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.

Improvement of high-density lipoprotein atheroprotective properties in patients with systemic lupus erythematosus after belimumab treatment

OBJECTIVE

Chronic inflammatory diseases, like Systemic Lupus Erythematosus (SLE), carry an increased risk for atherosclerosis and cardiovascular events, accompanied by impairment of atheroprotective properties of high-density lipoprotein (HDL). In SLE, serum BAFF (B cell-activating factor), a cytokine implicated in disease progression, has been correlated with subclinical atherosclerosis. We investigated the impact of treatment with belimumab -an anti-BAFF monoclonal antibody- on HDL atheroprotective properties and composition in SLE patients.

METHODS

Serum samples were collected from 35 SLE patients with active disease despite conventional therapy, before and after 6-month add-on treatment with belimumab, and 26 matched healthy individuals. We measured cholesterol efflux and antioxidant capacities, paraoxonase-1 activity, serum amyloid A1, myeloperoxidase and lipid peroxidation product levels of HDL. LC-MS/MS was performed to analyze the HDL lipidome.

RESULTS

Following treatment with belimumab, cholesterol efflux and antioxidant capacities of HDL were significantly increased in SLE patients and restored to levels of controls. HDL-associated paraoxonase-1 activity was also increased, whereas lipid peroxidation products were decreased following treatment. HDL cholesterol efflux and antioxidant capacities correlated negatively with the disease activity. Changes were noted in the HDL lipidome of SLE patients following belimumab treatment, as well as between SLE patients and healthy individuals, and specific changes in lipid species correlated with functional parameters of HDL.

CONCLUSIONS

HDL of SLE patients with active disease displays impaired atheroprotective properties accompanied by distinct lipidomic signature compared with controls. Belimumab treatment may improve the HDL atheroprotective properties and modify the HDL lipidomic signature in SLE patients, thus potentially mitigating atherosclerosis development.

Pragmatic targets for moderate/severe SLE and their implications for clinical care and trial design: sustained DORIS or LLDAS for at least 6 months is sufficient while their attainment for at least 24 months ensures high specificity for damage-free progression

OBJECTIVES

Treatment targets in systemic lupus erythematosus (SLE) have been validated in unselected-in terms of severity-cohorts, which limits their generalisability. We assessed remission (Definition of Remission in SLE (DORIS)) and Lupus Low Disease Activity State (LLDAS) in a historical cohort of 348 patients with active moderate-to-severe disease and median follow-up of 5 years.

METHODS

Active SLE was defined as Physician Global Assessment ≥1.5 and/or SLE Disease Activity Index 2000 ≥6, requiring therapy intensification. DORIS/LLDAS, organ damage, flares and adverse events were monitored. Shared frailty survival, generalised linear models and K-means clustering were applied.

RESULTS

Sustained DORIS and LLDAS for ≥6 months occurred in 41.1% and 80.4%, respectively, and resulted in reduced damage accrual (HR: 0.58; 95% CI 0.36 to 0.93 and 0.61; 0.43 to 0.86) and severe flares (HR: 0.14; 0.08 to 0.27 and 0.19; 0.13 to 0.27). LLDAS without DORIS was also protective (HR: 0.65; 0.43 to 0.98 for damage, 0.49; 0.36 to 0.67 for flares). Models fitting increasing duration of targets showed that DORIS ≥50% and LLDAS ≥60% of time, or alternatively, ≥24 and ≥36 months, achieved optimal balance between feasibility (20.2-41.7%) and specificity (73.3-86.1%) for damage-free outcome. These targets were linked to reduced serious adverse events (risk ratio (RR): 0.56-0.71), hospitalisation (RR: 0.70) and mortality (RR: 0.06-0.13). Patients with predominant arthritis and mucocutaneous disease experienced reduced DORIS/LLDAS, compared with counterparts with major organ involvement. Conventional drugs were more frequently used in the former group, whereas potent immunosuppressive/biological agents in the latter.

CONCLUSIONS

In moderate-to-severe SLE, sustained DORIS/LLDAS for at least 6 months is sufficient, while attainment for at least 24 months ensures higher specificity for damage-free progression, thus facilitating treat-to-target strategies and clinical trials. Arthritis and skin disease represent unmet therapeutic needs that could benefit from novel biologics.

Therapeutic Strategies and Outcomes in Neuropsychiatric Systemic Lupus Erythematosus: An International Multicenter Retrospective Study

OBJECTIVES

The management of neuropsychiatric systemic lupus erythematosus (NPSLE) poses considerable challenges due to limited clinical trials. Therapeutic decisions are customized based on suspected pathogenic mechanisms and symptom severity. This study aimed to investigate therapeutic strategies and disease outcome for patients with NPSLE experiencing their first neuropsychiatric (NP) manifestation.

METHODS

This retrospective cohort study defined NP events according to the American College of Rheumatology case definition, categorizing them into three clusters: central/diffuse, central/focal and peripheral. Clinical judgment and a validated attribution algorithm were used for NP event attribution. Data included demographic variables, SLE disease activity index, cumulative organ damage, and NP manifestation treatments. The clinical outcome of all NP events was determined by a physician seven-point Likert scale. Predictors of clinical improvement/resolution were investigated in a multivariable logistic regression analysis.

RESULTS

The analysis included 350 events. Immunosuppressants and corticosteroids were more frequently initiated/escalated for SLE-attributed central diffuse or focal NP manifestations. At 12 months of follow-up, 64% of patients showed a clinical improvement in NP manifestations. Focal central events and SLE-attributed manifestations correlated with higher rates of clinical improvement. Patients with NP manifestations attributed to SLE according to clinical judgment and treated with immunosuppressants had a significantly higher probability of achieving clinical response (OR 2.55, 95%CI 1.06-6.41, p= 0.04). Age at diagnosis and focal central events emerged as additional response predictors.

CONCLUSION

NP manifestations attributed to SLE by clinical judgment and treated with immunosuppressants demonstrated improved 12-month outcomes. This underscores the importance of accurate attribution and timely diagnosis of NPSLE.

Distinct long-term disease activity trajectories differentiate early on treatment with etanercept in both rheumatoid arthritis and spondylarthritis patients: a prospective cohort study

To characterize disease activity trajectories and compare long-term drug retention between rheumatoid (RA) and spondylarthritis (SpA) patients initiating tumor necrosis factor inhibitor (TNFi) treatment (etanercept). Prospective observational study of RA, axial (AxSpA) and peripheral SpA (PerSpA) patients initiating etanercept during 2004-2020. Kaplan-Meier plots were used for drug retention comparisons and multivariable Cox regression models for predictors of discontinuation. Long-term disease activity trajectories were identified by latent class growth models using DAS28-ESR or ASDAS-CRP as outcome for RA and AxSpA respectively. We assessed 711 patients (450 RA, 178 AxSpA and 83 PerSpA) with a median (IQR) follow-up of 12 (5-32) months. At 5 years, 22%, 30% and 21% of RA, AxSpA and PerSpA patients, respectively, remained on therapy. Etanercept discontinuation was independent of the diagnosis and was predicted by gender and obesity in both RA and SpA groups. Four disease activity (DA) trajectories were identified from 6th month of treatment in both RA and AxSpA. RA patients in remission-low DA groups (33.7%) were younger, had shorter disease duration, fewer comorbidities and lower baseline disease activity compared to moderate (40.6%) & high DA (25.7%) groups. In AxSpA 74% were in inactive-low DA and they were more often males, non-obese and had lower number of comorbidities compared to higher ASDAS-CRP trajectories. In RA and AxSpA patients, disease activity trajectories revealed heterogeneity of TNFi treatment responses and prognosis. Male gender, lower baseline disease activity and fewer comorbidities, characterize a favourable outcome in terms of disease burden accrual and TNFi survival.

A path to Glucocorticoid Stewardship: a critical review of clinical recommendations for the treatment of systemic lupus erythematosus

Glucocorticoids (GCs) have revolutionized the management of SLE, providing patients with rapid symptomatic relief and preventing flares when maintained at low dosages. However, there are increasing concerns over GC-associated adverse effects (AEs) and organ damage, which decrease patients' quality of life (QOL) and increase healthcare costs. This highlights the need to balance effective GC use and minimize toxicity in patients with SLE. Herein, we provide an overview of the theoretical considerations and clinical evidence, in addition to the variations and similarities across nine national and eight international recommendations regarding the use of GCs across SLE manifestations and how these compare with real-world usage. In line with this, we propose possible actions toward the goal of GC Stewardship to improve the QOL for patients with lupus while managing the disease burden.

Patterns of comorbidities differentially affect long-term functional evolution and disease activity in patients with 'difficult to treat' rheumatoid arthritis

BACKGROUND

Characterisation of the long-term outcome of patients with 'difficult to treat' (D2T) rheumatoid arthritis and factors contributing to its evolution are unknown. Herein, we explored the heterogeneity and contributing factors of D2T long-term outcome.

METHODS

Patients included from a prospective single centre cohort study. The EULAR definition of D2T was applied. Longitudinal clustering of functional status (modified Health Assessment Questionnaire (mHAQ)) and disease activity (Disease Activity Score-28 (DAS28)) were assessed using latent-class trajectory analysis. Multiple linear mixed models were used to examine the impact of comorbidities and their clusters on the long-term outcome.

RESULTS

251 out of 1264 patients (19.9%) were identified as D2T. Younger age, fibromyalgia, osteoarthritis, DAS28-erythrocyte sedimentation rate (ESR) at first biological or targeted synthetic disease-modifying antirheumatic drug (b/ts-DMARD) initiation and failure to reduce DAS28-ESR scores within the first 6 months of b/ts-DMARD therapy were significant predictors of patients becoming D2T. Long-term follow-up (total of 5872 person-years) revealed four groups of functional status evolution: 18.2% had stable, mildly compromised mHAQ (mean 0.41), 39.9% had gradual improvement (1.21-0.87) and two groups had either slow deterioration or stable significant functional impairment (HAQ>1). Similarly, four distinct groups of disease activity evolution were identified. Among the different clusters of comorbidities assessed, presence of 'mental-health and pain-related illnesses' or 'metabolic diseases' had significant contribution to mHAQ worsening (p<0.0001 for both) and DAS28 evolution (p<0.0001 and p=0.018, respectively).

