, appear to govern the pathophysiologic mechanisms (2). Among the different cellular populations, neutrophils may hold a central role in GCA pathogenesis, since they are present in abundance in tissue injury (3,4). Most importantly, they are a source of neutrophil extracellular traps (NETs) that may deliver immunocompetent substances, necessary for the perpetuation of the inflammatory response (5). The detection and function of NETs have not been studied in GCA.

Objectives:

To explore the presence and clinical significance of NETs in temporal artery biopsies (TABs) of patients with GCA.

Methods:

Ten patients with GCA [5 with limited cranial vasculitis (CV) and 5 with associated generalized large vessel vasculitis (LVV), as defined by 18F-fluorodeoxyglucose (FDG) positron-emission tomography with computed tomography (PET/CT)] and 8 patients with polymyalgia rheumatica (PMR) were studied. GCA and PMR patients fulfilled the 1990 ACR and 2012 EULAR/ACR provisional classification criteria, respectively. The presence, location, quantitation and decoration of NETs with IL-6, IL-1β, and IL-17A were assessed in TABs at the time of disease diagnosis by tissue immunofluorescence and confocal microscopy. Quantification of NETs in tissue sections was performed using the Imaris v.9.3 software that counts the total measure volume instead of only the projection area (6). Serum levels of IL-6 and IL-17A around the time of tissue biopsy were also evaluated in all patients.

Results:

All temporal artery biopsies from GCA patients had NETs located mainly in the adventitia, adjacent to the vasa vasorum, whereas TABs from PMR patients had no NET structures. LVV was associated with a higher NETs to total tissue volume ratio, compared to CV-GCA [p=0.0317]. NETs decorated with IL-6 were present in TABs of all LVV and 3 of 5 CV-GCA patients, while IL-17A positive NETs were observed in all GCA patients. IL-1β-positive NETs were not detected in any GCA patient. No relation was found between serum IL-6 and IL17A levels and NETs containing IL-6 and/or IL-17A.

Conclusion:

NETs bearing IL-6 and IL-17A cytokines are present in inflamed GCA-TABs. IL-6 positive NETs are associated with the LVV phenotype and might be useful as a tissue biomarker for disease severity and extent.

References:

[1]K. S. M. van der Geest et al. Arthritis Rheumatol, 2018;70:1366-76.

[2]C. Salvarani et al. Lancet, 2008;372:234-45.

[3]D. Chatelain et al. Ann Rheum Dis, 2009;68:84-8.

[4]S. Nadkarni et al. Circ Res, 2014;114:242-8.

[5]V. Mutua et al. Clin Rev Allergy Immunol, 2020.

[6]S. V. Costes et al. Biophys J, 2004;86:3993-4003.

Disclosure of Interests:

None declared

OP0294 SJÖGREN’S SYNDROME ASSOCIATED LYMPHOMAS: CLINICAL DESCRIPTION AND 10-YEAR SURVIVAL

Background:

Sjögren’s Syndrome (SS) is a chronic systemic autoimmune disease of unknown etiology, carrying the highest lymphoma risk among autoimmune diseases, with significant impact on mortality and morbidity of patients.

Objectives:

To describe: i) the clinical phenotype of SS, ii) the histologic type, stage, treatment options regarding lymphomas and iii) the prognosis of patients with SS related lymphoproliferative disorders.

Methods:

Eight hundred and fifteen consecutive SS patients’ records from a single center fulfilling the 2016 ACR/EULAR were reviewed retrospectively for the purpose of this study. One hundred twenty-one patients with a diagnosis of non-Hodgkin Lymphoma (NHL) were identified and enrolled in the study population. Cumulative clinical, laboratory and histologic data were recorded and overall survival as well as event free survival curves were constructed using the Kaplan-Meier method. An event was defined as a disease progression, lymphoma relapse, treatment failure, histologic transformation, development of a 2nd lymphoma or death from any cause.

Results:

From 121 pSS patients with lymphoma the most common histologic type encountered was MALT lymphoma (92/121, 76,0%) followed by DLBCL (11/121, 9.0%) and NMZL (8/119, 6.6%). The remaining 10 patients had various lymphomas of B (follicular, lymphoplasmacytic, chronic lymphocytic leukemia} and T cell origin (peripheral T cell lymphoma not otherwise specified, primary cutaneous T cell lymphoma, angioimmunoblastic t-cell lymphoma). Permanent salivary gland enlargement (66.1%, 80/121), palpable purpura (34,7% 42/121), peripheral nervous involvement (9,9%, 12/121), interstitial lung disease (8,2%, 10/121) presence of serum cryoglobulins (38,7%, 43/111) and C4 hypocomplementemia (69,8% 81/116) present at least 1 year before the development of lymphoma were the main pSS related features. The median age at lymphoma diagnosis was 58 years old (range 29-82) while MALT lymphomas developed earlier compared to DLBCL from pSS diagnosis (8 vs 3 OR= 3.84, 95%CI: 0.29 to 10.46; p=0.0266). The commonest biopsy proven extranodal sites included the labial minor salivary (43,8% patients) and parotid glands (30,5%) while 11% of patients had more than 1 extranodal sites affected. Bone marrow involvement was evident in 24,3% of patients (29/119) while nodal involvement in 35,5% (42/118). The majority of patients (65%) had limited disease (stage I or II). A watch and wait therapeutic policy was chosen in 40 patients while the rest received rituximab with or without chemotherapy. The 10-year survival and event free rates were 79% and 45,5% for MALT lymphomas, 40,9% and 24,2% for DLBCL and 46% and 31% for NMZL respectively (Figure 1). The Mantel-Cox log-rank comparison of the overall survival curves revealed a statistically significant difference (p=0.0016) among lymphoma subtypes.

Figure 1.

Overall and event free survival of SS-associated lymphoma patients. A. Kaplan-Meier overall survival analysis. B. A Kaplan-Meier event free survival analysis.

Conclusion:

This is the largest single center series of SS- associated lymphoma patients, providing a detailed description of SS and lymphoma related features, combined with a 10-year survival and event free curves for the first time in the literature.

Disclosure of Interests:

None declared.

OP0291 SEVERITY OF LABIAL MINOR SALIVARY GLAND FOCUS SCORE AND FUTURE LYMPHOMA DEVELOPMENT IN SJÖGREN’S SYNDROME

Background:

The typical histologic picture of focal sialadenitis in the labial minor salivary gland (LMSG) tissues has been incorporated as a parameter in the majority of Sjögren’s syndrome (SS) classification criteria, with focus score (FS) being the most widely used (1). In previous studies, higher FS has been associated with the presence of autoantibodies and extra-glandular manifestations including lymphoma, implying that FS can predict severe disease (2,3). However, there are no studies exploring the association of FS with lymphoma development along with the time interval from SS diagnosis to lymphoma diagnosis.

