Multimodal imaging and genetic characteristics of autosomal recessive bestrophinopathy

PURPOSE

To report the ocular manifestations, multimodal imaging characteristics and genetic testing results of six patients with autosomal recessive bestrophinopathy (ARB).

METHODS

This was an observational case series including 12 eyes of 6 patients who were diagnosed with ARB. All patients underwent a complete ophthalmic examination including refraction, slit-lamp biomicroscopy, dilated fundus examination, fundus autofluorescence, optical coherence tomography and electrooculography. BEST1 gene sequencing was also performed for all patients.

RESULTS

The mean age was 22.8years and the male-female ratio was 0.50. All ARB patients had a hyperopic refractive error. A spectrum of fundus abnormalities, including multifocal yellowish subretinal deposits in the posterior pole, subfoveal accumulation of vitelliform material and cystoid macular edema, was observed. Fundus autofluorescence imaging demonstrated marked hyperautofluorescence corresponding to the yellowish subretinal deposits. Optical coherence tomography revealed serous retinal detachment, intraretinal cysts, brush border appearance caused by elongation of the outer segments of photoreceptors, and hyperreflective dome-shaped deposits at the level of the retinal pigment epithelium. Fundus fluorescein angiography showed hyperfluorescence with staining of the yellowish subretinal deposits. Electrooculography showed reduced Arden ratio in all patients. In addition, biallelic pathogenic variants in the BEST1 gene were detected in all patients.

CONCLUSION

ARB is a rare autosomal recessive inherited retinal disorder with biallelic pathogenic variants in the BEST1 gene and may present with a wide range of ocular abnormalities that may not be easily diagnosed. Multimodal retinal imaging in conjunction with EOG is helpful to establish the correct diagnosis.

Prognostic significance of inflammation scores in malignant mesothelioma

OBJECTIVE

The relationship between inflammatory markers and survival in many cancers has been investigated previously. Inflammatory markers may also offer the possibility of predicting surveillance in patients with malignant mesothelioma. Our study seeks to enhance comprehension of how variables such as the nutritional status and inflammation indices of malignant mesothelioma patients impact the disease's progression and prognosis.

PATIENTS AND METHODS

This study included patients who were treated at the Erciyes University Medical Oncology Clinic between 2010 and 2022 and diagnosed with malignant mesothelioma. This is a retrospective single-center cohort study. Receiver Operating Characteristic (ROC) analysis was applied to determine the inflammation markers' optimal cut-off values with high sensitivity and specificity. Patients were categorized based on these values. The differences in overall survival (OS) and progression-free survival (PFS) between categorized groups were assessed using Log-rank curves and Kaplan-Meier tests. Multivariate analysis was performed using Cox regression analysis on statistically significant data. The relationship between inflammation markers and malignant mesothelioma survival was evaluated.

RESULTS

There are 115 patients in this study. Pre-treatment high neutrophil to lymphocyte ratio (NLR) (HR: 1.34, 95% CI: 1.12-2.83, p=0.04), high pan-immune inflammation value (PIIV) (HR: 2.01, 95% CI: 1.32-4.79, p=0.03), and high systemic inflammation response index (SIRI) (HR: 1.34, 95% CI: 1.2-2.78, p=0.04) were associated with poor OS. Conversely, high advanced lung cancer inflammation index (ALI) (HR: 0.73, 95% CI: 0.53-0.84, p=0.03) and high hemoglobin-albumin-lymphocyte and platelet (HALP) (HR: 0.67, 95% CI: 0.23-0.78, p=0.02) were associated with favorable survival.

CONCLUSIONS

Our study investigated the prognostic value of various inflammation markers in malignant mesothelioma patients and suggests that composite formulas like NLR, PIIV, SIRI, ALI, and HALP that incorporate CBC cells and nutritional parameters like albumin, height, and weight could more consistently and accurately predict malignant mesothelioma prognosis.

AB1300 AA AMYLOIDOSIS IN A PATIENT WITH MUTATIONS IN BOTH ADA2 AND A20 GENES

Background

Adenosine Deaminase 2 Deficiency (DADA2) and Haploinsufficiency of A20 (HA20) are two recently described monogenic autoinflammatory diseases (AID). The uncontrolled inflammatory response has been associated with an increased risk of AA amyloidosis in other AID, but there are only two reported patients with DADA2-related amyloidosis so far.1,2

Objectives

We herein report a patient with AA amyloidosis and AID associated with both DADA2 and HA20.

Methods

We used the Ion Torrent platform for deep sequencing.

Results

Case: A 20-year-old male patient born to consanguineous parents (Figure 1), was admitted to our hospital with fever and abdominal pain in June 2014. Peritonitis, hepatomegaly, and a palpable non-tender mass in the right axillary cavity were detected in physical examination, and his laboratory investigations revealed neutrophilic leukocytosis, high acute phase reactants (APR), and nephrotic range proteinuria. CT angiography showed multiple thrombotic microaneurysms in celiac, splenic, superior, and inferior mesenteric and bilateral renal arteries; and MRI documented an additional aneurysm in anterior communicating artery. No finding was detected in hepatitis serology. He had been diagnosed with polyarteritis nodosa, and prednisolone and azathioprine were started. Renal histopathology confirmed the AA amyloidosis. Genetic analysis revealed no pathogenic MEFV variant. Colchicine and anakinra 100 mg/day were added to his treatment. He experienced 1-2 abdominal episodes annually between 2014-2019, and APR were normal between attacks. In March 2019, he was admitted to the hospital because of abdominal pain, high APR, and iron deficiency anemia. No gross pathology was observed in endoscopic examination of gastrointestinal tract, but histopathological investigation of the gastric mucosa and terminal ileum showed AA amyloidosis. Multiple aneurysms were detected in renal arteries with angiography. Deep sequencing of the targeted genes revealed homozygous p.Pro251Leu in ADA2 gene and heterozygous p.Thr647Pro in TNFAIP3 gene encoding A20, confirming the molecular diagnosis of DADA2 and HA20. The patient described oral recurrent aphthous ulcers starting from his childhood, but he had no uveitis or genital ulcers. His mother and brother also had recurrent oral aphthous ulcers. Genetic analyses showed heterozygous p.Pro251Leu variant in ADA2 gene in his mother, and heterozygous p.Gln703Lys variant in NLRP3 gene as well as heterozygous p.Thr647Pro TNFAIP3 variant and heterozygous p.Pro251Leu ADA2 in his brother. An improvement in his findings was observed within 2 weeks after switching his anakinra to adalimumab 40 mg every other week. At his last visit in February 2021, the patient had no complaints with normal APR, and urinalysis analysis showed 200 mg/day proteinuria, which was regressed from 3 g/day.

Conclusion

This is the first case of AA amyloidosis associated with ADA2 and TNFAIP3 (A20) variants. ADA2 p.Pro251Leu variant has previously been validated as likely pathogenic, and our patient’s clinical findings were mainly compatible with DADA2. On the other hand, TNFAIP3 gene p.Thr647Pro mutation has been reported as variant of unknown significance, but it may have contributed to the DADA2 associated increased risk of amyloidosis. A better response of proteinuria to adalimumab treatment indicates superiority of anti-TNFs in DADA2 patients compared to anti-IL-1 drugs.

References

[1]Ekinci RMK, Balci S, Bisgin A, et al. Renal amyloidosis in deficiency of adenosine deaminase 2: successful experience with canakinumab. Pediatrics 2018;142.

[2]Batu ED, Karadag O, Taskiran EZ, et al. A case series of adenosine deaminase 2-deficient patients emphasizing treatment and genotype-phenotype correlations. The Journal of rheumatology 2015;42:1532-4.

Disclosure of Interests

None declared

AB0748 Anti-Fibrotic Therapy in Progressive Pulmonary Fibrosis Associated with Sytemic Sclerosis: Characteristics of SSc-İAH Patients Receiving Nintedanib and Advers Events during Treatment

Background

Nintedanib, an intracellular inhibitor of tyrosine kinases, has been recently approved for interstitial lung disease associated with systemic sclerosis (SSc-ILD). Nintedanib has shown antifibrotic and antiinflammtory effects in animal models of fibrosing ILDs.

Objectives

We aimed to evaluate clinical charcteristics of progressive SSc-ILD patients receiving anti-fibrotic therapy who were resistant to standart immunosuppressives (ISs) and adverse events during treatment period in this cohort.

Methods

Fifteen patients fulfilling ACR/EULAR (2013) classification criteria for SSc and receiving nintedanib for progressive ILD despite standart ISs included into this retrespective analysis.

Results

Demographics and clinical characteristics of SSc patients were summarised in Table 1. Median age, duration of Raynaud’s and duration of non-Raynaud symptom were 49 (35-72), 8 (1-30) and 4 years (1-21), respectively. ILD was evident median 2 years (0.5-20) after onset of Raynaud’s and 1 years (0.5-11) after onset of non-Raynaud symptom. Before pulmonary involvement, 7 patients received methotrexate and 1 patient cyclophosphamide (CYC) for diffuse cutaneous involvement. After evident ILD, 6 patients received CYC, 5 patients mycophenolate mofetil (MMF) and 4 patients azathioprine as first ISs for SSc-ILD. Median FVC(%) and DLCO(%) were 56 (39-67) and 44 (20-67) before antifibrotic therapy. Thirteen patients (%92,8) received ≥2 ISs before nintedanib. Duration of evident ILD to onset of antifibrotic therapy was median 5.5 years (2-11). Nintedanib was prescribed concomitantly with MMF in 8 or rituksimab-MMF in 6 patients. Median follow-up of antifibrotic treatment period was 7 months (2-18). Advers events during nintedanib were summarised in Table 2. One patient was deceased due to small cell lung cancer at 9.month of nintedanib.

Table 1.

Characteristics of SSc-ILD Patients Receiving Nintedanib

n (%)Females12 (80)Clinical CharacteristicsDiffuse Cutaneous SSc13 (86.7)Limited Cutaneous SSc2 (13.3)Synovitis3 (20)Digital ulsers8 (53.3)Pulmonary arterial pressure >30 mmHg (echo)5 (30)Gastrointestinal involvement10 (76.9)SerologyANA13(86.7)Anti-Scl7010 (66.7)ImmunosuppressivesCYC8 (53.3)MMF14 (93.3)AZA7 (46.7)MTX6 (40)RTX6 (40)Low dose steroids15 (100)Table 2.

Advers Events during Nintedanib Treatment in SSc-ILD patients

SSc-ILD (n=15)Any advers events n(%)8 (53.3) Diarrhoea5 (30) Nausea/ vomiting1 (6.7) Abdominal pain3 (20) Weight decreased3 (20) Yorgunluk2 (13.3) Cough3 (20) Infections (pneumonia)3 (20) Liver test abnormalities4 (26.7) Malignancy1 (7.1) Dose reduction and reescalation7 (46.7) Dose interruption2 (13.3)

Conclusion

Nintedanib was prescribed in progressive SSc-ILD patients who had predominatly diffuse cutaneous involvement, anti-SCL70 positivity and exposed to multiple standart ISs. Duration of ISs were higher than 5 years before antifibrotic therapy. Gastrointestinal (GI) advers events were frequent during nintedanib requiring dose reduction in half of the patients. Nintetanib can be used in progressive SSc-ILD patients considering some difficulties in such a disease with GI involvement. Efficacy analysis of the antifibrotic therapy needs further studies including long term follow-up.

Disclosure of Interests

None declared

POS1279 FAVOURABLE COURSE OF COVID-19 IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER USING BIOLOGIC AGENTS

Background

Serious infections are more frequently seen in patients with inflammatory rheumatic diseases, being treated with immunosuppressive or biologic disease-modifying antirheumatic drugs (b-DMARDs). Potential harmful effects of immunosuppressive drugs as well as b-DMARDs were a major concern during the early phases of the Coronavirus disease 2019 (COVID-19) pandemic, and preliminary data documented the worse outcome of COVID-19 associated with B cell depleting treatments (1). On the other hand, limited information has been shared about the course of COVID-19 in patients with monogenic autoinflammatory disorders using IL-1 inhibitors.

Objectives

We herein aimed to evaluate the course of COVID-19 in adult patients with the most common form of inflammasomopathy, Familial Mediterranean Fever (FMF), who were on biologic agents.

Methods

In this cross-sectionally study, FMF patients were evaluated by screening their clinical and electronic records in our database in October 2021. The FMF patients with a record of PCR-confirmed COVID-19 were investigated in more detail in our hospital. Characteristics of FMF findings as well as clinical and laboratory findings associated with COVID-19 were recorded from the outpatient follow-up cards.

Results

We identified 184 FMF patients using biologic agents, and their baseline characteristics are summarized in Table 1. Among them, 36 had PCR-confirmed COVID-19; 32 of them were currently on b-DMARD along with colchicine (31 anti-IL-1, 1 anti-TNF), and 4 of them had a previous history of b-DMARD treatment. Data about the course of COVID-19 could be reached in 34 patients. Four (11%) patients had an asymptomatic course. Remaining patients with symptomatic COVID-19 had the following symptoms: cough (50%), headache (47.2%), fever (44.4%), loss of taste and smell (41.6%), myalgia (0.6%), dyspnoea (27.8%), diarrhea (25%) abdominal pain (5.6%). Thorax computed tomography was performed in 10 patients, and findings of pneumonia were documented in 6 (16.7%). The mean values of the laboratory parameters were as follows: C-reactive protein 99.48 ± 112.66 mg/L; ferritin 316 ± 208.3; D-Dimer 2445 ± 3917, Lactate Dehydrogenase 253 ± 61, troponin T 26 ± 20, procalcitonin 0.348 ± 0.53. Lymphopenia was detected in 5 (13.9%) patients; mean lymphocyte count was 1080 ± 363. Data about the treatment could be reached in 34 patients. Antiviral therapy was prescribed in 25 (69.4%) patients (favipiravir, n=22; and oseltamivir, n=3). Antibiotics were given to 6 (16.7%) patients, and 6 (16.7%) received hydroxychloroquine. Parenteral steroids were administered to 2 patients during the hospitalization. Six (16.7%) patients required hospitalization, and 2 (5.6%) required oxygen support, non-invasive mechanical ventilation, and one of them followed in the intensive care unit. Twenty-two patients were on anakinra treatment, and none of them required additional dose. Only 1 patient, a 61-year-old male patient with a history of lung lobectomy and renal transplantation, received tocilizumab due to macrophage activation syndrome, and he later died of sepsis. This patient was on anakinra until 2 years before, and it was discontinued due to an allergic reaction. Only 4 patients had a history of vaccination before COVID-19, and none of them developed pneumonia and required hospitalization. Six patients had FMF attacks after recovering from COVID-19. None of the patients developed thromboembolism and secondary bacterial infections.

Conclusion

This survey identified 36 biologic b-DMARD receiving FMF patients, who had COVID-19. All but 1 patient had complete recovery, and b-DMARD usage did not negatively affect the COVID-19 course. None of the patients currently on anti-IL-1 or anti-TNF had a worse outcome. Based on these observations, it can be suggested that refractory FMF patients can continue their b-DMARD treatments when they had COVID-19.