CONCLUSION

D2T patients represent a heterogeneous group in terms of long-term disease course. Mental-health/pain-related illnesses as well as metabolic diseases contribute to long-term adverse outcomes and should be targeted in order to optimise the prognosis of this subset of rheumatoid arthritis.

EULAR recommendations for the management of systemic lupus erythematosus: 2023 update

OBJECTIVES

To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence.

METHODS

An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item.

RESULTS

The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease.

CONCLUSION

The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.

A Peripheral Blood Signature of Increased Th1 and Myeloid Cells Combined with Serum Inflammatory Mediators Is Associated with Response to Abatacept in Rheumatoid Arthritis Patients

Abatacept (CTLA4-Ig)-a monoclonal antibody which restricts T cell activation-is an effective treatment for rheumatoid arthritis (RA). Nevertheless, only 50% of RA patients attain clinical responses, while predictors of response are rather limited. Herein, we aimed to investigate for early biomarkers of response to abatacept, based on a detailed immunological profiling of peripheral blood (PB) cells and serum proteins. We applied flow cytometry and proteomics analysis on PB immune cells and serum respectively, of RA patients starting abatacept as the first biologic agent. After 6 months of treatment, 34.5% of patients attained response. At baseline, Th1 and FoxP3+ T cell populations were positively correlated with tender joint counts (p-value = 0.047 and p-value = 0.022, respectively). Upon treatment, CTLA4-Ig effectively reduced the percentages of Th1 and Th17 only in responders (p-value = 0.0277 and p-value = 0.0042, respectively). Notably, baseline levels of Th1 and myeloid cell populations were significantly increased in PB of responders compared to non-responders (p-value = 0.009 and p-value = 0.03, respectively). Proteomics analysis revealed that several inflammatory mediators were present in serum of responders before therapy initiation and strikingly 10 amongst 303 serum proteins were associated with clinical responses. Finally, a composite index based on selected baseline cellular and proteomics' analysis could predict response to abatacept with a high sensitivity (90%) and specificity (88.24%).

Arterial Stiffness as a Surrogate Marker of Cardiovascular Disease and Atherosclerosis in Patients with Vasculitides: A Literature Review

Vasculitis, a group of systemic inflammatory diseases that affect the cardiovascular (CV) system, presents with a variety of clinical manifestations that depend on the size of the affected blood vessels. While some types of vasculitis reveal distinct symptoms, others are characterized by more diffuse and nonspecific presentations that can result in delayed diagnosis and treatment initiation. Interestingly, patients with vasculitides share a significant comorbidity: an elevated CV risk, contributing to increased rates of CV events and mortality. This heightened risk is caused by cumulative inflammatory burden, traditional CV risk factors, medication effects, and reduced physical fitness. Traditional risk assessment tools, commonly used in the general population, frequently underestimate the CV risk in patients with inflammatory rheumatic conditions. Consequently, novel approaches are necessary to stratify the precise CV risk in vasculitis patients. A number of surrogate parameters for CV risk have been investigated, with arterial stiffness emerging as a promising marker. Pulse wave velocity (PWV) is a well-established method for assessing arterial stiffness and predicting CV risk across different populations. Among numerous PWV variants, carotid-femoral PWV (cfPWV) stands out as the most extensively studied and accepted reference standard. It has demonstrated its utility as a surrogate CV parameter both in the general population and in patients with systemic inflammatory rheumatic diseases. In recent years, research has expanded to assess arterial stiffness in systemic rheumatic diseases, such as arthritis, connective tissue diseases, rheumatologic overlap syndromes, and chronic pain disorders, using measurements of PWV and other markers of arterial compliance and elasticity. Despite burgeoning research in rheumatologic diseases, data on CV risk markers in vasculitides remain limited and fragmented. This narrative review aims to provide a comprehensive overview of arterial stiffness as a potential screening marker for CV diseases, atheromatosis, and ultimately CV risk among patients with vasculitides.

Comorbidities Burden and Implementation of the Treat-to-Target Strategy in Predicting Real-World Patient Outcomes in Spondyloarthritides

New biologic and small molecule targeted agents have expanded the armamentarium of Spondyloarthritides (SpA), allowing more therapeutic options for patients who do not respond to therapy. The implementation of the treat-to-target (T2T) strategy with close monitoring and frequent treatment adaptations targeting disease remission has been proposed as the means to prevent radiographic progression and long-term adverse outcomes. In this project we will employ the "University of Crete Rheumatology Clinic Registry" to prospectively study in real-world practice musculoskeletal and extraarticular disease activity, patient function, comorbidities, sociodemographics, imaging, compliance to therapy and other lifestyle factors in axial and peripheral SpA patients. The predictive value of these variables in long-term (2years) outcomes will be evaluated. We will also assess the implementation of the T2T approach as well as its impact on long-term patients' outcomes (quality of life, productivity, adverse events). The successful completion of this study could pave the way for improved and personalized therapy in patients with SpA.

Extensive Alternative Splicing Patterns in Systemic Lupus Erythematosus Highlight Sexual Differences

Substantial evidence highlights divergences in immune responses between men and women. Women are more susceptible to autoimmunity, whereas men suffer from the more severe presentation of autoimmune disorders. The molecular mechanism of this sexual dimorphism remains elusive. Herein, we conducted a comprehensive analysis of sex differences in whole-blood gene expression focusing on alternative splicing (AS) events in systemic lupus erythematosus (SLE), which is a prototype sex-biased disease. This study included 79 SLE patients with active disease and 58 matched healthy controls who underwent whole-blood RNA sequencing. Sex differences in splicing events were widespread, existent in both SLE and a healthy state. However, we observed distinct gene sets and molecular pathways targeted by sex-dependent AS in SLE patients as compared to healthy subjects, as well as a notable sex dissimilarity in intron retention events. Sexually differential spliced genes specific to SLE patients were enriched for dynamic cellular processes including chromatin remodeling, stress and inflammatory responses. Remarkably, the extent of sexual differences in AS in the SLE patients and healthy individuals exceeded those in gene expression. Overall, this study reveals an unprecedent variation in sex-dependent splicing events in SLE and the healthy state, with potential implications for understanding the molecular basis of sexual dimorphism in autoimmunity.

Management of systemic lupus erythematosus: A new scenario

The introduction of targeted biological agents in systemic lupus erythematosus (SLE) has created a momentum for improving overall disease management and patients' prognosis. To achieve this, a comprehensive strategy is required spanning the entire patient journey from diagnosis to prevention and management of late complications and comorbidities. In this review, we focus on four aspects that are closely linked to SLE prognosis, namely early disease recognition and treatment initiation, reduction of the cumulative glucocorticoid exposure, attainment of well-defined targets of remission and low disease activity, prevention of flares and, kidney-protective strategies with non-immune-directed agents. We review the recent literature related to these topics in conjunction with the existing treatment recommendations, highlighting areas of uncertainty and providing guidance towards facilitating the care of SLE patients.

Progressive Multifocal Leukoencephalopathy in Systemic Lupus Erythematosus: A Consequence of Patient-Intrinsic or -Extrinsic Factors?

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by reactivation of the polyomavirus JC (JCV) typically in immunocompromised individuals. The risk of PML among rheumatic diseases may be higher for systemic lupus erythematosus (SLE), without, however, a clear association with the type and intensity of background therapy. We present the development and outcome of PML in a 32-year-old female lupus patient under mild immunosuppressive treatment, yet with marked B-cell lymphopenia in the peripheral blood and bone marrow (<1% of total lymphocytes). Despite treatment with the immune checkpoint inhibitor pembrolizumab, the patient showed progressive neurological and brain imaging deterioration and eventually died 15 months after PML diagnosis. To unveil possible underlying genetic liabilities, whole exome sequencing was performed which identified deleterious variants in GATA2 and CDH7 genes, which both have been linked to defective T- and/or B-lymphocyte production. These findings reiterate the possible role of disease-/patient-intrinsic factors, rather than that of drug-induced immunosuppression, in driving immune dysregulation and susceptibility to PML in certain patients with SLE.

Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention

PURPOSE OF REVIEW

Discuss the prognostic significance of kidney flares in patients with lupus nephritis, associated risk factors, and possible preventative strategies.

RECENT FINDINGS

Recently performed clinical trials and observational cohort studies underscore the high frequency of relapses of kidney disease, following initial response, in patients with proliferative and/or membranous lupus nephritis. Analysis of hard disease outcomes such as progression to chronic kidney disease or end-stage kidney disease, coupled with histological findings from repeat kidney biopsy studies, have drawn attention to the importance of renal function preservation that should be pursued as early as lupus nephritis is diagnosed. In this respect, non-randomized and randomized evidence have suggested a number of factors associated with reduced risk of renal flares such as attaining a very low level of proteinuria (< 700-800 mg/24 h by 12 months), using mycophenolate over azathioprine, adding belimumab to standard therapy, maintaining immunosuppressive/biological treatment for at least 3 to 5 years, and using hydroxychloroquine. Other factors that warrant further clarification include serological activity and the use of repeat kidney biopsy to guide the intensity and duration of treatment in selected cases. The results from ongoing innovative studies integrating kidney histological and clinical outcomes, together with an expanding spectrum of therapies in lupus nephritis, are expected to facilitate individual medical care and long-term disease and patient prognosis.

Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature

Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.