Objectives:

To investigate an association of focus score grading with lymphoma development and time to lymphoma occurrence.

Methods:

From a total population 1998 consecutive patients fulfilling the 2016 ACR-EULAR criteria for SS who were followed-up in 5 Rheumatology centers from Greece and Italy (Universities of Athens, Pisa, Udine, Harokopio and Ioannina) (UPAHI group), those with positive (LMSG) (FS ≥1) were identified. (1). Patients who had not been subjected to an LMSG biopsy or had a negative biopsy (FS<1) or the biopsy was evaluated using other histologic classifications were excluded from the present study. Lymphoma patients with diagnostic LMSG biopsy performed within a year from lymphoma diagnosis as well as non-lymphoma patients with less than 1 year between SS diagnosis and their last follow up, were also excluded. Cumulative clinical and histologic data attributed to SS as defined by ESSDAI and/or ESSPRI, up to lymphoma diagnosis or last follow up, were recorded. A combined data driven Fast Correlation Based Feature selection (FCBF)/Logistic Regression (LR) model was applied on the unified dataset to identify independent lymphoma associated risk factors. A correlation between FS and time interval until lymphoma diagnosis was performed using the Pearson formula.

Results:

A unified dataset of 618 SS patients with FS≥1 and at least one year of disease duration from SS diagnosis to lymphoma diagnosis or last follow up, with 30 clinical, laboratory and histologic features, was constructed. The median age at SS diagnosis was 53 (range: 15 – 80) years old, the female to male ratio was 20:1 and the median disease duration was 6 years (range: 1-35). Half (49%) of the study population had focus score between one and two (1≤FS<2), followed by a declining proportion of patients accounted for every subsequent escalating FS group. No statistically significant difference was found regarding disease duration among the various FS escalating groups (p= 0.1603, Kruskal-Wallis test). Fifty eight patients had lymphoma with no statistically significant difference in disease duration compared to non-lymphoma controls. The data driven FCBF/LR algorithm with lymphoma on the whole dataset revealed that cryoglobulinemia (p=0.021), salivary gland enlargement (p=0.008) and FS (p=0,049) are independent lymphoma associated risk factors. A statistically significant negative correlation was found using a Pearson formula (R=-0.32 and p=0.015) regarding the focus score and the time to lymphoma diagnosis.

Conclusion:

This is the largest study of SS patients’ histologic analysis exploring the association of LMSG FS grading with lymphoma development and the time interval until its diagnosis. Higher FS values correlate with increased lymphoma risk and early lymphoma occurrence.

Figure 1.

Pearson correlation between FS and time interval until lymphoma diagnosis

References:

[1]Shiboski et al. Arhtritis Rheumatol. 2017

[2]Carrubi et al. Lupus 2015

[3]Risselada AP et al. Ann Rheum Dis 2014

Disclosure of Interests:

None declared

OP0041 SALIVA AND SERUM LEVELS OF CXCL13: ASSOCIATION WITH THE SEVERITY OF SALIVARY GLAND LESIONS AND LYMPHOMA IN PATIENTS WITH SJÖGREN’S SYNDROME (SS)

Background:

CXCL13 has been implicated in the formation of ectopic germinal centers (GC) in minor salivary gland (MSG) inflammatory lesions of SS patients. Recent studies suggest that serum CXCL13 levels associate with disease severity and risk for non-Hodgkin’s lymphoma (NHL) development.

Objectives:

To validate the clinical utility of CXCL13 by investigating potential associations of saliva and serum CXCL13 levels with various histopathologic (including severity of MSG autoimmune infiltrates and GC formation), serologic and clinical features of the disease, as well as NHL.

Methods:

CXCL13 levels were measured by a commercially available ELISA (sensitivity: 1 pg/ml; Abcam, Cambridge, UK) in paired serum and saliva specimens from 25 SS patients (9 with NHL; SSL), 9 sicca controls (SC; sicca-complaining individuals with no infiltrates in diagnostic MSG biopsy and negative autoantibody profile) and 6 healthy controls (HC). From the 16 SS patients without evidence of NHL, 5 had mild, 6 intermediate and 5 severe lesions at MSGs, as arbitrarily defined by focus (FS) and Tarpley (TS) biopsy scores (mild: FS:1-1.7, TS:1, intermediate: FS:1.8-2.95, TS:2 and severe: FS: 3.0-11, TS: 3-4). Furthermore, the organization of the MSG infiltrates to GCs has been evaluated in 23 patients revealing 10 with GCs.

Results:

Kruskal-Wallis analysis revealed that serum CXCL13 levels were significantly increased in SS patients without or with NHL (median: 94.83 pg/ml and 96.70 pg/ml, respectively), compared to SC and HC (35.44 and 40.92 pg/ml respectively; p<0.05), whereas saliva levels were only marginally increased (76.47, 84.10, 55.98 and 65.30 pg/ml in SS, SSL, SC and HC, respectively, p=0.051). Among SS patients with distinct MSG lesion severity, only those with severe lesions were found to express significantly higher serum CXCL13 levels (149.3 pg/ml) from SC and HC (p: 0,0051 and 0.0166, respectively). Spearman’s Rank correlation analysis showed that both serum and saliva levels correlated with SG biopsy focus score (r: 0.6889, p=0.0001 and r: 0.4222, p=0.01, respectively). Mann-Whitney test revealed that serum CXCL13 levels were significantly elevated in patients with GCs at MSG lesions (156.1 vs 69.64 pg/ml, p:0.0015), rheumatoid factor (105.0 vs 53.72 pg/ml, p: 0.015) and marginally with anti-Ro/La antibodies (121.8 vs 65.05 pg/ml, p: 0.06) compared to those without. Furthermore, CXCL13 levels were significantly increased in SS patients at high risk to develop NHL compared to low risk (149.3 vs 71.54 pg/ml, respectively, p: 0.0275). Saliva levels were not found to associate with the studied features.

Conclusion:

Serum and to a lesser extend saliva CXCL13 levels are increased in SS and SSL patients and associate with the degree of MSG infiltration, as assessed by focus score. Serum, but not saliva, CXCL13 associates with various disease features, including GC formation, and may have a clinical utility in identifying SS patients at high risk to develop lymphoma.

Disclosure of Interests:

None declared

AB0537 PSORIATIC ARTHRITIS BURDEN, QUALITY OF LIFE AND FUNCTIONAL ABILITY IMPAIRMENTS IN PATIENTS INITIATED ON APREMILAST IN THE ROUTINE CARE IN GREECE: INTERIM RESULTS FROM THE MULTICENTER PROSPECTIVE STUDY “APROACH”

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with substantial psychosocial burden and health-related quality of life (HRQoL) and functional ability impairments.