References

[1]Jérôme Avouac, Elodie Drumez, Eric Hachulla, Raphaèle Seror, Sophie Grorgian-Lavialle, et al. COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases trated with rituximab: a cohort study. Lancet Rheumatol 2021 Published Online March 25, 2021, https://doi.org/10.1016/S2665-9913(21)00059-X

Disclosure of Interests

None declared

AB0938 A new screening tool for Psoriatic Arthritis in Psoriasis Patients: TurPAS

Background

Psoriatic arthritis (PsA) is a heterogenous disease with different disease manifestations. Several tools have been developed for screening of PsA in patients with psoriasis with variable performances. An optimal screening tool for PsA is still an unmet need.

Objectives

We aimed to develop a new screening tool in Turkish which could detect different domains involved.

Methods

A core group was determined including 11 rheumatologists/10 dermatologist and a systematic literature review on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis` was performed. The review revealed tools named PEST, PASE, EARP, STRIPP, SIPAS, SIPAT, TOPAS-II, GEPARD, PASQ, CONTEST, A novel, short, and simple screening questionnaire. Each item of those tools were included in the Delphi set. After the 3 rounds of Delphi, a new set of screening questionss was developed.

Results

Overall 85 items were inquired, including questions on joint, dactylitis, enthesitis, back, skin-nail domains as well as morning stiffness, function, treatment and others for the first round of Delphi. Seventeen experts (9 dermatologists/ 8 rheumatologists from the core group) and fifteen patients (Female/Male= 9/6) answered the Delphi (mean (SD) age of 39.3 (10.9) participated to the first round. The involvemet types were peripheral (73.4%), axial (40%), entheseal (33.4) and dactylitis was present in 14% of the patients. As a result of this first evaluation, 44 out of 85 questions were selected and carried to second round The distribution of these questions was as follows; joint question n=13, skin and nail involvement n=6, dactylitis n=5, morning stiffness n=5, axial n=3, enthesitis n=2, general questions n=5. These questions were sent to the members through rheumatology and dermatology societies. In total, 85 rheumatology specialists and 48 dermatology specialists answered the questions in the second round. At the second tour, the number of questions was reduced from 44 to 22. The distribution of the questions was as follows; Skin and nail involvement n=5, dactylitis n=3, joint question n=2, axial involvement n=2, morning stiffness n=2, axial involvement and morning stiffness n=2, enthesitis n=1, general questions n=5. A consensus meeting was held to discuss 22 questions determined at the end of the second round within the initial core group. Each question was handled one by one, some of the questions were combined, if necessary, adapted to Turkish. The tool was given its final form. The final version of the questionnaire consists of 6 questions. (Table 1).

Table 1.

The new screening tool

DomainTurkish versionEnglish versionJointEl/ayak parmaklarinizda ya da herhangi bir ekleminizde hiç şişlik veya ağri oldu mu?Have you ever had swelling or pain in your fingers/toes or any of your joints?DactylitisResimde gösterildiği gibi el veya ayak parmağinizda sosis şeklinde şişlik oldu mu?Have you had a sausage-shaped swelling on your fingers or toes as shown in the picture?EnthesitisTopuk ağriniz olur mu?Do you have heel pain?Axial involvement and morning stiffnessBelinizde, sirtinizda veya boynunuzda istirahatle artan, özellikle sabaha karşi kötüleşen veya sabahlari hareketinizi kisitlayan ağriniz olur mu?Do you have pain in your lower back, back, or neck that increases with rest, worsens especially in the morning, or restricts your movement in the morning?Drug useEklem şikayetleriniz için zaman zaman ilaç kullanir misiniz?Do you take medication for your joint complaints from time to time?History of rheumatic diseaseSize daha önce iltihapli romatizma tanisi konuldu mu?Have you ever been diagnosed with a rheumatic disease before?

Conclusion

A new screening tool targeting different domains in Psoriatic disease was developed in Turkish. While cultural differences play an important role in screening, we believe that the first tool developed in Turkish will be helpful in clinical practice and research settings. Further assessments will be done to understand its validity and reliability within a large cohort of psoriatic patients.

Disclosure of Interests

None declared

POS1360 TRANSIENT ELASTOGRAPHY (FIBROSCAN); AS A NEW NON-INVASIVE DIAGNOSTIC METHOD FOR DETECTING HEPATIC INVOLVEMENT OF AMYLOIDOSIS

Background

Demonstration of deposits by non-invasive methods is important especially for organs difficult to sample in amyloidosis. Transient elastography (fibroscan) is a diagnostic method being used to measure liver stiffness (LS) in different chronic liver diseases.

Objectives

We herein aimed to test the place of fibroscan method for detecting increased LS associated with amyloid deposition in patients (pts) with amyloidosis.

Methods

Six categories of pts enrolled into this cross-sectional study; AA amyloidosis (AA-a), AL amyloidosis (AL-a), Familial Mediterranean Fever (FMF) pts without amyloidosis, cirrhotic chronic liver disease, non-cirrhotic chronic hepatitis B infection (CHB) and healthy controls (HC). LS assessment by fibroscan were categorized as normal for kPa<7, significant stiffness for kPa≥7, advanced stiffness for kPa≥9.5 and kPa≥F4 stiffness. FIB-4 and APRI scores were calculated for each patient when they indicated chronic liver disease. Pts with known chronic liver disease and viral hepatitis excluded from amyloidosis and FMF groups.

Results

A total of 165 pts (AA-a, n=65; AL-a, n=15; FMF, n=20; cirrhotic pts, n=16; CHB, n=22; HC, n=27) constituted the study group. Average age was higher in the AL-a group compared to others. Median LS was highest in cirrhotic pts, and it was also higher in AA-a and AL-a pts compared to FMF and HC. Median LS was numerically higher in AL-a compared to AA-a, but it did not reach statistical significance. Median LS was also higher in FMF pts compared to HC. FIB-4 and APRI scores were lower compared to cirrhotic patients in AA-a and AL-a. ALP levels were higher in AA-a and AL-a groups compared to FMF, CHB and HC. FIB-4 and APRI scores, ALP and GGT levels were correlated with LS both in AA-a (r=0.534***,r=0.485***,r=0.437***, r=0.506***) and, AL-a (r=0.536*, 0.579*, r=0.645*, r=0.752**) and FMF-AA (r=0.584***, r=0.566***,r=0.322*, r=0.306*; *p<0.001, **p<0.01, *p<0.5) groups.

Higher patient age, age at diagnosis of amylodosis, FIB-4 and LS scores, ALP levels, non-FMF causes of AA were associated with hepatic AA amyloid involvement in biopsy-proven pts. A cut-off value 12.05 kPa of LS provided 100% sensitivity and 85.5% specificity (LR=6.9, AUC=0.901, 95% CI 0.81-0.99) for pts with AA-a.

Conclusion

In our single center cohort, we showed a higher median LS by fibroscan in both AL-a and AA-a pts compared to CHB, FMF and HC. It was thought to be that fibroscan may be useful in detecting hepatic amyloid involvement.

Table 1.AA-a (n=65)FMF (n=20)AL-a (n=15)Cirrhosis (n=16)Chronic Hepatitis B (non-cirrhotic) (n=22)HC (n=27)p1p2p3p4p5p6Age (years)*46 (19)42.5(13)58 (16)49 (15)45 (21)45 (23)0.40.30.80.50.80.002Gender (n, %)Male38 (59)10 (50)6 (40)10 (62.5)13 (59)17 (55)0.50.810.70.70.2Female27 (41.5)10 (50)9 (60)6 (37.5)9 (40.9)14 (45.2)Diabetes Mellitus (n, %)5 (8)2 (11)2 (13)3 (15)2 (13)3 (10)0.70.60.40.80.90.6Body Mass Index (kg/m2) *25.7 (1.4)25.6 (5.4)24.8 (3.6)26.7 (6.7)25.5 (7)26 (5.7)0.90.410.70.70.3Liver stiffness (kPa)*6.7 (5.6)6.45 (2.7)9.8 (12)26.7 (22)5.7 (5)4.9 (1.6)<0.001<0.0010.03<0.001<0.0010.16Significant stiffness (kPa≥7)31 (48)11 (55)8 (58)16 (100)4 (18)2 (6.5)0.4<0.0010.012<0.001<0.0010.6Advanced stiffness (kPa≥9.5)17 (26)4 (20)7 (50)16 (100)3 (14)00.4<0.0010.20.0010.020.1S4 stiffness (kPa≥12.5)10 (15)05 (36)16 (100)2 (9)00.057<0.0010.40.020.1FIB-4 score0.97 (0.9)0.76 (0.56)1.3 (0.95)2.5 (3.4)0.85 (0.8)0.7 (0.5)<0.001<0.0010.40.0050.60.1APRI score*0.25 (0.2)0.26 (0.2)0.24 (0.2)0.77 (1.3)0.22 (0.2)0.16 (0.08)<0.001<0.0010.30.0020.020.4ALP (U/L)*97 (65)79 (55)103 (54)79 (126)76 (39)67 (22)<0.0010.50.002<0.0010.0020.7GGT (U/L)*18 (18)17 (26)24 (61)24 (51)16 (14)14 (14)0.070.20.20.070.20.08

p1: AA-a and FMF

p2: AA-a and cirrhosis

p3: AA-a and chronic liver disease

p4: AA-a and HC

p5: FMF and HC

p6: AA-a and AL-a

*Median, interquartile of range

Disclosure of Interests

None declared

AB0613 Vascular Events and Associated Factors in ANCA-associated Vasculitis: Analysis of 237 patients with Long-term Follow-up

Background

Patients with ANCA-associated vasculitis (AAV) reported to have an increased risk of vascular events (VE) compared to general population [1]. However, studies on risk factors for the development of VE in AAV patients (pts) are limited.

Objectives

In our study we aimed to evaluate the frequency, risk factors and mortality risk of VE pts with AAV.

Methods

In this study we retrospectively evaluated 287 pts with AAV. Patients with EGPA (n=33) were not included and 17 pts were excluded due to missing data. Arterial vascular events (a-VE) were recorded as myocardial infarction, unstable angina pectoris, peripheral artery disease, need for revascularization and cerebrovascular accident. Deep venous thrombosis and pulmonary embolism were recorded as venous thrombotic events (VTE). History of a-VE and/or VTE were grouped as all VE. ANCA test results were analyzed based on IFA and/or Elisa results and divided into two serological groups; c-ANCA/PR3+ (positive) and p-ANCA/MPO+.

Results

Data of 237 pts (46 % male) was analyzed. Mean age at diagnosis was 55.6±14 (range; 17-88) years and median disease duration was 77 (range; 3-255) months. Of those pts, 173 (73 %) had GPA and 64 (27 %) had MPA. ANCA results were available in 230 pts; 122 were c-ANCA/PR3+ (53.5 %), 85 were p-ANCA/MPO+ (37 %) and 22 were ANCA negative (ANCA-) (9.5 %). The most common organ involvements were kidneys (75.8 %) and lower respiratory tract (74.4 %).

Overall, 22 % (n=52) of the pts developed VE, 17 % (n=40) a-VE, 9 % (n=21) VTE and 3.8 % (n=9) both a-VE and VTE. In univariate analysis; development of VE was significantly higher in males, pts with c-ANCA/PR3 and pts with higher baseline CRP levels, GFR<50 mL/min, history of smoking, severe infection, higher VDI score. Development of a-VE was higher in pts with males, advanced age, pts with c-ANCA/PR3, history of smoking, higher VDI score, GFR<50 mL/min. Additionally, mortality was increased in pts with VE and a-VE. In multivariate analysis; while VE were associated with smoking [95 % CI:1.7-21; OR:6], c-ANCA/PR3 positivity [95 % CI: 1.15-92; OR:10.3] and higher VDI score [95 % CI:1.007-2.4; OR:1.5]; a-VE were associated with advanced age [95 % CI:1.002-1.08; OR:1.04], higher VDI score [95 % CI:1.3-2; OR:1.6] and c-ANCA/PR3+ [95 % CI:1.06-8.6; OR:3]. Development of VTE was associated with higher VDI score (p<0.001) in univariate and multivariate analysis [95 % CI: 1.2-1.8; OR:1.5].

In survival analysis, mortality rate was significantly higher in pts who had a history of VE (Log-Rank: p=0.04).

Conclusion

Our observational data of more than 5 years of follow-up revealed that, one in five pts with AAV developed VE after diagnosis. The risk of VE was significantly higher in c-ANCA/PR3+ pts, smokers and pts with high VDI scores. Older age increased the risk of a-VE. Mortality was increased in AAV pts with VE after diagnosis. Additional studies needed to delineate the mechanism of VE in AAV and precautions should be undertaken to avoid morbidity and mortality.

Table 1.

Factors associated with vascular events in pts with AAV

Univariate analysisVariablesVE+ (n=52)VE- (n=185)p value (OR) (95 % CI)Age*58.8±14.554.9±140.08 (0.99-1.04)Gender, male Ɨ31 (60)78 (42)0.03 (5) (1.08-3.8)Diagnosis ƗGPA (n=173)40 (23)133 (77)0.5MPA (n=64)12 (19)52 (81)ANCA status Ɨc-ANCA/PR333 (27)89 (73)0.045 (4) (1.007-4.2)p-ANCA/MPO13 (15)72 (85)Baseline CRP (mg/L)ĸ73 (85)48 (89)0.05 (1-1.009)GFR<50 ml/min Ɨ24 (47)57 (31)0.03 (4.7)BVAS score*19±716.3±70.06 (1-1.1)Smoking history (ever) Ɨ19/45 (42)34/162 (21)0.004 (8.3) (1.4-5.6)Cumulative steroid (MP) dosage (g/12 month) ĸ7.9 (17)7.5 (8)0.8Relapse Ɨ22/49 (45)58/180 (32)0.1Severe infection Ɨ23/46 (50)57/168 (34)0.046 (4) (1.006-3.8)VDI score*4.8±2.72.4±1.7<0.001 (1.4-1.96)Remission at 6. month Ɨ19 (56)85 (68)0.2Mortality Ɨ15 (29)27 (14.6)0.02 (5.7) (1.1-4.9)

*mean±std dev

Ɨ n, %

ĸmedian, interquartile range

. OR: Odds ratio

Figure 1.

Comparison of mortality rate between pts had VE and had not.

Log-rank: p=0.039

References

[1]Wallace et al. All-cause and cause-specific.Rheumatology, 2020

Disclosure of Interests

None declared

AB0495 SERUM AND URINE GALECTIN-9, IP-10 AND SIGLEC-1 AS BIOMARKERS OF DISEASE ACTIVITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Galectin-9, interferon-inducible protein-10 (IP-10) and sialoadhesin (SIGLEC-1) are proteins associated with interferon signature, and considered as potential biomarkers reflecting disease activity in patients with systemic lupus erythematosus (SLE).

Objectives

In this study, we aimed to investigate the association of serum and urine levels of galectin-9, IP-10 and SIGLEC-1 with disease activity in patients with SLE.

Methods

Sixty-three patients with active SLE (31 renal and 32 extrarenal) were included in the study. Thirty inactive patients with SLE (15 renal and 15 extrarenal) and 32 healthy volunteers were selected as control groups. Serum (s) and urine (u) levels of galectin-9, IP-10 and SIGLEC-1 were tested using ELISA. Urine levels of biomarkers were normalized by urine creatinine.

