Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Gathering expert consensus to inform a proposed trial in chronic nonbacterial osteomyelitis (CNO)

Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease that primarily affects children and adolescents. CNO is associated with pain, bone swelling, deformity, and fractures. Its pathophysiology is characterized by increased inflammasome assembly and imbalanced expression of cytokines. Treatment is currently based on personal experience, case series and resulting expert recommendations. Randomized controlled trials (RCTs) have not been initiated because of the rarity of CNO, expired patent protection of some medications, and the absence of agreed outcome measures. An international group of fourteen CNO experts and two patient/parent representatives was assembled to generate consensus to inform and conduct future RCTs. The exercise delivered consensus inclusion and exclusion criteria, patent protected (excludes TNF inhibitors) treatments of immediate interest (biological DMARDs targeting IL-1 and IL-17), primary (improvement of pain; physician global assessment) and secondary endpoints (improved MRI; improved PedCNO score which includes physician and patient global scores) for future RCTs in CNO.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

POS1372 THE 2021 EULAR AND ACR POINTS TO CONSIDER FOR DIAGNOSIS, MANAGEMENT AND MONITORING OF THE IL 1 MEDIATED AUTOINFLAMMATORY DISEASES: CAPS, TRAPS, MKD, AND DIRA

Background

The Interleukin-1 (IL-1) mediated systemic autoinflammatory diseases (SAIDs), including the cryopyrin-associated periodic syndromes (CAPS), tumor necrosis factor receptor-associated periodic syndrome (TRAPS), mevalonate kinase deficiency (MKD), and deficiency of the IL-1 receptor antagonist (DIRA) belong to a group of rare immunodysregulatory diseases that primarily present in early childhood with variable multiorgan involvement. When untreated, patients with severe clinical phenotypes have a poor prognosis, and diagnosis and management of these patients can be challenging. However, recently-approved treatments targeting the pro-inflammatory cytokine IL-1 have been life-changing and have significantly improved patient outcomes.

Objectives

We aimed to establish evidence-based recommendations on diagnosis, treatment, and monitoring to standardize the management of these patients.

Methods

A multinational, multidisciplinary task force consisting of physician experts including rheumatologists, patients or caregivers, and allied health care professionals was established. Evidence synthesis including systematic literature review and expert consensus (Delphi) via surveys were conducted. Consensus methodology was utilized to formulate and vote on statements to guide optimal patient care.

Results

The task force devised five overarching principles, 14 statements related to diagnosis, 10 on therapy, and 9 focused on long-term monitoring that were evidence and/or consensus-based for patients with IL-1 mediated diseases. An outline was developed for disease-specific monitoring of inflammation-induced organ damage progression and reported therapies of CAPS, TRAPS, MKD, and DIRA.

Conclusion

The 2021 EULAR/ACR points to consider provide state-of-the-art knowledge based on published data and expert opinion to guide diagnostic evaluation, treatment, and monitoring of patients with CAPS, TRAPS, MKD and DIRA, and inform the various stakeholders about optimized patient care to improve disease outcomes.

References

[1]Masters SL, Simon A, Aksentijevich I, et al. Horror autoinflammaticus: the molecular pathophysiology of autoinflammatory disease (*). Annu Rev Immunol 2009;27:621-68.