Multidisciplinary approach to lupus nephritis: Clinical pearls, pitfalls, and positioning of newly-approved agents

Lupus nephritis (LN) is a major course of morbidity and mortality in patients with systemic lupus erythematosus (SLE), best managed by a multidisciplinary group. To this end, we gathered a group of rheumatologists, nephrologists and a nephropathologist to review current evidence regarding diagnosis and management of LN. In this consensus paper, we summarize the key points from this meeting and provide practice guidelines for the management of kidney involvement in SLE, in view of emerging new data concerning novel agents approved recently. Renal biopsy is indispensable for the management of LN. Yet, important pearls and pitfalls need to be considered regarding indications and interpretation, which are summarized in informative tables. In new-onset LN, experts agreed that, although belimumab may be added from disease onset, patients with moderate to severe proliferative nephritis (defined as: NIH activity index > 5 plus ≥ 1 of the following: (i) NIH chronicity index > 2, (ii) proteinuria > 3 g/24 h, and (iii) increase in serum creatinine > 20%) may be more likely to benefit the most. In all other patients who have already started standard-of-care treatment with either mycophenolate mofetil (MMF) or cyclophosphamide (CY), belimumab could be considered in cases with an inadequate clinical response by 3 months, or in cases that experience a nephritic flare following initial response, or have an inability to reduce the dose of glucocorticoids. In all circumstances, the drug should be given as add-on therapy, that is, in combination with a standard-of-care therapy (MMF or CY). Voclosporin could be considered for up to 3 years, in combination with MMF, in patients with heavy proteinuria (well above the nephrotic range), wherein a quick reduction of protein loss in urine is desirable to avoid the complications of the nephrotic syndrome, either as part of the initial regimen, or in cases of inadequate reduction of proteinuria with MMF. In view of the potential scarring effects, long-term administration beyond the first year requires further documentation.

Altered hippocampal connectivity dynamics predicts memory performance in neuropsychiatric lupus: a resting-state fMRI study using cross-recurrence quantification analysis

OBJECTIVE

Τo determine whole-brain and regional functional connectivity (FC) characteristics of patients with neuropsychiatric SLE (NPSLE) or without neuropsychiatric manifestations (non-NPSLE) and examine their association with cognitive performance.

METHODS

Cross-recurrence quantification analysis (CRQA) of resting-state functional MRI (rs-fMRI) data was performed in 44 patients with NPSLE, 20 patients without NPSLE and 35 healthy controls (HCs). Volumetric analysis of total brain and specific cortical and subcortical regions, where significant connectivity changes were identified, was performed. Cognitive status of patients with NPSLE was assessed by neuropsychological tests. Group comparisons on nodal FC, global network metrics and regional volumetrics were conducted, and associations with cognitive performance were estimated (at p<0.05 false discovery rate corrected).

RESULTS

FC in patients with NPSLE was characterised by increased modularity (mean (SD)=0.31 (0.06)) as compared with HCs (mean (SD)=0.27 (0.06); p=0.05), hypoconnectivity of the left (mean (SD)=0.06 (0.018)) and right hippocampi (mean (SD)=0.051 (0.0.16)), and of the right amygdala (mean (SD)=0.091 (0.039)), as compared with HCs (mean (SD)=0.075 (0.022), p=0.02; 0.065 (0.019), p=0.01; 0.14 (0.096), p=0.05, respectively). Hyperconnectivity of the left angular gyrus (NPSLE/HCs: mean (SD)=0.29 (0.26) and 0.10 (0.09); p=0.01), left (NPSLE/HCs: mean (SD)=0.16 (0.09) and 0.09 (0.05); p=0.01) and right superior parietal lobule (SPL) (NPSLE/HCs: mean (SD)=0.25 (0.19) and 0.13 (0.13), p=0.01) was noted in NPSLE versus HC groups. Among patients with NPSLE, verbal episodic memory scores were positively associated with connectivity (local efficiency) of the left hippocampus (r²=0.22, p=0.005) and negatively with local efficiency of the left angular gyrus (r²=0.24, p=0.003). Patients without NPSLE displayed hypoconnectivity of the right hippocampus (mean (SD)=0.056 (0.014)) and hyperconnectivity of the left angular gyrus (mean (SD)=0.25 (0.13)) and SPL (mean (SD)=0.17 (0.12)).

CONCLUSION

By using dynamic CRQA of the rs-fMRI data, distorted FC was found globally, as well as in medial temporal and parietal brain regions in patients with SLE, that correlated significantly and adversely with memory capacity in NPSLE. These results highlight the value of dynamic approaches to assessing impaired brain network function in patients with lupus with and without neuropsychiatric symptoms.

2022 EULAR points to consider for the measurement, reporting and application of IFN-I pathway activation assays in clinical research and practice

BACKGROUND

Type I interferons (IFN-Is) play a role in a broad range of rheumatic and musculoskeletal diseases (RMDs), and compelling evidence suggests that their measurement could have clinical value, although testing has not progressed into clinical settings.

OBJECTIVE

To develop evidence-based points to consider (PtC) for the measurement and reporting of IFN-I assays in clinical research and to determine their potential clinical utility.

METHODS

EULAR standardised operating procedures were followed. A task force including rheumatologists, immunologists, translational scientists and a patient partner was formed. Two systematic reviews were conducted to address methodological and clinical questions. PtC were formulated based on the retrieved evidence and expert opinion. Level of evidence and agreement was determined.

RESULTS

Two overarching principles and 11 PtC were defined. The first set (PtC 1-4) concerned terminology, assay characteristics and reporting practices to enable more consistent reporting and facilitate translation and collaborations. The second set (PtC 5-11) addressed clinical applications for diagnosis and outcome assessments, including disease activity, prognosis and prediction of treatment response. The mean level of agreement was generally high, mainly in the first PtC set and for clinical applications in systemic lupus erythematosus. Harmonisation of assay methodology and clinical validation were key points for the research agenda.

CONCLUSIONS

IFN-I assays have a high potential for implementation in the clinical management of RMDs. Uptake of these PtC will facilitate the progress of IFN-I assays into clinical practice and may be also of interest beyond rheumatology.

Arterial Stiffness as a Surrogate Marker of Cardiovascular Disease and Atherosclerosis in Patients with Arthritides and Connective Tissue Diseases: A Literature Review

The increased cardiovascular (CV) risk among patients with autoimmune rheumatic diseases, such as arthritides and connective tissue diseases, has been extensively documented. From a pathophysiological standpoint, systemic inflammation in the context of the disease can lead to endothelial dysfunction, accelerated atherosclerosis, and structural changes in vessel walls, which, in turn, are associated with exaggerated CV morbidity and mortality. In addition to these abnormalities, the increased prevalence of traditional CV risk factors, such as obesity, dyslipidemia, arterial hypertension, and impaired glucose metabolism, can further worsen the status of and overall prognosis for CV in rheumatic patients. However, data on appropriate CV screening methods for patients with systemic autoimmune diseases are scarce, and traditional algorithms may lead to an underestimation of the true CV risk. The reason for this is that these calculations were developed for the general population and thus do not take into account the effect of the inflammatory burden, as well as other chronic-disease-associated CV risk factors. In recent years, different research groups, including ours, have examined the value of different CV surrogate markers, including carotid sonography, carotid-femoral pulse wave velocity, and flow-mediated arterial dilation, in the assessment of CV risk in healthy and rheumatic populations. In particular, arterial stiffness has been thoroughly examined in a number of studies, showing high diagnostic and predictive value for the occurrence of CV events. To this end, the present narrative review showcases a series of studies examining aortic and peripheral arterial stiffness as surrogates of all-cause CV disease and atherosclerosis in patients with rheumatoid and psoriatic arthritis, as well as in systemic lupus erythematosus and systemic sclerosis. Moreover, we discuss the associations of arterial stiffness with clinical, laboratory, and disease-specific parameters.

Evidence-Based Guideline for the diagnosis and management of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, characterized by asthma, eosinophilia and granulomatous or vasculitic involvement of several organs. The diagnosis and management of EGPA are often challenging and require an integrated, multidisciplinary approach. Current practice relies on recommendations and guidelines addressing the management of ANCA-associated vasculitis and not specifically developed for EGPA. Here, we present evidence-based, cross-discipline guidelines for the diagnosis and management of EGPA that reflect the substantial advances that have been made in the past few years in understanding the pathogenesis, clinical subphenotypes and differential diagnosis of the disease, as well as the availability of new treatment options. Developed by a panel of European experts on the basis of literature reviews and, where appropriate, expert opinion, the 16 statements and five overarching principles cover the diagnosis and staging, treatment, outcome and follow-up of EGPA. These recommendations are primarily intended to be used by healthcare professionals, pharmaceutical industries and drug regulatory authorities, to guide clinical practice and decision-making in EGPA. These guidelines are not intended to limit access to medications by healthcare agencies, nor to impose a fixed order on medication use.

Annals of the Rheumatic Diseases collection on lupus nephritis (2019-2022): novel insights and advances in therapy

No single organ has received as much attention in systemic lupus erythematosus (SLE) as the kidneys. During the period 2019-2022, the Annals of the Rheumatic Diseases published several original papers, brief reports and letters that further elucidate the pathogenesis and advance the management of LN. A selection of representative original papers is highlighted in this review.

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.

The genomic landscape of ANCA-associated vasculitis: Distinct transcriptional signatures, molecular endotypes and comparison with systemic lupus erythematosus

Introduction

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) present with a complex phenotype and are associated with high mortality and multi-organ involvement. We sought to define the transcriptional landscape and molecular endotypes of AAVs and compare it to systemic lupus erythematosus (SLE).

Methods

We performed whole blood mRNA sequencing from 30 patients with AAV (granulomatosis with polyangiitis/GPA and microscopic polyangiitis/MPA) combined with functional enrichment and network analysis for aberrant pathways. Key genes and pathways were validated in an independent cohort of 18 AAV patients. Co-expression network and hierarchical clustering analysis, identified molecular endotypes. Multi-level transcriptional overlap analysis to SLE was based on our published data from 142 patients.

Results

We report here that “Pan-vasculitis” signature contained 1,982 differentially expressed genes, enriched in leukocyte differentiation, cytokine signaling, type I and type II IFN signaling and aberrant B-T cell immunity. Active disease was characterized by signatures linked to cell cycle checkpoints and metabolism pathways, whereas ANCA-positive patients exhibited a humoral immunity transcriptional fingerprint. Differential expression analysis of GPA and MPA yielded an IFN-g pathway (in addition to a type I IFN) in the former and aberrant expression of genes related to autophagy and mRNA splicing in the latter. Unsupervised molecular taxonomy analysis revealed four endotypes with neutrophil degranulation, aberrant metabolism and B-cell responses as potential mechanistic drivers. Transcriptional perturbations and molecular heterogeneity were more pronounced in SLE. Molecular analysis and data-driven clustering of AAV uncovered distinct transcriptional pathways that could be exploited for targeted therapy.