Results

Groups were comparable with regard to sex and age distribution. Of 125 participants, 102 (81.6%) were female and median age was 33 (28-44.5) years. Proliferative lupus nephritis (LN) (class III/III+V and IV/IV+V) were found in 22 patients with active renal SLE (70.9%), while 6 patients (19.3%) had pure class V and 3 (9.7%) had class II LN. Levels of sIP-10, uIP-10, sGalectin-9 and uSIGLEC-1 were significantly higher in the active SLE group compared to the inactive SLE group (sIP-10 p=0.046, uIP-10 p<0.001, sGalectin-9 p=0.031 and uSIGLEC-1 p=0.006); however, no differences were detected in the comparison of uGalectin-9 and sSIGLEC-1 between the groups (uGalectin-9 p=0.180 and sSIGLEC-1 p=0.699) (Table 1). Serum and urine levels of galectin-9, IP-10 and SIGLEC-1 did not differ between patients with active renal and extrarenal SLE. Levels of sIP-10, uIP-10 and uSIGLEC-1 were correlated with SLE Disease Activity Index (SLEDAI). Serum and urine levels of all biomarkers were re-tested in 41 of 63 patients (65%) with active SLE after a median treatment of 8 (5-22.5) months. At the time of the second tests, there was a significant decrease in disease activity as measured by SLEDAI [2 (0-4)] compared to the time of the first tests [10 (6-15.5)]. Comparison of sGalectin-9 levels between the serum at the time of active disease and remission showed a very significant decline (p<0.001) as shown in Figure 1. uGalectin-9, sIP-10 and uSIGLEC-1 also decreased after treatment; however, the difference was not statistically significant.

Table 1.

Serum and urine levels of biomarkers across study groups.

BiomarkerActive SLE(n=63)Inactive SLE(n=30)Healthy Control(n=32)sGalectin-9 (ng/ml)11.73 (7.52-14.15)8.66 (7.51-10.02)5.61 (4.56-6.6)sIP-10 (pg/ml)279.4 (147.5-430.3)173.4 (142.2-247.9)74.3 (58.8-103)sSIGLEC-1 (pg/ml)181.2 (157.8-213.9)182.5 (169.9-203.1)258.3 (179-602)uGalectin-9 (ng/ml)8.83 (4.07-18.11)11.54 (7.03-15.07)10.63 (5.55-17.4)uIP-10 (pg/ml)34.4 (15.9-73,9)20.8 (9.9-53.3)12.2 (1.8-25.7)uSIGLEC-1 (pg/ml)321 (236.3-370.9)297.6 (247.7-371)290 (205.1-323.5)uGalectin-9 (ng/mgCre)15.50 (9.60-32.05)11.41 (8.78-19.54)13.57 (11.27-22.08)uIP-10 (pg/mgCre)73.4 (40.9-136.9)26.1 (18.1-55.1)16.4 (5-32.5)uSIGLEC-1 (pg/mgCre)619.6 (389.4-1056.5)393.2 (248.6-715.8)425.6 (264.7-925.9)Figure 1.

Serum levels of galectin-9 before and after the treatment in 41 patients with active SLE.

Conclusion

sIP-10, uIP-10, sGalectin-9 and uSIGLEC-1 are associated with disease activity in SLE. None is able to discriminate active renal from active extrarenal disease. sGalectin-9 may be a valuable biomarker to monitor response after treatment for active disease (Funded by Scientific Research Projects Coordination Unit of Istanbul University. Project number: TSA-2019-34218).

Disclosure of Interests

None declared

POS0223 AMYLOID BURDEN AND ASSOCIATED FACTORS PREDICT HIGHER MORTALITY AND POOR OUTCOME IN FAMILIAL MEDITERRANEAN FEVER-ASSOCIATED AA AMYLOIDOSIS: DATA FROM A TERTIARY REFERRAL AMYLOIDOSIS CENTER WITH 137 PATIENTS

Background

AA amyloidosis (AA-a) is a rare condition while the most common cause is Familial Mediterranean Fever (FMF) in Turkey. There is limited evidence about the impact of AA-a burden on prognosis and outcome in AA-a.

Objectives

We herein aimed to evaluate the AA-a burden and its association with outcome in patients (pts) with FMF-associated AA-a (FMF-AA)

Methods

We retrospectively evaluated FMF-AA pts from our AA-a cohort. Diagnosis of AA-a was confirmed by histologically. Heart involvement (inv.) was defined by documenting increased (>12 mm) septal wall thickness (CSWT) and at least one of three appropriate echocardiography findings (decreased ejection fraction, increased granular echogenicity or valvulopathy, diastolic dysfunction). The pts were divided in three groups according to AA-a burden: pts had only renal inv. (Group 1, G1), renal and gastrointestinal (GIS) (Group 2, G2); renal and GIS and heart (Group 3, G3)

Results

Data of 137 pts with FMF-AA (55% male) were analyzed. We classified 79 pts in G1, 20 in G2, and 14 in G3. CSWT, troponin (trop) and pro-BNP levels were higher in G3 than G1 and G2 but trop levels were not statistically (sts) significant (sig.) between G3 and G2. Overall mortality was in 15.3 %. While mortality rate increased gradually with higher AA-a burden (10 % in G1, 15 % in G2 and 43 % in G3), the difference was sts sig. between G3 and G1.

The number of MEFV variants was lower in pts with higher AA-a burden, especially those with M694V homozygosity were 93% and 72% in G1, 83% and 67% in G2, and 75% and 50% in G3 rsp; but the differences were not sts sig. (p=0.2 and p=0.7 for G1-G2, p=0.06 and p=0.2 for G1-G3, p=0.6 and p=0.4 for G2-G3).

The number of organ inv. was correlated with CSWT (r=0.559’ ‘p<0.001), trop (r=0.646’), pro-BNP (r=0.572’), bsl creatinine (Cre) (r=0.511’), bsl proteinuria (prt) levels (r=0.321 p=0.008) and negatively correlated with bsl e-GFR (r=-0.437’) and biologic DMARD duration (r=-0.235 p=0.03)

ROC analyses revealed 56% sensitivity (SS) and 70 % specificity (SP) for bsl Cre (cut off value [COV] 0.95, AUC=0.726 p=0.03 95% CI 0.56-0.9), 83.3 % SS and 74 % SP for trop (COV 35.5 AUC=0.864 p=0.006 CI 0.73-0.99), 100 % SS and 85.5 % SP for pro-BNP (COV 7246 AUC=0.897 p=0.024 CI 0.79-1.0), 79% SS and 58 % SP for CSWT (COV 11.5 AUC=727 p=0.007 CI 0.61-0.84) to be able to predict higher mortality.

Conclusion

This study showed the association of AA-a burden with higher morbidity such as ESRD and higher mortality in pts with FMF-AA. Bsl Cre, prt, trop and pro-BNP levels were correlated with extent of AA-a burden and predicted higher mortality. Lower frequency of pts with two exon 10 variants or M694V homozygosity in pts with higher AA-a burden indicates that additional genetic and environmental factors may play a role in the development and progression of AA-a in FMF.

Table 1.

Clinical and laboratory features of pts with FMF-AA according to AA-a burden

VariablesG1 (n=79)G2 (n=20)G3 (n=14)p1 (OR)p2p3Age * Ɨ42.8±1343.2±1348.9±110.90.10.2Gender, male**36 (45.6)15 (75)7 (50)0.02 (5.5)0.80.1Diagnosis age of AA-a * Ɨ30.7±1334.1±1434.9±150.30.30.9Duration of AA-a * Ɨ13.8±910.8±614.3±80.150.80.2BaselineCRP (mg/L) Ɨ20±1324±1913±70.40.050.07Prt (g/dL) Ɨ Ɨ3.8 (5.8)12.4 (16)5 (4.2)0.030.30.2Cre (mg/dL) Ɨ0.8±0.41.5±11.8±1.3<0.001<0.0010.6e-GFR Ɨ#104±31104±3159±390.020.0040.5CRF at admission**28/74 (38)13/19 (68)9/12 (75)0.02 (5.7)0.03 (6)0.7ESRD at admission**7/62 (11)6/18 (33)4/11 (36)0.03 (5)0.03 (4.6)0.9CSWT Ɨ10.2±1.710.6±1.113.9±1.60.3<0.001<0.001Trop ĸ Ɨ Ɨ9 (13)28 (68)75 (85)0.40.0050.1pro-BNP ĸ Ɨ Ɨ288 (1040)766 (1967)4968 (33800)0.50.0030.026ESRD (overall)**35 (45)10 (50)13 (93)0.70.001 (11)0.01 (7)Duration of b-DMARD (months) Ɨ##66±2967.7±3741.8±300.90.020.08Mortality **8 (10)3 (15)6 (43)0.50.006 (10)0.1

#estimated glomerular filtration rate

p1: G2-G1

p2: G3-G1

p3: G2-G3

Ɨ mean±std dev. Ɨ Ɨmedian (IQR) *years ** n, % ĸ pg/mL

Figure 1.

Comparison of survival rate between G3 and G1

Log-Rank: p=0.007

Disclosure of Interests

None declared

POS1359 TRANSIENT ELASTOGRAPHY (FIBROSCAN) AS A NON-INVASIVE METHOD FOR DETECTING AMYLOID DEPOSITION IN TRANSPLANTED KIDNEYS IN PATIENTS WITH AA AMYLOIDOSIS

Background

Amyloidosis is characterized by accumulation of insoluble fibrils composed of different monomers in extracellular spaces of different organs, and demonstration of deposits by non-invasive methods is important especially for organs difficult to sample. Transient elastography (Fibroscan) is a diagnostic method of measuring liver stiffness (LS) being used in chronic liver diseases.

Objectives

We herein aimed to search potential of fibroscan detecting kidney stiffness (KS) associated with amyloid deposition in patients with AA who received kidney transplants.

Methods

Renal transplant recipients (RTR) because of AA amyloidosis-related kidney failure (amyloidosis group; AG) and RTR due to other underlying diseases (control group; CG) enrolled into this study. KS and LS were measured by the same physician blinded to diagnosis. The stiffness results were expressed in kilopascals (kPa). Local ethics committee approval and patient consents were obtained.

Results

Nineteen AG and 16 CG patients included into the study. Patient age (p=0.4), gender (p=1), body mass index (BMI) (p=0.4), donor type (p=0.2), donor age (p=0.3), frequency of rejection history (p=0.4) and graft loss (p=0.2) did not show significant difference between two groups. Frequency of diabetes mellitus (DM) (p=0.01), median creatinine (p=0.015) and proteinuria (p<0.001) were higher in AG group than CG. Although median KS was higher in CG group (19.8 [IQR:34] vs 15.8 [IQR:16]), the difference was not significant (p=0.5). Baseline clinical and laboratory features were similar in AG patients with recurrent-amyloidosis (n=6) and non-recurrent AG patients (n=13). Median KS score was higher in recurrent compared to non-recurrent AG patients (p< 0.001). However median LS did not differ between two groups (p=0.4). In multivariate analysis only KS was associated with renal recurrence of AA (p=0.031; OR=1.18, 95% CI 1.015-1.362). In ROC analysis, a cut-off value of 24.55 kPa provided 83.3% sensitivity and 92.3% specificity (LR=10.8, AUC=0.936, p=0.003). Median KS was higher in patients with a history of rejection both among the patients with AG and CG, but the difference was not significant. Additionally, LS scores were similar between two groups.

In FMF-associated AA, median KS was higher in patients with one MEFV variant compared to those with two variants and tended to be higher in other MEFV variants compared to M694V homozygotes (p=0.027 and p=0.08, respectively). There was no correlation between the patient age, disease duration, duration of renal transplantation, donor age, BMI, LS, creatinine, CRP, proteinuria, and KS both in patients with AG and CG.

Table 1.

Comparison of clinical and laboratory features between patients had amyloidosis recurrence and not

VariablesTotalRecurrence -Recurrence +p valueAge (years)*48 (22)47 (17)50 (27)1Gender, maleƗ13 (68.4)9 (69.2)4 (66.7)1Duration of amyloidosis (months)*206 (89)220 (99)163 (203)0.08Diagnosis age of amyloidosis (years)*28 (17)27.5 (17)28 (20)1Duration of renal transplantation (months)*145 (137)144 (110)123 (50)0.7Kidney stiffness (kPa)*15.8 (15.8)10.9 (7.7)29.3 (18.9)<0.001Liver stiffness (kPa)*5.45 (2.8)5.4 (2.7)5.9 (8.9)0.4RejectionƗ(n, %)3 (15.8)2 (15.4)1 (16.7)1Creatinine (mg/dL)*1.4 (0.6)1.4 (0.7)1.7 (0.5)0.24CRP (mg/L)*2.7 (4.4)1.3 (4.1)3.5 (13.9)0.3ProteinuriaƗ3 (15.8)1 (7.7)2 (33.3)0.2Proteinuria (g/day)*0.4 (1.2)0.4

*median; IQR Ɨ n, %

Conclusion

Median KS scores were similar between AG and CG groups; however it was higher in AG patients with recurrent kidney amyloidosis than those without recurrent disease, which may support using the fibroscan method as a useful screening method for establishing AA recurrence. Additionally, higher KS scores in patients with one MEFV variant compared to those with two variants need further studies to be able to identify other yet unidentified amyloidogenic factors.

Disclosure of Interests

None declared

AB1299 DIFFERENCES IN THE CLINICAL SPECTRUM OF HAPLOINSUFFICIENCY OF A20 (HA20) CASES DIAGNOSED DURING ADULTHOOD

Background

Haploinsufficiency of A20 (HA20) is a monogenic autoinflammatory disease caused by heterozygous loss-of-function mutations in TNFAIP3 gene and characterized by Behçet disease (BD)-like manifestations such as mucocutaneous, articular, gastrointestinal, ocular symptoms as well as recurrent fever, elevated acute-phase reactants during relapses; and it usually starts during early childhood. Autoimmunity is another component of HA20 with autoantibodies and variable clinical features resembling systemic lupus erythematosus (SLE) and other autoimmune diseases.

Objectives

We herein present three cases of HA20 with different clinical features and diagnosed during adulthood.

Methods

We used the Ion Torrent platform for deep sequencing.

Results

Case 1: A 51-year old woman diagnosed with BD because of oral and genital aphthous ulcers, arthralgias, erythema nodosum, and pathergy positivity starting from age of 40 in 2012. She developed sudden vision loss (diagnosed with bilateral optic neuropathy), sixth nerve palsy, and entrapment neuropathies in the lower limbs in 2014; and she had flares of neurologic findings between 2014-2020. The only laboratory abnormality was elevated acute-phase reactants, and no pathologic finding was reported for cranial MRI. Pathological examination of sural nerve biopsy revealed chronic inflammatory demyelinating polyneuropathy (CIDP). She received adalimumab and then tofacitinib, and her treatment was switched to certolizumab and IVIG (30 g/6 weeks) in 2020. At the last visit, she was asymptomatic with normal acute phase response, and her examination revealed normal eye movements.

