Disentangling the riddle of systemic lupus erythematosus with antiphospholipid syndrome: blood transcriptome analysis reveals a less-pronounced IFN-signature and distinct molecular profiles in venous versus arterial events

INTRODUCTION

Systemic lupus erythematosus with antiphospholipid syndrome (SLE-APS) represents a challenging SLE endotype whose molecular basis remains unknown.

METHODS

We analysed whole-blood RNA-sequencing data from 299 patients with SLE (108 SLE-antiphospholipid antibodies (aPL)-positive, including 67 SLE-APS; 191 SLE-aPL-negative) and 72 matched healthy controls (HC). Pathway enrichment analysis, unsupervised weighted gene coexpression network analysis and machine learning were applied to distinguish disease endotypes.

RESULTS

Patients with SLE-APS demonstrated upregulated type I and II interferon (IFN) pathways compared with HC. Using a 100-gene random forests model, we achieved a cross-validated accuracy of 75.6% in distinguishing these two states. Additionally, the comparison between SLE-APS and SLE-aPL-negative revealed 227 differentially expressed genes, indicating downregulation of IFN-α and IFN-γ signatures, coupled with dysregulation of the complement cascade, B-cell activation and neutrophil degranulation. Unsupervised analysis of SLE transcriptome identified 21 gene modules, with SLE-APS strongly linked to upregulation of the 'neutrophilic/myeloid' module. Within SLE-APS, venous thromboses positively correlated with 'neutrophilic/myeloid' and 'B cell' modules, while arterial thromboses were associated with dysregulation of 'DNA damage response (DDR)' and 'metabolism' modules. Anticardiolipin and anti-β2GPI positivity-irrespective of APS status-were associated with the 'neutrophilic/myeloid' and 'protein-binding' module, respectively.

CONCLUSIONS

There is a hierarchical upregulation and-likely-dependence on IFN in SLE with the highest IFN signature observed in SLE-aPL-negative patients. Venous thrombotic events are associated with neutrophils and B cells while arterial events with DDR and impaired metabolism. This may account for their differential requirements for anticoagulation and provide rationale for the potential use of mTOR inhibitors such as sirolimus and the direct fIIa inhibitor dabigatran in SLE-APS.

Patients with neuropsychiatric involvement systemic lupus erythematosus experience poorer health-related quality of life and more fatigue than systemic lupus erythematosus patients with no neuropsychiatric involvement, irrespective of neuropsychiatric activity

OBJECTIVES

Substantial proportions of patients with systemic lupus erythematosus (SLE) report poor health-related quality of life (HRQoL). Our objective was to investigate the impact of neuropsychiatric involvement (NP) in SLE on patient-reported outcomes.

METHODS

We analysed data from four phase III trials (BLISS-52, BLISS-76, BLISS-SC, EMBRACE; N = 2968). The neuropsychiatric SLE (NPSLE) group comprised individuals with NP-British Isles Lupus Assessment group (BILAG) A/B/C/D or score in any descriptor of the NP-SLEDAI-2K at baseline (N = 350), while the non-NPSLE group consisted of patients with NP-BILAG E (N = 2618). HRQoL was assessed with the SF-36, EQ-5D-3L, and FACIT-F. Full health state (FHS) was defined as "no problems" in all EQ-5D dimensions.

RESULTS

NPSLE patients reported lower scores in the SF-36 physical and mental component summary compared with the non-NPSLE population (mean±s.d.: 35.7±9.1 versus 39.6±9.6; p<0.001 and 37.3±12.1 versus 41.4±11.0; p<0.001, respectively). NPSLE patients also exhibited impaired HRQoL in all EQ-5D dimensions compared with non-NPSLE patients (p<0.05 for all). A substantially lower proportion among NPSLE patients experienced FHS in comparison with the non-NPSLE group (3.3% versus 14.5%; p<0.001). NPSLE was associated with severe fatigue (23.8±12.2 versus 31.5±11.6; p<0.001). Notably, our findings revealed no discernible distinctions between active and inactive NPSLE patients with regard to SF-36, EQ-5D, FHS, and FACIT-F scores.

CONCLUSION

Neuropsychiatric involvement in patients with SLE has a detrimental effect on HRQoL experience and is associated with severe fatigue, regardless of the degree of neuropsychiatric disease activity. Early intervention is warranted in NPSLE patients to enhance long-term HRQoL experience.

Impaired serotonin synthesis in hippocampus of murine lupus represents an early neuropsychiatric event

BACKGROUND

Despite significant progress in understanding the mechanisms underlying hippocampal involvement in neuropsychiatric systemic lupus erythematosus (NPSLE), our understanding of how neuroinflammation affects the brain neurotransmitter systems is limited. To date, few studies have investigated the role of neurotransmitters in pathogenesis of NPSLE with contradictory results.

METHODS

Hippocampal tissue from NZB/W-F1 lupus-prone mice and age-matched control strains were dissected in both pre-nephritic (3-month-old) and nephritic (6-month-old) stages. High-Performance Liquid Chromatography (HPLC) was used to evaluate the level of serotonin (5-HT), dopamine (DA), and their metabolites 5-HIAA and DOPAC, respectively, in mouse hippocampi.

RESULTS

Lupus mice exhibit decreased levels of serotonin at the early stages of the disease, along with intact levels of its metabolite 5-HIAA. The 5-HT turnover ratio (5-HIAA/5-HT ratio) was increased in the hippocampus of lupus mice at pre-nephritic stage suggesting that low hippocampal serotonin levels in lupus are attributed to decreased serotonin synthesis. Both DA and DOPAC levels remained unaffected in lupus hippocampus at both early and late stages.

CONCLUSION

Impaired hippocampal serotonin synthesis in the hippocampus of lupus-prone mice represents an early neuropsychiatric event. These findings may have important implications for the use of symptomatic therapy in diffuse NPSLE.

Reframing health disparities in SLE: A critical reassessment of racial and ethnic differences in lupus disease outcomes

Health disparities in the prevalence and outcomes of systemic lupus erythematosus (SLE) are well documented across racial and ethnic groups. Similar to other chronic diseases, differences in disease severity among individuals with SLE are likely influenced by both genetic predisposition and multiple social determinants of health. However, research in SLE that jointly examines the genetic and environmental contributions to the disease course is limited, resulting in an incomplete understanding of the biologic and social mechanisms that underly health disparities. While research on health disparities can reveal inequalities and inform resource allocation to improve outcomes, research that relies on racial and ethnic categories to describe diverse groups of people can pose challenges. Additionally, results from research comparing outcomes across socially constructed groups without considering other contributing factors can be misleading. We herein comprehensively examine existing literature on health disparities in SLE, including both clinical studies that examine the relationship between self-reported race and ethnicity and disease outcomes and studies that explore the relationships between genomics and lupus outcomes. Having surveyed this body of research, we propose a framework for research examining health disparities in SLE, including ways to mitigate bias in future studies.

A network-based approach reveals long non-coding RNAs associated with disease activity in lupus nephritis: key pathways for flare and potential biomarkers to be used as liquid biopsies

Objective

A blood-based biomarker is needed to assess lupus nephritis (LN) disease activity, minimizing the need for invasive kidney biopsies. Long non-coding RNAs (lncRNAs) are known to regulate gene expression, appear to be stable in human plasma, and can serve as non-invasive biomarkers.

Methods

Transcriptomic data of whole blood samples from 74 LN patients and 20 healthy subjects (HC) were analyzed to identify differentially expressed (DE) lncRNAs associated with quiescent disease and flares. Weighted gene co-expression network analysis (WGCNA) was performed to uncover lncRNAs with a central role (hub lncRNAs) in regulating key biological processes that drive LN disease activity. The association of hub lncRNAs with disease activity was validated using RT-qPCR on an independent cohort of 15 LN patients and 9 HC. cis- and trans-targets of validated lncRNAs were explored in silico to examine potential mechanisms of their action.

Results

There were 444 DE lncRNAs associated with quiescent disease and 6 DE lncRNAs associated with flares (FDR <0.05). WGCNA highlighted IFN signaling and B-cell activity/adaptive immunity as the most significant processes contributing to nephritis activity. Four disease-activity-associated lncRNAs, namely, NRIR, KLHDC7B-DT, MIR600HG, and FAM30A, were detected as hub genes and validated in an independent cohort. NRIR and KLHDC7B-DT emerged as potential key regulators of IFN-mediated processes. Network analysis suggests that FAM30A and MIR600HG are likely to play a central role in the regulation of B-cells in LN through cis-regulation effects and a competing endogenous RNA mechanism affecting immunoglobulin gene expression and the IFN-λ pathway.

Conclusions

The expression of lncRNAs NRIR, KLHDC7B-DT, FAM30A, and MIR600HG were associated with disease activity and could be further explored as blood-based biomarkers and potential liquid biopsy on LN.

Janus kinase inhibitors in systemic lupus erythematosus: implications for tyrosine kinase 2 inhibition

Aberrant activation of the Janus kinase (JAK) and signal transducer and activator of transcription (STAT) pathway is common in systemic lupus erythematosus (SLE), conferring immune-mediated properties in target tissues. Multiple cytokines activate different combinations of JAKs and STATs to alter the cell fate of target tissue and induce end-organ damage. Thus, the simultaneous blockade of several different cytokines by small molecules acting downstream intracellular signalling has gained traction. JAK inhibitors have been approved for the treatment of several rheumatic diseases, yet hitherto not for SLE. Nevertheless, JAK inhibitors including tofacitinib, baricitinib, and deucravacitinib have shown merit as treatments for SLE. Tofacitinib, a JAK1/3 inhibitor, reduced cholesterol levels, improved vascular function, and decreased the type I interferon signature in SLE patients. Baricitinib, a JAK1/2 inhibitor, demonstrated significant improvements in lupus rashes and arthritis in a phase 2 and a phase 3 randomised controlled trial, but the results were not replicated in another phase 3 trial. Deucravacitinib, a selective tyrosine kinase 2 (TYK2) inhibitor, yielded greater response rates than placebo in a phase 2 trial of SLE and will be investigated in larger phase 3 trials. TYK2 is activated in response to cytokines actively involved in lupus pathogenesis; this review highlights the potential of targeting TYK2 as a promising therapy for SLE.

Restoration of aberrant gene expression of monocytes in systemic lupus erythematosus via a combined transcriptome-reversal and network-based drug repurposing strategy

BACKGROUND

Monocytes -key regulators of the innate immune response- are actively involved in the pathogenesis of systemic lupus erythematosus (SLE). We sought to identify novel compounds that might serve as monocyte-directed targeted therapies in SLE.

RESULTS

We performed mRNA sequencing in monocytes from 15 patients with active SLE and 10 healthy individuals. Disease activity was assessed with the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K). Leveraging the drug repurposing platforms iLINCS, CLUE and L1000CDS², we identified perturbagens capable of reversing the SLE monocyte signature. We identified transcription factors and microRNAs (miRNAs) that regulate the transcriptome of SLE monocytes, using the TRRUST and miRWalk databases, respectively. A gene regulatory network, integrating implicated transcription factors and miRNAs was constructed, and drugs targeting central components of the network were retrieved from the DGIDb database. Inhibitors of the NF-κB pathway, compounds targeting the heat shock protein 90 (HSP90), as well as a small molecule disrupting the Pim-1/NFATc1/NLRP3 signaling axis were predicted to efficiently counteract the aberrant monocyte gene signature in SLE. An additional analysis was conducted, to enhance the specificity of our drug repurposing approach on monocytes, using the iLINCS, CLUE and L1000CDS² platforms on publicly available datasets from circulating B-lymphocytes, CD4⁺ and CD8⁺ T-cells, derived from SLE patients. Through this approach we identified, small molecule compounds, that could potentially affect more selectively the transcriptome of SLE monocytes, such as, certain NF-κB pathway inhibitors, Pim-1 and SYK kinase inhibitors. Furthermore, according to our network-based drug repurposing approach, an IL-12/23 inhibitor and an EGFR inhibitor may represent potential drug candidates in SLE.

CONCLUSIONS

Application of two independent - a transcriptome-reversal and a network-based -drug repurposing strategies uncovered novel agents that might remedy transcriptional disturbances of monocytes in SLE.

Microglia activation in the presence of intact blood-brain barrier and disruption of hippocampal neurogenesis via IL-6 and IL-18 mediate early diffuse neuropsychiatric lupus

INTRODUCTION

Inflammatory mediators are detected in the cerebrospinal fluid of systemic lupus erythematosus patients with central nervous system involvement (NPSLE), yet the underlying cellular and molecular mechanisms leading to neuropsychiatric disease remain elusive.

METHODS

We performed a comprehensive phenotyping of NZB/W-F1 lupus-prone mice including tests for depression, anxiety and cognition. Immunofluorescence, flow cytometry, RNA-sequencing, qPCR, cytokine quantification and blood-brain barrier (BBB) permeability assays were applied in hippocampal tissue obtained in both prenephritic (3-month-old) and nephritic (6-month-old) lupus mice and matched control strains. Healthy adult hippocampal neural stem cells (hiNSCs) were exposed ex vivo to exogenous inflammatory cytokines to assess their effects on proliferation and apoptosis.