Discussion

We conclude that transcriptomic analysis of AAV reveals distinct endotypes and molecular pathways that could be targeted for therapy. The AAV transcriptome is more homogenous and less fragmented compared to the SLE which may account for its superior rates of response to therapy.

EULAR study group on ‘MHC-I-opathy’: identifying disease-overarching mechanisms across disciplines and borders

The ‘MHC-I (major histocompatibility complex class I)-opathy’ concept describes a family of inflammatory conditions with overlapping clinical manifestations and a strong genetic link to the MHC-I antigen presentation pathway. Classical MHC-I-opathies such as spondyloarthritis, Behçet’s disease, psoriasis and birdshot uveitis are widely recognised for their strong association with certain MHC-I alleles and gene variants of the antigen processing aminopeptidases ERAP1 and ERAP2 that implicates altered MHC-I peptide presentation to CD8+T cells in the pathogenesis. Progress in understanding the cause and treatment of these disorders is hampered by patient phenotypic heterogeneity and lack of systematic investigation of the MHC-I pathway.

Here, we discuss new insights into the biology of MHC-I-opathies that strongly advocate for disease-overarching and integrated molecular and clinical investigation to decipher underlying disease mechanisms. Because this requires transformative multidisciplinary collaboration, we introduce the EULAR study group on MHC-I-opathies to unite clinical expertise in rheumatology, dermatology and ophthalmology, with fundamental and translational researchers from multiple disciplines such as immunology, genomics and proteomics, alongside patient partners. We prioritise standardisation of disease phenotypes and scientific nomenclature and propose interdisciplinary genetic and translational studies to exploit emerging therapeutic strategies to understand MHC-I-mediated disease mechanisms. These collaborative efforts are required to address outstanding questions in the etiopathogenesis of MHC-I-opathies towards improving patient treatment and prognostication.

ERN ReCONNET points to consider for treating patients living with autoimmune rheumatic diseases with antiviral therapies and anti-SARS-CoV-2 antibody products

Recent studies have shown that people who are immunocompromised may inadvertently play a role in spurring the mutations of the virus that create new variants. This is because some immunocompromised individuals remain at risk of getting COVID-19 despite vaccination, experience more severe disease, are susceptible to being chronically infected and remain contagious for longer if they become infected and considering that immunocompromised individuals represent approximately 2% of the overall population, this aspect should be carefully considered. So far, some autoimmune rheumatic disease (ARD) patients with COVID-19 have been treated with antiviral therapies or anti-SARS-CoV-2 antibody products. However, there is no homogeneous approach to these treatment strategies. This issue was addressed within the European Reference Network (ERN) on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ReCONNET) in a discussion among experts and patient's representatives in the context of the rare and complex connective tissue diseases (rCTDs) covered by the Network. ERN ReCONNET is one of the 24 ERNs launched by the European Commission in 2017 with the aim of tackling low prevalence and rare diseases that require highly specialised treatment and promoting concentration of knowledge and resources through virtual networks involving healthcare providers (HCPs) across the European Union (EU). Considering the urgent need to provide guidance not only to the rCTDs community, but also to the whole ARDs community, a multidisciplinary Task Force, including expert clinicians and European Patient Advocacy Group (ePAG) Advocates, was created in the framework of ERN ReCONNET with the aim of developing overarching principles (OP) and points-to-consider (PtC) on a homogenous approach to treat immunocompromised patients with ARDs (with a particular focus on CTDs) affected by COVID-19 using antiviral therapies and anti-SARS-CoV-2 antibody products. The present work reports the final OP and PtC agreed by the Task Force.

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.

Type I interferon pathway assays in studies of rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

OBJECTIVES

To systematically review the literature for assay methods that aim to evaluate type I interferon (IFN-I) pathway activation and to harmonise-related terminology.

METHODS

Three databases were searched for reports of IFN-I and rheumatic musculoskeletal diseases. Information about the performance metrics of assays measuring IFN-I and measures of truth were extracted and summarised. A EULAR task force panel assessed feasibility and developed consensus terminology.

RESULTS

Of 10 037 abstracts, 276 fulfilled eligibility criteria for data extraction. Some reported more than one technique to measure IFN-I pathway activation. Hence, 276 papers generated data on 412 methods. IFN-I pathway activation was measured using: qPCR (n=121), immunoassays (n=101), microarray (n=69), reporter cell assay (n=38), DNA methylation (n=14), flow cytometry (n=14), cytopathic effect assay (n=11), RNA sequencing (n=9), plaque reduction assay (n=8), Nanostring (n=5), bisulphite sequencing (n=3). Principles of each assay are summarised for content validity. Concurrent validity (correlation with other IFN assays) was presented for n=150/412 assays. Reliability data were variable and provided for 13 assays. Gene expression and immunoassays were considered most feasible. Consensus terminology to define different aspects of IFN-I research and practice was produced.

CONCLUSIONS

Diverse methods have been reported as IFN-I assays and these differ in what elements or aspects of IFN-I pathway activation they measure and how. No 'gold standard' represents the entirety of the IFN pathway, some may not be specific for IFN-I. Data on reliability or comparing assays were limited, and feasibility is a challenge for many assays. Consensus terminology should improve consistency of reporting.

Association between type I interferon pathway activation and clinical outcomes in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

BACKGROUND

Type I interferons (IFN-I) contribute to a broad range of rheumatic and musculoskeletal diseases (RMDs). Compelling evidence suggests that the measurement of IFN-I pathway activation may have clinical value. Although several IFN-I pathway assays have been proposed, the exact clinical applications are unclear. We summarise the evidence on the potential clinical utility of assays measuring IFN-I pathway activation.

METHODS

A systematic literature review was conducted across three databases to evaluate the use of IFN-I assays in diagnosis and monitor disease activity, prognosis, response to treatment and responsiveness to change in several RMDs.

RESULTS

Of 366 screened, 276 studies were selected that reported the use of assays reflecting IFN-I pathway activation for disease diagnosis (n=188), assessment of disease activity (n=122), prognosis (n=20), response to treatment (n=23) and assay responsiveness (n=59). Immunoassays, quantitative PCR (qPCR) and microarrays were reported most frequently, while systemic lupus erythematosus (SLE), rheumatoid arthritis, myositis, systemic sclerosis and primary Sjögren's syndrome were the most studied RMDs. The literature demonstrated significant heterogeneity in techniques, analytical conditions, risk of bias and application in diseases. Inadequate study designs and technical heterogeneity were the main limitations. IFN-I pathway activation was associated with disease activity and flare occurrence in SLE, but their incremental value was uncertain. IFN-I pathway activation may predict response to IFN-I targeting therapies and may predict response to different treatments.

CONCLUSIONS

Evidence indicates potential clinical value of assays measuring IFN-I pathway activation in several RMDs, but assay harmonisation and clinical validation are urged. This review informs the EULAR points to consider for the measurement and reporting of IFN-I pathway assays.

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.

Treat to target in Behcet's disease: Should we follow the paradigm of other systemic rheumatic diseases?

During the last decades the efficacy of biologic agents, mainly of anti-TNFs, in controlling the activity of serious manifestations of Behcet's Disease (BD) has been established. On the other hand, the clinical heterogeneity of BD has precluded the validation of a widely-accepted composite index for disease assessment and for target disease-state definitions, such as low disease activity and remission, and the testing of their implementation in clinical practice. Therefore, in contrast to other systemic rheumatic diseases, a treat-to-target strategy has not yet been developed in BD. There are several challenges towards this approach, including standardization of outcome measures for assessing the disease activity in each-affected organ and construction of a composite disease activity index. The challenges for the development of a treat-to-target strategy and possible solutions are discussed in this position paper, which stemmed from a round table discussion that took place in the 19th International Conference on BD.

Correction: Nikoloudaki et al. Persistence of Depression and Anxiety despite Short-Term Disease Activity Improvement in Patients with Systemic Lupus Erythematosus: A Single-Centre, Prospective Study. J. Clin. Med. 2022, 11, 4316

There was an error in the original publication [...].

Accrual of organ damage in Behçet’s syndrome: trajectory, associated factors, and impact on patients’ quality of life over a 2-year prospective follow-up study

Background

This study aimed to investigate the trajectory of damage accrual, associated factors, and impact on health-related quality of life (HR-QoL) in a multicenter cohort of patients with Behçet’s syndrome (BS) over 2 years of follow-up.

Methods

Patients recruited in the BS Overall Damage Index (BODI) validation study were prospectively monitored for 2 years and assessed for damage accrual, defined as an increase ≥1 in the BODI score, and HR-QoL was evaluated by the SF-36 questionnaire. Logistic and multiple linear regression models were built to determine factors associated with damage accrual and impairment in the different SF-36 domains.

Results

During follow-up, 36 out of 189 (19.0%) patients had an increase ≥1 in the BODI score with a mean (SD) difference of 1.7 (0.8) (p <0.001). The incidence rate of damage accrual was stable over time, regardless of the disease duration. Out of 61 new BODI items, 25 (41.0%) were considered related to glucocorticoid (GC) use. In multivariate analysis, duration of GC therapy (OR per 1-year 1.15, 95% CI 1.07–1.23; p <0.001) and occurrence of ≥1 disease relapse (OR 3.15, 95% CI 1.09–9.12; p 0.038) were identified as predictors of damage accrual, whereas the use of immunosuppressants showed a protective effect (OR 0.20, 95% CI 0.08–0.54, p<0.001). Damage accrual was independently associated with the impairment of different physical domains and, to a greater extent, in emotional domains of the SF-36 questionnaire. Female sex, higher disease activity, and fibromyalgia were also significantly associated with impairment in HR-QoL.