Disclosure of Interests

micol romano: None declared, Zehra Serap Arici: None declared, David Piskin: None declared, Sara Alehashemi: None declared, Daniel Aletaha Speakers bureau: Lilly, Merck, Pfizer, Roche, Sandoz, Consultant of: Abbvie, Amgen, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Karyl Barron: None declared, Susa Benseler: None declared, Roberta Berard Consultant of: Sandoz and Roche, Lori Broderick Grant/research support from: Novartis and Regeneron, Fatma Dedeoglu Consultant of: Novartis, Michelle Diebold: None declared, Karen Durrant: None declared, Polly Ferguson Consultant of: Novartis, Grant/research support from: NIH, CARRA, Inc, Dirk Foell Speakers bureau: Novartis, Peer Voice and SoBi, Consultant of: Boehringer Ingelheim, Chugai-Roche, Merck, Novartis, SoBi, Grant/research support from: Novartis and SoBi, Jonathan Hausmann Consultant of: Novartis, Biogen and Pfizer, Grant/research support from: CARRA, SoBi, Olcay Jones: None declared, Daniel Kastner: None declared, Helen J. Lachmann: None declared, Ronald Laxer Consultant of: SoBi, Novartis, Sanofi, Dorelia Rivera: None declared, Nicolino Ruperto Speakers bureau: Eli-Lilly, GSK, Pfizer SoBi and UCB, Consultant of: Ablynx, Amgen, Astrazeneca-Medimmune, Aurinia, Bayer, Bristol Myers and Squib, Cambridge Healthcare research, Celgene, Domain therapeutic, Eli-Lilly, EMD Serono, GSK, Idorsia, Janssen, Novartis, SoBi, Pfizer and UCB, Anna Simon: None declared, Marinka Twilt: None declared, Joost Frenkel: None declared, Hal Hoffman Consultant of: Novartis, Regeneron, SoBi, Aclaris, Grant/research support from: Bristol-Meyer-Squib, Jecure, Takeda and Zomagen, Adriana de Jesus: None declared, Jasmin Kuemmerle-Deschner Speakers bureau: Novartis and SoBi, Consultant of: Novartis and SoBi, Grant/research support from: Novartis and SoBi, Seza Özen Speakers bureau: Novartis and SoBi, Marco Gattorno Speakers bureau: Novartis and SoBi, Grant/research support from: Novartis, Raphaela goldbach-mansky: None declared, Erkan Demirkaya Grant/research support from: Sobi

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

OP0271 JUVENILE LOCALIZED SCLERODERMA: A LARGE RETROSPECTIVE COHORT STUDY FROM A TERTIARY CARE CENTER

Background:

Juvenile Localized Scleroderma (jLS) is a rare pediatric inflammatory disease of skin and underlying tissues that may cause significant functional impairment and disfigurement. Management approaches vary and an optimum treatment regimen is lacking. In 2012, a group of jLS researchers of Childhood Arthritis and Rheumatology Research Alliance (CARRA) proposed consensus treatment plans (CTPs), aimed to streamline the approach to care for jLS patients.

Objectives:

This study aimed to evaluate a large jLS patient cohort seen over a 21-year period in a single tertiary care pediatric hospital in the USA, in order to examine treatments utilized and determine parameters for systemic therapy initiation.

Methods:

This retrospective cohort study included jLS patients with disease onset in childhood (≤18-years of age) who were seen in rheumatology, dermatology, or combined rheumatology-dermatology clinics from 1999-2020, with ≤ 3 years of follow-up. Data on demographics, disease characteristics, therapies prescribed, and treatment trends were analyzed.

Results:

Of the 270 jLS patients identified, 101 fulfilled the inclusion criteria. The primary reason for exclusion was <3 years of follow-up. Selected demographic data and disease characteristics of patients are shown in Table 1. There were no statistically significant differences in most patient and disease characteristics between patients who received systemic treatment and those who did not. There were no significant differences in baseline laboratory values. The group treated with systemic therapy did have higher rates of extracutaneous involvement and had a higher proportion of patients with a generalized morphea phenotype.

Table 1.

Demographic and Disease Characteristics

All Patients(n=101)On Systemic Therapy(n=63)No Systemic Therapy(n=38)p valueAge-onset (Y), median (IQR)7.5 (6.4)9 (6)7 (4)NSAge-diagnosis(Y), median (IQR)9 (7.9)10 (6.7)9 (3.7)NSDiagnostic delay(M), median (IQR)10 (2.9)12 (13)7.5 (17)NSFollow-up (M), median (IQR)74 (69.3)65 (44.5)78 (47.7)NSSubtype Linear563917NS Face29209NS Circumscribed23419<0.0001 Mixed220NS Generalized201820.004Extracutaneous Involvement191810.001Clinic type Dermatology29227<0.0001 Rheumatology211920.003 Combined51429<0.0001