Case 2: A 33-year old woman was followed for 12 years with the diagnosis of SLE, based on fever, photosensitivity, alopecia, polyarthritis, serositis, positive anti-nuclear antibody (ANA) at a titer of 1:1280 with a homogeneous pattern, positive anti-dsDNA, anti-Sm, anti-Sm/RNP, and lupus anticoagulant test, and leukopenia, lymphopenia, hypocomplementemia in 2008. She developed shrinking lung syndrome and Jaccoud arthropathy during the disease course. She received several drugs including corticosteroids, hydroxychloroquine, cyclophosphamide, mycophenolate mofetil, belimumab, rituximab, tocilizumab, abatacept, tofacitinib because of fever, arthritis, skin rash, increased acute-phase reactants, pancytopenia, anti-dsDNA positivity. Her fever, red arthritis attacks with high CRP values did not respond, and after the genetic diagnosis of HA20, anakinra was added to treatment. Due to the high dose anakinra requirement, her treatment was switched to canakinumab (150 mg/2 week), and at the last visit, her attacks were significantly reduced.

Case 3: A 44-year old woman was evaluated because of recurrent prolonged >38°C fever attacks (2 days-2 weeks duration), arthritis of the elbow, wrist, knee joints, and high acute phase reactant in 2004. She did not have a history of recurrent oral and genital aphthous ulcers, intermittent periorbital edema, rash, any ocular symptoms, or sensorineural hearing loss. ANA, RF, anti-CCP, and MEFV gene mutation were negative on admission. PET-CT demonstrated FDG uptake in the wall of the ascending aorta, aortic arch, and descending aorta in 2011. She had used colchicine in 2004, etanercept between 2009 and 2010, anakinra in 2011, tocilizumab in 2012, and canakinumab in 2013. She repeatedly received IV methylprednisolone pulse therapy, but she experienced a relapse of fever when she reduced the dose of methylprednisolone to <8 mg/day. Her knee arthritis did not respond to adalimumab, and she is currently on infliximab treatment since 2019 with a Daily methylprednisolone dose of 8-12 mg.

Conclusion

HA20 can be diagnosed even in adult patients, and the clinical picture of presented cases suggests that monogenic autoinflammatory disorders including HA20 should be suspected in any patient with flares of described manifestations along with strong acute phase response even in adults. Response to corticosteroids and targeted treatments may also be variable.

Disclosure of Interests

None declared

AB0610 Development of Malignancy in Patients with ANCA-associated Vasculitis

Background

Patients (pts) with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) reported to have an increased risk of malignancy compared to general population [1]. However, studies on risk factors for the development of malignancy in AAV pts are limited.

Objectives

We aimed to evaluate the frequency, clinical features and associated factors of malignancy in pts with AAV.

Methods

In this study, we retrospectively evaluated 287 pts with AAV. Thirty-three pts with EGPA and 14 pts with missing data were excluded. ANCA test was analysed based on immunofluorescence and/or Elisa results and divided into two serological groups; c-ANCA/PR3+ (positive) and p-ANCA/MPO+.

Results

Data of 240 pts (54.6 % female) were analysed. Mean age of diagnosis was 55.6±14 (range; 17-88) years and median disease duration was 67.5 (range; 3-255) months. Of those pts, 175 (73 %) had GPA and 65 (27 %) had MPA. ANCA results were available in 230 pts; 123 were c-ANCA/PR3+ (53.5 %), 85 were p-ANCA/MPO+ (37 %) and 22 were ANCA negative (ANCA-) (9.5 %). Kidney (75.8 %) and lower respiratory tract (74.4 %) were the most common organs involved but they did not differ according to presence of malignancy (9.4 % vs 5.1 %; p=0.4 and 9.4 % vs 5 % p=0.4 respectively.)

Twenty-two malignancies were observed in 20 pts (8.3 %; eleven c-ANCA/PR3+, three p-ANCA/MPO+ and two ANCA negative pts). Lung and thyroid papillary cancer in three; bladder, prostate, breast and kidney in two; adrenal gland, oral squamous cavity and sarcoma of retroperitoneum in one patient, hematological (three myelodysplastic syndrome, one chronic lymphocytic leukemia and one lymphoma) in five pts. Six pts (30 %) had prior and/or concomitant AAV diagnosis.

Development of malignancy did not differ according to age, gender, diagnosis, seropositivity (ANCA+ vs ANCA-) and ANCA subgroups (Table 1). There was no association between malignancy and cumulative dose of cyclophosphamide (CYC) or history of smoking (p=0.96 and p=0.2, respectively). In univariate analysis, malignancy was associated with presence of cardiovascular disease (CVD) (p=0.003 OR 11.7) and mortality (p=0.04 OR 4.6), higher BVAS score at baseline (p=0.049) and higher VDI score (p=0.02). Significant association was observed between malignancy with CVD (95 % CI 2.2-83 OR 13.4 p=0.005) and mortality (p=0.044 95 % CI 1.03-8.5 OR:2.95) in multivariate analysis.

Table 1.

Factors associated with malignancy in pts with AAV

Univariate analysisVariablesMalignancy + (n=20)Malignancy – (n=220)p value (OR)Age (years) Ɨ60±13.455.3±140.15Gender (female)10 (50)121 (55)0.7Diagnosis *GPA15 (8.6)160 (91.4)0.8MPA5 (7.7)60 (92)ANCA status*c-ANCA/PR311 (9)112 (91)0.16p-ANCA/MPO3 (3.5)82 (97)Cardiovascular disease*8/38 (21)10/199 (5)0.003 (11.7)Cerebrovascular accident*2/15 (13)16/222 (7)0.3Coronary heart disease*4/18 (22)19/218 (9)0.08Avascular necrosis*4/35 (11)14/199 (7)0.3Venous thrombosis*3/21 (14)15/217 (7)0.2BVAS score at admission Ɨ21.3±616.6±6.70.049Smoking history (ever)*6/53 (11)8/156 (5)0.2Cumulative CYC dose (g) ĸ5 (7.4)4.5 (7.8)0.96VDI scoreĸ3.5 (4)2 (2)0.02Relapse (n=230, %)5/80 (6.3)11/150 (7.3)0.8Remission at six months (n=160, %)8/104 (7.7)5/56 (9)0.8Mortality*7 (35)35 (16)0.04 (4.6)

OR: Odds ratio *(n, %) Ɨ mean± Std dev. ĸmedian; IQR

In survival analysis, mortality rate was higher in pts had malignancy compared to those without (Figure 1, p=0.035).

Figure 1.

Survival analysis of mortality according to presence of malignancy in pts with AAV.

Log-Rank: p=0.035

Conclusion

Significant proportion of pts with AAV developed malignancy in our cohort. Development of malignancy was associated with CVD, higher baseline BVAS and VDI scores. Our study also revealed lower survival rate in patients who developed malignancy. Further studies are needed to clarify risk factors for malignancy in patients with AAV.

References

[1]Wester et al. Curr Opin Rhe, 2018. 30(1): p. 44-49

Disclosure of Interests

None declared

POS0710 ANALYSIS OF 5-YEAR HOSPITALIZATION DATA OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: DAMAGE IS A RISK FACTOR FOR FREQUENT AND LONGER STAYS

Background:

The rates of hospitalization in patients with SLE is around 10% per year.1

Objectives:

In this study, we aimed to examine the hospitalization data of patients with SLE in the last 5 years at our center and determine the factors that affect hospitalization.

Methods:

Hospitalization data of patients with SLE (2012 SLICC classification) admitted to our rheumatology ward between January 2015 and 2020 were analyzed. Cumulative clinical and laboratory findings were retrieved from the existing SLE database and revised. SLICC SLE damage index (SDI), and the disease activity at admission were determined (SLEDAI-2K).

Results:

Eighty-six % (n=138) of 161 hospitalized patients were female. The mean age of the patients was 38 ± 13 years whilst mean duration of disease was 97.3 ±96.9 months. Thirty-eight% of the patients were hospitalized more than once and the mean number of hospitalizations was 1.8±1.5 The mean hospitalization duration covering all stays for each patient was 25±27 days. Active disease followed by infection and damage-related complications ranked the first three among all causes of hospitalization.

Compared to patients hospitalized for active disease or other reasons, patients hospitalized for infection had a significantly higher number of readmissions (p<0.05) and their total duration of hospitalization was longer (p<0.01). Duration of disease was significantly shorter in patients hospitalized for active disease compared to patients hospitalized for infection and damage related causes (p<0.05).

The frequency of patients with damage and the mean SDI score was significantly lower in the group with active disease (68% and 1.9 ± 2) compared to patients hospitalized for infection (90% and 2.7±1.6) and other causes (96% and 3±1.7) (p<0.05 for both). Distribution of damage according to organ/systems is presented in Graph 1. Highest frequency of damage was detected in the cardiovascular (30%), followed by neuropsychiatric (26.7%), renal (23%), pulmonary (23%) and musculoskeletal (20.5%) domains. A positive correlation was found between the mean SDI score and duration of hospitalization (r=0.551, p<0.001) as well as the number of hospitalizations (r=0.393, p<0.001). Regarding disease activity at the time of admission, the mean score of patients hospitalized for active disease was 11.0 ± 6.1 whilst was 3.2 ± 2.8 in patients hospitalized for infection and 2.9 ± 3.3 in patients hospitalized for other reasons (p<0.001). Renal active disease was the most common (44%), followed by hematological (34.8%), articular (21.7%) and mucocutaneous (21%) activity. Ten% of the patients all of whom had damage were admitted to intensive care unit (ICU). Total hospitalization duration (p=0.012), mean SDI (p=0.008), antiphospholipid syndrome (p=0.033), lupus anticoagulant (p=0.010), thrombocytopenia (p=0.015), serositis (p=0.034), pulmonary hypertension (p=0.021), history of alveolar haemorrhage (p<0.001) and cardiac valve involvement (p=0.002) were associated with ICU hospitalization.

Conclusion:

Disease activity, infections and damage are the leading causes of hospitalization in patients with SLE. Damage increases the frequency of hospitalizations, prolongs the duration of stay, and increases the need for follow-up in the ICU. Tight control of disease activity with rational use of immunosuppressive treatment is important to reduce damage and hospitalizations.

Graphic 1.

Distribution of damage according to organs/systems in hospitalized patients

References:

[1]Gu K, Gladman DD, Su J, Urowitz MB. Hospitalizations in patients with systemic lupus erythematosus in an academic health science center. The Journal of rheumatology 2017;44:1173-8.

Disclosure of Interests:

None declared

POS1259 FAVOURABLE SHORT-TERM COURSE OF COVID-19 IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER USING BIOLOGIC AGENTS

Background:

COVID-19 runs a variable course resulting in acute respiratory distress syndrome and death in a subset of patients. The entry of SARS-CoV-2 into the cell stimulates innate immunity including NLRP3 inflammasome and lead to development of adaptive immunity later. Hyperinflammatory response with the release of proinflammatory cytokines including IL-1β and IL-6 results in cytokine storm in some patients with a worse outcome. Colchicine acts on NLRP3 inflammasome and inhibits and IL-1 mediated inflammatory attacks in gout and familial Mediterranean fever (FMF) patients. Patients with inadequate response to colchicine may benefit from anti-IL-1 biologic agents such as anakinra and canakinumab. Recently, favourable effects of anakinra have been observed in COVID-19 patients with findings of cytokine storm.

Objectives:

We aimed to evaluate the impact of COVID-19 among refractory FMF patients followed-up in tertiary referral with the treatment of biologic agents and also document the course of COVID-19 in these patients.

Methods:

We searched out database of FMF patients to identify those using biologic agents (anti-IL-1, anti-IL-6 or anti-TNF) for colchicine-refractory FMF. We interviewed the patients using a standard questionnaire by phone call for symptomatic COVID-19 and evaluated those patients who described findings of COVID-19 further by their hospital records or inviting them to the hospital for additional investigations.

Results:

We identified 183 patients and contacted 106 of them by phone in May-October 2020. A history of symptomatic COVID-19 was documented in 7 FMF patients who were on a biologic agent. Six were on anti-IL-1 and one was on anti-TNF, and one of the patients was not taking his biologic agents for 1 year. All of 7 patients had a favourable outcome. All but 1 patient followed at home and none of them developed findings of cytokine storm, thromboembolism and secondary bacterial infection. Hospitalized patient did not require intensive care unit (ICU) support or mechanical ventilation, and he was not given additional anti-inflammatory medications.

Conclusion:

This series of refractory FMF patients with potentially higher inflammatory characteristics showed COVID-19 did not result in a worse outcome in those patients during the first phase of the pandemic, and none developed findings of cytokine storm. Observations in these patients supports further that biologic agents blocking IL-1 and possibly TNF may contribute to the uneventful course of COVID-19 by preventing the development of hyperinflammatory response. Data collection from a larger group of patients, especially those with amyloidosis, will clarify the protective effects of colchicine and contribution of anti-IL-1 treatments on the favourable disease course during the second phase of the pandemic.

Patient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Age (years)45483953323731MEFV variantsUnknownM694V/M680IUnknownM694V/ M694VM694V/ M694VM694V/ M694VM694V/ M694VAmyloidosisNoNoNoNoNoNoNoBiologic agentsAnakinra100 mg/dayNot takenfor 1 yearAdalimu-mabCanakinumab150 mg/monthAnakinra100 mg/dayCanakinumab150 mg/monthAnakinra100 mg/dayPrednisone (mg/day)5NoNoNoNoNoNoColchicine(mg/day)21,51,51,51,52,02,0RT-PCR positivityYesYesYesYesYesYesYesChest CT signsYesYesNot doneNot doneNot doneNot doneNot doneHospitalisationNoNoNoYesNoNoNoAntiviral therapyOseltamivirOseltamivirNoFavipravirFavipravirFavipravirFavipravirHCQ useYesYesYesYesNoNoNoNew FMF attackduring COVID-19NoNoNoNoNoNoNo

Disclosure of Interests:

None declared

OP0289 LLDAS (LOW LUPUS DISEASE ACTIVITY STATE), LOW DISEASE ACTIVITY (LDA) AND REMISSION (ON- OR OFF-TREATMENT) PREVENT DAMAGE ACCRUAL IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS IN A MULTINATIONAL MULTICENTER COHORT

Background:

Remission, LDA and LDAS have been proposed as treatment goals for SLE. However, the independent impact of these states on damage accrual has not been fully evaluated.

Objectives:

To determine the independent impact of remission (both off & on treatment), LDA, and LLDAS on damage accrual.

Methods:

We studied a long-term longitudinal multinational SLE cohort, including patients completing at least two annual assessments. Remission off-treatment was defined as a SLEDAI (excluding serology) =0, without prednisone and immunosuppressive (IS) drugs. Remission on-treatment was defined as a SLEDAI (excluding serology) =0, prednisone daily dose<=5 mg/d and maintenance IS drugs. LDA was defined as a SLEDAI (excluding serology) <=2, without prednisone or IS drugs. LLDAS was defined as a SLEDAI <=4 with no activity in major organ systems, with no new features of lupus disease activity compared to the previous assessment, prednisone daily dose<=7.5 mg/d and maintenance IS drugs. Antimalarials were allowed in all groups. Damage accrual was ascertained with the SLICC/ACR damage index (SDI). Univariable and multivariable generalized estimated equation (GEE) negative binomial regression models were used. To create mutually exclusive groups, disease activity was divided into five states: remission off-treatment, remission on-treatment (minus remission off treatment), LDA (minus remission), LLDAS (minus remission and LDA) and not-optimally controlled. The proportion of the time that patients were in the specific state at each visit since cohort entry was determined. Possible effect modifiers and confounders adjusted for included sex, age at diagnosis, race/ethnicity, education, baseline disease duration, follow-up time, the highest-ever glucocorticoid dose prior to cohort entry, antimalarials and SDI. Time-dependent covariates were determined at the same annual visit as disease activity state; the outcome was the increase in the SDI and it was assessed at the subsequent visit.