RESULTS

At the prenephritic stage, BBB is intact yet mice exhibit hippocampus-related behavioural deficits recapitulating the human diffuse neuropsychiatric disease. This phenotype is accounted by disrupted hippocampal neurogenesis with hiNSCs exhibiting increased proliferation combined with decreased differentiation and increased apoptosis in combination with microglia activation and increased secretion of proinflammatory cytokines and chemokines. Among these cytokines, IL-6 and IL-18 directly induce apoptosis of adult hiNSCs ex vivo. During the nephritic stage, BBB becomes disrupted which facilitates immune components of peripheral blood, particularly B-cells, to penetrate into the hippocampus further augmenting inflammation with locally increased levels of IL-6, IL-12, IL-18 and IL-23. Of note, an interferon gene signature was observed only at nephritic-stage.

CONCLUSION

An intact BBB with microglial activation disrupting the formation of new neurons within the hippocampus represent early events in NPSLE. Disturbances of the BBB and interferon signature are evident later in the course of the disease.

Relapses are common in severe hematologic systemic lupus erythematosus and may be prevented by early institution of immunosuppressive agents: Α real-life single-center study

BACKGROUND

Hematologic manifestations are common in systemic lupus erythematosus (SLE), either at initial presentation or during the course of the disease, but data regarding their natural history are scarce.

OBJECTIVE

To describe the characteristics, treatments, and outcomes of severe hematological manifestations in a large cohort of lupus patients.

METHODS

Retrospective cohort study of patients in the "Attikon" lupus cohort who had a history of a severe hematologic manifestation, defined as autoimmune hemolytic anemia (AIHA) with hemoglobin < 8 g/dL, thrombocytopenia with platelet count < 30,000/mm³, Evans syndrome with hemoglobin < 8 g/dL, and/or platelet count < 30,000/mm³, neutropenia with < 500 neutrophils/mm³, thrombotic microangiopathy (TMA)/thrombotic thrombocytopenic purpura (TTP)-like syndrome, or macrophage activation syndrome (MAS). Demographic and clinical characteristics, treatments, and outcomes were recorded.

RESULTS

From over 300 patients with hematologic manifestations, 41 qualified as severe (70.7% women, mean [SD] age at SLE diagnosis 42.6 [18.0] years). Hematologic manifestations preceded SLE diagnosis in 13 patients (31.7%), was concomitant to SLE diagnosis in 16 patients (39%), and occurred during the course of the disease in 12 (29.3%) patients, with a mean (SD) disease duration of 8.7 (5.5) years. Thrombocytopenia was the most common severe hematological manifestation (56.1%), followed by AIHA (17.1%) and TTP-like syndrome (12.2%). For initial treatment, all patients were treated with glucocorticoids (GC), while rituximab and cyclophosphamide were the most frequently used immunosuppressive agents. Following initial treatment, relapse occurred in 22 patients (53.7%). Compared to patients that did not relapse, those that relapsed had less often received concomitant immunosuppressive agents following treatment of initial episode (n = 17/23, 73.9% vs 5/17, 29.4%, p = 0.005).

CONCLUSION

Severe hematologic disease in SLE has a high risk of relapse, which may be mitigated by the early institution of GC-sparing agents.

Clinical response trajectories and drug persistence in systemic lupus erythematosus patients on belimumab treatment: A real-life, multicentre observational study

Objective

To obtain real-world data on outcomes of belimumab treatment and respective prognostic factors in patients with systemic lupus erythematosus (SLE).

Methods

Observational study of 188 active SLE patients (median disease duration 6.2 years, two previous immunosuppressive/biological agents) treated with belimumab, who were monitored for SLEDAI-2K, Physician Global Assessment (PGA), LLDAS (lupus low disease activity state), remission (DORIS/Padua definitions), SELENA-SLEDAI Flare Index, SLICC/ACR damage index and treatment discontinuations. Group-based disease activity trajectories were modelled followed by multinomial regression for predictive variables. Drug survival was analysed by Cox-regression.

Results

At 6, 12 and 24 months, LLDAS was attained by 36.2%, 36.7% and 33.5%, DORIS-remission by 12.3%, 11.6% and 17.8%, and Padua-remission by 21.3%, 17.9% and 29.0%, respectively (attrition-corrected). Trajectory analysis of activity indices classified patients into complete (25.5%), partial (42.0%) and non-responder (32.4%) groups, which were predicted by baseline PGA, inflammatory rash, leukopenia and prior use of mycophenolate. During median follow-up of 15 months, efficacy-related discontinuations occurred in 31.4% of the cohort, especially in patients with higher baseline PGA (hazard ratio [HR] 2.78 per 1-unit; 95% CI 1.32-5.85). Conversely, PGA improvement at 3 months predicted longer drug retention (HR 0.57; 95% CI 0.33-0.97). Use of hydroxychloroquine was associated with lower risk for safety-related drug discontinuation (HR 0.33; 95% CI 0.13-0.85). Although severe flares were reduced, flares were not uncommon (58.0%) and contributed to treatment stops (odds ratio [OR] 1.73 per major flare; 95% CI 1.09-2.75) and damage accrual (OR 1.83 per mild/moderate flare; 95% CI 1.15-2.93).

Conclusions

In a real-life setting with predominant long-standing SLE, belimumab was effective in the majority of patients, facilitating the achievement of therapeutic targets. Monitoring PGA helps to identify patients who will likely benefit and stay on the treatment. Vigilance is required for the prevention and management of flares while on belimumab.

ATR-mediated DNA damage responses underlie aberrant B cell activity in systemic lupus erythematosus

B cells orchestrate autoimmune responses in patients with systemic lupus erythematosus (SLE), but broad-based B cell-directed therapies show only modest efficacy while blunting humoral immune responses to vaccines and inducing immunosuppression. Development of more effective therapies targeting pathogenic clones is a currently unmet need. Here, we demonstrate enhanced activation of the ATR/Chk1 pathway of the DNA damage response (DDR) in B cells of patients with active SLE disease. Treatment of B cells with type I IFN, a key driver of immunity in SLE, induced expression of ATR via binding of interferon regulatory factor 1 to its gene promoter. Pharmacologic targeting of ATR in B cells, via a specific inhibitor (VE-822), attenuated their immunogenic profile, including proinflammatory cytokine secretion, plasmablast formation, and antibody production. Together, these findings identify the ATR-mediated DDR axis as the orchestrator of the type I IFN-mediated B cell responses in SLE and as a potential novel therapeutic target.

Cross-species transcriptome analysis for early detection and specific therapeutic targeting of human lupus nephritis

Objectives

Patients with lupus nephritis (LN) are in urgent need for early diagnosis and therapeutic interventions targeting aberrant molecular pathways enriched in affected kidneys.

Methods

We used mRNA-sequencing in effector (spleen) and target (kidneys, brain) tissues from lupus and control mice at sequential time points, and in the blood from 367 individuals (261 systemic lupus erythematosus (SLE) patients and 106 healthy individuals). Comparative cross-tissue and cross-species analyses were performed. The human dataset was split into training and validation sets and machine learning was applied to build LN predictive models.

Results

In murine SLE, we defined a kidney-specific molecular signature, as well as a molecular signature that underlies transition from preclinical to overt disease and encompasses pathways linked to metabolism, innate immune system and neutrophil degranulation. The murine kidney transcriptome partially mirrors the blood transcriptome of patients with LN with 11 key transcription factors regulating the cross-species active LN molecular signature. Integrated protein-to-protein interaction and drug prediction analyses identified the kinases TRRAP, AKT2, CDK16 and SCYL1 as putative targets of these factors and capable of reversing the LN signature. Using murine kidney-specific genes as disease predictors and machine-learning training of the human RNA-sequencing dataset, we developed and validated a peripheral blood-based algorithm that discriminates LN patients from normal individuals (based on 18 genes) and non-LN SLE patients (based on 20 genes) with excellent sensitivity and specificity (area under the curve range from 0.80 to 0.99).

Conclusions

Machine-learning analysis of a large whole blood RNA-sequencing dataset of SLE patients using human orthologs of mouse kidney-specific genes can be used for early, non-invasive diagnosis and therapeutic targeting of LN. The kidney-specific gene predictors may facilitate prevention and early intervention trials.

POS0122 CENTRAL NERVOUS SYSTEM DEMYELINATING SYNDROMES IN SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM “ATTIKON” LUPUS COHORT

Background

Central nervous system (CNS) demyelinating syndromes that occur in the context of SLE may represent a manifestation of neuropsychiatric lupus, or an overlap of SLE and multiple sclerosis (MS). The differential diagnosis between the two entities has important clinical implications, because the therapeutic management differs between the two conditions.

Objectives

To characterize CNS demyelinating syndromes in a large SLE cohort as neuropsychiatric SLE or SLE-MS overlap, using a multidisciplinary approach and existing diagnostic (MS) and classification criteria (SLE)

Methods

Patients from the “Attikon” lupus cohort (n=707) were evaluated for demyelinating syndromes. Clinical, laboratory and neuroimaging data were recorded for each patient. Following multidisciplinary evaluation and application of criteria, the demyelinating syndrome was attributed to either SLE or MS. Patients with transverse myelitis were not included in this study.

Results

We identified 26 patients with demyelinating syndromes (3.7%) with mean age at diagnosis 46.9 (SD 12.3) years and median disease duration at last follow-up 60 (IQR 52) months. Of them, 12 were diagnosed as primary SLE-demyelination (46.2%) and 14 as overlap SLE-MS (53.8%). The two groups did not differ with respect to rheumatologic and neurologic manifestations, or serologic findings (ANA, dsDNA, C3/C4, aPL, ENA). SLE patients with demyelination manifested mild extra-CNS disease mainly involving joints and skin, while severe non-CNS manifestations were rare. However, patients with SLE-demyelination were less likely to have elevated IgG index (OR 0.055 95% CI: 0.008-0.40) and positive oligoclonal bands (OR 0.09 95% CI: 0.014-0.56). SLE patients with primary demyelinating syndrome were less likely to exhibit brain lesions in the spinal cord, infratentorial, periventricular and juxtacortical regions. A single brain region was affected in 9 SLE-demyelination patients (75%), while all MS-SLE patients had multiple affected brain regions. MS-SLE overlap was associated with increased likelihood of neurologic relapses (OR 18.2, 95% CI: 1.76-188), while SLE-demyelination patients were less likely to exhibit neurological deficits (EDSS>0) at last follow-up visit (50% vs. 78.6%in SLE-MS, respectively).

Conclusion

Demyelination in the context of SLE follows a more benign course compared to a frank SLE-MS overlap. Prolongation of follow-up will ascertain whether SLE-demyelination patients evolve to MS, or this is a bona fide NPSLE syndrome.

Disclosure of Interests

None declared

POS0210 A PREDOMINANT NON-SPECIFIC INTERSTITIAL PNEUMONIA PATTERN AND ABERRANT TRANSCRIPTOMIC NEUTROPHIL-MEDIATED IMMUNITY CHARACTERIZE A CONTEMPORARY RA-ILD COHORT

Background

Lung involvement is the most common extra-articular manifestation. Rheumatoid arthritis related interstitial lung disease (RA-ILD) comprises a heterogeneous group of parenchymal lung disorders classified by distinct clinical, pathologic, and radiographic features. According to the current paradigm, circulating immune complexes and aberrant neutrophil extracellular trap formation (NETosis) contribute to disease pathogenesis.

Objectives

To characterize the pattern of lung disease in “Attikon” RA-ILD cohort and develop insights about the pathophysiologic mechanisms via whole blood RNA sequencing.

Methods

Retrospective and prospective study to identify clinical, laboratory and radiologic characteristics of patients with RA and pulmonary manifestations in the “Attikon” RA-ILD cohort. Changes in pulmonary function tests (PFTs), pattern of lung involvement (chest HRCT), disease activity (DAS28-ESR) and incidence of complications and comorbidities, were prospectively analyzed during the one-year follow-up period. Peripheral blood was collected in a subset of RA-ILD (n=11) and control RA patients (n=9) for RNA isolation and RNA sequencing. The gene expression profile of RA-ILD was inferred through differential gene expression analysis, followed by pathway and enrichment analyses.

Results

114 patients with RA-ILD were included [67% female, mean (SD) age at diagnosis 71.5 (9) years, 58% seropositive]. Non-specific interstitial pneumonia (NSIP) was the radiologic pattern most frequently observed (52%), followed by usual interstitial pneumonia (UIP) (24%). RA was diagnosed after ILD in 40% of patients. Mean (SD) FVC and DLCOsb at baseline was 80.5 (19.2) and 55.4 (19.5), respectively. Disease activity was lower in seropositive compared to seronegative both at baseline and at 1-year follow-up (p=0.025). PFTs at 12 months from baseline had been stabilized. Respiratory infections were observed in 17.6% of patients during the first year of follow-up, more common in the NSIP vs UIP group (p=0.01), possibly due to the higher doses of glucocorticoids in NSIP patients. RNA-sequencing analysis revealed a distinct gene expression profile in RA-ILD, characterized by the activation of type I interferon response, neutrophil activation and degranulation, and CCR1 chemokine interactions.

Conclusion

NSIP is the most frequent pattern of ILD in this RA-ILD cohort, carrying a higher risk for respiratory infections probably related to higher doses of glucocorticoid used. Myeloid cells’ migration via CCR1 and the formation of pro-inflammatory and pro-fibrotic NETs by activated neutrophils may contribute to RA-ILD pathogenesis.

References

[1]Y Dai et al, Rheumatoid arthritis–associated interstitial lung disease: an overview of epidemiology, pathogenesis and management Clin Rheumatol. 2021 Apr;40(4):1211-1220

[2]X Zulma Yunt et al, Lung Disease in Rheumatoid Arthritis Rheum Dis Clin North Am. 2015 May;41(2):225-36

Table 1.