The majority of patients who were on systemic immunomodulatory therapy were treated with methotrexate (59/63, 93.6 %) and/or systemic corticosteroids (21/63, 33 %). 5 patients were treated with hydroxychloroquine, 2 of which were also on methotrexate. 6 patients on methotrexate were either switched to or had mycophenolate mofetil added as concomitant therapy. The most common adverse effects observed in methotrexate-treated patients were gastrointestinal complaints (12/61, 19.7%) and fatigue (7/61, 11.5%). The median treatment duration was 50 months (IQR: 33.5). Patients were more likely to receive systemic therapy if they were followed in rheumatology or combined rheumatology-dermatology clinics as compared to dermatology clinics. Finally, 78% of patients with jLS received systemic treatment after 2013 (a year after publication of the CARRA jLS CTP) as compared to 55% of patients prior to 2013 (p < 0.05).

Conclusion:

This jLS cohort is one of the largest reported from a single center and reflects an increase in the use of systemic therapy since publication of CARRA CTPs in 2012. Further studies on long-term treatment outcomes and therapeutic approaches utilized when first-line treatment failures occur are warranted.

References:

[1]Li SC, Torok KS, Pope E, et al. Development of consensus treatment plans for juvenile localized scleroderma: a roadmap toward comparative effectiveness studies in juvenile localized scleroderma. Arthritis Care Res (Hoboken). 2012;64(8):1175-1185.

Disclosure of Interests:

Bugra Egeli: None declared, Johnathan Dallas: None declared, Edwin Anderson: None declared, Michelle Min: None declared, Daniel Mazori: None declared, Stephen Gellis: None declared, Mary Beth Son: None declared, Robert Sundel: None declared, Ruth Vleugels: None declared, Fatma Dedeoglu Consultant of: Novartis

Successful treatment of retroperitoneal fibrosis with tamoxifen in a child

We describe our experience with tamoxifen in a prepubertal girl with retroperitoneal fibrosis who had failed treatment with high dose corticosteroid therapy. Her response was excellent.

Cross-reactions of anti-immunoglobulin sera with synthetic T-cell receptor beta peptides: mapping on a 3-dimension model

The derived amino acid sequences of human T-cell receptor beta chain shows significant homology to lambda light chains of immunoglobulins in its variable, joining, and constant regions. We assessed the cross-reactivity between Tcr beta chains and immunoglobulin light chains by determining the capacity of rabbit antisera to human or murine immunoglobulins to react to a synthesized set of nested, overlapping 16-mer peptides corresponding to the VDJC sequence of the Tcr beta chain YT35. The observed reactivities were consistent with homologies to lambda and kappa light chains, the strongest reactivity being with a peptide that corresponds to the "switch peptide" of light chains, as assessed by ELISA binding and competitive inhibitions assays. Other regions reactive with anti-light chain sera corresponded to CDR1 and Fr3 segments of the variable domain and a segment of the constant region predicted to loop out of the tight globular structure. The peptide immunochemical results, together with the identification of specific regions of sequence correspondence between Tcr beta and the characterized lambda light chain Mcg, allowed us to develop a 3-dimensional model of the beta chain consistent with its role in antigen recognition.

Light and heavy chains specifying a human IgM kappa autoantibody to a T-cell receptor V beta-antigen

Humans frequently produce serum IgM autoantibodies reactive with T-cell receptor beta chains at a determinant defined by peptides corresponding to the first complementarity determining region. It is likely that this determinant serves as a public idiotype involved in immunoregulation. Following screening of culture supernatants from over 60 Epstein-Barr virus-carrying B-cell lines of normal and neoplastic origin, we identified a line, IARC307, that secretes an IgM kappa protein showing marked specificity for the V beta 8.1 CDR1 sequence CKPISGHNSLFQWYRQT. We cloned and sequenced the complete variable regions of the V kappa and VH chains used by the autoantibody. The light chain has a V kappa III sequence related to the 'a' subgroup and uses J kappa 2. The heavy chain has a VHIII sequence essentially identical to the germ-line sequence DP54 and uses the JH6C minigene. The CDR3 is unique, differing from those of other autoantibodies. The antibody is rigorously specific in its specificity for the V beta 8 peptide and does not show polyspecificity for protein or DNA antigens.