Results:

There were 1,652 patients, 1464 (88.6%) were female, mean age at diagnosis was 34.6 (SD 13.4) years and mean baseline disease duration was 5.5 (SD 4.1) months. Patients had a mean follow-up of 6.5 (SD 4.3) years, 11686 visits were included. 763 patients (46.2%) had an increase in SDI score ≥1 during follow-up. 2483 (21.2%) of the visits were classified as remission off-treatment, 2276 (19.5%) as remission on-treatment, 544 (4.7%) as LDA, 657 (5.6%) as LLDAS and 5726 (49.0%) as not-optimally controlled. Being in remission off-treatment, remission on-treatment, LDA and LLDAS were predictive of a lower probability of damage accrual [remission off-treatment IRR=0.403, 95% CI 0.301-0.541); remission on-treatment IRR=0.313 (95% CI 0.218-0.451) LDA: IRR=0.469 (CI 95% CI 0.272-0.809); LLDAS IRR=0.440 (95% CI 0.241-0.803)]. The multivariable model is summarized in Table 1.

Table 1.

Multivariable GEE model of the impact of disease activity states on damage accrual.

Incidence Rate Ratio95% CIDisease activity stateRemission off treatment0.4030.301-0.541Remission on treatment0.3130.218-0.451LDA0.4690.272-0.809LLDAS0.4400.241-0.803Gender, male1.2741.086-1.495Age at diagnosis1.0241.020-1.029EthnicityCaucasian USRef.Caucasian other1.0170.849-1.217African1.4671.211-1.776Asian0.8630.693-1.075Hispanic1.2661.034-1.550Other1.1210.759-1.656Educational level, years0.9770.957-0.996Disease duration at baseline0.9600.801-1.150Follow-up time0.9420.923-0.960Antimalarial use0.7860.681-0.908Highest prednisone dose before baseline1.0021.001-1.007SDI before1.1001.050-1.1152

LLDAS: Low lupus disease activity state LDA: Low disease activity SDI: SLICC/ACR Damage Index

Conclusion:

Remission on- and off-treatment, LDA and LLDAS were associated with less damage accrual, even adjusting for possible confounders and effect modifiers. This highlights the importance of treating to target in SLE.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, John Hanly: None declared, Murray B Urowitz: None declared, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MFP, Sanofi, UCB, Sang-Cheol Bae: None declared, Juanita Romero-Diaz: None declared, Jorge Sanchez-Guerrero: None declared, Sasha Bernatsky: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, and Exagen Diagnostics, Daniel J Wallace Grant/research support from: Exagen, David Isenberg: None declared, Anisur Rahman: None declared, Joan T Merrill: None declared, Paul Fortin: None declared, Dafna D Gladman Consultant of: Abbvie, Janssen, Pfizer, Novartis, Amgen, Grant/research support from: Abbvie, Janssen, Pfizer, Novartis, Amgen, Ian N. Bruce: None declared, Michelle A Petri: None declared, Ellen M Ginzler Grant/research support from: Aurinia pharmaceutical, M.A. Dooley: None declared, Rosalind Ramsey-Goldman: None declared, Susan Manzi: None declared, Andreas Jonsen: None declared, Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, UCB, Consultant of: Abbvie, AstraZeneca, Biogen, Biotest, Celgen, Galapagos, Gilead, Janssen, Pfizer, Sanofie, Servier, UCB, Vielabo, Grant/research support from: BMS, GSK, Lilly, UCB, Cynthia Aranow: None declared, Meggan Mackay: None declared, Guillermo Ruiz-Irastorza: None declared, S. Sam Lim: None declared, Murat Inanc: None declared, Kenneth C Kalunian Consultant of: Roche, Biogen, Janssen, AstraZeneca, Eli Lilly, Genetech, Gilead, ILTOO, Nektar, Viela, Equillium, Bristol-Meyers Squibb, Soren Jacobsen Grant/research support from: BMS, Christine Peschken: None declared, Diane L Kamen: None declared, Anca Askanase Consultant of: Abbvie, Grant/research support from: Glaxo Smith Kline, Astra Zeneca, Janssen, Eli Lilly and Company, Mallinckrodt, Pfizer, Bernardo Pons-Estel Consultant of: GSK, Janssen, Graciela S Alarcon: None declared.

POS1257 HYPOGAMMAGLOBULINEMIA IS A SIGNIFICANT RISK FACTOR FOR MORTALITY IN PATIENTS WITH ANCA ASSOCIATED VASCULITIS AND COVID-19

Background:

The negative impact of COVID-19 in patients with ANCA associated vasculitis (AAV) and patients on rituximab (RTX) treatment have been reported (1). Risk factors for severe course of COVID-19 and increased mortality in these patients are unclear.

Objectives:

To evaluate the course of COVID-19 in our AAV cohort and identifying risk factors for mortality.

Methods:

Patients with AAV who were classified according to CHCC and whose scheduled last visit were after December 2019 were screened and evaluated for COVID-19 either by phone call or in the clinic. Records of patients with a history of hospital admission due to COVID-19 were evaluated. Cumulative clinical findings and treatment history were noted. Hypogammaglobulinemia (hIgG) was defined as IgG level below 700 mg/dl. All inpatients with a diagnosis of COVID-19 were screened for hIgG and IVIG was administered if necessary.

Results:

Eighty-nine patients (47.2% female, mean age 56 + 12.5 (28-81)) were included into the study. The diagnosis was GPA in 56 (62.9%) and MPA in 33 (37.1%) patients. Mean follow up time was 91 + 53.4 (26-272) months. Anti-PR3 and anti-MPO were positive in 46 (51.7%) and 32 (35.9%) patients, respectively. Lower respiratory tract (LRT) involvement was present in 72 (80.9%) and 10 patients had a history of diffuse alveolar haemorrhage (DAH). Sixty-one patients (68.2%) had a history of rapidly progressive glomerulonephritis (RPGN) and 21 (23.6%) had peripheral nervous system (PNS) involvement.

Fifteen (16.9%) patients had COVID-19; 14 of them were PCR positive, one patient had symptoms and thorax CT findings compatible with COVID-19. Pulmonary infiltrates were observed in 13 patients (86.7%); 9 (60%) had severe pneumonia. Twelve patients (85.7%) were hospitalized, 6 patients (42.9%) needed ICU admission and 5 patients (35.7%) died. Tocilizumab and anakinra for hyperinflammation during COVID-19 were used in 1 (6.7%) and 4 (26.7%) patients, respectively.

Four out of five deceased patients (3 on RTX treatment, 1 with renal transplant) were in remission at the time of COVID-19. COVID-19 was detected in a patient with disease flare and DAH, during treatment with high dose steroids and plasmapheresis. hIgG was detected in all deceased patients from COVID-19 during hospital admission (mean IgG: 495±113.2 mg/dL).

Symptomatic COVID-19 was more frequent in patients with a history of DAH, RPGN and hIgG. hIgG during the follow-up was significantly associated with COVID-19 in multivariable analysis (p=0.01, OR=20,6 %95 CI (2-210). Comparison of patients who died of COVID-19 and survived showed that female sex, PNS involvement and hIgG during the clinical course and hospital admission were risk factors for increased mortality (Table 1). Age, smoking, treatments, history of flares or serious infections, remission status and chronic renal insufficiency did not differ between groups.

Conclusion:

The frequency and mortality from COVID-19 is found to be high in our AAV cohort compared to previous reports (1). Patients with serious lung or renal involvement are prone to symptomatic COVID-19. Previously reported severe outcomes on RTX therapy might be related to consequent hIgG. High dose IVIG treatment may not be sufficient in improving survival in AAV patients with severe COVID-19 and hIgG.

References:

[1]Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients. 2020:annrheumdis-2020-218310.

Table 1.

Comparison of risk factors for CI and mortality in patients with AAV

COVID-19 (n=15)Non-infected (n=74)pORDeath (n=5)Survive (n=10)p2OR2Age53.4±11.956.6±12.6NS51.2±12.654.6±12.1NSSex (female)635NS420.03614 (0.9-207)LRT Involvement1458NS59NSDAH460.0384.1 (1-16.9)13NSRPGN15460.0048.5 (1-68.4)57NSPNS involvement318NS300.0059 (1.4 - 57)RTX treatment1033NS37NShIgG in outpatient visits670.026.3 (1.8-23.3)420.0216(1.5-234)hIgG during hospitalization due to CI----540.0252.5 (1.2-5.4)Flares≥1725NS43NSChronic Renal Insufficiency722NS43NS

Disclosure of Interests:

None declared

AB0331 PULMONARY INVOLVEMENT IN A SINGLE CENTER COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The prevalence of SLE pulmonary involvement varies depending on several factors, including diagnostic methods [1].

Objectives:

We aimed to determine the frequency of involvement with different diagnostic methods in a single center cohort.

Methods:

300 SLE patients were included. Chest x-ray (CXR), lung spirometry, carbonmonoxide diffusion test (DLCOc) and echocardiography were performed. High resolution thorax computed tomography (HRCT) was done for a definite diagnosis of interstitial lung disease (ILD) whilst diagram electromyography (EMG), ultrasonography (USG) and magnetic resonance imaging (MR) were utilized to diagnose shrinking lung syndrome (SLS).

Results:

The mean age and follow-up time were 43 and 11,5 years respectively. Of 300 patients, 16% had ILD, 6,7% had pulmonary hypertension (PHT), 3% had SLS, 0,3% had pulmonary infarction. At the start of the study, patients’ records showed that 4% had ILD, 5% PHT, 0,3% SLS and 0,3% pulmonary infarction. The median age, mean duration of disease and follow-up time were significantly higher and longer in patients with ILD compared to patients without (p<0.05). Forced expiratory volume (FEV1), forced vital capacity (FVC), DLCOc and total lung capacity (TLC) were significantly lower in patients with ILD and with SLS (p<0,001). Patients with ILD had significantly higher frequency of arthritis, serositis, Raynaud myositis and anti-Scl70 positivity. Avascular necrosis, diabetes and malignancy were significantly more frequent in those patients. All patients with suspected SLS undergone diagram EMG, USG and MR. Out of 10 suspected cases, in 6 EMG, in 5 USG and in 9 MR was compatible with SLS diagnosis. 5 patients had 3 of the diagnostic methods positive to diagnose SLS. Muscle atrophy and weakness, avascular necrosis were more frequent in this group of patients (p<0.05). There were more patients treated with mycophenolate mofetil (MMF) and cyclophosphamide in the SLS group whilst more with MMF in the ILD group. Significantly higher frequency of patients had stopped using hydroxychloroquine (HCQ) in the ILD group (p=0,04).

Conclusion:

Interstitial lung disease is common in patients with SLE and considerable number of patients have SLS [2]. Spirometry, DLCOc and CXR are simple but valuable to diagnose pulmonary involvement in SLE patients. Diaphragm MR, USG and EMG are complementary methods for definite diagnosis in SLS [2]. Considering the significant difference of prevalence between the start and the end of the study, one of the possibbilities is the underrecognition of SLE pulmonary disease due to its being part of a multisystemic presentation. Higher usage of immunosuppressives in these patients may support a multisystemic active disease. Although drug effect is another concern, it is hard to establish a causal relationship due to the study’s cross-sectional design. HCQ may have a role in ILD prevention.

References:

[1]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax 2000;55:159-166.

[2]Singh R, Huang W, Menon Y, Espinoza LR. Shrinking lung syndrome in systemic lupus erythematosus and Sjogren’s syndrome. J Clin Rheumatol. 2002 Dec;8(6):340-5.

Table 1.

Spirometry; DLCO; diaphragm EMG, USG and MRI results of patients with SLS.

Patient/Age/Sex1/44/F2/57/F3/39/F4/38/M5/23/F6/60/F7/58/F8/37/F9/66/F10/28/FFEV1 (%)47655963676271537039FVC (%)56735962797072556237DLCO (%)45504465535547656245TLC (%)61716566786454636245USG deep inspiration (L)4,704,742,593,013,063,065,734,172,121,59USG deep inspiration (R)3,721,982,262,242,772,174,672,834,622,49USG diaphragm thickness (L)4,823,002,482,842,551,592,093,181,621,44USG diaphragm thickness R(R)1,231,041,841,802,191,311,791,972,081,63MR high sideRRRRRRRLLMR height difference4,926,192,872,641,672,451,730,950,78EMG resting AMP (R)0,20,30,60,50,60,40,10,80,90,7EMG resting LAT (R)76,47,166,786,154,7565,8EMG resting AMP (L)0,40,50,80,71,20,60,31,20,50,5EMG resting LAT (L)6,355,756,855,66,05664,355,26,15

Disclosure of Interests:

None declared

POS0766 CLUSTER ANALYSIS AND COMPARISON OF CUMULATIVE DAMAGE BY DIAPS IN A SINGLE CENTER COHORT OF APS PATIENTS

Background:

Antiphospholipid syndrome (APS) is a chronic autoimmune disease with significant morbidity and mortality. The recently developed damage index for APS (DIAPS) considers thrombotic APS specific damage.

Objectives:

Herein we aimed to identify disease clusters based on clinical characteristics and compare DIAPS between these clusters in a single center cohort of patients with APS ± systemic lupus erythematosus (SLE).

Methods:

This retrospective study included 237 consecutive patients with APS [114 primary APS (PAPS) and 123 SLE+APS]. Data regarding demographics, clinical and laboratory characteristics and cardiovascular risk factors were retrieved from the existing database and revised. Two-step cluster analysis was performed. Cumulative damage was calculated for all patients by applying DIAPS as described previously.

Results:

237 patients were classified into 4 subgroups by cluster analysis. Cluster 1 (n=74) consisted of older patients with arterial-predominant VT, livedo reticularis and increased cardiovascular risk, cluster 2 (n=70) of SLE+APS patients with thrombocytopenia and heart valve disease, cluster 3 (n=59) of patients with venous-predominant VT, less extra-criteria manifestations and cluster 4 (n=34) of patients with only PM with a lower frequency of extra-criteria features and cardiovascular risk (table 1).

Table 1.