Patients’ characteristics with RA-ILD in Attikon cohort

Patients CharacteristicsN=114Mean age71.5±9Female: Male76/38Smoking (current/ex)23/43Arterial hypertension71Diabetes mellitus32Dyslipidemia52COPD/BA17Thyroid disease30Latent TB17Seropositive66Diagnosis RA before ILD34Diagnosis RA after ILD45NSIP59UIP27Mixed NSIP-UIP5Organizing Pneumonia (OP)17Nodules21

Disclosure of Interests

None declared

POS0365 RELAPSES ARE COMMON ΙΝ SEVERE HEMATOLOGICAL SLE: REAL-LIFE EXPERIENCE FROM THE “ATTIKON” LUPUS COHORT

Background

Hematological manifestations are common in systemic lupus erythematosus (SLE), and are thought to result from immune-mediated peripheral cell destruction or bone marrow failure(1,2).

Objectives

To assess the clinical characteristics and outcomes of severe hematological disease in a large cohort of lupus patients.

Methods

Retrospective analysis of the “Attikon” lupus cohort (over 800 patients total) (3) for the identification of patients with a history of severe hematological manifestation. The latter were defined as: thrombocytopenia with a platelet count <30.000/mm3, hemolytic anemia with an hemoglobin <8 g/dL, neutropenia with less than 500 neutrophils/mm3, history of thrombotic microangiopathy (TMA) or macrophage activation syndrome (MAS). Treatments and long-term outcomes (relapses, mortality) were recorded.

Results

Among 300 patients with hematologic manifestations, 40 patients had severe disease. Most of them were women (75%). Mean age at SLE diagnosis was 41,1 years and mean disease duration at diagnosis of cytopenia was 3.8 years. Hematologic manifestation preceded SLE diagnosis in 13 patients (32,5%).

Autoimmune thrombocytopenia was the most common (57,5%), followed by hemolytic anemia (17.5%), TMA (12.5%) and Evans syndrome (7,5%). All patients received glucocorticoids (GC). Rituximab (15%) and cyclophosphamide (12,5%) were the most frequently used GC-sparing agents during the first episode. Nine patients (22,5%) received intravenous immunoglobulin (IVIg). Relapse occurred in 23 patients (57,5%), most of which (N=17, 73,9%) were treated with GC alone or in combination with IVIg or plasma exchange at initial presentation, without the use of GC-sparing agents. Most of the flares (60,8%) were severe. No deaths were observed.

Conclusion

Hematological disease in SLE is treatment-responsive. GC remain the mainstay of treatment, but the high relapse rates underscore the need for more efficient GC-sparing agents.

References

[1]Fayyaz A, Igoe A, Kurien BT, Danda D, James JA, Stafford HA, Scofield RH. Haematological manifestations of lupus. Lupus Sci Med. 2015 Mar 3;2(1):e000078.

[2]Hepburn AL, Narat S, Mason JC. The management of peripheral blood cytopenias in systemic lupus erythematosus. Rheumatology (Oxford). 2010 Dec;49(12):2243-54

[3]Nikolopoulos D, Kostopoulou M, Pieta A, Karageorgas T, Tseronis D, Chavatza K, Flouda S, Rapsomaniki P, Banos A, Kremasmenou E, Tzavara V, Katsimbri P, Fanouriakis A, Boumpas DT. Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the ‘Attikon’ cohort. Lupus. 2020 Apr;29(5):514-522.

Table 1.

Characteristics of patients with hematological manifestations

Age at diagnosis, mean (years)41,1Women N(%)30(75)Mean disease duration at cytopenia diagnosis (years)3,8Thrombocytopenia, N=23, (mean platelet count,/mm3)11682Hemolytic anemia,N=7 (mean Hb,g/dL)6,75Neutropenia N=1,(mean neutrophil count)450Evans syndrome, N=3 (mean Hb, g, mean platelet count)7 /46600TMA,N=5, (mean platelet count)8750MAS, N=1Immunosuppressive treatment at initial presentationAzathioprine (N,%) 4(10) Corticosteroids (N,%) 40 (100) Cyclophosphamide (N,%) 5(12,5) IgIV (N,%) 9 (22,5) Mycophenolate mofetil (N,%) 2(5) Rituximab (N,%) 6(15)Relapse N(%)23(57,5)Severe relapse (N,%)14(60,8)Non responder to corticosteroids/IgIV (N,%)1(2,5)

Disclosure of Interests

None declared

POS0368 EARLY (3 MONTHS) IMPROVEMENT IN PHYSICIAN GLOBAL ASSESSMENT OF DISEASE ACTIVITY PREDICTS LONG-TERM RETENTION OF BELIMUMAB TREATMENT IN SLE: A MULTICENTRE OBSERVATIONAL STUDY OF 184 PATIENTS

Background

Belimumab has been introduced in the management of SLE for more than 10 years, however long-term efficacy and safety data are still limited and mostly derive from the extended phase of randomized clinical trials.

Objectives

To evaluate the long-term survival of belimumab treatment, reasons for treatment cessation and associated predictors in routine care setting.

Methods

Multicentre observational study of adult SLE patients who were treated with belimumab according to physician discretion and in line with the EULAR recommendations. Disease activity (Physician Global Assessment [PGA]: scale 0-3; SLE disease activity index-2000 [S2K]), flares (SELENA-SLEDAI Flare Index), organ damage (SLICC damage index [SDI]), co-administered treatments and dosage, adverse events and causes of belimumab discontinuation were monitored prospectively at 3–6-month intervals. Cox-regression analysis was performed to identify factors associated with reduced drug survival.

Results

A total 184 patients treated with belimumab for at least 3 months were included (women 95.6%; mean ± SD age 48.8 ± 13.4 years; disease duration 9.2 ± 11.3 years). Baseline S2K and PGA were 7.5 ± 3.0 and 1.64 ± 0.42, respectively, both demonstrating significant improvement at 6 months (4.5 ± 3.5 and 1.02 ± 0.69, respectively; p<0.001) and 12 months (3.5 ± 3.1 and 0.68 ± 0.55, respectively; p<0.001). Of patients receiving glucocorticoids at onset, 49.0% tapered the dose and 17.6% completely withdrew them. After a median (interquartile range) follow-up of 15.1 (16.9) months, 44.0% of patients discontinued belimumab due to suboptimal efficacy as judged by the treating physician (28.3%), adverse events (including infections) (9.8%) or other causes (e.g., pregnancy, patient decision). Accordingly, efficacy-related drug survival rates at 1 and 2 years were 70% and 61%, respectively, with corresponding safety-related survival rates of 94% and 87%, respectively. Baseline factors associated with belimumab discontinuation due to suboptimal efficacy included PGA >1.50 (hazard ratio [HR] 3.66; 95% confidence interval [95% CI] 1.14–11.73; p=0.029) and severe (RA-like) arthritis (HR 2.56; 95% CI 1.16–5.68; p=0.020) but not disease duration, use of glucocorticoids, active serology or organ damage. Notably, patients with early (3 months) improvement (i.e., any decrease in PGA) showed significantly lower risk for treatment cessation (HR 0.38; 95% CI 0.22–0.67; p=0.001) (Figure 1) and this effect was independent of the initial PGA level. Baseline use of hydroxychloroquine was associated with prolonged safety-related belimumab survival (HR 0.32; 95% CI 0.12–0.88; p=0.028).

Figure 1.

Efficacy-related survival of belimumab according to improvement or not of PGA at 3 months since treatment initiation.

Conclusion

In real-life setting, about 28% of SLE patients discontinue belimumab due to suboptimal treatment response per physician judgement, especially those with moderate-to-high activity and severe arthritis. Improvement in PGA at 3 months predicts long-term drug maintenance, therefore suggesting its value for patient monitoring. Our data confirm the very good tolerability of belimumab and identify hydroxychloroquine co-administration as a predictor for prolonged safety-related drug survival.

Acknowledgements

The study was partly funded by the Greek Rheumatology Society and the Greek Association of Professional Rheumatologists (ERE-EPERE) and by Pfizer Global Medical Grants

Disclosure of Interests

Myrto Nikoloudaki: None declared, Dionysis Nikolopoulos: None declared, SOFIA KOUTSOVITI: None declared, Irini Flouri: None declared, Noemin Kapsala: None declared, ARGYRO REPA: None declared, PELAGIA KATSIMPRI: None declared, EVANGELOS THEOTIKOS: None declared, Sofia Pitsigavdaki: None declared, Katerina Pateromichelaki: None declared, Anastasios Eskitzis: None declared, ANTONIA ELEZOGLOU: None declared, Prodromos Sidiropoulos: None declared, Antonis Fanouriakis: None declared, Dimitrios Boumpas: None declared, George Bertsias Speakers bureau: GSK, AstraZeneca, Pfizer, SOBI, UCB, Novartis, AENORASIS, Abbvie, Grant/research support from: GSK, Pfizer

POS0461 DISRUPTED HIPPOCAMPAL NEUROGENESIS MEDIATED BY IL-6 AND IL-18 INDUCE NEUROPSYCHIATRIC CHANGES IN MURINE LUPUS

Background

Systemic lupus erythematosus (SLE) frequently affects the nervous system (NPSLE), however, its pathogenesis is only partly understood. We have previously characterized the behavioral phenotype of the NZΒ/W-F1 lupus-prone mouse which recapitulates the NPSLE phenotype exhibiting hippocampal-linked behavior including depressive-like disorder, anxiety and cognitive impairment both at early and late stages of the disease characterized by a profound hippocampal inflammatory response1,2. Defective hippocampal neural stem cell (hNSC) response is associated with cognitive dysfunction, depression and anxiety, all of which represent common neuropsychiatric features of both human and murine SLE.

Objectives

To further investigate the hippocampal neurogenesis in lupus mice and determine its involvement in disease pathogenesis.

Methods

All experiments were performed in female NZW/NZB F1 and C57BL/6 (WT) mice at the age of 3 months (pre-nephritic) and 6 months (nephritic stage) (n=5-8/condition/experiment). Neurogenesis was assessed in sagittal sections of hippocampus by immunohistochemical staining (DCX, Sox2, GFAP, Iba1) and morphological criteria. RNA-sequencing was performed in hippocampal tissue followed by pathway and enrichment analysis. Apoptosis (cleaved-caspase 3) and immune cell infiltration (CD11b, CD45, Ly6G, Ly6C, MHC-II, CD4, CD8, B220, Iba1, CD80, CD86, Argianse-1, iNOS) were assessed by flow-cytometry. Cytokines levels were measured by Legendplex. Ex vivo assays were performed in adult hippocampal neural stem cells extracted by 2-month-old female WT mice.

Results

We identified a profound disruption (~2-fold) of hippocampal neurogenesis (decreased DCX+ cells) both at 3 ad 6 month-old lupus mice together with decreased differentiated cells in both time-points, suggesting that lupus mice exhibit impaired neuronal differentiation. Although the number of the neuronal precursors radial glial-like cells (RGLs) was normal at pre-nephritic stage, lupus mice express increased number of both activated RGLs (Sox2+/GFAP+) and proliferating neuronal progenitors (Sox2+ cells) indicating enhanced self-renewal ability of neural precursors and augmented proliferation. Levels of cleaved-caspase 3 were elevated in lupus hippocampus supporting increased hippocampal apoptosis. Transcriptomic analysis of hippocampal tissue revealed a profound inflammatory response in lupus mice. Flow-cytometry analyses showed a pronounced immune cell trafficking in lupus hippocampus with a myeloid predominant response –involving predominantly the microglia- both at early and late stages of the disease. Multiplex assays revealed elevated levels of IL-6 and IL-18 in lupus hippocampus. Ex vivo exposure of adult hNSCs to IL-6 or IL-18 promoted cell proliferation and induced apoptosis.

Conclusion

The NZB/W-F1 mouse model of SLE exhibits defective neurogenesis due to increased apoptosis, and decreased differentiation of neuronal progenitors. Inflammation in lupus hippocampus results in elevated levels of IL-6 and IL-18 with both cytokines negatively affecting the hNSCs response. IL-6 and IL-18 may induce behavioral changes in NZB/W-F1 lupus mediated by altered neurogenesis and may represent therapeutic targets in NPSLE.

References

[1]Nikolopoulos, D., et al. “THU0223 THE NEUROPSYCHIATRIC PHENOTYPE OF NZB/W LUPUS-PRONE MOUSE MODEL AT PRE-NEPHRITIC AND NEPHRITIC STAGES OF THE DISEASE: MURINE MODEL RECAPITULATES HUMAN DISEASE.” (2020): 334-335. http://dx.doi.org/10.1136/annrheumdis-2020-eular.1807

[2]Nikolopoulos D. et al. “OP0040 HIPPOCAMPAL IMMUNE CELL TRAFFICKING AND A MYELOID PREDOMINANT INFLAMMATORY RESPONSE WITH ENHANCED ANTIGEN PRESENTATION AND DECREASED LEVELS OF NEUROTRANSMITTERS UNDERLY THE NEUROPSYCHIATRIC PHENOTYPE OF THE NZW/NZB MURINE LUPUS MODEL.” (2021): 2021. http://dx.doi.org/10.1136/annrheumdis-2021-eular.3972

Acknowledgements

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests

None declared.

Demyelinating Syndromes in Systemic Lupus Erythematosus: Data From the "Attikon" Lupus Cohort

Background

The demyelinating syndromes of the central nervous system (CNS) that occur in the context of systemic lupus erythematosus (SLE) may represent a manifestation of neuropsychiatric lupus (NPSLE) or an overlap of SLE and multiple sclerosis (MS). The differential diagnosis between the two entities has important clinical implications because the therapeutic management differs.