Objectives:

To characterize the profile of patients with PsA initiating therapy with apremilast in routine care settings, in terms of the physician-assessed clinical disease burden and the patient-reported generic and disease-related HRQoL and functional disability.

Methods:

This is an ongoing 52-week multicenter, prospective study conducted in the Greek healthcare environment. Eligible patients are bio-naïve adults with active peripheral PsA, inadequate (within the first 12 months of treatment) response/intolerance to a prior conventional synthetic disease-modifying antirheumatic drug (csDMARD), and no prior use of tofacitinib, initiating apremilast as per the approved label. Data are being collected by physician assessments, as performed in routine clinical practice, and by patient-reported outcomes. 170 patients enrolled in the study; data at apremilast initiation (baseline) from the first 100 eligible consenting patients are presented in this interim analysis as per protocol.

Results:

99 evaluable patients were consecutively enrolled in 19 rheumatology departments between 15-Apr-2019 and 13-Jan-2020. At baseline (Table 1) [mean (SD) age: 53.8 (11.7) years], 43.4% of the patients had at least one (30.3% had ≥2) ongoing comorbidity other than PsA/PSO. The median [interquartile range (IQR)] PsA and psoriasis duration were 1.9 (1.0-3.5) and 7.5 (3.9-16.8) years, respectively. All subjects were on csDMARD while 24.2% received combination therapy, oral non-steroid anti-inflammatory drugs (32.3%), topical treatments (20.2%) and systemic steroids (11.1%). Based on the Clinical Disease Activity in PsA (cDAPSA) score, 58.6% of the patients had moderate, and 29.3% high disease activity. In the EuroQol (EQ) 5-Dimensions (5D) 5-Levels questionnaire, 93.9, 82.8, 82.8, 73.7, and 51.5% of the patients reported problems in ‘pain/discomfort’, ‘anxiety/depression’, ‘usual activities’, ‘mobility’, and ‘self-care’, respectively. The median (IQR) baseline UK-weighted EQ-5D index and EQ-Visual Analogue Scale scores were 0.55 (0.44-0.70) and 50.0 (40.0-70.0), respectively. The median (IQR) Health Assessment Questionnaire-Disability Index (HAQ-DI) and mean (SD) PsA Impact of Disease 12-item (PsAID12) scores were 1.0 (0.5-1.4) and 4.6 (2.0), respectively.

Conclusion:

More than 8 out of 10 bio-naïve patients initiated on apremilast in the routine clinical care in Greece have at least moderate disease activity, active psoriasis, and problems with pain/discomfort, anxiety/depression, and performance of usual activities at a median of 2 years post-diagnosis. HAQ-DI and PsAID12 scores indicate moderate impairment of physical functionality and PsA-related HRQoL. The findings underscore considerable disease burden early in the disease course.

Table 1.

Baseline characteristics

N%/Mean/MedianWomen, %57/9957.6Peripheral joint involvement only, %92/9992.9Polyarthritis (≥5 joints), %69/9969.7cDAPSA (range: 0-154), median (IQR)9922.0 (16.0-29.0)Number of SJC (0-66) / TJC (0-68), median (IQR)994 (2-8) / 6 (2-10)Active psoriasis (BSA>0%), %83/9983.8BSA score, median (IQR)77/835.0 (2.0-12.0)Nail involvement, %38/9639.6Enthesitis and/or dactylitis, %30/9531.6Dactylitis, %11/9511.6Finger and toe Dactylitis Severity Score (DSS) (range: 0-60), median (IQR)10/112.0 (1.0-6.0)Enthesitis, %22/9523.2 LEI score (range: 0-14), median (IQR)222.0 (1.0-2.0)Extra-articular manifestations (mainly fatigue), %10/9910.1Comorbidities in ≥15% of the patientsHypertension, Essential hypertension, %23/9923.2Dyslipidemia, hypercholesterolemia, (type V) hyperlipidemia, %15/9915.2Total PsAID12 score (range: 0-10), mean (SD)984.6 (2.0)Total HAQ-DI score (range: 0-3), median (IQR)991.0 (0.5-1.4)

Disclosure of Interests:

PELAGIA KATSIMPRI Speakers bureau: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Consultant of: Janssen, Genesis pharma, Novartis, Abbvie, UCB, Hospital Line, Actelion Pharmaceuticals, Pfizer, Dimitrios Vassilopoulos Speakers bureau: AbbVie, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, GenesisPharma, Νovartis, Pfizer, Roche, UCB, Janssen, MSD, Gkikas Katsifis Speakers bureau: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, Grant/research support from: Abbvie, Aenorasis, Amgen, Genesis Pharma, Bausch Health, BMS, Celgene, Janssen, MSD, Novartis, Roche, Pfizer, UCB, GEORGIOS VOSVOTEKAS Speakers bureau: MSD, Consultant of: AbbVie, Novartis, Dimitrios Bogdanos Speakers bureau: Menarini, Novartis, Consultant of: Fresenius Kabi Hellas, Novartis, Grant/research support from: Aenorasis, Elpen, Genesis Pharma, GlaxoSmithKline, Boehringer Ingelheim, Lilly, Prodromos Sidiropoulos Grant/research support from: University of Crete Special Account for Research and pharma, Periklis Vounotrypidis Speakers bureau: Genesis Pharma, MSD, Novartis, Grant/research support from: Genesis Pharma, MSD, Novartis, Athanasios Georgountzos Grant/research support from: AbbVie, Genesis Pharma, Janssen, Mylan SAS, Pfizer, Roche, UCB, Andreas Bounas: None declared., Alexandros Garyfallos Speakers bureau: AbbVie, BGP, Roche, Consultant of: Genesis Pharma, UCB, Pfizer, Sousana Gazi: None declared., Panagiotis Georgiou Grant/research support from: Janssen-Cilag, Novartis, UCB, Evaggelia Kataxaki Speakers bureau: Novartis, Charalampos Papagoras Speakers bureau: Abbvie, Novartis, Genesis, Lilly, Biogen, Aenorasis, GSK, Pfizer, ANTONIA ELEZOGLOU: None declared., Stamatis-Nick Liossis: None declared., Athanasios Tzioufas Grant/research support from: AbbVie, Genesis Pharma, GSK, Horizon, Lilly, Novartis, Pfizer, Paraskevi Voulgari Speakers bureau: GlaxoSmithKline, Novartis, UCB, Consultant of: GlaxoSmithKline, Novartis, UCB, FOTEINI SATRA TZOUFRA Employee of: GENESIS PHARMA S.A., ZAFEIRIOS ANAGNOSTOPOULOS Employee of: GENESIS PHARMA S.A., NIKOLAOS ANTONAKOPOULOS Employee of: GENESIS PHARMA S.A., Petros Sfikakis Speakers bureau: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Boehringer Ingelheim, GenesisPharma, Novartis, Pfizer, UCB.