Demographic, clinical and laboratory characteristics of clusters

All (n=237)Cluster 1 (n=74)Cluster 2 (n=70)Cluster 3(n=59)Cluster 4 (n=34)PAge (years), median (range)43 (20-81)51 (20-81)40 (27-72)42 (24-69)40.5 (26-65)<0.001Duration of disease (years), median (range)9.5 (1-37.7)13.1 (1-37.7)10.4 (1-28.7)8.5 (1-32.8)7 (1-22.4)0.028Female, n (%)198 (83.5)56 (75.7)61 (87.1)47 (79.7)34 (100)<0.05SLE, n (%)123 (51.9)31 (41.9)46 (65.7)32 (54.2)14 (41.2)<0.05Vascular thrombosis, n (%)191 (80.6)73 (98.6)59 (84.3)59 (100)0 (0)<0.001Arterial thrombosis, n (%)109 (46)50 (67.6)31 (44.3)28 (47.5)0 (0)<0.001Venous thrombosis, n (%)112 (47.3)36 (48.6)37 (52.9)39 (66.1)0 (0)<0.001Pregnancy morbidity, n (%)117 (49.4)22 (29.7)46 (65.7)15 (25.4)34 (100)<0.001Livedo reticularis, n (%)38 (16)21 (28.4)10 (14.3)5 (8.5)2 (5.9)<0.01Thrombocytopenia, n (%)81 (34.2)4 (5.4)65 (92.9)4 (6.8)8 (23.5)<0.001Heart valve disease, n (%)92 (38.8)32 (43.2)46 (65.7)8 (13.6)6 (17.6)<0.001Arterial hypertension, n (%)101 (42.6)49 (66.2)34 (48.6)18 (30.5)0 (0)<0.001Hyperlipidemia, n (%)103 (43.5)69 (93.2)26 (37.1)0 (0)8 (23.5)<0.001Smoking, n (%)58 (24.5)31 (41.9)7 (10)17 (28.8)3 (8.8)<0.001Lupus anticoagulant, n (%)156 (65.8)53 (71.6)48 (68.6)35 (59.3)20 (58.8)0.36Anticardiolipin IgG/IgM, n (%)155 (65.4)46 (62.2)46 (65.7)38 (64.4)25 (73.5)0.71Anti-β2-glycoprotein I IgG/IgM, n (%)93 (39.2)25 (33.8)33 (47.1)26 (44.1)9 (26.5)0.13Triple aPL positivity, n (%)45 (19)12 (16.2)16 (22.9)13 (22)4 (11.8)0.46

Cluster 2 had the highest cumulative damage (mean DIAPS 2.48 ± 1.67) followed by cluster 1 (2.24 ± 1.44), cluster 3 (1.69 ± 1.27) and cluster 4 (0.32 ± 0.68). Comparison of DIAPS (total and major domains) between the clusters is shown in figure 1.

Patients with SLE+APS had a higher mean DIAPS compared to those with PAPS (2.10 ± 1.61 vs 1.69 ± 1.47, P=0.046). Cardiovascular domain was the most frequently affected DIAPS domain in both groups. Proteinuria and avascular necrosis were significantly more frequent in SLE+APS (9.8% vs 2.2%, P=0.02 and 5.7% vs 0%, P=0.009, respectively). DIAPS was positively correlated with disease duration (r=0.192, P=0.003).

Conclusion:

Elder APS patients with arterial thrombosis and increased cardiovascular risk and SLE+APS patients with extra-criteria manifestations had higher cumulative DIAPS. Longer disease duration, higher frequency of major organ involvement and higher immunosuppressive usage may have contributed to this difference. Therefore, control of cardiovascular risk factors, prevention and effective treatment of SLE flares may help to reduce damage in these subgroups.

Figure 1.

Comparison of mean DIAPS (total and major domains) between the clusters

Disclosure of Interests:

None declared

AB0369 EVALUATION OF BASELINE POSITRON EMISSION TOMOGRAPHY IN THE DIAGNOSIS AND ASSESSMENT OF GIANT CELL ARTERITIS

Background:

Positron emission tomography (PET/CT) has gained importance in the diagnosis and assessment of large vessel vasculitis (LVV) recently.

Objectives:

We aimed to investigate the diagnostic importance and clinical significance of PET/CT findings in giant cell arteritis (GCA).

Methods:

Data of the patients who underwent PET/CT to investigate large vessel involvement and who had at least 6 months of follow-up with a clinical diagnosis of GCA were retrospectively evaluated. PET/CT images were assessed by an experienced nuclear medicine specialist, regions of interest were drawn for major vascular territories and standardized maximum uptake values (SUVmax) of these areas were recorded.

Results:

Twenty-nine consecutive patients (median age 68 (50-83), mean follow-up time 37.1 ± 48.8 (6-242)) were included into the study. All patients were over 50 years old and had erythrocyte sedimentation rate (ESR) over 50 mm/h at the time of imaging. Twenty patients (68.9%) met the ACR 1990 Classification criteria (ACR (+) group). The number of patients who had hypermetabolism in the aorta and its major branches in favour of LVV in PET/CT was 23 (79.3%) (PET-CT (+) group). Thoracic and abdominal aorta involvement were detected in 22 (75.8%) and 16 (55.2%) patients, respectively. There was positive correlation between SUVmax in thoracic and abdominal aorta on PET/CT and ESR at diagnosis (r = 0.63 p = 0.002 and r = 0.77 p <0.001, respectively) and SUVmax in thoracic aorta and CRP (r=0.50 p=0.026). PET/CT (-) patients had more frequent disease flares during the follow-up (4/6 vs. 5/23 p = 0.035 OR = 7.2 (1.01- 51)). Three distinct subgroups were defined by implementing both ACR criteria and PET/CT positivity. Among ACR (+) patients (n=20); comparison of PET/CT (+) (n=14) and PET/CT (-) (n=6) patients did not show any difference in age of diagnosis, presence of polymyalgia rheumatica (PMR), flare rate and damage scores. Among PET/CT (+) patients (n=23), the mean age at diagnosis was higher, PMR and bilateral axillary artery involvement was more frequent in ACR (+) group (n=14) (Table 1).

Conclusion:

PET/CT is increasingly used in the diagnosis and assessment of GCA in our center. The level of FDG uptake of the vessel wall in PET/CT correlates with the acute phase response. Flare was rarely observed in PET/CT (+) patients at diagnosis. Axillary artery involvement detected on PET/CT may be associated with the classical GCA clinic in ACR(+) patients (1). PET/CT (+) patients who does not met ACR criteria seems to have a diverse clinic features like young age and rare presence of PMR. PET/CT findings may be helpful in recognizing subgroups and predicting prognosis of GCA although prospective studies with follow-up scans are warranted.

References:

[1]Grayson PC, Maksimowicz-McKinnon K, Clark TM, Tomasson G, Cuthbertson D, Carette S, et al. Distribution of arterial lesions in Takayasu’s arteritis and giant cell arteritis. Annals of the rheumatic diseases. 2012;71(8):1329-34.

Table 1.

Comparison of patients who fulfilled and not fulfilled ACR 1990 classification criteria among PET/CT (+) patients.

ACR (+) PET/CT (+)(n=14)ACR (-) PET/CT (+)(n=9)pOR (%95 CI)Age at diagnosis68,8±4,563.3±9,20.004PMR1020.0212.5 (1 – 6.1)History of flare41NSCRP at diagnosis75,1±30,6130,8±93,40.024ESR at diagnosis93,9±28,1112,5±21,2NSBrachiocephalic artery96NSRight subclavian85NSLef subclavian95NSRight carotid85NSLeft carotid96NSRight axillary700.0112 (1.18 – 3.3)Bilateral axillary600.0221.75 (1.1-2.7)Thoracic aorta SUVmax (mean)3,9±1,14,6±1,3NSAbdominal aorta SUVmax (mean)4,5±1,25,3±1,8NS

Disclosure of Interests:

None declared

POS1445 RETINOL BINDING PROTEIN 4 AS AN ACUTE PHASE REACTANT AND BIOMARKER IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER AND AMYLOIDOSIS COMPARED TO INFECTIONS

Background:

Retinol binding protein 4 (RBP4) is a plasma retinol transporter that transports retinol from liver to periphery. RBP4 has been studied as a biomarker in metabolic and neoplastic conditions, however its association with inflammation is not clear. Serum amyloid A (SAA), another retinol binding protein, has been known as a sensitive biomarker of inflammation in familial Mediterranean fever (FMF) and other autoinflammatory disorders. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and SAA are commonly used as acute phase reactants, but they are not successful in differentiating non-infectious inflammatory conditions from infections.

Objectives:

We aimed to evaluate the potential of serum RBP4 as a biomarker of acute phase response and to determine its performance in differentiation of inflammation of patients with FMF and AA amyloidosis from infections.

Methods:

A total of 169 participants in 5 groups, consisting of FMF (n = 60), FMF with AA amyloidosis (n = 58), non-FMF AA amyloidosis (n = 23), infections (n = 10, 3 pneumonia, 3 sepsis, 1 pyelonephritis, 1 fungal infection, 1 cellulitis, 1 disseminated zoster), and healthy controls (HC) (n = 18), were included and evaluated cross sectionally. Hemogram and serum CRP, ESR, SAA, ferritin, creatinine, AST, ALT, albumin levels were recorded from the patient charts. FMF and FMF + amyloidosis patients were evaluated during attack-free period. Serum RBP4 levels were investigated by ELISA (Elabscience, USA). Mean values and relative changes compared to healthy controls were evaluated for SAA, CRP, RBP4 levels in all groups.

Results:

Serum RBP4 level was found to be higher in FMF group compared to the patients with infection (p = 0.002) and HC (p <0.001) as well as in patients with amyloidosis. Compared to HC, 47%, 28% and 27% increase was observed in mean RBP4 levels in FMF, FMF + amyloidosis and non-FMF amyloidosis patients, despite no significant change in patients with infections. However, CRP and SAA elevations were much more prominent in patients with infections (58 and 134 times, respectively) compared to the patients with FMF (13 and 35 times, respectively), FMF + amyloidosis and non-FMF amyloidosis (Table 1). There was no significant difference in RBP4 levels between FMF, FMF-amyloidosis and non-FMF amyloidosis groups. CRP, ESR, ferritin and SAA levels were higher in the infection group compared to HCs.

Table 1.

Demographic features and laboratory findings of the participants

VariablesFMF(n=60)FMF- Amyloidosis(n=58)Non-FMF-AA Amyloidosis(n=23)Infection(n=10)Healthy control(n=18)Female/Male46/1433/258/153/78/10Age (SD)*38±13(18-74)43±11(21-69)53±1365±1533±9Creatinine (mg/dL)*0,8±0,21,7±1,72,0±1,61,7±1,00,7±0,2Albumin(mg/dL)*4,7±0,44,3±0,63,3±0,93,0±0,94,8±0,2Ferritin (ng/mL)*70±94245±315139±168554±3883±72RBP4 (ng/mL)*772±183671±214666±256512±204524±117RBP4 (median)770(434-1142)653(227-1259)645(331-1214)487(226-876)498(566-738)CRP (mg/L)*16±47,112,8±32,825,7±36,469±36,81,2±1,2SAA (mg/dL)*10,3±31,45,0±13,97,1±14,140,2±18,50,3±0,1ESR*15±1319±1641±2945±427±5Relative RBP4 increase1,47±0,351,28±0,411,27±0,490,98±0,39Relative CRP increase13,4±39,210,6±27,321,4±30,357,7±30,6Relative SAA increase34,5±104,816,0±45,723,7±47,1133,9±61,7

*mean, RBP4 (Retinol Binding Protein 4), C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Serum Amyloid A (SAA).

Conclusion:

This preliminary study showed that RBP4 levels may be increased about 1.5 times in FMF and to lesser extent in AA amyloidosis patients despite no significant change during acute phase response of different infections. Patients with infections show strong CRP and SAA response, and the differential response of RBP4 in FMF patients warrants further analysis in larger group of patients with different clinical characteristics.

Disclosure of Interests:

None declared

AB0766 SUCCESSFUL TEATMENT OF ANKYLOSING SPONDILITIS ASSOCIATED AA AMYLOIDOSIS WITH SECUKINUMAB: A CASE SERIES WITH THREE PATIENTS

Background:

Systemic AA amyloidosis is a serious and life-threatening complication of chronic inflammatory diseases such as rheumatoid arthritis, spondyloarthritis (SpA), and periodic fever syndromes. While most common cause of AA amyloidosis is Familial Mediterranean Fever; Ankylosing Spondylitis (AS) is another frequent cause of AA amyloidosis in Turkey.

Objectives:

We aimed to evaluate the response of secukinumab (SEC) treatment in three patients with AS and AA amyloidosis (AS-AA) in our tertiary referral centre.

Methods:

We retrospectively evaluated three AA amyloidosis patients who fulfilled Modified New York Criteria for diagnosis of AS in our AA amyloidosis cohort with 163 patients. Diagnosis of AA amyloidosis was confirmed by Congo red stain and by monoclonal AA-specific antibodies.

Results:

Patient 1: 61-year-old male patient with inflammatory back pain (IBP) and peripheral arthritis for 14 years was evaluated in our clinic. After methotrexate (MTX) failure, he used adalimumab (ADA), etanercept (ETA) and certolizumab (CZP). Nephrotic range proteinuria was detected when he was on CZP, and rectum biopsy documented AA amyloidosis 3 years ago. After the diagnosis, CZP treatment was switched to infliximab (IFX). IFX was ineffective in controlling inflammatory findings. SEC was started 15 months ago and he responded partially. The dose of SEC was increased to 300 mg monthly, which resulted in a sustained improvement in clinical and laboratory findings.

Patient 2: 69-year-old woman was admitted to our clinic with peripheral arthritis in addition to the history of IBP for 19 years in 2005. MTX, NSAID and prednisolone were started. Because of inefficacy to conventional treatments and development of nephrotic range proteinuria, ETA was added to treatment. The patient responded to ETA and was followed-up for 13 years without symptoms of AS and proteinuria. ETA was switched to IFX due to secondary inefficacy two years ago. On the third month of IFX treatment, she developed demyelinating polyneuropathy. IFX treatment was switched to SEC and she is still being followed-up on SEC without any findings of AS and proteinuria.

Patient 3: 49-year-old woman who was on sulphasalasine for 24 years for treatment of ulcerative colitis (UC) was evaluated for recent onset IBP and peripheral arthritis in 2007. After failure of MTX, she started to receive IFX. She did not respond to first IFX and then ADA and CZP, and she developed nephrotic range proteinuria when she was on anti-TNF. Her serum creatinine increased progressively, and haemodialysis (H/D) was started six months later. Due to ongoing IBP and elevated acute phase response with CZP treatment, SEC was started. Significant improvement was observed in both clinical and laboratory findings with no worsening of UC.

Table 1.

Clinical characteristics, laboratory findings and treatment responses of patients

Patient 1Patient 2Patient 3Age (year)616949SexMaleFemaleFemaleAge of AS onset (year)473525Age of amyloidosis diagnosis (year)575046Amyloidosis duration (months)4216830 Family historyNoAS and amyloidosis in siblingsNoHLA-B 27 statusPositivePositiveNot available MEFV statusNegativeNegativeM694V heterozygousOrgan involvement of amyloidosisGIS and kidneyKidney, liver, heart, bone marrowGIS, kidneySecukinumab duration (months)151824 CRP (mg/L) Before271523 After2.44.52.8Creatinine (mg/dl) Before0.51.6H/D After0.51.3H/DProteinuria (g/day) Before4.25.5H/DAfter2.40.9H/DAlbumin (g/dL)Before2.72.53.1After3.14.34.2ASDASBefore4.11.64.6After1.81.11.7

GIS: Gastrointestinal System, ASDAS: Ankylosing Spondylitis Disease Activity Score

Conclusion:

AA amyloidosis is a rare complication of SpA, and SEC treatment was found to be safe and effective in our three patients with AS-AA. Although anti-TNF agents have previously used successfully in treatment of AS-AA, SEC may be a new option especially in patients who are resistant or intolerant to anti-TNFs.