Objectives

To characterize CNS demyelinating syndromes in a large SLE cohort as neuropsychiatric SLE (NPSLE) or SLE-MS overlap using a multidisciplinary approach and existing diagnostic (for MS) and classification criteria (for SLE).

Methods

Patients from the "Attikon" lupus cohort (n = 707) were evaluated for demyelinating syndromes. Clinical, laboratory, and neuroimaging data were recorded for each patient. Following multidisciplinary evaluation and application of criteria, the demyelinating syndrome was attributed to either SLE or MS. Patients with transverse myelitis were not included in this study.

Results

We identified 26 patients with demyelinating syndromes (3.7%). Of them, 12 were diagnosed as primary SLE-demyelination (46.2%) and 14 as overlap SLE-MS (53.8%). The two groups did not differ with respect to rheumatologic and neurologic manifestations or autoantibodies. SLE patients with demyelination manifested mild extra-CNS disease mainly involving joints and skin, while severe non-CNS manifestations were rare. However, these patients were less likely to have elevated IgG index (OR 0.055 95% CI: 0.008-0.40) and positive oligoclonal bands (OR 0.09 95% CI: 0.014-0.56), as well as brain lesions in the spinal cord, infratentorial, periventricular, and juxtacortical regions. A single brain region was affected in 9 patients with SLE-demyelination (75%), while all patients with MS-SLE had multiple affected brain regions. MS-SLE overlap was associated with an increased likelihood of neurologic relapses (OR 18.2, 95% CI: 1.76-188), while SLE-demyelination patients were less likely to exhibit neurological deficits (EDSS >0) at the last follow-up visit (50 vs. 78.6% in SLE-MS, respectively).

Conclusions

Demyelination in the context of SLE follows a more benign course compared to a frank SLE-MS overlap. Extension of follow-up will ascertain whether patients with SLE-demyelination evolve to MS, or this is a bona fide NPSLE syndrome.

Tailored treatment strategies and future directions in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) represents a diagnostic and therapeutic challenge for physicians due to its protean manifestations and unpredictable course. The disease may manifest as multisystemic or organ-dominant and severity at presentation may vary according to age at onset (childhood-, adult- or late-onset SLE). Different manifestations may respond variably to different immunosuppressive medications and, even within the same organ-system, the severity of inflammation may vary from mild to organ-threatening. Current "state-of-the-art" in SLE treatment aims at remission or low disease activity in all organ systems. Apart from hydroxychloroquine and glucocorticoids (which should be used with caution), the choice of the appropriate immunosuppressive agent should be individualized and depend on the prevailing manifestation, severity stratification and patient childbearing potential. In this review, we provide an overview of therapeutic options for the various organ manifestations and severity patterns of the disease, different phenotypes (such as multisystem versus organ-dominant disease), as well as specific considerations, including lupus with antiphospholipid antibodies, childhood and late-onset disease, as well as treatment options during pregnancy and lactation.

First Diagnosis of Systemic Lupus Erythematosus in Hospitalized Patients: Clinical Phenotypes and Pitfalls for the Non-Specialist

BACKGROUND

Prompt recognition of systemic lupus erythematosus (SLE) in hospitalized patients presenting with severe disease is essential to initiate treatment. We sought to characterize the phenotype of hospitalized patients with new-onset SLE and estimate potential diagnostic delays.

METHODS

An observational study of 855 patients ("Attikon" SLE cohort). Clinical phenotype was categorized according to the leading manifestation that led to hospitalization. Disease features, time to diagnosis, classification criteria, and the SLE Risk Probability Index (SLERPI) were recorded for each patient.

RESULTS

There were 191 patients (22.3% of the total cohort) hospitalized due to manifestations eventually attributed to SLE. Main causes of admission were neuropsychiatric syndromes (21.4%), cytopenias (17.8%), nephritis (17.2%), and thrombotic events (16.2%). Although 79.5% of patients were diagnosed within 3 months from hospitalization, in 39 patients diagnosis was delayed, particularly in those with hematological manifestations. At hospitalization, a SLERPI >7 (indicating high probability for SLE) was found in 87.4% of patients. Patients missed by the SLERPI had fever, thrombotic or neuropsychiatric manifestations not included in the algorithm. Lowering the SLERPI threshold to 5 in patients with fever or thrombotic events increased the diagnostic rate from 88.8% to 97.9% in this subgroup, while inclusion of all neuropsychiatric events yielded no additional diagnostic value.

CONCLUSION

One in five patients with new-onset SLE manifest disease presentations required hospitalization. Although early diagnosis was achieved in the majority of cases, in approximately 20%, diagnosis was delayed. A lower SLERPI cut-off (≥5) in patients with fever or thrombosis could enhance early diagnosis.

Demyelination with autoimmune features: a distinct clinical entity? Results from a longitudinal cohort

OBJECTIVE

CNS demyelinating syndromes occurring in the context of SLE may represent a manifestation of neuropsychiatric lupus, or an overlap of SLE and multiple sclerosis (MS). We evaluated prospectively patients presenting with demyelinating syndrome for clinical and serological evidence of SLE and characterized the evolution of their clinical syndrome to a defined disease.

METHODS

Patients with CNS demyelinating syndromes not fulfilling the criteria for MS were evaluated in a rheumatology unit for features of SLE and followed longitudinally (enrolment period 2016-20). Clinical, laboratory and neuroimaging data were recorded at every visit, following multidisciplinary evaluation. At end of follow-up, patients were assessed for their final neurological and rheumatological diagnosis, and classified accordingly.

RESULTS

A total of 79 patients were included in the study [91.1% female, mean (s.d.) age at first demyelinating episode 38.4 (10.3) years, median (interquartile range) observation period 39 (57) months]. At last follow-up, 38 patients (48.1%) had evolved into MS. Of the remaining patients, 7 (17.1%) had SLE, while 34 (82.9%) had features of systemic autoimmunity without fulfilling classification criteria for SLE. The most common rheumatological features of these patients were inflammatory arthritis (73.5%), acute cutaneous lupus (47.1%) and positive ANA (72.1%). Importantly, these patients were less likely to have elevated IgG index (odds ratio 0.11, 95% CI 0.04, 0.32) and positive oligoclonal bands (odds ratio 0.21, 95% CI 0.08, 0.55).

CONCLUSION

A significant number of patients with demyelination do not fulfill criteria for either MS or SLE at follow-up. These patients exhibit lupus-like autoimmune features and may represent a distinct entity, 'demyelination with autoimmune features'.

Quality indicators for systemic lupus erythematosus based on the 2019 EULAR recommendations: development and initial validation in a cohort of 220 patients

BACKGROUND

Quality of care is receiving increased attention in systemic lupus erythematosus (SLE). We developed quality indicators (QIs) for SLE based on the 2019 update of European League Against Rheumatism recommendations.

METHODS

A total of 44 candidate QIs corresponding to diagnosis, monitoring and treatment, were independently rated for validity and feasibility by 12 experts and analysed by a modified Research and Development Corporation/University of California Los Angeles model. Adherence to the final set of QIs and correlation with disease outcomes (flares, hospitalisations and organ damage) was tested in a cohort of 220 SLE patients with a median monitoring of 2 years (IQR 2-4).

RESULTS

The panel selected a total of 18 QIs as valid and feasible. On average, SLE patients received 54% (95% CI 52.3% to 56.2%) of recommended care, with adherence ranging from 44.7% (95% CI 40.8% to 48.6%) for diagnosis-related QIs to 84.3% (95% CI 80.6% to 87.5%) for treatment-related QIs. Sustained remission or low disease activity were achieved in 26.8% (95% CI 21.1% to 33.2%). Tapering of prednisone dose to less than 7.5 mg/day was achieved in 93.6% (95% CI 88.2% to 97.0%) while 73.5% (95% CI 66.6% to 79.6%) received the recommended hydroxychloroquine dose. Higher adherence to monitoring-related QIs was associated with reduced risk for a composite adverse outcome (flare, hospitalisation or damage accrual) during the last year of observation (OR 0.97 per 1% adherence rate, 95% CI 0.96 to 0.99).

CONCLUSION

We developed QIs for assessing and improving the care of SLE patients. Initial real-life data suggest face validity, but a variable degree of adherence and a need for further improvement.

POS0764 EULAR RECOMMENDATION-BASED QUALITY INDICATORS (QIS) FOR SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): ELABORATION, FINAL SET, PERFORMANCE AND INITIAL VALIDATION

Background:

Targets of therapy and quality of care are receiving increased attention in systemic lupus erythematosus (SLE).

Objectives:

To develop Quality Indicators (QIs) for the care of SLE patients based on the EULAR recommendations, and assess their performance.

Methods:

Using the published EULAR recommendations for SLE, we developed 44 candidate QIs. These were independently rated for validity and feasibility by 12 experts, analysed by a modified RAND/UCLA model and further scrutinized based on the scorings and expert opinion. (Fig.1) Adherence to the final set of QIs was tested in a cohort of 220 SLE patients combined with an assessment on its impact on disease outcomes such as flares, hospitalizations and organ damage.

Results:

The panel rated 18 QIs as valid and feasible. These involve diagnosis; disease and damage assessment; monitoring for lupus nephritis and drug toxicity; therapy and targets of therapy; fertility and pregnancy; and adjunct therapy (preventive measures for osteoporosis, vaccination, cardiovascular disease). On average, SLE patients received 54% (95%CI 52–56%) of the indicated care with adherence ranging from 41% for QIs related to monitoring to 88% for treatment-related QIs. Regarding targets of therapy, sustained remission or low disease activity were achieved in 27%, while 94% of patients received low-dose glucocorticoids, and 92% the recommended hydroxychloroquine dose. Dependent upon individual QI tested, adherence for lupus nephritis-related QIs was 88% for receiving appropriate adjunct therapy (ACE inhibitors) to 100% for being treated with the indicated immunosuppressive treatment. In contrast, adherence to QIs related to preventive measures and other adjunct therapies was moderate to low. Notably, patients who were eligible for cardiovascular risk modification, vaccination, and osteoporosis management received lower quality of care (40.5%, 47.7% and 45.5% respectively) while 91.4% had sunscreen protection. In reference to laboratory work-up and monitoring, complete laboratory work-up at diagnosis was performed in 48%, while disease activity and damage, were fully assessed only in 14.1% (in three consecutive visits) and 28.6% (annually) respectively, Similarly, reproductive health and pregnancy counselling adherence rates were modest estimated at 50% and 62% respectively. Higher adherence to the indicated care during follow-up (monitoring QIs) was associated with reduced risk for adverse outcomes during the last year of observation (OR 0.97, 95%CI 0.96-0.99). Patients who achieved sustained remission or LLDAS, exhibited fewer flares (OR=0.15, p-value<0.001) and damage accrual (OR=0.35, p-value<0.001). Of interest, patients who received low-dose of GCs or were appropriately vaccinated, had a lower risk of experiencing a flare (OR=0.23 and 0.46 respectively).

Conclusion:

A set of 18 QIs based on the EULAR recommendations for SLE was developed to be used towards improving care in SLE. Initial real-life data suggest variable degree of adherence with higher adherence resulting in reduced adverse outcomes.

References:

[1]Fanouriakis, et al., 2019 Update of the EULAR recommendations for the management of systemic lupus erythematosus. In Annals of the Rheumatic Diseases (Vol. 78, Issue 6, pp. 736–745). BMJ Publishing Group. https://doi.org/10.1136/annrheumdis-2019-215089.

[2]Nikolopoulos, D., et al., Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the ‘Attikon’ cohort. Lupus, 29(5), 514–522. https://doi.org/10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

POS0421 COMBINED ANALYSIS OF METABOLIC AND TRANSCRIPTOMIC KIDNEY PROFILES OF NZW/B-F1 MURINE LUPUS UNCOVERS BIOLOGICAL MECHANISMS PRECEDING THE ONSET OF NEPHRITIS

Background:

Metabolic pathways are important regulators of immune differentiation and activation in kidneys. Kidneys directly impact systemic metabolism, circulating metabolite levels, and express intrinsic metabolic activity. The integration of renal metabolomic and transcriptomic profiles may unravel unique gene-metabolite pairs of biological significance in lupus nephritis (LN).

Objectives:

To decipher gene-metabolite signatures at both pre-nephritic and nephritic stages of lupus.

Methods:

Kidneys were isolated and snap-frozen after perfusion from female NZB/NZW-F1 lupus mice at the pre-nephritic (3-month-old) and nephritic (6-month-old exhibiting ≥100 ng/dL of urine protein) stage of lupus (n=6/group). Age-matched female C57BL/6 mice were used as healthy controls. Sample extracts were used for RNA sequencing and 1H-NMR spectroscopy metabolic profiling. DESeq2 was used to identify differentially expressed genes. Univariate analysis was used to reveal metabolic differences characteristic for nephritis.

Results:

Comparative transcriptomic analyses uncovered multiple transcripts related to metabolic pathways: In pre-nephritic kidneys, lipid metabolism, cellular respiration, TCA cycle, amino acid metabolism processes were overrepresented in the upregulated genes while in nephritic kidneys, amino acid metabolism processes were overrepresented among the downregulated genes (Figure 1). 1H-NMR analysis revealed a total of 49 metabolites. Comparison of the metabolic levels of nephritic and pre-nephritic animals revealed that ADP, ATP, NAD+, Taurine and Myo-inositol decreased, while Thr increased significantly. The comparison to corresponding control animals, demonstrated that only myo-inositol increased significantly. Integration of kidney metabolomics and transcriptomics indicated the involvement of processes related to glutathione metabolism, leukocyte trans-endothelial migration and antigen presentation during the established renal disease stage.