AB0697 ANTI-SARS-COV-2 ANTIBODIES AND AUTOANTIBODIES IN COVID-19 PATIENTS SURVIVED AFTER ICU ADMISSION, 6 MONTHS LATER

Background:

We1 and others2 have previously shown that ICU admitted patients with COVID-19 developed high titers of anti-SARS-CoV-2 antibodies, but also autoantibodies, some of which are pathogenic. We re-evaluated 8 patients of those survived after admission to the ICU of Evangelismos Hospital of Athens -1st Department of Internal Medicine, Medical School, NKUA3 6 months later. We did not know whether these autoantibodies still exist, are associated with COVID-19 or with ARDS as described after septic shock4.

Objectives:

To investigate the presence and titers of anti-SARS-CoV-2 antibodies and autoantibodies in patients survived after COVID-19 ICU stay, in the ICU and 6 months later.

Methods:

Case series to evaluate titers of anti-SARS-CoV-2 antibodies, specificities of autoantibodies as well as clinical features in ICU admitted COVID-19 patients, initially and 6 months after their discharge. Evaluation of current clinical status included evaluation of lung, heart, kidney, central and peripheral nervous system and mental status using standardized methods. Methods for detection of anti-SARS-CoV-2 antibodies and autoantibodies were described in our previous report1.

Results:

We had initially evaluated1 29 ICU admitted COVID-19 patients’ files and sera, of which 4 had been already died during serum evaluation. Six more patients died thereafter. Out of 19 having been discharged, 8 were willing to be re-evaluated. On second evaluation 6 months later, serum anti-SARS-CoV-2 antibodies were highly positive, although at lower titers compared to the titers at disease onset (median [range]) 8.705 (range: 7.95-9.56) vs 6.640 (range: 6.29-6.76), p=0.0002, Mann-Whitney test. Initially 3 out of 8 patients expressed antinuclear antibodies (ANA) at titers 1/160, 1/320 and 1/320 with a fine speckled pattern with the second patient also expressing at a titer of 1/160, antimitochondrial (AMA) antibodies. Six months later the same patients and not anyone else expressed ANA of the same pattern at titers 1/640, 1/160 and 1/160 respectively. Two patients with 1/20 p-ANCA and 1/640 c-ANCA initially, lost their respective autoantibodies after 6 months. One patient initially negative for IgM anti-β2GPI became positive at low titer and an initially positive became negative. One patient initially positive for anti-Ro60 antibody continued to be positive 6 months later. One patient initially negative developed anti-Tg antibodies and 3 patients initially positive for anti-TPO antibodies remained positive 6 months later.

Conclusion:

Patients with COVID-19 survived after ICU admission still retain high titers of anti-SARS-CoV-2 antibodies but significantly lower that at disease onset, but they tend to lose autoantibodies with pathogenic potential.

References:

[1]Vlachoyiannopoulos P et al, Ann Rheum Dis 2020,

[2]2. Wang EY et al, medRxiv preprint doi: https://doi.org/10.1101/2020.12.10.20247205

[3]National and Kapodistrian University of Athens, Athens, Greece

[4]Burbelo et al. Journal of Translational Medicine 2010

Disclosure of Interests:

None declared

POS0829 SPECIFICITY OF PANCA AUTOANTIBODIES IN AUTOIMMUNE DISEASES

Background:

The clinical significance of pANCA by indirect immunofluorescence is well-established. However, their clinical utility is sometimes hindered by the fact that pANCA are also detected in various autoimmune diseases. Myeloperoxidase (MPO) is considered as the major autoantigen recognized by pANCA in ANCA-associated vasculitides (AAV) and predominantly in microscopic polyangiitis (MPA). However, information regarding the targets of pANCA in other autoimmune diseases is still elusive.

Objectives:

To investigate the specific autoantigens recognized by pANCA in autoimmune diseases.

Methods:

Sera from all patients that were found positive for pANCA in the diagnostic laboratories of the Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens and the Department of Immunology and Histocompatibility, Evangelismos General Hospital, Athens, Greece during the last two years were studied. The pANCA+ sera were evaluated for reactivity with the major antigens that are recognized by pANCA [MPO, lactoferrin, neutrophil elastase, cathepsin G and bactericidal/permeability increasing protein (BPI)] by a commercially available multiplex ELISA (ANCA profile ELISA, Euroimmun, Lubeck, Germany).

Results:

A total of 82 patients were included in the study. All patients had positive pANCA by indirect immunofluorescence with a title ranging from 1/160 to 1/640. According to respective classification criteria, 21 patients had systemic vasculitides (15 MPA, 1 granulomatosis with polyangiitis; GPA, 1 Behcet’s disease; BD, 1 aortitis, 2 Henoch-Schonlein purpura; HSP and 1 cryoglobulinemic vasculitis; CV), 29 had systemic lupus erythematosus (SLE), 6 antiphospholipid syndrome (APS), 8 Sjögren’s syndrome (SS), 2 rheumatoid arthritis (RA), 1 systemic scleroderma (SScl), 14 Hashimoto thyroiditis and 1 sarcoidosis. The specificities of pANCA in each entity are shown in the following table.

Autoimmune DiseasesAntigens recognized by pANCA+ seraMPOElastaseCathepsin GBPILactoferrinVasculitidesMPA66.7 (10/15)0 (0/15)0 (0/15)0 (0/15)0 (0/15)GPA100 (1/1)0 (0/1)0 (0/1)0 (0/1)0 (0/1)BD100 (1/1)0 (0/1)0 (0/1)0 (0/1)0 (0/1)Aortitis0 (0/1)0 (0/1)0 (0/1)0 (0/1)0 (0/1)HSP0 (0/2)0 (0/2)0 (0/2)0 (0/2)0 (0/2)CV0 (0/1)0 (0/1)0 (0/1)0(0/1)100 (1/1)SLE6.9 (2/29)0 (0/29)0 (0/29)0 (0/29)6.9 (2/29)APS16.6 (1/6)16.6 (1/6)0 (0/6)0 (0/6)0 (0/6)SS0 (0/8)12.5 (1/8)0 (0/8)12.5 (1/8)0 (0/8)RA50 (1/2)0 (0/2)0 (0/2)0 (0/2)0 (0/2)SScl100 (1/1)0 (0/1)0 (0/1)0 (0/1)0 (0/1)Hashimoto0 (0/14)0 (0/14)0 (0/14)0 (0/14)0 (0/14)Sarcoidosis0 (0/1)0 (0/1)0 (0/1)0 (0/1)0 (0/1)

Conclusion:

pANCA positive staining in AAVs is highly restricted to MPO specificity. On the contrary, pANCA staining pattern in other autoimmune diseases, involves unknown autoantigens that are under investigation in our laboratory.