Disclosure of Interests:

None declared

POS0142 MINIMAL DISEASE ACTIVITY IN PATIENTS WITH PSORIATIC ARTHRITIS AND ASSOCIATED FACTORS: REAL LIFE DATA FROM A SINGLE CENTER

Background:

Psoriatic arthritis (PsA) is a heterogeneous disease and GRAPPA have proposed Minimal disease activity (MDA) as a composite outcome measure and has been validated in PsA.

Objectives:

In this study, we aimed to evaluate the characteristics, MDA frequencies, first biological disease modifying antirheumatic drugs (b-DMARD) continuation rate and associated factors in our PsA cohort.

Methods:

PsA patients who fulfilled the CASPAR classification criteria and had at least six months of follow-up data were evaluated cross-sectionally for MDA.Clinical data were collected from patient charts with standard forms.b-DMARD treatment was initiated in patients who did not respond to at least one conventional synthetic (cs) DMARD for at least three months. Only anti-TNFs were used as a first line b-DMARD therefore secukinumab (Secu) was used after first line b-DMARD treatment. Adalimumab, certolizumab, etanercept, golimumab were grouped as subcutaneous (s.c) anti-TNFs. MDA was defined as meeting five out of seven criteria during follow-up [1].

Results:

One hundred seventy-two patients (61% female) were included into the analysis. The mean follow-up time was 105.4±76 (6-444) months and the mean age was 50.2±13.3 (16-81) years. Mean age of onset for PsA was 38±11.9 (11-79) years; mean PsA and PsO duration were 140±90.7 (7.9-528) and 253±138 (0-756) months, respectively. Methotrexate was the most commonly used (88 %) cs-DMARD and biological DMARDs were used in 74 patients (43.3%)

Overall, 95 patients (55.2 %) were observed at MDA which was significantly lower in b-DMARD users compared to only cs-DMARD users (45.9 % vs 61.9 %; p=0.038, OR: 4.3). MDA did not differ according to PsA subtypes. The addition of cs-DMARD treatment to b-DMARDs did not affect MDA frequency In univariate analysis; higher MDA frequency was associated with older age (p=0.002), longer PsO duration (p=0.036), late onset of PsA (p=0.007) and continuation of first b-DMARD (OR:13.9 p<0.001). In multivariate analysis, older age (OR:1.3;95 % CI:1.02-1.68), late onset PsA (OR:1.03; 95 % CI:1.01-1.067) and continuation of first b-DMARD (OR:46.8; 95 % CI:1.6-1371) were associated with MDA.

Conclusion:

Although frequency of MDA in our cohort was consistent with previous reports, a significant number of patients could not achieve MDA. Frequency of MDA was found to be lower in b-DMARD users compared to cs-DMARD users, possibly resulted from initiation of b-DMARD in patients with higher disease activity. Higher MDA rate was associated with higher continuation rate at first line b-DMARD treatment (TNF-inhibitor) and decreased gradually after b-DMARD switches. Although combined use of cs-DMARD with b-DMARDs did not increase the frequency of MDA, it was associated with higher b-DMARD retention. MDA is a useful outcome measure in daily follow-up of PsA patients and the importance of reaching sustained MDA for prognosis should be investigated further.

References:

[1]Coates, L.C., J. Fransen, and P.S. Helliwell, Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis, 2010. 69(1): p. 48-53.

Table 1.

b-DMARD responses, continuation rate and frequency of achieving MDA in patients with PsA

b-DMARD treatmentMean (median) duration (month)Continuation rate n, (%)Primary inefficacy n, (%)Secondary inefficacy n, (%)MDAn, (%)First line b-DMARD (n=74)50.4 (36)37 (50)9 (24.3)17 (46)34 (45.9) *s.c TNF inhibitors (n=62; 83.8 %)50.8 (35.5)32 (51.7)8 (26.7)9 (30)31 (50) Infliximab (n=12; 16.2 %)13.8 (11)3 (25)1 (11.1)7 (77.8)3 (25)Second line b-DMARD (n=29)28.4 (13.5)15 (51.7)5 (35.7)3 (21.4)8 (27.6) *s.c TNF inhibitors (n=22; 75.9 %)28.6 (15)11 (50)4 (36.4)2 (18.2)5 (22.7) Infliximab (n=5; 17.2 %)35.2 (36)3 (60)--2 (40) Secukinumab (n=2; 6.9 %)9 (9)1 (50)1 (50)-1 (50)

s.c:subcutaneous

Figure 1.

Comparison of b-DMARD retention according to MDA status in patients with ongoing first line b-DMARD treatment Log rank: p=0.001

Disclosure of Interests:

None declared

AB0579 INSTRUMENTS FOR SCREENING PSORIATIC ARTHRITIS AMONG PATIENTS WITH PSORIASIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Timely diagnosis is essential for the optimal management of psoriatic arthritis (PsA). Several instruments have been developed for screening PsA among patients with psoriasis. However, a delay in diagnosis is still frequently reported, possibly due to the lack of a wide use of these instruments.

Objectives:

We aimed to identify and compare the reported performance of these instruments with special emphasis on the PsA phenotypes.

Methods:

We conducted a systematic literature search on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis’. Two independent reviewers identified all studies published in English, that report on the validation, psychometric evaluation or use of an instrument for screening PsA. Any disagreements were resolved by the third investigator. Data on sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were extracted or calculated for each instrument. Additionally, instruments were assessed for their performance in patients with different disease phenotypes.

Results:

A total of 10754 references were screened, and 42 were identified that reported on 15 different screening instruments. Psoriatic Arthritis Screening and Evaluation (PASE), Psoriasis Epidemiology Screening Tool (PEST), Early Arthritis for Psoriatic Patients questionnaire (EARP) were the most commonly used instruments. There was important variability across studies regarding the sensitivity, specificity, PPV and NPV of these instruments based on the cut-offs for positivity, setting, patient population and disease phenotypes (Table 1). Specificity was higher when patients with a previous diagnosis of other rheumatic diseases were excluded. Lower sensitivity was reported among patients with shorter disease duration and when patients with a prior diagnosis of PsA were excluded from the study, whereas higher sensitivity was reported among patients with prior NSAID use. Screening tools showed differences in sensitivity in different domains (Figure 1).

Figure 1.

Performance Among Patients with Each Domain

Conclusion:

This systematic literature review revealed wide variability in the diagnostic estimates of currently available questionnaire-based screening instruments for identifying PsA among psoriasis patients, depending on study populations and disease phenotypes. There is an unmet need for a screening instrument with a better performance in all disease domains.

Table 1.

Diagnostic estimates of screening tools in different studies

InstrumentNumber of studiesSensitivity%Specificity%PPV%NPV%PASE1824-9138-9518-8813-96PEST1140 – 8537.2-98.623-9647.1-99.3EARP941-97.234-97.214-93.357.5-100TOPAS641-89.129.7-9025.7-91.868-81.6TOPAS-II444-95.880.5-9863.4-95.891-98PsA-Disk questionnaire187.246.458.678.5CONTEST270-76.556.5-9116-8968-95STRIPP191.593.379.697.5SiPAS179877390PASQ267-92.764-81.84383GEPARD277706680Swedish- Psoriasis Assessment Questionnaire163724585PAQ160622687.5SiPAT169699169A novel, short, and simple screening questionnaire186.971.35393.6

PASE: Psoriatic Arthritis Screening and Evaluation, PEST: Psoriasis Epidemiology Screening Tool, EARP: Early Arthritis for Psoriatic Patients questionnaire, TOPAS: Toronto Psoriatic Arthritis Screening Questionnaire, STRIPP: Screening Tool for Rheumatologic Investigation,

SIPAS: Simple Psoriatic Arthritis Screening questionnaire, PASQ: Psoriasis and Arthritis Screening Questionnaire, GEPARD: German Psoriatic Arthritis Diagnostic Questionnaire, PAQ: Psoriatic and Arthritic Questionnaire, SiPAT: Siriraj Psoriatic Arthritis Screening Tool

Disclosure of Interests:

None declared.

POS1339 MORE FREQUENT AND EARLIER HIP INVOLVEMENT IN SPONDYLOARTHRITIS ASSOCIATED WITH FAMILIAL MEDITERRANEAN FEVER

Background:

Familial Mediterranean fever (FMF) is a hereditary autoinflammatory disorder caused by the MEFV gene variants. Although association between FMF and spondyloarthritis (SpA) has previously been reported, clinical and laboratory features of patients with FMF and SpA have not been defined in detail.

Objectives:

We aimed to evaluate clinical and laboratory characteristics, disease outcome and biologic responses of patients with FMF+SpA compared to patients with only SpA who were followed-up in our tertiary referral center.

Methods:

Database of FMF Clinic was screened for FMF patients with coexistent SpA and 113 patients were identified fulfilling Tel Hashomer and ASAS criteria for FMF and SpA, respectively. A group of patients with SpA without FMF matched for age, gender and disease duration were selected as the control group.

Results:

Thirteen patients were excluded because of missing data, and 100 patients (F/M: 52/48) were included into the analysis. Mean follow-up time was 93.6 ± 77 (range[r]: 3-324) months and mean patient age was 43.3 ± 12 (r: 20-87) years. Mean age of onset for FMF was 12.5 ± 8 (r: 1-36) and for SpA was 25 ± 11 (r: 7-72) years. SpA findings was classified as axial in 35.4%, axial and peripheral in 47.9% and only peripheral in 16.7% in FMF+SpA group. Half (49%) of the patients had hip involvement (70% bilaterally), and 21.5% of them needed total hip joint replacement (TJR), which were significantly more frequent compared to control group. Two exon 10 MEFV variants were found in 69.4%, and most (69.8%) had homozygous M694V. Hip involvement was more frequent in patients with two exon 10 variants (p=0.036; OR=4.4) compared to those with one variant; and TJR was more frequent in those with homozygous M694V compared to other exon 10 variants (p=0.001; OR=10). Radiographic sacroiliitis was less frequent in patients with homozygous M694V (p=0.019; OR=5.48). HLA-B27 positivity was not associated with hip or axial involvement in patients with FMF+SpA.

Biologics were used in 60 patients (anti-TNF in 43, secukinumab in 1, and tocilizumab in 2). Anti-IL-1 drugs were used in 23 patients for refractory FMF. In 9 patients, anti-TNF and anti-IL-1 drugs were tried for refractory joint involvement: 5 switched to anti-TNFs from anti-IL-1, 4 patients switched to anti-IL-1 from anti-TNFs. Biologic DMARD requirement was more frequent in patients with two exon 10 variants (p=0.006; OR=7.4), especially in those with homozygous M694V (p=0.006; OR=7.6). Although anti-IL-1 usage did not differ among MEFV variants, anti-TNF was used more frequently in patients with homozygous M694V (p=0.007; OR=7.2). FMF+SpA patients had higher serum CRP and developed amyloidosis more frequently than those patients with SpA.

Table 1.

Comparison of clinical and laboratory findings between the patients with FMF+SpA and SpA control

FMF + SpA (n=100)SpA (n=217)P valueAge (years)*43.3 ± 1243.4 ± 110.6Sex (n, %) Male48104 (47.9)0.99 Female52113 (52.1)Duration of SpA (monnths)*181.6 ± 108180.2 ± 1120.8Age onset of SpA (years)*25.1±1128.4±80.008Peripheral arthritis (n, %)35/80 (43.8)79/212 (37.3)0.3HLA-B27 positivity (n, %)6/21 (28.6)105/139 (75.5)<0.001 (OR=18.9)CRP (mg/dL)*26.7 ± 25**18.96±290.001ESR (mm/hour)*39.7 ± 2739.4 ± 280.8Hip involvement (n, %)47/96 (49)23/118 (19.5)<0.001 (OR=20.9)TJR (n, %)20/93 (21.5)8/205 (3.9)<0.001 (OR=23.3)Fulfilling mNY criteria (n, %)52/81 (64.2)164/199 (82.4)0.001 (OR=10.8)Biologic DMARD (n, %)6068/214 (31.8)<0.001 (OR=22.5)Anti-TNF (n, %)4668/214 (31.8)0.015 (OR=5.96)Amyloidosis (n, %)165/205 (2.4)<0.001 (OR=19.3)

* mean±standard deviation, **during the attack-free period

Conclusion:

In this group of FMF+SpA patients, hip involvement and need for TJR were more frequent and associated with penetrant MEFV variants rather than HLA-B27 positivity. These patients had higher inflammatory response and risk of developing amyloidosis, and they needed biologics more frequently compared to SpA group. More severe disease course in FMF+SpA patients requires further attention and analysis in larger cohorts.

Disclosure of Interests:

None declared

POS0706 PERFORMANCES OF DIFFERENT CLASSIFICATION CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS IN A SINGLE CENTER COHORT FROM TURKEY

Background:

Recently developed EULAR/ACR classification criteria for systemic lupus erythematosus (SLE) have important differences compared to the 2012 Systemic Lupus International Collaborating Clinics (SLICC) SLE classification criteria and the revised 1997 American College of Rheumatology (ACR) criteria: The obligatory entry criterion of antinuclear antibody (ANA) positivity is introduced and a “weighted” approach is used1. Sensitivity and specificity of these three criteria have been debated and may vary in different populations and clinical settings.

Objectives:

We aim to compare the performances of three criteria sets/rules in a large cohort of patients and relevant diseased controls from a reference center with dedicated clinics for SLE and other autoimmune/inflammatory connective tissue diseases from Turkey.

Methods:

We reviewed the medical records of SLE patients and diseased controls for clinical and laboratory features relevant to all sets of criteria. Criteria sets/rules were analysed based on sensitivity, positive predictive value, specificity and negative predictive value, using clinical diagnosis with at least 6 months of follow-up as the gold standard. A subgroup analysis was performed in ANA positive patients for both SLE patients and diseased controls. SLE patients that did not fulfil 2012 SLICC criteria and 2019 EULAR/ACR criteria and diseased controls that fulfilled these criteria were evaluated.

Results:

A total of 392 SLE patients and 294 non-SLE diseased controls (48 undifferentiated connective tissue disease, 51 Sjögren’s syndrome, 43 idiopathic inflammatory myopathy, 50 systemic sclerosis, 52 primary antiphospholipid syndrome, 15 rheumatoid arthritis, 15 psoriatic arthritis and 20 ANCA associated vasculitis) were included into the study. Hundred and fourteen patients (16.6%) were ANA negative.

Sensitivity was more than 90% for 2012 SLICC criteria and 2019 EULAR/ACR criteria and positive predictive value was more than 90% for all three criteria (Table 1). Specificity was the highest for 1997 ACR criteria. Negative predictive value was 76.9% for ACR criteria, 88.4% for SLICC criteria and 91.7% for EULAR/ACR criteria.

In only ANA positive patients, sensitivity was 79.6% for 1997 ACR criteria, 92.2% for 2012 SLICC criteria and 96.1% for 2019 EULAR/ACR criteria. Specificity was 92.6% for ACR criteria, 87.8% for SLICC criteria 85.2% for EULAR/ACR criteria.