Conclusion

In BS, organ damage accrues over time, also in long-standing disease, resulting in an impairment of the perceived physical and mental health. Adequate immunosuppressive treatment, preventing disease flares and minimizing exposure to GCs have a crucial role in lowering the risk of damage accrual.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02947-y.

IL-6 Signaling Attenuates TNF-α Production by Plasmacytoid Dendritic Cells in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is characterized by autoimmune joint destruction with debilitating consequences. Despite treatment advancements with biologic therapies, a significant proportion of RA patients show an inadequate clinical response, and restoration of immune self-tolerance represents an unmet therapeutic need. We have previously described a tolerogenic phenotype of plasmacytoid dendritic cells (pDCs) in RA patients responding to anti-TNF-α agents. However, the molecular mechanisms involved in tolerogenic reprogramming of pDCs in RA remain elusive. In this study, guided by transcriptomic analysis of CD303+CD123+ pDCs from RA patients in remission, we revealed enhanced expression of IL-6R and its downstream signaling compared with healthy pDCs. Functional assessment demonstrated that IL-6R engagement resulted in marked reduction of TNF-α secretion by pDCs whereas intracellular TNF-α was significantly increased. Accordingly, pharmacologic inhibition of IL-6R signaling restored TNF-α secretion levels by pDCs. Mechanistic analysis demonstrated impaired activity and decreased lysosomal degradation of ADAM17 (a disintegrin and metalloproteinase 17) sheddase in pDCs, which is essential for TNF-α cleavage. Importantly, reduction of TNF-α secretion by IL-6-treated pDCs attenuated the inflammatory potential of RA patient-derived synovial fibroblasts. Collectively, these findings position pDCs as an important source of TNF-α in RA pathogenesis and unravel an anti-inflammatory mechanism of IL-6 by limiting the pDC-derived TNF-α secretion.

Residual disease activity and treatment intensification in systemic lupus erythematosus: A cross-sectional study to quantify the need for new therapies

OBJECTIVE

The proportion of SLE patients with residual disease activity in routine settings is variable. We assessed disease activity state in patients during their most recent visit, and whether patients with residual activity were offered therapy intensification.

METHODS

Cross-sectional study of consecutive lupus patients in three tertiary centers. Patients were categorized as: i) remission off-therapy, ii) remission on-therapy, iii) low disease activity, and iv) non-optimally controlled disease. Multivariable regression identified factors associated with treatment intensification and ROC analysis calculated the accuracy of SLEDAI-2K to predict this intensification.

RESULTS

Three hundred and thirty-two patients were included [93.1% female, mean (SD) age 48.5 (14.7) years, median (IQR) disease duration 6.5 (12.4) years]. Mean (SD) total and clinical SLEDAI at last visit were 3.7 (3.0) and 3.0 (2.9), respectively. Although 23.2% of patients were in remission, 40.1% were categorized as non-optimally controlled disease (79.2% due to SLEDAI-2K > 4), but less than 50% of them were offered therapy intensification. Proteinuria (OR 6.78, 95% CI 2.06-22.25), arthritis (OR 5.48, 95% CI 3.20-9.40), and rash (OR 3.23, 95% CI 1.81-5.75) were associated with intensification of therapy, but the accuracy of either total or clinical SLEDAI to predict it was moderate (ROC area under the curve 0.761 and 0.779, respectively).

CONCLUSIONS

About 40% of patients have evidence of residual disease activity and could qualify for novel treatments. Most treatment changes were triggered by active renal, joint, and skin disease, whereas the predictive value of SLEDAI-2K as a metric of disease activity was modest.

Baseline IgG-Fc N-glycosylation profile is associated with long-term outcome in a cohort of early inflammatory arthritis patients

Background

Rheumatoid arthritis (RA) is a chronic autoimmune disease for which prediction of long-term prognosis from disease’s outset is not clinically feasible. The importance of immunoglobulin G (IgG) and its Fc N-glycosylation in inflammation is well-known and studies described its relevance for several autoimmune diseases, including RA. Herein we assessed the association between IgG N-glycoforms and disease prognosis at 2 years in an early inflammatory arthritis cohort.

Methods

Sera from 118 patients with early inflammatory arthritis naïve to treatment sampled at baseline were used to obtain IgG Fc glycopeptides, which were then analyzed in a subclass-specific manner by liquid chromatography coupled to mass spectrometry (LC-MS). Patients were prospectively followed and a favorable prognosis at 2 years was assessed by a combined index as remission or low disease activity (DAS28 < 3.2) and normal functionality (HAQ ≤ 0.25) while on treatment with conventional synthetic DMARDs and never used biologic DMARDs.

Results

We observed a significant association between high levels of IgG2/3 Fc galactosylation (effect 0.627 and adjusted p value 0.036 for the fully galactosylated glycoform H5N4F1; effect −0.551 and adjusted p value 0.04963 for the agalactosylated H3N4F1) and favorable outcome after 2 years of treatment. The inclusion of IgG glycoprofiling in a multivariate analysis to predict the outcome (with HAQ, DAS28, RF, and ACPA included in the model) did not improve the prognostic performance of the model.

Conclusion

Pending confirmation of these findings in larger cohorts, IgG glycosylation levels could be used as a prognostic marker in early arthritis, to overcome the limitations of the current prognostic tools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02897-5.

Gender equity in academic rheumatology, current status and potential for improvement: a cross-sectional study to inform an EULAR task force

OBJECTIVES

Evidence on the current status of gender equity in academic rheumatology in Europe and potential for its improvement is limited. The EULAR convened a task force to obtain empirical evidence on the potential unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology.

METHODS

This cross-sectional study comprised three web-based surveys conducted in 2020 among: (1) EULAR scientific member society leaders, (2) EULAR and Emerging EULAR Network (EMEUNET) members and (3) EULAR Council members. Statistics were descriptive with significance testing for male/female responses assessed by χ² test and t-test.

RESULTS

Data from EULAR scientific member societies in 13 countries indicated that there were disproportionately fewer women in academic rheumatology than in clinical rheumatology, and they tended to be under-represented in senior academic roles. From 324 responses of EULAR and EMEUNET members (24 countries), we detected no gender differences in leadership aspirations, self-efficacy in career advancement and work-life integration as well as the share of time spent on research, but there were gender differences in working hours and the levels of perceived gender discrimination and sexual harassment. There were gender differences in the ranking of 7 of 26 factors impacting career advancement and of 8 of 24 potential interventions to aid career advancement.

CONCLUSIONS

There are gender differences in career advancement in academic rheumatology. The study informs a EULAR task force developing a framework of potential interventions to accelerate gender-equitable career advancement in academic rheumatology.

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.

Persistence of Depression and Anxiety despite Short-Term Disease Activity Improvement in Patients with Systemic Lupus Erythematosus: A Single-Centre, Prospective Study

Mental disorders such as anxiety and depression are prevalent in systemic lupus erythematosus (SLE) patients, yet their association with the underlying disease activity remains uncertain and has been mostly evaluated at a cross-sectional level. To examine longitudinal trends in anxiety, depression, and lupus activity, a prospective observational study was performed on 40 adult SLE outpatients with active disease (SLE Disease Activity Index [SLEDAI]-2K ≥ 3 [excluding serology]) who received standard-of-care. Anxiety and depression were determined at baseline and 6 months by the Hospital Anxiety and Depression Scale. Treatment adherence was assessed with the Morisky Medication Adherence Scale-4. Increased anxiety (median [interquartile range] HADS-A: 11.0 [7.8]) and depression (HADS-D: 8.0 [4.8]) were found at inclusion, which remained stable and non-improving during follow-up (difference: 0.0 [4.8] and −0.5 [4.0], respectively) despite reduced SLEDAI-2K by 2.0 (4.0) (p < 0.001). Among possible baseline predictors, paid employment—but not disease activity—correlated with reduced HADS-A and HADS-D with corresponding standardized beta-coefficients of −0.35 (p = 0.017) and −0.27 (p = 0.093). Higher anxiety and depression correlated with lower treatment adherence (p = 0.041 and p = 0.088, respectively). These results indicate a high-mental disease burden in active SLE that persists despite disease control and emphasize the need to consider socioeconomic factors as part of comprehensive patient assessment.

AB0631 Impact of Behçet’s Syndrome on work activity and productivity: results from a sub-analysis of the BODI Project cohort

Background

Behçet’s Syndrome (BS) is a multisystem recurring inflammatory disorder characterised by a wide spectrum of clinical manifestations, which can vary from limited mucocutaneous lesions up to severe and even life-threatening events.

Objectives

To evaluate the impact of BS on the patients’ work activity and productivity.

Methods

A sub-cohort of 148 patients from the original Behçet’s syndrome Overall Damage Index (BODI) Project study was enrolled. The Work Productivity and Activity Impairment: General Health (WPAI:GH) questionnaire was administered. Demographics, disease duration, comorbidity, major organ involvement, ongoing therapy, Behçet's Disease Current Activity Form (BDCAF), Physician Global Assessment (PGA), Patient Global Assessment (PtGA), and the BODI were recorded. Multiple regression models were built to investigate the independent effect of BS features on WPAI.

Results

Overall, 97 (65.6%) out of 148 patients who completed the WPAI:GH questionnaire resulted working for pay; 22 out of 97 (27.8%) patients reported missing work in the past week due to their health, accounting for a mean (SD) of 34.4% (17.8) of their working time (absenteeism). The only factor significantly associated with absenteeism in multivariate analysis was the presence of ocular damage, as assessed by the BODI (β 0.255, p = 0.027).

Although 93 patients reported that they worked in the previous week, mean 27.3% (30.7) of their actual work productivity was impaired due to their health problem (presenteeism), with only 37 (38.5%) patients reporting no such loss. Factors associated with work impairment were female gender (β 0.319, p = 0.001), higher PtGA (β 0.298, p = 0.002), and an increased BODI score in the last 2 years follow-up (β 0.212 for one-point increased BODI score, p = 0.024).