Conclusion:

The combined transcriptomics and metabolomics analysis revealed metabolic derangements in lupus-affected kidneys both during subclinical and overt LN. Deregulated tissue-levels of taurine and myo-inositol at the subclinical stage of the disease suggest aberrant renal biochemistry preceding the development of overt LN that may directly impact systemic metabolism and circulating metabolite levels.

Figure 1.

Pathways linked to cell metabolism were overrepresented among 3-month upregulated and 6-month lupus mice (F1) downregulated DEGS (differentially expressed genes) compared to controls (C57BL/6).

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390).

Disclosure of Interests:

None declared

POS0759 THE JOURNEY OF PATIENTS FROM FIRST SYMPTOMS TO DIAGNOSIS OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): AN OBSERVATIONAL STUDY

Background:

The lack of pathognomonic features poses a considerable challenge in SLE diagnosis. The time from symptom onset to diagnosis has been reported to range from two to six years1.

Objectives:

To document the initial symptoms of the disease and the time lapse until its diagnosis.

Methods:

We examined 438 patients from the “Attikon” SLE cohort2. For diagnosis, we used the classification criteria (ACR, SLICC, EULAR-ACR) or in few cases clinical diagnosis (n=32, 7.3%). Data were collected using patient interviews, in-person clinical visits and medical charts review. Initial symptoms were recorded and determined chronologically using prespecified forms with a list of typical manifestations (skin, joints, renal, nervous system, pleuropulmonary, cardiovascular, anti-phospholipid syndrome) as well as characteristic disease features (Raynaud’s phenomenon, fatigue, fever, sicca symptoms). Questions also included the time between symptom onset and initial physician visit, the time from first medical consultation until first rheumatologist assessment, the time from rheumatologist assessment to SLE definite diagnosis, the number of physicians seen before SLE diagnosis, the specialty of first physician and of diagnosing physician. Information on demographic and clinical characteristics, disease activity and disease damage, was collected both at enrolment and at last follow-up visit.

Results:

88.5% of patients were females, mean (±SD) age at diagnosis was 41.9 years ± 15.4 and disease duration was 6.7 ± 7 years. Most common systems involved were joints (94.5%), skin (73.7%), blood (39.2%) and renal (17.5%). At diagnosis, 9.8% of patients were ANA negative. The most common initial symptoms at disease onset were arthritis/arthralgia (74.4%), followed by fatigue (53.1%) and photosensitive rash (50.9%) (Table 1). Among non-criteria features, Raynaud’s phenomenon was reported by 146 patients (33.3%) prior the diagnosis. The median interval between symptoms onset and the SLE diagnosis was 16 months (IQR 5-60). SLE was diagnosed earlier in ANA-positive than -negative patients [median time 14 months (IQR 5-60) vs 36 months (IQR 10.5-84); P=0.1, t-test]. Approximately half of the patients (52.5%) were diagnosed after 12 months from disease onset with only 15.9% diagnosed within 3 months of symptoms presentation. The median lag time between onset of symptoms and the first medical consultation was 2 months (IQR 1-12). Internists were the most common first consultants (27.8%) followed by orthopedists (15.9%), dermatologists (13.6%) and rheumatologists (13.4%). The median interval between the first medical assessment and first rheumatologist evaluation was 3 months (IQR 0-11.5) while the median time from rheumatologist assessment to definite diagnosis was 0 months (IQR 0-4). SLE patients consulted an average of 3 different physicians before the definite diagnosis, which in 95.8% was established by rheumatologists.

Conclusion:

Approximately 50% of patients were diagnosed with SLE after 12 months from symptom onset with a mean time from symptoms to definite diagnosis almost 4 years. Increasing awareness of internists to SLE and avoidance of strict adherence to ANA as a requirement for diagnosis may improve early diagnosis.

Table 1.

Initial symptoms prior to diagnosis

SymptomsN=438 (%)Duration*(mean months ±SD)Arthralgias326 (74.4)37.5 ±69.4Photosensitive rash223 (50.9)30.6 ±70.2Malar rash168 (38.3)22.6 ±62Alopecia167 (38.1)19.6 ±54.6Ulcers106 (24.2)16.8 ±54.4Fever103 (23.5)9.3 ±43.8Raynaud’s phenomenon146 (33.3)22.3 ±68.5Fatigue233 (53.1)19.7 ±45.7

*Mean time from symptom onset to established diagnosis

References:

[1]Nightingale AL, Davidson JE, Molta CT et al. Lupus Science & Medicine 2017; doi:10.1136/lupus-2016-000172.

[2]D Nikolopoulos et al. Lupus 2020; doi: 10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

OP0040 HIPPOCAMPAL IMMUNE CELL TRAFFICKING AND A MYELOID PREDOMINANT INFLAMMATORY RESPONSE WITH ENHANCED ANTIGEN PRESENTATION AND DECREASED LEVELS OF NEUROTRANSMITTERS UNDERLY THE NEUROPSYCHIATRIC PHENOTYPE OF THE NZW/NZB MURINE LUPUS MODEL

Background:

Neuropsychiatric events are common in patients with systemic lupus erythematosus (SLE), yet the underlying pathogenesis remains ill-defined, as the access to brain tissue is limited. We have previously shown that NZW/NZB F1 murine lupus model recapitulates the neuropsychiatric lupus phenotype including depressive-like behavior, increased rates of anxiety, cognitive dysfunction and motor disturbances, both at pre-nephritic and nephritic stages of the disease.

Objectives:

To dissect specific regions in the brain, which account for this phenotype and elucidate inflammatory and non-inflammatory mechanisms involved.

Methods:

Four distinct brain regions (hippocampus, amygdala, striatum and pre-frontal cortex) were dissected from brains of female C57BL/6 (WT) and NZW/NZB F1 mice at the age of 3 months (pre-nephritic) and 6 months (nephritic stage) (n=5-8/condition/experiment). Since most of the behavioral phenotype corresponds to the hippocampus, we first examined in depth the hippocampal pathology by bulk RNA sequencing, measurements of neurotransmitters levels via high-performance liquid chromatography (HPLC) and by immunophenotyping via flow cytometry analyses. For comparisons, statistical significance was indicated as a two-sided P<0.05.

Results:

Transcriptomic analysis revealed aberrant immune mediated response in the hippocampus of 6 month-old lupus mice compared to WT. Specifically, inflammatory pathways including both innate and adaptive immune responses, increased cytokine production, increased antigen presentation and immune cell trafficking, along with increased apoptosis and decreased cell proliferation suggest that immune aberrancies may lead to neuronal damage. These aberrancies were present in mice at 3 month-old, yet were progressed with time being more prominent at 6 month of age in lupus hippocampus. The RNA sequencing date were validated by immunophenotyping on lupus hippocampus demonstrating increased reactive GFAP+ astrocytes both at 3 and 6-month old mice. Activated IBA1+ microglia and CD11b+CD45hi CNS myeloid cells were increased only at 6 months of age. Furthermore, increased immune cell infiltration from the periphery including lymphocytes (CD45+CD11b-) mainly T cells (CD4+/CD8+) and monocytes (CD45+CD11b+Ly6G-Ly6C+), was evident only in 6 month-old lupus hippocampus compared to WT. Importantly, microglia cells in lupus hippocampus at 6 but not at 3 month of age, exhibited increased expression of antigen presenting markers including CD80, CD86 and MHC-II indicating that microglia cells may carry out the antigen presentation process seen in transcriptomic data. Low levels of serotonin and noradrenaline were observed at both 3 and 6 months of age in lupus mice; these aberrancies were mainly attributed to decreased serotonin synthesis as evidenced by intact serotonin metabolism (no differences were observed at its metabolite: 5-hydroxyindoleacetic acid). Analysis of the remaining regions of the brain combined with studies of metabolic activities of various brain regions by PET-CT scanning is in progress.

Conclusion:

Immune cell trafficking from the periphery combined with marked inflammatory response in the hippocampus underlie the neuropsychiatric phenotype in NZW/B murine lupus. Our data indicate increased expression of activated myeloid cells -including microglia- in the hippocampus of lupus mice culminating in increased antigen presentation and decreased neurotransmitter levels.

References:

[1]Nikolopoulos, D., et al. “THU0223 THE NEUROPSYCHIATRIC PHENOTYPE OF NZB/W LUPUS-PRONE MOUSE MODEL AT PRE-NEPHRITIC AND NEPHRITIC STAGES OF THE DISEASE: MURINE MODEL RECAPITULATES HUMAN DISEASE.” (2020): 334-335.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

POS0757 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) DIAGNOSED DURING HOSPITALIZATION: CLINICAL PHENOTYPE AND PERFORMANCE OF THE SLE RISK PROBABILITY INDEX (SLERPI)

Background:

Systemic Lupus Erythematosus (SLE) can first present with severe or critical disease leading to hospitalization. Prompt recognition of the disease in hospitalized patients may lead to early institution of treatment and improve outcomes. We have recently developed a clinician-friendly algorithm for SLE diagnosis based on classical clinical and serological SLE features [SLE Risk Probability Index (SLERPI)]1.

Objectives:

To determine the clinical phenotype of SLE patients first diagnosed during hospitalization, the interval between hospitalization and SLE diagnosis and the potential impact of SLERPI on early diagnosis.

Methods:

Mixed prospective (from June 2020 to January 2021) and retrospective study of SLE patients from “Attikon” cohort (n=820)2. Clinical phenotype was divided into 10 core domains (neuropsychiatric, thrombosis, nephritis, serosal, haematologic, pulmonary, cardiovascular, gastrointestinal, skin-joints, other). Chart review and patient interview was performed to assess the lag time between 1) the onset of symptoms and 2) the hospitalization and the final diagnosis. Demographic and clinical characteristics, SLERPI and SLICC damage index were recorded for each patient at the time of diagnosis. SLE diagnosis was based on at least one of the three existing classification criteria.

Results:

Out of 820 SLE patients, 202 (24.6%) diagnosed during hospitalization were included. Among them, 185 patients (91.5%) were hospitalized because of a lupus related feature, while in the remaining 17 SLE patients, hospitalization was due to non-lupus related manifestations. The most common lupus-related clinical phenotype leading to hospital admission was neuropsychiatric lupus (n=51, 25.2%) with cerebrovascular events constituting the dominant clinical syndrome (n=8/51). Thrombotic events (n=32, 15.8%), mainly pulmonary embolism (n=20/32), cytopenias (n=32, 15.8%), lupus nephritis (n=30, 14.8%), skin-joint disease (n=26, 12.8%) and serositis (n=24, 11.8%) were also common as dominant manifestations. Pulmonary disease (n=16, 7.9%), heart disease (n= 4, 1.9%) and gastrointestinal disease (n=2, 0.9%) were less common. On admission, 11.3% of patients (n=23) had symptoms from at least 2 clinical domains as defined. Most patients (93.5%) had multisystem disease while only 6.5% had organ-dominant disease. Early diagnosis (within 3 months from hospitalization) was established in 86.6% while 27 patients had their SLE diagnosis more than 3 months from hospitalization. The mean lag time between the hospitalization and the diagnosis was approximately 14 months (SD 19.9). Overall, the mean interval between the onset of symptoms and the diagnosis was 48.2 months (SD 73.2). Importantly, a SLERPI >7 (suggesting probable SLE) at hospitalization was present in 92.5% of SLE patients with delayed diagnosis.

Conclusion:

One out of four SLE patients first present with moderate to severe disease necessitating hospitalization, while in approximately 15% of such patients, diagnosis is initially missed. Application of the SLERPI may facilitate early SLE diagnosis.

References:

[1]Adamichou C et al. Ann Rheum Dis. 2021; DOI: 10.1136/annrheumdis-2020-219069.

[2]D Nikolopoulos et al. Lupus 2020; doi: 10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

Lupus or not? SLE Risk Probability Index (SLERPI): a simple, clinician-friendly machine learning-based model to assist the diagnosis of systemic lupus erythematosus

Objectives

Diagnostic reasoning in systemic lupus erythematosus (SLE) is a complex process reflecting the probability of disease at a given timepoint against competing diagnoses. We applied machine learning in well-characterised patient data sets to develop an algorithm that can aid SLE diagnosis.

Methods

From a discovery cohort of randomly selected 802 adults with SLE or control rheumatologic diseases, clinically selected panels of deconvoluted classification criteria and non-criteria features were analysed. Feature selection and model construction were done with Random Forests and Least Absolute Shrinkage and Selection Operator-logistic regression (LASSO-LR). The best model in 10-fold cross-validation was tested in a validation cohort (512 SLE, 143 disease controls).

Results

A novel LASSO-LR model had the best performance and included 14 variably weighed features with thrombocytopenia/haemolytic anaemia, malar/maculopapular rash, proteinuria, low C3 and C4, antinuclear antibodies (ANA) and immunologic disorder being the strongest SLE predictors. Our model produced SLE risk probabilities (depending on the combination of features) correlating positively with disease severity and organ damage, and allowing the unbiased classification of a validation cohort into diagnostic certainty levels (unlikely, possible, likely, definitive SLE) based on the likelihood of SLE against other diagnoses. Operating the model as binary (lupus/not-lupus), we noted excellent accuracy (94.8%) for identifying SLE, and high sensitivity for early disease (93.8%), nephritis (97.9%), neuropsychiatric (91.8%) and severe lupus requiring immunosuppressives/biologics (96.4%). This was converted into a scoring system, whereby a score >7 has 94.2% accuracy.