Disclosure of Interests:

None declared

AB0511 INTERNATIONAL CONSENSUS ON ANCA TESTING AND INTERPRETATION BEYOND SYSTEMIC VASCULITIS

Background:

ANCA can be detected in sera from patients with autoimmune, inflammatory, infectious or neoplastic diseases.

Objectives:

To issue a Consensus Statement on ANCA testing and interpretation beyond systemic vasculitis.

Methods:

This Statement was prepared by a group of experts, based on the results of a comprehensive search in PubMed.

Results:

In certain settings beyond systemic vasculitis, ANCA may have diagnostic, clinical, and/or prognostic relevance. Testing for PR3- and MPO-ANCA by specific immunoassays should be performed in any patient with clinical features suggesting ANCA-associated vasculitis and in patients with anti-GBM disease and idiopathic interstitial pneumonia. Routine ANCA testing is not recommended in patients with connective tissue diseases (CTD), autoimmune liver diseases, inflammatory bowel diseases, infections, and/or malignancy unless there is evidence for small vessel vasculitis. ANCA testing by specific immunoassays may be useful in patients with rheumatoid arthritis, systemic sclerosis or primary Sjögren’s syndrome who have kidney disease with a nephritic sediment or in patients with systemic lupus erythematosus if a kidney biopsy shows prominent necrotizing and crescentic lesions or proliferative lupus nephritis. ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1, who do not have conventional disease-related autoantibodies, or in patients with inflammatory bowel diseases in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn’s disease. In these cases, ANCA should be tested by indirect immunofluorescence since target antigens are not well characterized. ANCA against bactericidal/permeability-increasing protein may be a biomarker for deteriorating lung function and a poor prognosis in patients with cystic fibrosis.

Conclusion:

ANCA testing is clinically relevant not only in patients with manifestations suggesting systemic vasculitis, but also in patients with certain other disorders, particularly in patients with anti-GBM disease or idiopathic interstitial pneumonia.

Disclosure of Interests:

Sergey Moiseev Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Jan Willem Cohen Tervaert: None declared, Yoshihiro Arimura: None declared, Dimitrios Bogdanos: None declared, Csernok Elena: None declared, Jan Damoiseaux: None declared, Marc Ferrante: None declared, Luis Felipe Flores-Suárez: None declared, Marvin Fritzler: None declared, Pietro Invernizzi: None declared, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, J. Charles Jennette: None declared, Mark Little: None declared, Stephen P. McAdoo: None declared, Pavel Novikov Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Charles D. Pusey: None declared, Antonella Radice: None declared, Alan D. Salama: None declared, Judith Savige: None declared, Mårten Segelmark: None declared, Yehuda Shoenfeld: None declared, Renato Alberto Sinico: None declared, Maria Jose Rego de Sousa: None declared, Ulrich Specks: None declared, Benjamin Terrier: None declared, Athanasios Tzioufas: None declared, Severine Vermeire: None declared, Ming-hui Zhao: None declared, Xavier Bossuyt: None declared

AB0208 ASSOCIATION OF RHEUMATOID FACTOR, HLA-DRB1 SHARED EPITOPE (SE) AND SMOKING WITH RADIOGRAPHIC OUTCOME IN RHEUMATOID ARTHRITIS

Background:

Genetic and environmental factors interact in aetiopathogenesis of Rheumatoid Arthritis (RA). However, it remains unclear whether current smoking, presence of Rheumatoid factor (RF) and HLA-DRB1 SE influence the radiographic outcome.

Objectives:

To clarify the possible associations between radiographic outcome, HLA-DRB1 SE, RF and smoking status in patients with longstanding RA.

Methods:

An observational study of 240 consecutive Greek patients with RA, whose mean age and mean disease duration was 65.31±12.5 and 12.7±11.8 years respectively. Among them 74.17% were female, 40% were smokers, 60.42% had positive RF and 68.33% possessed at least one SE allele. HLA-DRB1 alleles were typed by molecular techniques (PCR-SSOP and SSP). X-rays of hands and feet were performed and scored by the Sharp-van der Hejde score (SHS) method.

Results:

Results were stratified by RF and smoking status and analyzed by multivariate logistic regression. Overall, the mean SHS was significantly higher in RF positive than RF negative patients and in smokers than non-smokers (52.76±31.1 vs 38.4±31.96, p: 0.0007, 55.33±38.56 vs 26.8±22.32, p <0.0001, respectively). Furthermore, patients that possessed at least one SE allele had higher SHS than SE negative (35.49±24.76 vs 25.74±19.22, p: 0.0013). An association between radiographic severity and SE was found in RF positive patients. More specifically, seropositive patients carrying at least one SE allele had higher SHS than those lacking SE (40.85±33.21 vs 29.23±24.72, p: 0.037). On the other hand, smokers with at least one SE allele had higher SHS when compared to smokers without SE (29.27±25.20 vs 20±17.22, p: 0.048). Among RF negative and non-smokers RA patients, no significant association was found between the presence of HLA-DRB1 SE and radiographic severity.

Conclusion:

Our data indicate that in longstanding RA there is an association between RF positivity, the presence of SE, current smoking status and radiographic outcome.

Disclosure of Interests:

None declared

THU0265 THYMIC STROMAL LYMPHOPOIETIN (TSLP) AS A BIOMARKER OF PRIMARY SJÖGREN’S SYNDROME (PSS) AND RELATED LYMPHOMA: VALIDATION IN INDEPENDENT COHORTS

Background:

Thymic stromal lymphopoietin (TSLP) has been implicated in primary Sjögren’s syndrome (pSS) and related B-cell lymphoproliferation/lymphoma (NHL) by tissue studies on salivary glands (SG) (1). It resulted significantly higher in the serum of pSS patients compared to non-pSS sicca and to healthy subjects, with the highest levels found in NHL.

Objectives:

The purpose of this work was to confirm that serum TSLP is elevated in pSS by the study of independent cohorts.