Finally, 99 (66.9%) of the total 148 patients complained of a daily activity impairment, reporting that a mean of 33.3% (30.6) of their regular daily activities had been prevented due to their health problems. Factors significantly associated with patients’ daily activity impairment were younger age at enrolment (β 0.187, p = 0.021), higher BDCAF disease activity (β 0.235, p = 0.002) and fibromyalgia (β 0.324, p = 0.033).

Conclusion

BS can lead to missing work time and significantly affect both the patient’s work productivity and daily activities. Active disease seems to be one of the major determinants together with a higher burden of damage and the association of some specific comorbidities, such as fibromyalgia.

Table 1.

WPAI:GH questionnaire results

Variablesn°Mean (SD)All patients148Patients working for pay97Percent work time missed due to health977.9 (21.7)Percent work time missed due to health (patients with missed time >0) *2234.4 (17.8)Patients who actually worked in the past seven days**93Percent impairment while working due to health9327.3 (30.7)Percent impairment while working due to health (pts with % impairment while working > 0) ***5645.4 (27.2)Percent activity impairment due to health14833.3 (30.6)Percent activity impairment due to health (those with % activity impairment >0)9949.8 (23.9)

* Patients working for pay who missed at least on hour of work, 22/97 = 22.7%.

** Patients working for pay, but who worked for > 0 hours in the last week = 93/97

*** Patients with impairment while working > 0 among patients who actually worked in the previous 7 day = 56/93.

Disclosure of Interests

None declared

AB0538 INCREASED BURDEN OF MENTAL DISORDERS DESPITE IMPROVEMENT IN DISEASE ACTIVITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A PROSPECTIVE STUDY

Background

Mental disorders such as anxiety and depression are highly prevalent in SLE patients,[1] yet their association with the underlying disease activity remains elusive and has been mostly evaluated at cross-sectional level.[2] This is further complicated by the often-increased rates of treatment non-adherence,[3] an important determinant of heightened lupus activity, among patients with depression.[4]

Objectives

To examine the relationship between longitudinal changes in anxiety (ICD-10-CM F41.9), depression (ICD-10-CM F32.x) and disease activity levels in adult SLE patients. Second, to test the association between the aforementioned mental disorders with treatment adherence and sociodemographic factors.

Methods

A prospective 6-month observational study of outpatients aged 18-65 years who fulfilled the EULAR/ACR 2019 classification criteria and had active disease ascertained by a SLEDAI-2K ≥3 and PGA (physician global assessment; scale 0–3) >1. Patients were enrolled by consecutive sampling technique during May-September 2021. Excluding criteria were overlap rheumatic diseases, active neuropsychiatric lupus, ongoing pregnancy or post-partum period, history of dementia or malignancy. Sociodemographic factors (age, disease duration, education level, working status) and comorbidities were collected. Anxiety and depression levels (assessed with the Hospital Anxiety and Depression Scale [HADS-A/D subscales]), disease activity (SLEDAI-2K, PGA), use of medications, and treatment adherence (Morisky Medication Adherence Scale-4 items scale) were monitored during the observation period.

Results

Forty SLE patients (39 females) with an average [standard deviation] age 50.5 (10.3) years and disease duration 10.3 (7.0) years, were enrolled. Baseline SLEDAI-2K was 6.0 (2.0) driven predominantly from the musculoskeletal and mucocutaneous domains. The prevalence of anxiety (HADS-A >11) and depression (HADS-D >8) were 42.5% and 45.0%, respectively. During follow-up, disease activity was significantly reduced (average [SD] reduction in SLEDAI-2K: 1.90 [2.80], p<0.001), however, anxiety and depression levels remained unchanged (average [SD] change in HADS-A -0.05 [3.76] and HADS-D 0.53 [3.25], respectively, p>0.300 for both). Accordingly, Spearman’s non-parametric test showed that longitudinal changes in SLEDAI-2K were not significantly correlated with the corresponding changes in the HADS-A (rho = 0.13, p=0.417) or HADS-D (rho = -0.05, p=0.781) scores. Treatment non-adherence was found in 19 patients (47.5%) but did not correlate with anxiety and depression (p>0.500 for both). Notably, mental disorders were not significantly associated with comorbidities (including fibromyalgia) but unemployment status predicted the presence of anxiety (odds ratio 7.73, p-value 0.018).

Conclusion

Anxiety and depression are frequent comorbidities in active SLE and do not correlate with short-term disease improvement, thus underscoring the need for adjunct treatment. Physician awareness in the detection of treatment adherence is necessary. Larger studies in early disease and with longer follow-up will be required to further explore the possible interaction between of mental disorder and lupus disease course.

References

[1]Zhang L, et al. BMC Psychiatry. 2017;17(1).

[2]Tay SH, et al. Lupus. 2015;24(13):1392–9.

[3]Costedoat-Chalumeau N, et al. Clin Pharmacol Ther. 2018;103(6):1074–82.

[4]Alsowaida N, et al. Lupus. 2018;27(2):327–32.

Disclosure of Interests

None declared

AB0013 THE COHESIN COMPLEX PROTEIN SMC1A IS A PUTATIVE REGULATOR OF SEX-BIASED INFLAMMATORY RESPONSES IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

A strong female predisposition is characteristic of Systemic Lupus Erythematosus (SLE), with female-to-male ratio ranging from 7:1 to 15:1. The molecular basis of this gender bias remains incompletely understood. In a previous whole-blood RNA profiling study, we identified genes with differential expression in SLE males versus females but not in their healthy counterparts. Among these genes, the cohesin complex protein SMC1A (Structural Maintenance of Chromosomes 1A) displayed the highest statistical significance [1].

Objectives

To (a) determine the immune cell type that displays the strongest gender-biased SMC1A expression in SLE versus healthy individuals, and (b) elucidate the role of SMC1A in regulating immune/inflammatory responses in the context of SLE.

Methods

Multiple immune cell types (CD19+ B cells, CD4+ T cells, CD14+ monocytes, neutrophils) were purified from peripheral blood specimens of SLE and healthy individuals, followed by Taqman PCR and Western blot to measure SMC1A mRNA and protein levels, respectively. The genome-binding properties of SMC1A were assayed by chromatin immunoprecipitation (ChIP)-sequencing in monocytes cultured under lupus-inducing conditions (lupus-like monocytes) [2]. To recapitulate the female/male difference in SMC1A expression, ex vivo cultured lupus-like monocytes were transfected with si-SMC1A (to downregulate SMC1A) versus si-control reagent, followed by genome-wide transcriptome analysis by RNA-sequencing.

Results

Among the various tested immune cell types, CD14+ monocytes best recapitulated the initial whole blood RNA-seq findings, demonstrating significantly decreased SMC1A mRNA and protein expression in male versus female SLE patients but not in their healthy counterparts. In blood monocytes cultured under lupus-inducing conditions and tested by ChIP-sequencing, SMC1A binding was increased on enhancers and promoters of genes associated with inflammation (including type I/II interferon and other inflammatory cytokines) and cell migration. In accordance, lupus-like monocytes with lowered SMC1A expression (i.e., male-like) displayed significantly reduced expression of inflammatory genes like IL6, GBP5, ADA and IL1A, as compared to monocytes with unaffected SMC1A (i.e., female-like). Furthermore, IL6 mRNA synthesis was significantly enhanced in female versus male monocytes cultured under lupus-inducing conditions.

Conclusion

SMC1A may transcriptionally regulate genes associated with the inflammatory response of monocytes. Our findings of gender-biased SMC1A levels in SLE monocytes raise the hypothesis that differential SMC1A expression and function might contribute to the disease gender bias and/or sexual dimorphism.

References

[1]Panousis NI, et al. Ann Rheum Dis. 2019 Aug;78(8):1079-1089.

[2]Park SH, et al. Nat Immunol. 2017 Oct;18(10):1104-1116.

Acknowledgements

The current work is funded by the Hellenic Foundation for Research & Innovation (HFRI). This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Strengthening Human Resources Research Potential via Doctorate Research” (MIS-5000432), implemented by the State Scholarships Foundation (IΚΥ)

Disclosure of Interests

None declared

AB0008 ACESO APPLICATION: AN INTEGRATED GENOTYPE ANALYSIS WEB SERVER FOR CLINICAL GENOMICS IN CROHN’S DISEASE AND IBD-RELATED ARTHRITIS

Background

Genome Wide Association Studies (GWAS) observe the set of different variants throughout the genome of different individuals and study whether a particular trait is due to one variant. Many autoimmune diseases have been identified to have a linkage with specific loci and metabolic pathways, but the exact cause of disorders is still remaining unknown [1]. Aceso Application is an integrated bioinformatics web-tool designed for researchers and medical experts towards to estimating the clinical genomic profile of a candidate patient with Crohn’s Disease (CD)[2-4].

Objectives

To identify the most reliable gene variants, single nucleotide polymorphisms (SNPs) and epigenetic related SNPs that causing CD using the genomic data provided for the patient and aid the medical expert in CD diagnosis.

Methods

In the present study, we have analyzed more than 149.000 CD related publications using data mining and semantic techniques towards extracting the Crohn’s Disease-related genes, non-coding regions and generally candidate SNPs. The extracted knowledge has been filtered, evaluated, annotated, classified, and stored in the Aceso Application Database (AAD). This was followed by the design and development of the Aceso application, in which the generated datasets and results were included. The application has been tested and presented here with whole-exome sequencing data from several related patients with CD.

Results

CD-related SNPs and variants identified in genome-wide association studies (GWAS), whole-genome (WGS), whole-exome (WES), or targeted sequencing information are classified, annotated, and analyzed in an integrated patient profile with clinical significance information. Probable genes associated with the patient’s genomic profile are visualized with chromosome ideograms, statistic bars, and regulatory networks through data mining studies with relative publications. An evaluation study was performed on 2 patients from a three-generation family with CD [5].

Conclusion

The Aceso application was designed to assist early stage diagnosis by using the patients’s genomic data. It provides the patient’s genomic profile which is generated based on the list of the most predictable candidate gene variants related to CD and has implications also for IBD-related arthritis. This novel and accessible webserver tool of CD to assist medical experts in the clinical genomics and precision medicine procedure is available at http://geneticslab.aua.gr/aceso.