Conclusions

We have developed and validated an accurate, clinician-friendly algorithm based on classical disease features for early SLE diagnosis and treatment to improve patient outcomes.

Treatment of neuropsychiatric systemic lupus erythematosus: clinical challenges and future perspectives

Introduction: Neuropsychiatric (NP) involvement represents an emerging frontier in systemic lupus erythematosus (SLE), posing significant challenges due to its clinical diversity and obscure pathophysiology. The authors herein discuss selected aspects in the management of NPSLE based on existing literature and our experience, aiming to facilitate routine medical care.Areas covered: Research related to diagnosis, neuroimaging, treatment and outcome is discussed, focusing on data published in PubMed during the last 5 years. Selected translational studies of clinical relevance are included.Expert opinion: Identification of NPSLE patients who may benefit from appropriate treatment can be facilitated by attribution algorithms. Immunosuppressants are typically indicated in recurrent seizures, optic neuritis, myelopathy, psychosis and peripheral nerve disease, although a low threshold is recommended for cerebrovascular disease and other NP manifestations, especially when SLE is active. With the exception of stroke with positive antiphospholipid antibodies, anti-coagulation is rarely indicated in other syndromes. Refractory NPSLE can be treated with rituximab, whereas the role of other biologics remains unknown. Advances in the fields of biomarkers, neuroimaging for brain structural, perfusion or functional abnormalities, and design of novel compounds targeting not only systemic autoimmunity but also inflammatory and regenerative pathways within the nervous system, hold promise for optimizing NPSLE management.

Lupus or not? SLE Risk Probability Index (SLERPI): a simple, clinician-friendly machine learning-based model to assist the diagnosis of systemic lupus erythematosus

OBJECTIVES

Diagnostic reasoning in systemic lupus erythematosus (SLE) is a complex process reflecting the probability of disease at a given timepoint against competing diagnoses. We applied machine learning in well-characterised patient data sets to develop an algorithm that can aid SLE diagnosis.

METHODS

From a discovery cohort of randomly selected 802 adults with SLE or control rheumatologic diseases, clinically selected panels of deconvoluted classification criteria and non-criteria features were analysed. Feature selection and model construction were done with Random Forests and Least Absolute Shrinkage and Selection Operator-logistic regression (LASSO-LR). The best model in 10-fold cross-validation was tested in a validation cohort (512 SLE, 143 disease controls).

RESULTS

A novel LASSO-LR model had the best performance and included 14 variably weighed features with thrombocytopenia/haemolytic anaemia, malar/maculopapular rash, proteinuria, low C3 and C4, antinuclear antibodies (ANA) and immunologic disorder being the strongest SLE predictors. Our model produced SLE risk probabilities (depending on the combination of features) correlating positively with disease severity and organ damage, and allowing the unbiased classification of a validation cohort into diagnostic certainty levels (unlikely, possible, likely, definitive SLE) based on the likelihood of SLE against other diagnoses. Operating the model as binary (lupus/not-lupus), we noted excellent accuracy (94.8%) for identifying SLE, and high sensitivity for early disease (93.8%), nephritis (97.9%), neuropsychiatric (91.8%) and severe lupus requiring immunosuppressives/biologics (96.4%). This was converted into a scoring system, whereby a score >7 has 94.2% accuracy.

CONCLUSIONS

We have developed and validated an accurate, clinician-friendly algorithm based on classical disease features for early SLE diagnosis and treatment to improve patient outcomes.

The role of plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis: a meta-analysis

BACKGROUND

Plasma exchange (PLEX) in addition to standard immunosuppressive treatment in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AVV) remains controversial. The aim of this study is to evaluate the effect of PLEX on AVV outcomes.

METHODS

Literature search was performed using Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov databases, and Google Scholar. The statistical meta-analysis and leave-one-out analysis were conducted using the Review Manager 5.3 and Open Meta-Analyst software, respectively.

RESULTS

Ten studies were included in the meta-analysis comprising 1235 patients; 633 received conventional treatment and 602 were treated with PLEX in conjunction with induction therapy. PLEX was not associated with lower rates of either mortality at 3 (RR: 0.79, 95% CI: 0.19-3.25) and 12 months (RR: 0.73, 95% CI: 0.40-1.34) or ESRD at 3 (RR: 0.30, 95% CI: 0.30-2.42) and 12 months (RR: 1.32, 95% CI: 0.53-3.25). Similarly, no differences were captured concerning disease relapses (RR: 0.92, 95% CI: 0.62-1.36), the incidence of infections (RR: 1.05, 95% CI: 0.63-1.76), and severe adverse effects (RR: 1.04, 95% CI: 0.59-1.81). Time-to-event analysis revealed lower incidence of ESRD (HR: 0.71, 95% CI: 0.55-0.92) among patients who received PLEX, while the overall mortality was similar (HR: 0.96, 95% CI: 0.72-1.29) between the two groups.

CONCLUSION

The present meta-analysis does not support the wide use of PLEX for the management of AAV in routine clinical practice. Future well-designed randomized controlled trials focusing on specific disease-related manifestations are necessary to reach firm conclusions about the potential efficacy of PLEX. Key Points • PLEX is not widely recommended for the management of ANCA-associated vasculitis. • PLEX performance may reduce the overall incidence of ESRD in severe ANCA-associated vasculitis. • Well-designed randomized controlled trials focusing on specific disease-related manifestations are necessary to reach firm conclusions about the potential efficacy of PLEX on AAV-related outcome.

THU0223 THE NEUROPSYCHIATRIC PHENOTYPE OF NZB/W LUPUS-PRONE MOUSE MODEL AT PRE-NEPHRITIC AND NEPHRITIC STAGES OF THE DISEASE: MURINE MODEL RECAPITULATES HUMAN DISEASE

Background:

The pathogenesis of neuropsychiatric lupus (NPSLE) remains ill-defined due to limited access to tissue and the diversity and complexity of clinical manifestations with most evidence deriving from animal studies in MLR/lpr lupus-prone mouse.

Objectives:

To phenotype and characterize the neuropsychiatric disease in New Zealand Black/White (NZΒ/W) F1 strain; a spontaneous lupus prone mouse which is characterized by systemic autoimmunity.

Methods:

Mice were tested in a comprehensive behavioral test battery to assess possible effects on general depressive-like disorders, anxiety, cognitive function and motor performance/coordination. The following tests were conducted in the same order for all subjects (All females, NZB/W strain n=13 and C57BL/6 n=14) at 3 and 6 months of age: Open field, Novel object recognition (NOR), Novel object location (NOL), Elevated plus maze (EPM), Rotarod, Tail suspension test (TST), Prepulse inhibition (PPI), and Sucrose preference test (SPT). For comparisons, statistical significance was indicated as a two-sided P<0.05.

Results:

NZB/W mice at 3 months and 6 months of age exhibit depressive-like disorder as assessed by SPT and TST (P <0.05 and <0.0001, respectively). Anxiety-like phenotype was evident in lupus-prone mice at both time points based on EPM test (Graph 1). Open-field test revealed decreased locomotor activity and rotarod (Graph 2) showed impaired motor coordination in 3 month-old and 6 month-old NZB/W mice (P<0.001 and <0.01, respectively). NZB/W mice exhibit cognitive dysfunction at 3 and 6 months of age based on NOR test (P<0.05). No differences in cognitive function was observed between the two groups (P=0.11). Prepulse inhibition test revealed decreased sensorimotor gating in 3 month-old NZB/W mice, a difference not reaching statistical significance (P=.078). It was not possible to interpret correctly the PPI at second time point (6 months of age) due to age-related hearing loss in B6 at 6 month-old. NZB/W become more anxious over the course of the disease as assessed by EPM (3 mo. versus 6 mo. P<0.001, paired t-test, Graph 1).

Conclusion:

The NZB/W lupus-prone strain exhibit depressive-like behavior, anxiety, cognitive impairment and motor disturbances both at early and late stages of the disease. This polygenic murine model may be more suitable for investigating the autoimmunity-mediated neuroinflammation in human SLE.

Disclosure of Interests: :

None declared

FRI0543 BIRTH REGISTRY OF WOMEN WITH SYSTEMATIC LUPUS ERYTHEMATOSUSAND COURSE OF THE DISEASE DURING FIRST YEARS POST-PARTUM-THE GREEK EXPERIENCE

Background:

Pregnancy in women with SLE Systematic Lupus Erythematosus (SLE) has been related with adverse events both in the mother and the foetus.1Many studies have reported relapse of the disease during the pregnancy and post-labour, while others have not confirmed this finding.2To this end, most of these results originate from retrospective studies with patients of diverge ethnicities.

Objectives:

To record the Greek experience with pregnancies in mothers with SLE and their outcomes, as well as the course of the disease during first year post labor.

Methods:

This is a prospective, multicentre, observation study lasting three years. Women diagnosed with SLE who became pregnant consented to be monitored by their treating Rheumatologist. A structured questionnaire is used for monitoring at the beginning of pregnancy (positive pregnancy test) and at least every 3 months thereafter, depending on the course of the disease and pregnancy, until one year after childbirth.

Results:

A total 64 women and 81 pregnancies were recorded (1.27 pregnancies per patient). Patient’s age at conception was 32.8 ± 5.9 years (mean ± standard deviation). Thirteen patients (20.3%) had past history of nephritis. Regarding pregnancy outcomes, 62 (76.5%) pregnancies ended in live births, miscarriages during 1st, 2ndand 3rdtrimester occurred in 13 (16%). Six pregnancies were lost to followup. Prematurity occurred in 28 live births (45.1% in total), 26-32w (3.2%), 32-36w (22.5%), <37w (19.3%). No cases of preeclampsia occurred. Mean age of birth36.9 weeksand mean birth weight2750gr.The majority (72.5%) of deliveries were performed by caesarean section. In terms of disease activity, most of the women had mild disease at conception, (SLEDAI-2K: 2.67±2.69) that declined during 1st/2ndpregnancy trimester (SLEDAI-2K:1.91±2.09, 1.70±2.22)) but increased during the 1stand 2ndtrimester post labor (SLEDAI-2K: 2.47±4.29 and 2.52±3.2).

Conclusion:

This is the first Greek inception cohort with prospective monitoring of pregnant SLE patients. Adverse outcomes occur with prematurity being the most frequent. In our cohort disease activity tends to increase during 1stand 2ndtrimester post-labor without serious relapses. Vigilant monitoring during pregnancy and post-labour is advised.

References:

[1] Bundhun PK, Soogund MZ, Huang F. Impact of systemic lupus erythematosus on maternal and fetal outcomes following pregnancy: A meta-analysis of studies published between years 2001-2016. J Autoimmun 2017;79:17-27. [https://doi. org/10.1016/j.jaut.2017.02.009] [PMID: 28256367]

[2] Wei S, Lai K, Yang Z, Zeng K. Systemic lupus erythematosus and risk of preterm birth: a systematic review and meta-analysis of observational studies. Lupus 2017;26:563-71. [https://doi. org/10.1177/0961203316686704] [PMID: 28121241]

Acknowledgments:

Hellenic Rheumatology Association

Disclosure of Interests:

Stella Ntali: None declared, Lina Pantazi: None declared, Kyriaki Boki: None declared, Dionysis Nikolopoulos: None declared, Antonis Fanouriakis: None declared, Despoina Dimopoulou: None declared, Ioannis Kallitsakis Grant/research support from: MSD, Speakers bureau: Genesis pharma, Bristol-Myers Squibb, CHARALAMPOS PAPAGORAS: None declared, Vasiliki Dania: None declared, Evgenia Emmanouilidou: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

FRI0170 THERAPEUTIC ΤARGETS AND QUALITY INDICATORS IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), DEFINED ACCORDING TO THE 2019 UPDATE OF THE EULAR RECOMMENDATIONS: DATA FROM THE “ATTIKON“ LUPUS COHORT

Background:

Targets of therapy and quality of care are receiving increased attention in the management of SLE, as outlined in the 2019 update of the EULAR recommendations for SLE treatment.

Objectives:

To assess compliance with quality indicators and attainment of treatment targets, according to recent EULAR recommendations, in the SLE cohort of “Attikon” Rheumatology Unit.

Methods:

100 consecutive SLE patients followed for at least one year were. A 30 item Quality Indicator Set (QIS) was developed, according to the 2019 EULAR recommendations for SLE, to include laboratory tests for diagnosis and monitoring, evaluation of disease activity and damage using validated indices, use of patient-reported outcomes, counselling for women’s health and reproduction issues, attainment of targets of therapy [remission or low disease activity state (LLDAS) with low-dose glucocorticoids (GC, ≤7.5mg/day prednizone) and hydroxychloroquine (HCQ dose≤5mg/kg/day)], prevention of disease flares and prevention and management of co-morbidities. Chart review and patient interview was performed to assess the degree of compliance with each item of the QIS and achievement of treatment targets.