Methods:

Serum TSLP levels were measured by ELISA in 91 pSS patients (F=86, 94.5%; mean age 57.2 years, 25-80) from the Udine cohort (cohort 1, UD), Italy. One additional multicentre cohort (cohort 2) from the Italian SS Study Group (GRISS) was studied, including 125 pSS patients from the Universities of Roma (RO), L’Aquila (L’AQ), Pisa (PI) and Perugia (PG). pSS patients with active NHL (n=12 in cohort 1; n=1 in cohort 2) were excluded from comparative analyses to avoid bias. Secondly, additional serum samples from pSS-related NHL in stable and complete remission, from both cohort 1 and 2, were analysed in a separate subgroup (n = 12). Thirdly, a preliminary evaluation of serum TSLP was performed in pSS patients from a different geographical area (University of Athens, Greece; cohort 3).

Results:

Cohort 2 included 125 pSS patients (F=114, 91.2%; mean age 58.1 years, 23-84): 124 benign, 1 with NHL. In this cohort, serum TSLP levels were confirmed to be high (mean 30.26 pg/mL, 0.41-95.21) and comparable to cohort 1 (mean 33.81 pg/mL, 0-140.8; p=ns). No difference was found by the separate analysis of pSS from each single Centres (RO n=49, mean 33.21, 1.4-95.21; L’AQ n=34, mean 38.6, 16.31-85.11; PI n=28, mean 20.23, 0.41-56.67; PG n=13, mean 19.39, 1.03-68.38; p=ns), and vs cohort 1 (p=ns). The only patient in cohort 2 with NHL showed serum TSLP of 160.91 pg/mL, comparable to the mean TSLP in the 12 UD pSS-NHL (151.96 pg/mL). Importantly, in pSS-related NHL in stable remission, serum TSLP resulted undetectable (7/13) or detectable at very low levels (6/13) (mean 10.46, 0-38.5), and significantly lower than in benign pSS patients from the two cohorts (n=203, mean 31.48, 0-140.8; p=0.0022). Metachronous samples from one patient, at the stage of NHL activity and then at NHL remission, showed a decrease in TSLP from 128.04 pg/mL to undetectable levels. Finally, TSLP levels were increased also in the Greek cohort (mean 54.9, 26.72-78.95), and significantly higher than the two Italian cohorts (p=0.0085 and p<0.0001, vs cohort 1 and 2, respectively).

Conclusion:

Serum TSLP levels are increased in pSS, as herein confirmed in independent cohorts. TSLP might be important in the disease pathophysiology and mirrors the course of pSS-related B-cell lymphoproliferation itself. It may thus represent a novel important biomarker.

References:

[1]Gandolfo S. et al, Clin Exp Rheumatol. 2019 May-Jun;37 Suppl 118(3):55-64.

Disclosure of Interests:

Saviana Gandolfo: None declared, Cinzia Fabro: None declared, Serena Colafrancesco: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Francesco Ferro: None declared, Elena Bartoloni Bocci: None declared, Efstathia Kapsogeorgou: None declared, Andreas Goules: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Roberta Priori: None declared, Alessia Alunno: None declared, Guido Valesini: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared, Chiara Baldini: None declared, Athanasios Tzioufas: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis

OP0096 THE DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH COMBINED SERONEGATIVITY AND ANTI-RO/SSA SEROPOSITIVITY

Background:

Sjögren’s syndrome (SS) is characterized by B cell hyperactivity reflected by hypergammaglobulinemia as well as a plethora of autoantibodies including antinuclear antibodies (ANA), anti-Ro/SSA, anti-La/SSB and rheumatoid factors (RF). Previous studies have focused on the phenotype of single positive (ANA or anti-Ro/SSA or anti-La/SSB) or double positive (anti-Ro/SSA and anti-La/SSB positive) SS patients, showing differences regarding the age of diagnosis, sicca manifestations and specific extraglandular manifestations. To our knowledge, no study has ever explored the clinical spectrum of triple seronegative (anti-Ro/SSA + anti-La/SSB + RF negative) and quadruple seronegative (ANA +anti-Ro/SSA + anti-La/SSB + RF negative) SS patients.

Objectives:

To study the differences in the clinical phenotype of triple and quadruple seronegative (SS) patients in a large cohort of well characterized patients, after comparison with anti-Ro/SSA positive patients.

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities of Pisa and Athens, Harokopio and Ioannina, (PAHI)], those who have been found triple or quadruple seronegative were identified and compared with matched anti-Ro/SSA positive SS patients according to age of SS onset, disease duration and gender, in 1:1 and 1:2 ratio respectively. Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, chronic fatigue arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) were compared between the 2 seronegative groups and the anti-Ro/SSA positive control group. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Two hundred and four SS patients (11,8%) were identified as triple negatives and 53 (3,0%) as quadruple, with a median disease duration of 6 years (range: 0-41) and 5 years (range: 0-32) respectively. The matched anti-Ro/SSA controls were 204 for the triple and 103 for the quadruple negatives. Triple negatives had lower frequency of monoclonal gammopathy (5,5% vs 12,1% p=0,04), low C4 serum levels (23% vs 36%, p=0,009) and lymphoma (3,4% vs 9,8%, OR= 3,06, 95% CI =1,27-7,85) while quadruple negatives exhibited higher prevalence of dry eyes (100% vs 90%) and lower prevalence of long standing lymphadenopathy (2,7% vs 19,5%, p=0,001) and lymphoma (0% vs 15%, p=0,001) compared to anti-Ro/SSA matched controls.

Conclusion:

Combined seronegativity account for more than 10% of SS population and is associated with lower prevalence of lymphoma compared to anti-Ro/SSA positive patients.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared, Andreas Goules: None declared

FRI0149 THE CLINICAL FEATURES OF SJÖGREN’S SYNDROME PATIENTS WITH EARLY AND LATE DISEASE ONSET

Background:

Sjögren’s syndrome (SS) affects mainly individuals of the 4thor 5thdecade of life, although patients with early (≤35 years old) or late (≥65 years old) disease onset have been described in the literature. The clinical spectrum of the disease extends from mild dryness to severe systemic vasculitis and lymphoproliferative disorders. The phenotypic diversity of SS is defined by many factors, including age, since many parameters related to age may affect the clinical expression of the disease. Few studies have been conducted to study the effect of age on the clinical phenotype of SS, though with limited number of patients. Large and well-defined groups of SS are required to address such questions.