References

[1]Ramos et al, J Hum Genet 2015;60:657

[2]Papageorgiou et al, Int J Mol Med 2022;49:8

[3]Papageorgiou et al, Int J Mol Med 2021;47:115

[4]Van Limbergen and Satsangi, Annu Rev Genomics Hum Genet 2009;10:89

[5]Albertsen et al, Mol Med Rep 2019;19:1716

Figure 1.

The Aceso app web-server Database. Left are shown the three identified SNPs classes of the genomic “grammar“ of CD.

Disclosure of Interests

None declared

AB0090 BASELINE IgG-Fc N-GLYCOSYLATION PROFILE IS ASSOCIATED WITH LONG-TERM OUTCOME IN A COHORT OF EARLY INFLAMMATORY ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) is a systemic autoimmune disease which causes chronic joint inflammation and functional limitation1,2. The diagnosis of rheumatoid arthritis (RA) is mainly based on clinical data and RA specific autoantibodies, while the prediction of long-term prognosis from disease outset is not clinically reliable3,4. The importance of immunoglobulin G (IgG) and its Fc N-glycosylation in inflammation of RA has been described, with changes in the glycosylation profiles observed years before the diagnosis of RA5.

Objectives

We herein sought to assess the value of total serum IgG Fc N-glycosylation as a diagnostic and prognostic biomarker in patients with early inflammatory arthritis (EIA). Specifically, we aim to assess whether IgG N-glycoform levels may predict the diagnosis of RA or undifferentiated arthritis (UA) and the long-term disease‘s outcome in patients with EIA arthritis patients naïve to treatment.

Methods

The “Early Arthritis Clinic” of the University Hospital of Heraklion is a prospective cohort of patients with inflammatory arthritis. For the present study, we selected a group of patients naïve to any immunosuppressive treatments with available serum at baseline evaluation (n=118). At baseline, demographics, RA clinical characteristics (DAS28, HAQ-DI) and laboratory tests [autoantibodies (RF and/or ACPA)], were also recorded. The patients were prospectively followed for two years, with clinical, laboratory and disease-related treatments documented. A diagnosis of RA or UA was based on established classification criteria6. In order to assess long-term prognosis we formulated a combined “index” of favourable outcome if the patients fulfilled all the following at 24 months of follow-up: remission or low disease activity (based on DAS28 < 3.2) and normal functionality (based on HAQ ≤ 0.25) while on treatment with csDMARDs and never use bDMARDs. We applied a state-of-the-art liquid chromatography - mass spectrometry (LC-MS) based workflow for analysis of subclass-specific IgG Fc N-glycosylation at the baseline7.

Results

We studied 118 EIA patients [age (mean, SD) (53, 15.6) years, females (80.5%), symptoms duration (53.8, 8.7) years, ACPA positive (16%), DAS28 (4.8, 0.14)]. During the 2 years of follow-up, 60% of the patients were diagnosed with RA and 40% with UA. Although patients with UA had higher relative abundances of galactosylated and sialylated N-glycoforms (H4N4F1, H5N4F1 and H5N4F1S1) in all IgG subclasses at baseline compared to RA patients, differences were not statistically important. Interestingly, we observed a significant association between high levels of IgG2/3 galactosylation for H5N4F1 [effect 0.63, adjusted p=0.036)] and H3N4F1 [effect -0.55122, adjusted p=0.0496) and favorable outcome after two years of treatment.

Conclusion

In our cohort of EIA we found IgG2/3 Fc N-glycoforms to be associated with a favorable prognosis after 2 years of follow-up. Should the present data be confirmed in a larger cohort could be of clinical value. Since currently available prognostic tools have significant limitations, further research should aim to the development of a predictive tool of high specificity and sensitivity based on the combination of clinical, serological data and novel biomarkers.

References

[1]Smolen JS, et al. Lancet (2016) 388(10055):2023-38. doi: 10.1016/S0140-6736(16)30173-8

[2]Firestein GS, McInnes IB. Immunity (2017) 46(2):183-96. doi: 10.1016/j.immuni.2017.02.006.

[3]Scott DL, et al.J. Lancet (2010) 376(9746):1094-108. doi: Doi 10.1016/S0140-6736(10)60826-4.

[4]Weyand CM, Goronzy JJ. Nat Immunol (2021) 22(1):10-8. doi: 10.1038/s41590-020-00816-x.

[5]Ligier S, et al. Br J Rheumatol (1998) 37(12):1307-14. doi: 10.1093/rheumatology/37.12.1307.

[6]Aletaha D, et al. Ann Rheum Dis (2010) 69(9):1580-8. doi: 10.1136/ard.2010.138461.

[7]De Leoz MLA, et al. Molecular & Cellular Proteomics (2020) 19(1):11-30. doi: 10.1074/mcp.RA119.001677.

Acknowledgements

This research was funded by the GlySign and SYSCID – European Union’s Horizon 2020 research and innovation programs under the Marie Skłodowska-Curie, grant numbers 722095 and 733100, respectively.

Disclosure of Interests

Thomas Sénard: None declared, Irini Flouri: None declared, Frano Vučković Employee of: Genos Ltd, Garyfalia Papadaki: None declared, Panagiota Goutakoli: None declared, Aggelos Banos: None declared, Maja Pučić-Baković Employee of: Genos Ltd, Marija Pezer Employee of: Genos Ltd, George Bertsias: None declared, Gordan Lauc Shareholder of: Genos Ltd, a private research organization that specializes in high-throughput glycomic analyses and has several patents in this field., Prodromos Sidiropoulos: None declared

POS0404 IFNα-MEDIATED METABOLIC REPROGRAMMING IN HUMAN SLE MONOCYTES INVOLVES PERTURBATIONS IN GLYCOLYTIC AND LIPID METABOLISM TO REGULATE PROINFLAMMATORY MARKERS AND CYTOKINES

Background

Systemic Lupus Erythematosus (SLE) is a prototype interferonopathy characterized by multiple organ damage1. Metabolomic analyses of patient-derived sera indicate distinct metabolic pertubations in oxidative and lipid metabolism2,3. Among innate effectors, monocytes (Mo) are implicated in SLE pathogenesis and also display a perturbed metabolic phenotype4.

Objectives

Based on previous data indicating a prominent IFNα-gene signature in SLE monocytes even during disease remission5, we herein sought to delineate the metabolic repercussion of IFNα signaling contributing to SLE autoimmunity.

Methods

Using transcriptomic data, we compared the enriched metabolic categories of IFNα(+) and IFNα(-) SLE-Mo6. In order to compare metabolic perturbations pertaining to SLE, we performed transcriptomic Gene Set Enrichment Analysis (GSEA)7 from in vitro cultured IFNα-activated Mo. We supplemented the analysis with selective ex vivo biochemical inhibition of the metabolic pathways arising from the GSEA and evaluated the effect on inflammatory markers of healthy IFNα-Mo.

Results

We found a statistically significant enrichment of transcripts associated with glycolytic metabolism and lipid biosynthetic and catabolic processes in both IFNα(+)-SLE Mo and healthy IFNα-Mo, but not in IFNα(-)-SLE Mo, which in turn resembled healthy-Mo. Additionally, transcripts associated with cholesterol biosynthetic processes such PMVK, SQLE, LSS, DHCR7, and LDLR, MVK, FFT1 were significantly upregulated in IFNα(+)-SLE Mo and healthy IFNα-Mo respectively. In accordance, blockade of either glycolysis with the use of 2-DG hexokinase inhibitor, or mevalonic acid synthesis with the use of fluvastatin, attenuated proinflammatory cytokine secretion (IL6, CXCL10) associated with IFN-response in both IFNα(+)-SLE Mo and healthy IFNα-Mo.

Conclusion

Our results link IFNα mediated metabolic shifts in Mo with corresponding metabolic perturbations found in SLE patient-Mo. Pending further confirmation with targeted metabolomics, these data further rationalize the use of IFN blockade and also suggest the potential use of specific metabolites as novel therapeutic targets in SLE.

References

[1]Crampton, S. P., Morawski, P. A. & Bolland, S. Linking susceptibility genes and pathogenesis mechanisms using mouse models of systemic lupus erythematosus. Dis. Model. Mech. 9, 1033–1046 (2014).

[2]Yan, B. et al. Serum metabolomic profiling in patients with systemic lupus erythematosus by GC/MS. Mod. Rheumatol. 26, 914–922 (2016).

[3]Gkirtzimanaki, K. et al. IFNα impairs autophagic degradation of mtDNA promoting autoreactivity of SLE monocytes in a STING-dependent fashion. Cell Rep. 25, 921-933.e5 (2018).

[4]Huang, N. & Perl, A. Metabolism as a target for modulation in autoimmune diseases. Trends Immunol. 39, 562–576 (2018).

[5]Panousis, N. I. et al. Combined genetic and transcriptome analysis of patients with SLE : distinct, targetable signatures for susceptibility and severity. Ann. Rheum. Dis. 78, 1079–1089 (2019).

[6]El-Sherbiny, Y. M. et al. A novel two-score system for interferon status segregates autoimmune diseases and correlates with clinical features. Sci. Rep. 8, 5793 (2018).

[7]Subramanian, A. et al. Gene set enrichment analysis: A knowledge-based approach for interpreting genome-wide expression profiles. Proc. Natl. Acad. Sci. 102, 15545–15550 (2005).

Disclosure of Interests

None declared.

POS0768 PRESENCE OF ANTI-Ro/SSA AUTOANTIBODIES, HYPOCOMPLEMENTEMIA AND PHOTOSENSITIVITY INDICATE INDIVIDUALS WITH CONNECTIVE TISSUE DISEASE FEATURES WHO ARE AT INCREASED RISK FOR TRANSITION TO SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Early or pre-clinical forms of lupus encompass a broad range of presentations, spanning from asymptomatic individuals with immunological abnormalities to individuals with autoantibodies and some features suggestive of SLE who do not yet meet the classification criteria. Research on this topic could reveal predictive and diagnostic biomarkers for individuals at-risk for progression to SLE.