Results:

Disease activity was monitored by means of validated indices in 31% and antiphospholipid antibody testing during the first 6 months from diagnosis was performed in 58.8% of patients. Sustained remission (defined as remission of a sustained period of 12 months) or LLDAS was achieved by only 3% and 22% respectively; in contrast, other targets of therapy, such as ≤1 minor flares during last year, were achieved by 85% (43% had complete absence of flares), with 90.2% of patients receiving low-dose GC and 81.8% corrected HCQ dose. Fertility and pregnancy counselling were offered in 40% (12/30 eligible women) and 63.3% (19/30) of patients, respectively, while 65.4% had a Pap Test and only 3 of 32 eligible patients had received the HPV vaccine. Annual lipid status was assessed in 43% and counselling for smoking cessation in 44.6%. Flu vaccination was performed in 77%, while pneumococcal (including both of the pneumococcal vaccines) and herpes-zoster vaccination, were given in 32.7% and 2% (1/44 eligible patients) respectively.

Conclusion:

Our real-life data suggest low vaccination rates (excluding flu) and suboptimal management of cardiovascular risk factors in lupus patients. While the majority of patients received the suggested doses of GC and HCQ, only one quarter of patients achieved remission or LLDAS. There is an unmet need for new therapies in SLE to improve therapy targets.

References:

[1]Arora S, Sequeira W, Yazdany J, Jolly M, “Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?”, Arthritis Care Res. 2018 Dec;70(12):1771-1777. doi: 10.1002/acr.23569. Epub 2018 Nov 10.

Disclosure of Interests:

KATERINA HAVATZA: None declared, KONSTANTINA TOGIA: None declared, Sofia Flouda: None declared, Antigoni Pieta: None declared, Ourania Gioti: None declared, Dionysis Nikolopoulos: None declared, Noemin Kapsala: None declared, Aliki Ntourou: None declared, Panagiota Rapsomaniki: None declared, Thaleia Gerogianni: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Theofanis Karageorgas: None declared, PELAGIA KATSIMPRI: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Konstantinos Thomas: None declared, DIMITRIOS BOUMPAS Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan

THU0245 PENALIZED REGRESSION ANALYSIS IDENTIFIES CRITERIA AND NON-CRITERIA FEATURES THAT MAY INCREASE THE ACCURACY OF EXISTING SETS OF CRITERIA FOR CLASSIFYING SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

The ACR-1997, SLICC-2012 and EULAR/ACR-2019 classification criteria have high sensitivity and specificity for SLE, yet they classify non-overlapping groups of patients suggesting that they can be supplemented with additional features to improve their diagnostic performance.

Objectives:

To identify criteria and non-criteria manifestations that are significantly associated with SLE in clinical practice and can be used to complement the existing sets of classification criteria.

Methods:

Individual items from all three classification criteria (ACR-1997, SLICC-2012, EULAR/ACR-2019) and non-criteria features were analyzed in a randomly selected sample of 800 adults diagnosed with SLE or control rheumatologic diseases (1:1 ratio). The classification performance of each set of criteria was analyzed in combination with complementary features; multivariable least absolute shrinkage and selection operator (LASSO) logistic regression was performed for feature selection. We calculated the diagnostic odds ratio (DOR) of the criteria and the additional features retained in each model.

Results:

Τhe EULAR/ACR-2019 and SLICC-2012 criteria have increased accuracy for SLE classification as compared to the ACR-1997 criteria (univariate DOR: 243.2 and 157.3versus78.8, respectively). In multivariable regression based on the ACR-1997 criteria, inclusion of additional features such as maculopapular rash, alopecia and hypocomplementemia significantly enhanced the model predictive capacity (area under the curve [AUC]: 0.95versus0.87 of the ACR-1997 criteria alone). Similar analysis based on the SLICC-2012 and EULAR/ACR-2019 criteria identified photosensitivity as an additional criterion significantly associated with SLE (multivariable DOR: 5.4 and 9.4, respectively). Accordingly, models including photosensitivity had superior predictive capacity over the criteria-only models (AUC: 0.94versus0.91 for SLICC-2012, 0.96versus0.91 for EULAR/ACR-2019). Furthermore, non-criteria features including Raynaud’s/livedo reticularis, anti-RNP antibodies, splenomegaly and myocarditis were independently associated with SLE thus enhancing further the predictive capacity of criteria-based models.

Conclusion:

We identified a number of criteria and non-criteria features which can be used in combination with the existing sets of criteria to increase classification of SLE patients in clinical practice. Photosensitivity could be considered as an additional feature to improve sensitivity of the recent classification criteria.

Disclosure of Interests:

Christina Adamichou: None declared, Irini Genitsaridi: None declared, Dionysis Nikolopoulos: None declared, Alessandra Bortoluzzi: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Eleni Kalogiannaki: None declared, Emmanouil Papastefanakis: None declared, Irini Gergianaki: None declared, Prodromos Sidiropoulos: None declared, Dimitrios Boumpas: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

AB0788 GENDER DIFFERENCES IN PSORIATIC ARTHRITIS DISEASE CHARACTERISTICS: EVIDENCE FOR WORSE DISEASE IN WOMEN

Background:

Psoriatic arthritis (PsA) affects both sexes equally, however there seem to be significant differences in disease expression between the genders.

Objectives:

To investigate gender differences in disease manifestations, patient-reported outcomes and comorbidities among patients with PsA.

Methods:

This cross-sectional study of patients with PsA followed at an academic rheumatology outpatient clinic between 1/6/2017 and 1/12/2019. We compared clinical characteristics, patient-reported outcomes, disease activity and comorbidities in male and female patients with PsA. All patients were over 18 years of age and fulfilled the CASPAR criteria for PsA. Differences between gender in values of continuous variables were assessed by T-tests or Mann-Whitney tests. The association between categorical variables and gender was assessed by Pearson chi-square test or Fisher’s exact test.

Results:

135 patients, 83 (62%) women and 52 (38%) men were included. Factors studied for gender differences are shown in Table 1. Women had significantly more tender (11 vs 3 p 0.001) and swollen (10 vs 3, p 0.013) joints, worse VAS (Visual Analogue Scale 0-10) pain (6 vs 5, p <0.001), higher ESR (20 vs 11, p 0.001) and worse DAPSA(Disease Activity in Psoriatic Arthritis) (33 vs 18 p 0.006) and presented with more enthesitis (32.5% vs 13.5%, p 0.013). In contrast, men achieved Minimal Disease Activity (MDA) more frequently (26.9% vs 3.6% p<0.001)and had significantly more comorbidities than women. Polyarthritic disease was more frequent in women (62% vs 31%), although at non-significant levels.

Conclusion:

Male patients with PsA have more comorbidities, while female patients have greater disease activity, worse patient reported outcomes and achieve MDA less frequently.

References:

[1]Determinants of Patient-Reported Psoriatic Arthritis Impact of Disease: An Analysis of the Association with Gender in 458 Patients from 14 Countries.

[2]Orbai AM, Perin J, et al Arthritis Care Res (Hoboken). 2019 Oct 14. doi: 10.1002/acr.24090.

FactorWomen (n=83)Men (n=52)P valueMedian (25th-75thpercentile)Age55.1 (46.8-63)56.6 (50-65.7)0.419*BMI27.9 (24.9-35)30.1 (26.8-33.3)0.181#Pso duration/ PsA duration (years)8.3 (3.9-24.5)/ 2.4 (0-5.7)14.3 (4.7-22.7)/ 2.8 (0-6.4)0.451#/0.605#Smoking (Packyears)15 (5-30)27.5 (0-46)0.002#TJC/SJC11 (4-16)/ 10 (5-17)3 (0-13)/ 3 (0-14)0.001#/0.013#VASPain/ VASGA6 (5-8)/ 5 (3-6)5 (1-6)/ 4 (2-5)<0.001*/0.121*CRP/ ESR1.4 (0.4-3.2)/20(11-33)1.1 (0.2-2.7)/ 11 (7-18)0.398#/0.001#BSA/PASI0 (0-2)/0(0-2)2 (0-6)/1(0-4.8)0.139#/0.258#DAPSA33 (24.1-45)18 (9.3-45)0.006#n (%)Enthesitis/ Dactylitis27 (32.5)/ 20 (24.1)7 (13.5)/ 10 (19.2)0.013***/ 0.508***Dyslipidemia33 (40.2)31 (59.6)0.029***Liver3 (3.6)7 (13.5)0.046**Eyes0 (0)3 (5.8)0.055**Uricemia3 (3.6)8 (15.4)0.023**Depression or anxiety16 (19.3)11 (21.1)0.817***CAD2 (2.4)12 (23.1)<0.001**DM14 (16.9)12 (23.1)0.392MDA3 (3.6)14 (26.9)<0.001

*: T-test with unequal variances;#: Mann-Whitney test; **: Fisher’s exact test; ***: Pearson chi2 test;

Pso: Psoriasis; PsA: Psoriatic arthritis; BMI: Body mass index; TJC: Tender joint count; SJC: Swollen joint count; VASPain: Visual analogue scale 0-10 for pain; VASGA: Visual analogue scale 0-10 for general assessement; CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; BSA: Body surface area; PASI: Psoriasis area severity index; DAPSA: Disease activity in psoriatic arthritis; CAD: Coronary artery disease; DM: Diabetes mellitus; MDA: Minimal disease activity;

Disclosure of Interests:

ALEXANDROS GRIVAS: None declared, IRENE KAPNIARI: None declared, KIMON TZANNIS: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Dimitra Kassara: None declared, KATERINA HAVATZA: None declared, Sofia Flouda: None declared, Dionysis Nikolopoulos: None declared, Theofanis Karageorgas: None declared, EVAGELIA PAPADAVID: None declared, DIMITRIOS BOUMPAS Grant/research support from: Unrestricted grant support from various pharmaceutical companies, PELAGIA KATSIMPRI: None declared

FRI0155 Α MULTICENTER “AT-RISK” COHORT FOR THE DISCOVERY OF ENVIRONMENTAL, CLINICAL AND MOLECULAR PREDICTORS FOR THE TRANSITION INTO SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

SLE onset is preceded by a preclinical phase evidenced by the presence of anti-nuclear and other autoantibodies (autoAbs), which however, have low predictive value for development of clinical SLE.

Objectives:

To define the subgroup of autoAbs-positive individuals who are at high risk for progression into SLE by integrating environmental, clinical/serological, genetic and transcriptome data.

Methods:

A multicenter, across five European countries, inception cohort of autoAbs-positive individuals or first-degree relatives (FDRs) of SLE patients who are monitored prospectively over five years for possible transition to SLE according to the classification criteria. Structured data collection on demographics, family and medical history, clinical (criteria and selected non-criteria manifestations) and serological parameters, use of medications, hydroxyvitamin D levels and lifestyle (tobacco, alcohol use, physical activity, adherence to Mediterranean diet). Blood samples are stored for RNA-sequencing and genotyping.

Results:

A total 254 at-risk individuals (93% women, 99% Caucasians, aged [mean ± standard deviation] 36 ± 12 years) have been included and enrolment/monitoring is still ongoing. Forty individuals (16%) have FDR with SLE and 88 individuals (35%) have FDR with another autoimmune disorder. The frequency of active and past use of tobacco was 28% and 20%, respectively. Sedentary lifestyle (moving only for necessary chores or outdoor activity 1-2 times/week) was reported by 54% and adherence to the Mediterranean diet was low (3.4 ± 2.3, maximum score: 9). At enrolment, individuals had 1.9 ± 1.1 ACR-1997 classification criteria, with anti-nuclear antibodies (ANA) being the most frequent (88%), followed by synovitis (39%), photosensitivity (33%) and immunologic disorder (30%) (Table 1). During follow-up of 15.2 ± 7.2 months, a total 15 individuals (5.9%) have progressed into classified SLE, including cases with severe hematological and neurological disease.

Table 1.

Baseline characteristics of the at-risk for SLE cohort

N (%) or mean ± SDACR 1997 classification criteria1.9 ± 1.1 Malar rash68 (27%) Discoid rash29 (11%) Photosensitivity83 (33%) Mucosal ulcers49 (19%) Synovitis100 (39%) Serositis30 (12%) Renal disorder28 (11%) Neurologic disorder31 (12%) Hematologic disorder58 (23%) Immunologic disorder77 (30%) ANA222 (88%)SLICC 2012 classification criteria Clinical criteria1.0 ± 0.9 Immunological criteria1.3 ± 0.9

Conclusion:

Among individuals with positive autoAbs or FDRs with SLE, the short-term risk for transition into clinical SLE is low. Following the study completion, clinical and lifestyle data will be combined with blood transcriptome to define a high-risk subgroup of individuals for progression into SLE.

Acknowledgments:

The study is supported by the Foundation for Research in Rheumatology (FOREUM; preclin016)

Disclosure of Interests:

Christina Adamichou: None declared, Dionysis Nikolopoulos: None declared, Myrto Nikoloudaki: None declared, Zahra Rahme: None declared, Micaela Fredi: None declared, Antigoni Pieta: None declared, ARGYRO REPA: None declared, Alice Parma: None declared, Eleni Kalogiannaki: None declared, Nestor Avgustidis: None declared, Nikolaos Kougkas: None declared, Aggelos Banos: None declared, Anastasios Eskitzis: None declared, Alessandra Bortoluzzi: None declared, Søren Jacobsen: None declared, Prodromos Sidiropoulos: None declared, Emmanouil Dermitzakis: None declared, Marta Mosca: None declared, Luís Inês: None declared, Laura Andreoli: None declared, Angela Tincani: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

AB1216 INTERSTITIAL PNEUMONIA WITH AUTOIMMUNE FEATURES (IPAF): A SINGLE CENTER, PROSPECTIVE STUDY

Background:

Interstitial pneumonia with autoimmune features (IPAF)1describes a group of patients with interstitial lung disease and autoimmune features who do not meet the classification criteria for a specific connective tissue disease. Limited data regarding IPAF are available so far.