Objectives:

To study the clinical phenotype of SS patients with early and late disease onset and to explore the association of age with lymphoma development in a unified multicenter cohort.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those with either early (≤35 years) or late (≥65 years) disease onset were identified and matched according to gender and disease duration with middle aged controls whose disease onset was at the 4thor 5thdecade of life. Glandular manifestations, extra-glandular manifestations, serologic characteristics and histologic features were compared between the 2 age groups and the middle-aged control groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Three hundred seventy-nine (19%) SS patients with early and 293 (15%) with late disease onset were identified and compared with 353 and 285 middle aged SS controls respectively. The median disease duration of patients with early onset was 12 years (range:0-68) and for those with late disease onset was 5 years (range: 0-27). SS patients with early disease onset had statistically significant higher frequency of Raynaud’s phenomenon, lymphadenopathy, hypergammaglobulinemia, anti-Ro/SSA, anti-La/SSB, rheumatoid factor, salivary gland enlargement, low C4 complement levels, leukopenia and lymphoma (10,3% vs 5,7%, p= 0.03, OR= 1,91, 95% CI: 1,11-3,27) while SS patients with late disease onset had more frequently dry mouth, interstitial lung disease and lymphoma (6,8% vs 2,1%, p=0,01, OR= 3,4. 95%CI: 1,35-1,81).

Conclusion:

In a multicenter cohort of 1997 consecutive SS patients, those with early and late disease onset comprise more than one third of the total SS population. Patients with early disease onset, exhibit robust B cell responses with traditional risk factors for lymphoma as opposed to patients with late disease onset. Both age groups have increased lymphoma prevalence but presumably for different reasons, since late onset patients lack classical predictors of lymphoma. Therefore, these predictors deserve further study in different disease subsets.

Disclosure of Interests:

Andreas Goules: None declared, Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Marco Binutti: None declared, Sara Zandonella Callegher: None declared, Loukas Chatzis: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared

THU0294 THE DIFFERENCES IN THE CLINICAL SPECTRUM OF CRYOGLOBULINEMIC VASCULITIS BETWEEN SJÖGREN’S SYNDROME AND HCV HEPATITIS

Background:

Cryoglobulinemic vasculitis (CV) is a serious complication of Sjögren’s syndrome (SS) and is closely associated with type II IgMk cryoglobulins. CV has been well documented in HCV patients without SS, and shares common features with CV in SS. So far, few studies have described the clinical picture of CV in HCV negative SS, but the number of studied patients was rather small and CV was not well defined. To better describe the clinical spectrum of CV in SS and explore the differences compared to HCV-related CV, a large cohort of well characterized patients is required.

Objectives:

To study the clinical phenotype of CV in HCV-negative SS patients, in a large cohort of well characterized patients, after applying stringent classification CV criteria and in comparison with the classical CV of HCV patients.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those who fulfil the 2011 classification criteria for CV were identified and compared with matched HCV-CV patients according to age and gender. Glandular, extra-glandular manifestations and serologic features were compared between the 2 CV groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Among the 1083 SS patients who have been evaluated for cryoglobulins, 114 (9,8%) were found positive. Seventy-one (6,5%) SS patients met the 2011 CV criteria while 44 patients presented with type II IgMk cryoglobulinemia without CV. Sixty nine of 71 (97%) SS related CV patients were females and 2 of 71 (3%) males. Forty eight of 71 (68%) had SS disease onset >35 and <65 years old while 14/71 (19,7%) and 9/71 (12,7%) had SS disease onset <35 and >65 years old respectively. The most common clinical manifestations of CV among SS patients were purpura (90%) followed by arthralgias (70%), fatigue (59%), Raynaud’s phenomenon (48%), lymphadenopathy (31%), peripheral neuropathy (22,3%), vasculitic ulcer (11,3%) and glomerulonephritis (11,3%). Interestingly, almost 50% of SS related CV patients developed lymphoma and displayed high frequency of strong predictors including purpura, low C4 complement (88,6%) and salivary gland enlargement (SGE). Compared to HCV-CV patients, SS-CV patients had higher frequency of sicca manifestations, SGE, fatigue, arthritis, Raynaud’s phenomenon, lymphadenopathy, type II IgMk cryoglobulins and lymphoma.

Conclusion:

The prevalence of cryoglobulinemia and CV among SS patients is about 10% and 6-7% respectively. SS-CV patients are mainly middle-aged females with purpura as the main clinical manifestation, and up to one half of them may develop lymphoma, which is rarer in HCV-CV. Compared to HCV-CV patients, SS patients with CV have more frequently sicca symptoms, SGE and type II IgMk cryoglobulins.

Disclosure of Interests:

Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Luca Quartuccio: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Loukas Chatzis: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Massimo Galli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

FRI0161 PHENOTYPIC DIFFERENCES BETWEEN SJÖGREN’S SYNDROME PATIENTS WITH LOW AND HIGH-GRADE INFLAMMATION BASED ON SALIVARY GLAND FOCUS SCORE

Background:

Sjögren’s syndrome (SS) is characterized by the presence of lymphocytic infiltration around the ductal epithelium of the salivary and lachrymal glands. The periepithelial inflammatory lesions and the enclosed B cell component are responsible for the glandular and extraglandular manifestations of the disease. Previous studies have shown that the severity of inflammation observed within the salivary glands is correlated with the occurrence of extraglandular manifestations. However, in these studies either the number of patients is small or the SS criteria are not well defined. To explore the association between the degree of inflammation within the salivary glands and the phenotype of the disease, large and well characterized cohorts of SS patients is required.

Objectives:

To compare the phenotypic features of SS patients with low and high degree of inflammation within the minor salivary glands as reflected by the focus score (FS).

Methods:

From a total cohort of 1723 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 4 clinical centers ([Universities ofPisa,Athens,Harokopio andIoannina, (PAHI)], those who had performed a lip biopsy and the focused score was available, were classified into low grade (FS<3) or high grade (FS≥3). Glandular (dry mouth, dry eyes, parotid gland enlargement) and extra-glandular manifestations (Raynaud’s phenomenon, arthralgias/myalgias, arthritis, palpable purpura, liver involvement, kidney involvement, lung involvement, neurologic involvement, long standing lymphadenopathy and lymphoma) as well as serologic features (ANA, RF, anti-Ro/SSA, anti-La/SSB) were compared between the 2 groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Eight hundred and eight minor salivary gland biopsies were available and evaluated based on focus score at the initial evaluation of SS patients, of whom 753 had low grade (FS<3) and 153 high grade (≥3) inflammation. The median disease duration after SS diagnosis was not statistically significant different for the 2 groups (median: 4 years, range: 0-36 years). SS patients with high grade inflammation displayed higher prevalence of salivary gland enlargement (SGE) (40% vs 25%, p=0,0002), long standing lymphadenopathy (22% vs 14%, p=0,02), ANA (97% vs 88%, p=0,0001), anti-La/SSB (52% vs 32%, p<0,0001), RF (61,5% vs 48%, p=0,003), peripheral neuropathy (PN) (5,3% vs 1,5, p=0,01) and of lymphoma (26% vs 8%, p<0,0001, OR=4,142, 95%CI=2,65 to 6,47) compared to those with low grade inflammation.