Objectives

To examine the rate of transition from at-risk to classified (ACR 1997 criteria) SLE, and identify demographic and clinical predictors. To prospectively evaluate the sensitivity and accuracy of the newer classification criteria (SLICC 2012, EULAR/ACR 2019) and the SLE Risk Predictive Index (SLERPI)[1] in patients at-risk who progress or not to classified SLE.

Methods

This is a single-centre analysis of individuals at-risk for SLE as part of an ongoing multicentric inception cohort study aiming to identify clinical, environmental and molecular prognostic factors for SLE onset. Enrolled individuals: a) were 18–55 years old; b) had clinical and/or serological features suggestive of SLE; c) had no clinical diagnosis of SLE or other autoimmune rheumatic disease; and d) did not fulfill the ACR 1997 classification criteria. Prospective monitoring at 6-month intervals was performed to determine accrual of classification and non-classification features, and ascertain the disease status (at-risk/undifferentiated connective tissue disease, SLE, other connective tissue disease).

Results

A total 124 subjects were included, all Whites, 94.4% women, with an average (standard deviation) age 36 (11) years. At first assessment, individuals fulfilled 2.25 (0.72) ACR 1997 criteria with ANA being the most prevalent feature (75.8%) followed by low complement (43.5%), arthritis (37.9%), photosensitivity (28.2%), malar rash (23.4%), and non-scarring alopecia (18.5%). After a median follow-up of 16 months, 27 participants (21.8%) fulfilled the ACR 1997 criteria, of whom 8 (6.5%) developed moderate or severe SLE. Multivariable-adjusted logistic regression identified anti-Ro/SSA (odds ratio [OR] 6.93; 95% confidence interval [95% CI] 1.75–27.5, p=0.006), combined low C3 and low C4 (OR 4.82; 95% CI 1.42–16.3, p=0.012) and photosensitivity (OR 3.25; 95% CI 1.17–8.99, p=0.023) as independent predictors for transition to classified SLE. The sensitivity of SLICC 2012, EULAR/ACR 2019 and SLERPI (>7) at baseline for detecting individuals who progressed to SLE (ACR 1997) was 40.7%, 25.9% and 40.7%, respectively, with corresponding specificities of 83.5%, 88.7% and 79.4%.

Conclusion

Among individuals at-risk for SLE, about 20% may evolve into classified disease after a medium follow up of 16 months which is predominantly of mild severity. Presence of anti-Ro/SSA, hypocomplementemia, and photosensitivity indicate subjects who at increased risk for transition to SLE. Newer classification systems may capture as many as 40% of progressors with acceptable specificity.

References

[1]doi: 10.1136/annrheumdis-2020-219069

Acknowledgements

This work was funded by the Foundation for Research in Rheumatology (FOREUM).

Disclosure of Interests

None declared

AB0636 Relationship between organ damage and impairment of health-related quality of life in patients with Behçet’s Syndrome: results from a longitudinal extension of the BODI Project

Background

Preventing accrual of organ damage represents a primary goal in the treatment of Behçet’s Syndrome (BS), as it may result in impairment of other outcomes, including the health-related quality of life (HR-QoL).

Objectives

The objective of this study was to investigate whether the recent accrual of organ damage, rather than its extent at a single time point, correlate with an impairment of the HR-QoL.

Methods

A sub-analysis of data from patients recruited in the longitudinal phase of the BODI Project validation cohort was performed. The HR-QoL and damage were measured by the Short-form 36 questionnaire (SF-36) and the BS Overall Damage Index (BODI), respectively, at the baseline visit and at a follow-up (FU) 24 ±3 months later. Then the possible increase of damage over FU was assessed by calculating the difference between the BODI score (Δ-BODI) in the two visits. Then, the relationship between the Δ-BODI and the individual and summary domains of the SF-36 was analysed by building multivariate regression models, including age, gender, concomitant fibromyalgia and/or depression, current disease activity as assessed by the BDCAF, as confounding variables.

Results

From the BODI validation cohort, 147 patients were recruitable for this sub-analysis;73 (49.8%) were males. The mean (SD) age and disease duration at enrolment were, respectively, 46.2 (12.4) and 13.4 (10.1) years. BODI score did not influence the SF-36 domains assessed at the baseline visit. In contrast, a significant correlation was recorded between the Δ-BODI and the following SF-36 domains: physical function (PF) (β -0.158 for 1 unit increase in BODI score, p 0.025), role physical (RP) (β -0.150, p 0.044), general health (GH) (β -0.199, p 0.004), role emotional (RE) (β -0.180, p 0.001), mental health (MH) (β -0.244, p 0.001), and the mental components summary (MCS) (-0.203, p 0.008)(Figure 1). Gender, age, fibromyalgia and disease activity were also confirmed to significantly influence HR-QoL (Table 1).

Table 1.

Multiple regression for the assessment of the relationship between Δ-BODI and SF-36 domains

Δ-BODIMaleAgeFBMDPRBDCAFPhysical function (PF)-0.158 (p 0.025)0.180 (p 0.010)-0.299 (p<0.001)-0.358 (p<0.001)-- (p 0.552)-0.141 (p 0.044)Role-physical (RP)-0.150 (p 0.044)0.154 (p 0.039)-0.212 (p 0.001)-0.278 (p<0.001)-- (0.086)-0.251 (p<0.001)Body-pain (BP)-- 0.8680.266 (p<0.001)-0.286 (p<0.001)-0.276 (p<0.001)-- (p 0.799)-262 (p<0.001)General health (GH)-0.199 (p 0.004)0.187 (p 0.010)-- (0.136)-0.296 (p<0.001)-- (0.861)-0.352 (p<0.001)Vitality (VT)-- (p 0.868)0.238 (p 0.001)-0.178 (p 0.008)-0.213 (0.002)-- (p 0.855)-0.371 (p<0.001)Social function (SF)-- (p 0.239)0.299 (p 0.004)-0.166 (p 0.024)-0.242 (p 0.001)-- (0.831)-0.202 (p 0.010)Role emotional (RE)-0.180 0.003)0.158 (p 0.047)-0.157 (p 0.048)-0.233 (p 0.003)-- (0.531)-0.191 (p 0.016)Mental health (MH)-0.244 (p 0.001)-- (p 0.142)-- (p 0.142)-0.292 (p<0.001)-- (p 0.073)-0.254 (p 0.001)Physical Component Summary (PCS)-- 0.1050.229 (p 0.001)-0.298 (p<0.001)-0.296 (p<0.001)-0.254 (p<0.001)Mental Component Summary (MCS)-0.203 (p 0.008)-- (p 0.068)-- (0.246)-0.255 (p 0.001)-- (0.122)-0.302 (p<0.001)

FBM: fibromyalgia; DPR: depression

Conclusion

The recent accrual of organ damage, rather than its extent assessed in a single visit, is associated with impairment of different aspects of heath related quality of life, especially those mental related. Such phenomenon is similar to that observed in other systemic rheumatic disease, may be due to coping mechanisms.

Disclosure of Interests

None declared

POS0366 MODERATE RATES OF TREATMENT INTENSIFICATION IN SLE PATIENTS WITH RESIDUAL DISEASE ACTIVITY

Background

The treat-to-target (T2T) strategy has gained significant attention in SLE,1 while EULAR has set remission or low disease activity as the goal of treatment.2 Nevertheless, the degree to which T2T is followed in real-life clinical settings has not been extensively studied.

Objectives

To assess the proportion of lupus patients with residual disease activity that had their therapy intensified during their most recent visit, identify associated factors, and assess the validity of the SLEDAI-2k as a predictor of this intensification.

Methods

Cross-sectional study of SLE patients who were evaluated in three tertiary centers in Greece during their last visit. Patients were categorized in four disease activity states (remission on and off treatment, low disease activity and non-optimally controlled), according to definitions used in previous studies.3 Intensification of treatment was defined as addition/increase of glucocorticoids (GC) or addition/increase of immunosuppressive (IS) agent (conventional or biologic). Logistic regression analysis was used to identify factors associated with treatment intensification and ROC analysis tο calculate sensitivity, specificity of different SLEDAI-2k cut-off values to predict this escalation.

Results

332 patients were included [93.1% female, mean (SD) age 48.5 (14.7) years, median (IQR) disease duration 6.5 (12.4) years]. Regarding disease activity states, 23.2% (n=77) of patients were in remission (off or on therapy), 36.7% (n=122) were in LDA, while 40.1% (n=133) were categorized as non-optimally controlled disease.

Within patients with residual disease activity, therapy intensification was offered to 25.8% and 48.9% of those with low disease activity and non-optimally controlled disease, respectively. In multivariable analysis, proteinuria (OR 6.78, 95% CI 2.06 – 22.25), arthritis (OR 5.48, 95% CI 3.20 - 9.40) and rash (OR 3.23, 95% CI 1.81 - 5.75), were associated with intensification of therapy. The AUC of the ROC analysis for total SLEDAI-2k to predict therapy escalation was 0.761, indicating only fair accuracy; the cut-off value with the best combination of sensitivity and specificity was 3 (sensitivity 87%, with a specificity of 55%). For clinical SLEDAI-2k, the respective AUC was marginally better (0.779), with a cut-off of 3 being associated with the best sensitivity (80%), with compromised specificity (64%). (Figure 1).

Figure 1.

ROC analysis of total and clinical SLEDAI to predict any increase in therapy

Conclusion

In real-life clinical settings, no therapy intensification was offered in more than half of patients categorized as non-optimally controlled disease. Total and clinical SLEDAI-2k showed only fair accuracy to predict therapy escalation, reflecting the role of additional parameters in the decision to escalate therapy in an individual patient.

References

[1]van Vollenhoven RF, Mosca M, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis 2014; 73: 958–967.

[2]Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78: 736–745.

[3]Ugarte-Gil MF, Wojdyla D, Pons-Estel GJ, et al. Remission and Low Disease Activity Status (LDAS) protect lupus patients from damage occurrence: data from a multiethnic, multinational Latin American Lupus Cohort (GLADEL). Ann Rheum Dis 2017; 76: 2071–2074.

Disclosure of Interests

None declared