Objectives:

To identify the epidemiological and clinical characteristics of patients with IPAF and to observe disease progression, response to treatment and frequency of infections in 1-year follow-up period.

Methods:

Thirty-nine patients from ‘Attikon’ University Hospital of Athens fulfilling the IPAF criteria were enrolled. Clinical and laboratory findings, comorbidities, medications, pulmonary outcomes assessed with repeated pulmonary function tests (PFTs) and chest HRCT and complications in a 1-year follow-up period were documented for each patient. Univariate models were performed in order to identify determinants of infection and clinically significant difference in PFTs (defined as change of ≥ 10% in FVC and/or ≥ 15% in DLCO).

Results:

The mean age at the time of IPAF diagnosis was 63.2 (±11) years and 62% of the patients were female. The most common clinical features included in the IPAF criteria were arthritis (82%) and Raynaud’s phenomenon (26%). A morbilliform and/or polymorphic rash of the face, neck and extremities (not included in the IPAF criteria) was noted in 54% of patients. ANA (59%) and anti–Ro (21%) were the most common auto-antibodies. Non-specific Interstitial Pneumonia (NSIP) was the most prevalent radiological pattern (61.5%) as shown in table 1. Treatment comprised corticosteroids and immunosuppressants including hydroxychloroquine, methotrexate, azathioprine, mycophenolate and cyclophosphamide. PFTs following treatment at 6 and 12 months from baseline showed a trend of improvement (Table 2, p> 0.05). At 1 year from baseline, 20.5% of patients showed a clinically significant deterioration while 25% had a clinically significant improvement. Infections were observed in 23.1% of patients during the first semester and in 12.8% during the second semester of the follow-up period. All were respiratory tract infections and two patients (5.1%) required hospitalization. All infections occurred in patients with non-UIP pattern (p=0.02) which might be attributed to higher doses of corticosteroids used in these patients (mean initial prednisolone dose = 27 (±18) mg/d in patients with non-UIP pattern versus 17 (±16) mg/d in patients with UIP pattern, p=0.4).

Table 1.

Prevalence of HRCT patterns in 39 patients.

Radiological patternNo (%)NSIP24 (61,5%)OP2 (5,1%)NSIP with OP overlap2 (5,1%)LIP1 (2,6%)UIP7 (18%)NSIP and UIP3 (7,7%)

NSIP: Non-specific Interstitial Pneumonia, OP: Organizing Pneumonia, LIP: Lymphocytic Interstitial Pneumonia, UIP: Usual Interstitial Pneumonia.

Table 2.

PFTs at baseline, 6 and 12 months.

PFTs (% of predicted value ± SD)Baseline6 months12 monthsP valueFVC79% (±19%)82% (±18%)84% (±17%)nsDLCO49% (±16%)52% (±17%)53% (±17%)ns

Conclusion:

Rash is a common feature in IPAF and may be considered for inclusion into IPAF criteria. A trend of improvement in PFTs and a significant risk of respiratory tract infections mainly in the first semester of treatment and in patients with non-UIP radiological pattern were observed. Larger prospective studies are warranted in order to elucidate IPAF’s prognosis and to identify effective management approaches.

References:

[1]Fischer A, et al. An official European Respiratory Society/American Thoracic Society research statement: interstitial pneumonia with autoimmune features. Eur Respir J 2015; 46: 976-987.

Disclosure of Interests:

Maria Karampeli: None declared, Konstantinos Thomas: None declared, Dimitrios Tseronis: None declared, Michail Aggelakos: None declared, Dimitra Kassara: None declared, Katerina Havatza: None declared, Sofia Flouda: None declared, Dionysis Nikolopoulos: None declared, Antigoni Pieta: None declared, Vasiliki Tzavara: None declared, Pelagia Katsimbri: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Theofanis Karageorgas: None declared

Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the 'Attikon' cohort

OBJECTIVE

This study aimed to analyse the phenotype of systemic lupus erythematosus (SLE) at first presentation and during follow-up in a newly established SLE cohort based at 'Attikon' University Hospital. The hospital combines primary, secondary and tertiary care for the region of Western Attica, Greece.

METHODS

This study comprised a mixed prevalent and incident cohort of 555 Caucasian patients diagnosed with SLE according to American College of Rheumatology 1997 criteria and/or the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) 2012 criteria. Demographic and clinical characteristics, patterns of severity, treatments and SLICC damage index were recorded for each patient at the time of diagnosis and at last evaluation.

RESULTS

The mean age at lupus diagnosis was 38.3 years (standard deviation = 15.6 years), with a median disease duration at last follow-up of two years (interquartile range 1-11). At initial presentation, the most common 'classification' manifestations were arthritis (73.3%), acute cutaneous lupus (65%) and unexplained fever (25%), while among symptoms not included in any criteria set, Raynaud's phenomenon (33%) was the most common. Kidney and neuropsychiatric involvement as presenting manifestations were present in 10.3% and 11.5% cases, respectively. Irreversible damage accrual was present in 17.8% within six months of disease diagnosis, attributed mainly to thrombotic and neuropsychiatric disease. At last evaluation, 202 (36.4%) patients had developed severe disease, of whom more than half were treated with pulse cyclophosphamide.

CONCLUSION

In this cohort of Caucasian patients, lupus nephritis is not as common as in older cohorts, while neuropsychiatric disease is emerging as a major frontier in lupus prevention and care. These data may help to document changes in the natural history and treatment of SLE over time and may have implications for its early recognition and management.

Transcriptome reprogramming and myeloid skewing in haematopoietic stem and progenitor cells in systemic lupus erythematosus

Objectives

Haematopoietic stem and progenitor cells (HSPCs) are multipotent cells giving rise to both myeloid and lymphoid cell lineages. We reasoned that the aberrancies of immune cells in systemic lupus erythematosus (SLE) could be traced back to HSPCs.

Methods

A global gene expression map of bone marrow (BM)-derived HSPCs was completed by RNA sequencing followed by pathway and enrichment analysis. The cell cycle status and apoptosis status of HSPCs were assessed by flow cytometry, while DNA damage was assessed via immunofluorescence.

Results

Transcriptomic analysis of Lin⁻Sca-1⁺c-Kit⁺ haematopoietic progenitors from diseased lupus mice demonstrated a strong myeloid signature with expanded frequencies of common myeloid progenitors (CMPs)—but not of common lymphoid progenitors—reminiscent of a ‘trained immunity’ signature. CMP profiling revealed an intense transcriptome reprogramming with suppression of granulocytic regulators indicative of a differentiation arrest with downregulation trend of major regulators such as Cebpe, Cebpd and Csf3r, and disturbed myelopoiesis. Despite the differentiation arrest, frequencies of BM neutrophils were markedly increased in diseased mice, suggesting an alternative granulopoiesis pathway. In patients with SLE with severe disease, haematopoietic progenitor cells (CD34⁺) demonstrated enhanced proliferation, cell differentiation and transcriptional activation of cytokines and chemokines that drive differentiation towards myelopoiesis, thus mirroring the murine data.

Conclusions

Aberrancies of immune cells in SLE can be traced back to the BM HSPCs. Priming of HSPCs and aberrant regulation of myelopoiesis may contribute to inflammation and risk of flare.

Trial registration number

4948/19-07-2016.

In an early SLE cohort the ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria classify non-overlapping groups of patients: use of all three criteria ensures optimal capture for clinical studies while their modification earlier classification and treatment

OBJECTIVES

Classification criteria are biased towards classifying long-standing disease. We compared the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR)-2019, Systemic Lupus International Collaborating Clinics (SLICC)-2012 and ACR-1997 criteria in an early (median 48 months) systemic lupus erythematosus (SLE) cohort.

METHODS

Patients diagnosed with SLE (n=690) or control diseases (n=401). Sensitivity, specificity of the criteria and time-to-classification were calculated. Modified classification algorithms were derived from a random 80% and validated in the remaining 20% of the dataset running multiple iterations.

RESULTS

At last assessment, sensitivities of ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria were 85.7%, 91.3% and 88.6%, with specificities 93.0%, 93.8% and 97.3%, respectively. Both SLICC and EULAR/ACR enabled earlier classification. Only 76.7% of patients with SLE met all three criteria suggesting non-overlapping groups. Notably, unclassified patients had high prevalence of British Isles Lupus Assessment Group moderate/severe manifestations (43.3%-60%) and SLICC/ACR organ damage (30%-50%). At diagnosis, criteria missed 25.6%-30.5% of patients. Modification of EULAR/ACR and SLICC algorithms to include hypocomplementaemia and/or positive anti-phospholipid antibodies as alternative entry criterion, and/or allow classification with fewer clinical criteria from multiple organs, increased their sensitivity at diagnosis (median 82.0% and 86.2%) and overall (93.7% and 97.1%) with modest decreases in specificity. Importantly, patients who were still missed by the modified criteria had lower incidence of major organ involvement, use of immunosuppressive/biological therapies and organ damage.

CONCLUSIONS

The SLICC and EULAR/ACR are more sensitive than the ACR and the EULAR/ACR criteria have superior specificity in early SLE, although patients with significant disease can be missed. Combination and/or modification of the classification algorithms may enhance their sensitivity, allowing earlier classification and treatment of more patients with high disease burden.

Sex-specific structural and functional leaf traits and sun-shade acclimation in the dioecious tree Pistacia vera (Anacardiaceae)

In dioecious species, sex-related adaptive strategies, influenced by natural and sexual selection, allow each sex to meet the specific demands of reproduction. Differences in ecophysiological traits between males and females may rely on innate differences in secondary sex traits such as structural and functional leaf traits. We tested structural sexual leaf dimorphism in Pistacia vera L. and the intersexual differences in sun-shade acclimation processes expected from the different adaptive strategies of males and females. Fifteen structural and functional leaf traits were compared in 50-year-old trees between females with low fruit load and males under sun and shade conditions. Despite the low additional energy investment in reproduction in females, remarkable sex effects in leaf structure and function were observed. Male trees had smaller leaves with significantly lower total conducting petiole area (TCA) and higher stomatal density, water use efficiency and concentration of phenolic compounds; females had larger leaves with greater thickness, leaf mass per area, TCA and maximum photosynthetic capacity per area (Amax,a). The higher Amax,a and stomatal conductance of female leaves were associated with their ~20-fold higher TCA compared with male trees. Females seem to invest more in high xylem efficiency and rates of C gain; males invest more in defence-protection. Sun-shade plastic responses were sex- and trait-specific, but the plasticity assessment indicated that both sexes have evolved an almost equal degree of phenotypic plasticity that allows them to perform optimally under varying environmental conditions. However, the trait-specific differences indicate that each sex displays a different strategy of optimisation.

Cerebrovascular Events in Systemic Lupus Erythematosus: Diagnosis and Management

Stroke is a major cause of morbidity, mortality and disability in systemic lupus erythematosus (SLE). Patients with SLE have a two-fold increase in the risk of stroke with younger patients (ie, less than 50 years of age) having an ever-higher risk (up to 10-fold). Although the prognosis of SLE has improved, mortality due to cerebrovascular events (CVE) remains unchanged. Cerebrovascular disease may be directly attributed to the disease per se, as a manifestation of neuropsychiatric SLE, or be the result of traditional cardiovascular risk factors accompanying the disease. Elucidation of the underlying mechanism(s) of CVE is essential as it may guide the type of therapy (ie, antithrombotic or anticoagulant therapy versus immunosuppressive). Strokes attributed to lupus usually occur early in the course of the disease and are often accompanied by evidence of activity in other organs; those related to antiphospholipid antibodies can occur at any time, in patients with either active or inactive SLE. In this review, we discuss the epidemiology, work-up, management and primary prevention of CVE in patients with lupus. In view of the effectiveness of thrombolysis, physicians need to educate lupus patients and their families for the early recognition of the signs of stroke and the need to seek prompt attention. To this end acronyms, such as FAST (Facial drooping, Arm weakness, Speech difficulties and Time to call emergency service) can be used as a mnemonic to help detect and enhance responsiveness to the needs of a person having a stroke.

How does long-term drought acclimation modify structure-function relationships? A quantitative approach to leaf phenotypic plasticity of barley

Under drought conditions the growth and survival of a plant depend on its adaptive characteristics and acclimation ability. Adaptation refers to inherent morpho-physiological characters providing protection against water losses. Acclimation, however, is a special case of phenotypic plasticity: environment-dependent phenotypic expression resulting to a 'new' phenotype through drought-induced modulations in leaf morphology, anatomy and physiology. Given that phenotypic plasticity influences environmental tolerance, a multi-trait plasticity index could be of great importance. Therefore, we examined the acclimation processes of three different barley genotypes using a multi-trait plasticity assessment with emphasis on the leaf water economy-related traits. Our results showed that (i) the structure-function co-ordination during long-term drought acclimation follows the trade-off between carbon gain and water saving as well as the competition between investments in photosynthesis vs synthesis of protective compounds; (ii) the genotypes with smaller leaf area, narrower and denser veins, as well as smaller and denser stomata i.e. traits providing tolerance, exhibited less drastic adjustments under stress conditions, suggesting a trade-off between acclimation and tolerance-adaptation; and (iii) the slope values of a multi-trait 'reaction norm' based on regression analysis of PCA scores were indicative of the degree of plasticity for each genotype, providing an accurate representation of a complex set of data with single numeric results easily comparable.