Conclusion:

SS patients with FS ≥3 at the initial evaluation, display higher prevalence of lymphoma as well as higher B cell hyperactivity and certain clinical manifestations (SGE, PNS, lymphadenopathy) that constitute risk factors for lymphoma development.

Disclosure of Interests:

Loukas Chatzis: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Dimitris Fotiadis: None declared, Fotini Skopouli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Gorgoulis Vassilis: None declared, Chiara Baldini: None declared, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

Cost-utility analysis of certolizumab pegol in combination with methotrexate in patients with moderate-to-severe active rheumatoid arthritis in Greece

We aimed to evaluate the cost-effectiveness of certolizumab pegol (CZP), a pegylated fc-free anti-TNF, as add-on therapy to methotrexate (MTX) versus etanercept, adalimumab, or golimumab in patients with moderate-to-severe active rheumatoid arthritis (RA) not responding to the conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). A Markov model (6-month cycle length) assessed health and cost outcomes of CZP versus other anti-TNFs recommended for RA in Greece over a patient's lifetime. Following discontinuation of first-line anti-TNF, patients switched to second anti-TNF and then to a biologic with another mode of action. Sequential use of csDMARDs followed third biologic. Clinical data and utilities were extracted from published literature. Analysis was conducted from third-party payer perspective in Greece. Costs (drug acquisition, administration, monitoring, and patient management) were considered for 2014. Results presented are incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY). Probabilistic sensitivity analysis (PSA) ascertained robustness of base-case findings. Base-case analysis indicated that CZP+MTX was more costly and more effective compared with Etanercept+MTX (base-case ICER: €3,177 per QALY), whilst versus adalimumab/golimumab, CZP was dominant (less costly, more effective). For all comparisons, CZP treatment resulted in greater improvements in life expectancy and QALYs. PSA indicated that at the willingness-to-pay threshold of €34,000/QALY, CZP+MTX was associated with a 71.6, 97.9, or 99.2% probability of being cost-effective versus etanercept, golimumab, or adalimumab, respectively, in combination with MTX. This analysis demonstrates CZP+MTX to be a cost-effective alternative over Etanercept+MTX and a dominant option over Adalimumab+MTX and Golimumab+MTX for management of RA in Greece.

Clinical and financial burden of active lupus in Greece: a nationwide study

Analyses of the medical and economic burden of chronic disorders such as systemic lupus erythematosus (SLE) are valuable for clinical and health policy decisions. We performed a chart-based review of 215 adult SLE patients with active autoantibody-positive disease at the predefined ratio of 30% severe (involvement of major organs requiring treatment) and 70% non-severe, followed at seven hospital centres in Greece. We reviewed 318 patients consecutively registered over three months (sub-study). Disease activity, organ damage, flares and healthcare resource utilization were recorded. Costs were assessed from the third-party payer perspective. Severe SLE patients had chronic active disease more frequently (22.4% vs 4.7%), higher average SLE disease activity index (SLEDAI) (10.5 vs 6.1) and systemic lupus international collaborating clinics (SLICC) damage index (1.1 vs 0.6) than non-severe patients. The mean annual direct medical cost was €3741 for severe vs €1225 for non-severe patients. Severe flares, active renal disease and organ damage were independent cost predictors. In the sub-study, 19% of unselected patients were classified as severe SLE, and 30% of them had chronic active disease. In conclusion, this is the first study to demonstrate the significant clinical and financial burden of Greek SLE patients with active major organ disease. Among them, 30% display chronic activity, in spite of standard care, which represents a significant unmet medical need.

On the Growth of the One-Dimensional Reverse Immunization Contact Processes

We are concerned with the variation of the supercritical nearest-neighbours contact process such that first infection occurs at a lower rate; it is known that the process survives with positive probability. Regarding the rightmost infected of the process started from one site infected and conditioned to survive, we specify a sequence of space-time points at which its behaviour regenerates and, thus, obtain the corresponding strong law and central limit theorem. We also extend complete convergence in this case.

Preliminary classification criteria for the cryoglobulinaemic vasculitis

Background

To develop preliminary classification criteria for the cryoglobulinaemic syndrome or cryoglobulinaemic vasculitis (CV).

Methods

Study part I developed a questionnaire for CV to be included in the formal, second part (study part II). Positivity of serum cryoglobulins was defined by experts as an essential condition for CV classification. In study part II, a core set of classification items (questionnaire, clinical and laboratory items, as agreed) was tested in three groups of patients and controls—that is, group A (new patients with the CV), group B (controls with serum cryoglobulins but lacking CV) and group C (controls without serum cryoglobulins but with features which can be observed in CV).

Results

In study part I (188 cases, 284 controls), a positive response to at least two of three selected questions showed a sensitivity of 81.9% and a specificity of 83.5% for CV. This questionnaire was employed and validated in study part II, which included 272 patients in group A and 228 controls in group B. The final classification criteria for CV, by pooling data from group A and group B, required the positivity of questionnaire plus clinical, questionnaire plus laboratory, or clinical plus laboratory items, or all the three, providing a sensitivity of 88.5% and a specificity of 93.6% for CV. By comparing data in group A versus group C (425 controls), the same classification criteria showed a sensitivity 88.5% and a specificity 97.0% for CV.

Conclusion

Classification criteria for CV were developed, and now need validation.

Development and standardization of solid phase assays for the detection of anti-neutrophil cytoplasmic antibodies (ANCA). A report on the second phase of an international cooperative study on the standardization of ANCA assays

Anti-neutrophil cytoplasmic antibodies (ANCA) are diagnostic markers for systemic vasculitis. They are classically detected by an indirect immunofluorescence test using normal donor neutrophils as substrate. This assay lacks antigenic specificity and is not quantitative. The 'EC/BCR Project for ANCA Assay Standardization' is an international collaboration study with the aim to develop and standardize solid phase assays for ANCA detection. In this part of the study the isolation and characterization of proteinase-3 and myeloperoxidase, the two main target molecules for ANCA, and the development and standardization of ELISAs with these antigens are described. Six laboratories successfully isolated purified proteinase-3 preparations that could be used. Three of these preparations, together with one myeloperoxidase preparation, were subsequently used for ANCA testing by ELISA. The ELISA technique was standardized in two rounds of testing in the 14 participating laboratories. The coefficient of variation of these new assays decreased from values of approx. 50% in the first round to approx. 20% in the second round. We conclude that purified proteinase-3 and myeloperoxidase can be used in standardized ELISAs for ANCA detection. Whether such procedures offer advantages over the IIF test will be determined in a prospective clinical study.