Reactions of anti-immunoglobulin sera with synthetic T cell receptor peptides: implications for the three-dimensional structure and function of the TCR beta chain

The derived amino acid sequence of the human TCR beta chain shows considerable homology to lg lambda light chains in its variable (V) and constant (C) domains, and in its joining segment (J). We assessed the cross-reactivity between TCR beta chains and lg light chains by synthesizing a set of nested, overlapping 16-mer peptides that duplicated the sequence that corresponds to the continuous VDJC sequence of TCR beta chain and determining the capacity of rabbit antisera to human or murine lgs to react with these peptides. The reactivities we observed were consistent with homologies to lambda and kappa light chains. The strongest reactivity in ELISA binding and competitive inhibition was with a peptide that corresponds to the 'switch peptide' of light chains. The sequence is encoded by the C-terminal region of the J segment (Fr4) and the N-terminus of the C region. Other regions reactive with anti-light chain sera corresponded respectively to CDR1 and Fr3 segments of the V region, and a segment of the constant region predicted to loop out of the tight globular structure. The peptide immunochemical results, coupled with the identification of specific regions of sequence correspondence between TCR beta and the characterized lambda light chain Mcg, allowed us to develop a three-dimensional model of the beta chain consistent with its role in antigen recognition and response to superantigens.

Lack of preferential V beta usage in synovial T cells of rheumatoid arthritis patients

The T-cell receptor V beta subfamily repertoires of synovial and peripheral T cells of 8 rheumatoid arthritis (RA) patients were determined using the polymerase chain reaction. Three normal controls were included. Some of the rheumatoid synovial samples did not express the complete range of V beta families and lacked as many as 6 gene families. However, these patients showed considerable individual variation in expression. Overall, the data do not support preferential T-cell receptor V beta usage in synovial T cells of RA patients either in comparison to their autochthonous peripheral T cells or to peripheral T cells of normal subjects.

Human autoantibodies reactive with synthetic autoantigens from T-cell receptor beta chain

We used mapping with synthetic overlapping peptides in combination with molecular modeling to analyze the IgG antibodies that humans naturally produce against human T-cell receptor beta chains and to localize the recognized peptide autoantigens in the three-dimensional structure of the molecule. Healthy individuals produce low levels of antibodies against T-cell receptor peptides, and these can be increased in autoimmune diseases. We characterized the reactivities in detail because IgG molecules reactive with self peptides occur in preparations of intravenous immunoglobulin and can be isolated by immunoaffinity chromatography. Natural IgG antibodies were directed against three major peptides. One corresponds to the first complementarity-determining region of the variable region. A second corresponds to the third framework of the variable region. The third is located in the constant region and is predicted to be a loop that extends out of the beta-barrel structure. This peptide is one that would give a characteristic structural distinction between the beta-chain constant region and the constant regions of immunoglobulin light chains to which beta chains are homologous. The capacity to bind these peptides is found in small fractions of normal polyclonal IgG, which contains both kappa chains and lambda chains. The activity is antibody-like in being confined to the Fab fragment and in its capacity to discriminate among homologous synthetic peptides corresponding to distinct beta-chain variable-region genes. We propose that a recognition and regulatory process naturally occurs that parallels the immune network for the regulation of the production of antibodies.

Antigenic mapping of a human lambda light chain: correlation with three dimensional structure

Although the amino acid sequence and three-dimensional structure of human immunoglobulin light chains have been known for more than 15 years, the location of antigenic markers characteristic of lambda chains has not been determined. Here, we use a set of synthetic overlapping peptides to completely model the sequence of the lambda chain Mcg and test these for the binding of rabbit and goat antisera specific for lambda chain determinants. We assess peptide contributions to lambda-antigenic reactivity and also to identify a portion of C-region where conformational factors contribute to the antigenicity. Specific determinants occur both in the constant and variable (first and third framework) domains of the molecule. The fourth framework of the variable region, a segment specified by the joining gene, is also recognized and cross-reacts antigenically with the homologous region of T cell receptor beta chains. Major lambda specific determinants are localized in the N- and C-terminal segments, which are linear and devoid of major conformational folding. Other segments that are strongly antigenic, such as the third framework of the V region (residue 78-93) and a segment of the constant region (residues 177-192), show strong conformational dependence in antigenicity.