Eleven clinically diagnosed SLE patients had insufficient number of items for both 2012 SLICC and 2019 EULAR/ACR criteria. Both criteria were fulfilled by 16 diseased controls: 9 with Sjögren’s syndrome, 5 with antiphospholipid syndrome, one with dermatomyositis and one with systemic sclerosis.

Table 1.

Sensitivity, positive predictive value, specificity and negative predictive value of 1997 ACR, 2012 SLICC and 2019 EULAR/ACR classification criteria

SLE (+)SLE (-)Sensitivity (%)Positive Predictive Value (%)Specificity (%)Negative Predictive Value (%)1997 ACR(+) 308(-) 841527978.695.494.976.92012 SLICC(+) 357(-) 352626891.193.291.288.42019 EULAR/ACR(+) 368(-) 242826693.892.990.591.7

Conclusion:

In this cohort, although all three criteria have sufficient specificity, sensitivity and negative predictive value of 1997 ACR criteria are the lowest. Overall, 2019 EULAR/ACR and 2012 SLICC criteria have a comparable performance, but if only ANA positive cases and controls are analysed, the specificity of both criteria decrease to less than 90%. Some SLE patients with a clinical diagnosis lacked sufficient number of criteria. Mostly, patients with Sjögren’s syndrome or antiphospholipid syndrome are prone to misclassification by both recent criteria.

References:

[1]Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Ann Rheum Dis 2019;78:1151-1159.

Disclosure of Interests:

None declared

AB0448 SYSTEMIC SCLEROSIS ASSOCIATED PULMONARY ARTERIAL HYPERTENSION: PREDOMINANCE OF PULMONARY FIBROSIS AS A RISK FACTOR FOR MORTALITY IN A SINGLE CENTER COHORT

Background:

Pulmonary arterial hypertension (PAH) is a severe vasculopathic complication for systemic sclerosis (SSc) patients. The availability of oral-specific vasodilator therapies has provided better outcomes.

Objectives:

We aimed to analyze the characteristics of SSc-PAH patients and factors associated with mortality.

Methods:

Medical records of 291 SSc patients fulfilling ACR/EULAR criteria (2013) and followed–up during 2008-2020 years were screened and the patients who diagnosed PAH evaluated by right heart catheterization (mean PAB≥20 mmHg) (n=26, 8,9%) were included into this retrospective cross-sectional study.

Results:

The characteristics of 26 SSc-PAH(24 females) patients were summarised in Table 1.

Table 1.

Characteristics of SSc patients with PAH

SSc-PAH(n=26)DemographicsAge(yrs)53.6±8.9Duration of Raynaud’s(yrs)16.1±11.8Duration of Non-Raynaud’s(yrs)9.2±6.6Raynaud’s to Diagnosis of PAH(yrs)10.8±6.7Clinical Characteristics (%)LcSSc9 (34.6)DcSSc18 (65.4)Digital ulcer14 (53.8)Gastrointestinal20 (69.0)Synovitis5(19.2)Flex contractures7 (26.9)Tendon friction rubs3(11.5)Renal crisis1 (3.8)Pulmonary fibrosis19 (73.1)Auto-antibodies (%)ANA23 (88.5)Anti-centromere6(23.1)Anti-Scl7013(50)Treatment (%)Specific vasodilatorERA (bosentan/macicentan/ambricentan)15 (51.7)PDE5-i (sildenafil/tadalafil)17 (58.6)Prostacyclin-analog (İloprost/treprostenil/selexipag)15 (51.7) Riociguat5 (17.2)Immunosuppressives21(80.8)Steroids16(61.5)

Twenty-four (92,3%) of the SSc-PAH patients had PAH-related symptoms at the time of diagnosis, 2 (7,7%) were asymptomatic and diagnosed by screening. RHC and treatment details were stated in Table 2.

Table 2.

Right Heart Catheterization (RHC) ve treatment details of SSc-PAH patients

n=26Initial RHC -mean PAB30,4±7,9 (median 28, 20-53mmHg) -PVR5,1±2,4 (median 4, 3-9 woods) -PCWP10,8±5,5 (median 10, 0-15 mmHg)Initial treatment -monotherapy5 (19,2%) -combination10 (38,5%) -add-on combination12 (46,2%)

Eleven out of 26 patients (42,3 %) were deceased after a mean follow up of 43,7±24,6 (median 48,1-84) from PAH diagnosis and 15,1±9,9 (median 13, 0,6-34) years after SSc diagnosis. Deceased patients were younger and had younger age at disease onset (49,1± 8,8 vs 56,9±7,7, p=0.032 and 30,8±13,0 vs 42.0 ±10,9, 0.027). All deceased patients had associated pulmonary fibrosis (100 vs 53.3%, p=0.01). No significant difference was observed for initial RHC parameters between deceased and survived SSc-PAH patients. Specific monotherapy was found to be more frequent in deceased patients (45,5 vs 0%, p=0,007).

Conclusion:

The prevalence of SSc-PAH was found to be 8.9% with increased mortality in our cohort. SSc-PAH patients predominantly had diffuse cutaneous involvement with digital vasculopathy, pulmonary fibrosis, and anti-Scl70 positivity. PAH was diagnosed after a median of 10 years of the Raynaud’s, mainly in symptomatic patients. Mortality in PAH-SSc patients was associated with early onset of disease, pulmonary fibrosis, and monotherapy. Initial RHC parameters were not found to be related to mortality.

Disclosure of Interests:

None declared.

AB0653 COURSE OF COVID-19 INFECTION IN A SERIES OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Infection is a remarkable cause of morbidity and mortality in patients with SLE.

Objectives:

We aimed to determine the clinical course of COVID-19 infection in our patients with SLE and the factors affecting this course

Methods:

SLE patients (2012 SLICC criteria) diagnosed with COVID-19 infection by a positive PCR test and/or typical findings of lung involvement in CT (computed tomography) imaging were included. Data regarding cumulative clinical and laboratory characteristics, histopathology results, autoantibody profiles, immunsuppressives and damage (SLICC damage index/SDI)) were retrieved from the existing database and revised. SLE Disease Activity Index (SLEDAI-2K) was determined at the time of infection.

Results:

Sixteen SLE patients with COVID-19 infection were identified. Most (87.5%) of these patients were female. Seventy % (n=11) had lupus nephritis. Twenty-five % had thrombotic antiphospholipid syndrome.

PCR was positive in 70% (n=11) of the patients. Pulmonary parenchymal findings compatible with COVID-19 were observed in 56% (n=9) of those patients. Regarding complaints upon admission, 50% (n=8) had fever, 44% (n=7) cough, 44% (n=7) dyspnea, 19% (n=3) myalgia, 12.5% (n=2) headache, 12.5% (n=2) nausea /vomiting, 6% (n=1) diarrhea, and 6 % (n=1) had anosmia. Eight patients were hospitalized. Six of these patients needed oxygen therapy via nasal cannula. None needed a follow-up in the intensive care unit. The mean hospitalization duration was 14 ± 5 (8-25) days.

Regarding disease activity at the time of infection, 9 had inactive disease with a SLEDAI-2K score of 0 whilst in 5 patients SLEDA-2K score was ≥4. The mean SLEDAI-2K score at the time of infection was 1.7 ± 2.3 (0-6). System/organwise, 1 patient with chronic thrombocytopenia presented with a worsening platelet count accompanied by serologic activity. This patient was a non-adherent to treatment who had stopped taking mycophenolic acid months before COVID19. Three patients 2 of whom had proliferative nephritis experienced nephritic flares.1 patient who had a history of cutaneous lupus and was in remission presented with oral ulcer, leukopenia and hypocomplementemia during infection. Of 16 patients, 7 had system damage at the time of infection. The mean SDI score of the patients was 1.4±1.8. Comparison of patients with and without damage revealed no significant differences in disease activity, symptoms associated with COVID, in the need for hospitalization, hospitalization duration, and the requirement for oxygen therapy. However,CT findings compatible with COVID19, were more common in patients with damage (87% vs.33%,p=0.04) and their mean CRP levels were higher at diagnosis (65 ± 47 vs.22 ± 48 mg/l;p=0.032).

All patients received similar treatment for COVID-19 except active patients who required high dose steroids (2 with active renal, 1 with thrombocytopenia and 1 with oral ulcer, leukopenia and hypocomplementemia).The patient with thrombocytopenia also received intravenous immunoglobulin and 1 with cutaneous active disease received tocilizumab as she developed macrophage activation syndrome. Six patients (37.5%) had received rituximab (RTX) in the last 6 months before COVID. No significant difference, in terms of hospitalization and need for oxygen therapy due to COVID19 was found between patients who had received RTX vs who had not. No hypogammaglobulinemia was detected in patients who received RTX despite lower levels of IgG (998 ± 184 vs 1481± 51 mg/dl, p=0.02)

Conclusion:

Although half of the patients in our series of COVID19 infected SLE patients required hospitalization, there were no mortalities. More patients with damage (none pulmonary) displayed CT findings compatible with COVID19 and further follow up will reveal whether they will suffer from fibrotic lung disease. Patients can experience disease flares during COVID. But it is also important to consider that some manifestations such as thrombocytopenia may also be a sign of severe infection. Immunosupressive agents may not have a negative impact on the course of infection.

*the first two authors contributed equally

Disclosure of Interests:

None declared.

SAT0178 HYDROXYCHLOROQUINE CONTROLS DISEASE ACTIVITY IN SLE AND MULTIMODAL IMAGING TECHNIQUES SHOULD BE USED TO DETECT OCULAR TOXICITY

Background:

Hydroxychloroquine (HCQ) is an immunomodulatory drug that has been shown to improve disease activity in systemic lupus erythematosus (SLE). However, retinal toxicity is an important concern.

Objectives:

In this study we sought to evaluate the effect of HCQ on disease activity and damage in patients with SLE in whom HCQ was discontinued due to retinal toxicity and whether it could be restarted by a detailed ophthalmologic examination.

Methods:

Patients who met SLE SLICC classification criteria and were on HCQ for at least 3 years after reaching Lupus Low Disease Activity State (LLDAS) following remission induction and were followed up for at least 3 years after termination of HCQ treatment due to retinal toxicity diagnosed with visual field test were analyzed. Disease activity (LLDAS and SLEDAI-2K) and both the number and severity of flares were recorded for each patient whilst on HCQ and after cessation of treatment. All patients were examined by two experienced ophthalmologists and were assessed by computerized visual field, optical coherence tomography (OCT), fundus autofluorescence (FAF) and fundus florescein angiography (FFA) to further analyze toxicity.

Results:

Out of 88 patients with recorded HCQ retinal toxicity in a cohort of 1500 patients with SLE, 64 patients (mean age at diagnosis 33.4 ± 10.5 (10-57); 88.5% female) with complete data and opthalmologic re-examination results were included in the analyses. The average duration on HCQ was 122 ±85 (39-336) months, and the mean follow-up time was 74.6 ± 48.3 (36-239) months after the drug was discontinued. Comparison of mean disease activity in the 3-year period when patients were on HCQ to 3 years post-cessation revealed a significantly lower mean SLEDAI-2K score in the former (0.89±1.28 vs.1.3±1.6, p=0.02). The % of visits maintaining LLDAS was higher during HCQ treatment (89.7 ± 17.6 vs. 80.1 ± 23.5, p=0.001). There was significantly a higher frequency of flares with a dominance of mild-moderate types after HCQ was ceased (47.5 vs. 26.2%, p=0.03; 39.3 vs. 22.9%, p=0.024 respectively). There were more patients with serious flares in the post-discontinuation period but without statistical significance (13.1% vs. 4.9% p=0.08). Thirty-seven (60%) of patients restarted the treatment after ophthalmological examination. Although 38 (62,3%) patients had visual field defects in the latest examination, multimodal imaging with OCT, FAF and FFA revealed that only 19 (31%) patient had typical retinal toxicity. Five patients were found to have macular atrophy due to other causes (4 age related macular degeneration and 1 vitromacular adhesion). Since the discrimination of macular pathology would not be possible with imaging in these patients, HCQ was not prescribed. Comparison of patients with and without retinal toxicity showed that duration of HCQ use and HCQ-free time was not significantly different between patients.

Conclusion:

HCQ is effective in controlling disease activity in patients with SLE and an opportunity for re-medication with HCQ is valuable. More than half of the patients being able to restart HCQ after ophthalmologic examination in this study shows that it is important to perform multimodal imaging techniques in patients with retinal toxicity diagnosis. Since macular pathology can have a different etiologic background, an initial opthalmologic examination is also necessary. Lack of difference in the duration of HCQ exposure and drug-free time between patients who restarted treatment and who could not may be a sign of personal sensitivity to HCQ toxicity.

Disclosure of Interests: :

None declared

SAT0200 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Pregnancies of patients with systemic lupus erythematosus (SLE) can be risky both for the mother and the fetus because of disease activity and pregnancy complications.1

Objectives:

In this study, we evaluated the risk factors related to adverse pregnancy outcomes (APO) in our pregnant SLE cohort who were followed up by both Rheumatology and Obstetrics and Gynecology departments at our university.

Methods:

168 pregnancy data were analyzed from 136 patients who fulfilled ACR classification criteria for SLE. The course of pregnancies were monitored and fetal/neonatal outcomes were recorded. Unexplained fetal death after 12 weeks of gestation, neonatal death, preterm birth due to preeclampsia, eclampsia or HELLP and birth of small for gestational age (SGA) infant were defined as APO. Cumulative clinical, laboratory and serological findings, disease activity (SLEDAI-2K) and damage (SLICC/ACR), and conventional risk factors were compared between APO(+) and APO(-) groups.

Results:

The comparison of demographics, conventional risk factors and disease characteristics in APO(+) and APO(-) groups are summarized in Table-1. In APO(+) pregnancies, the duration of disease was longer (p <0.05) and the frequency of chronic hypertension was higher (p <0.05) compared to APO(-) pregnancies. Renal and neuropsychiatric (NP) involvement, thrombocytopenia, antiphospholipid syndrome (APS), lupus anticoagulant and anti-cardiolipin IgM positivity were significantly higher in APO(+) group. Mean SLEDAI-2K scores of three trimesters and postpartum 6 months were higher in APO(+) patients compared to APO(-) patients (2.2 ± 3.6 vs 1.2 ± 2.04, p <0.05; 4.9 ± 6.03 vs 2.7 ± 5.01, p = 0.02, respectively). Percentage of patients with damage at the beginning of pregnancy and the mean SLICC damage score were significantly higher in APO(+) group compared to APO(-) group (1.8 ± 2.1 vs 0.8 ± 1.3, p <0.05). In APO(+) group, damage was significantly higher in neuropsychiatric, renal and cardiovascular and locomotor systems (p <0.05).

Conclusion:

Although an important proportion of SLE pregnancies result in live birth, active disease, especially renal and NP involvement, and presence of damage at the beginning of pregnancy increase the risk of maternal and fetal complications. Furthermore, the presence of APS or antiphospholipid antibody positivity are important risk factors for obstetric complications. In conclusion, pregnancy should be allowed after controlling the disease activity and patients should be closely monitored in coordination with Obstetrics and Gynecology clinics. In case of presence of damage, both the patient and the physician should be aware of a possible adverse pregnancy outcome.

References:

[1]Ann Intern Med. 2015 August 4; 163(3): 153–163. doi:10.7326/M14-2235.

Table 1.

Demographic data of APO (+) and APO (-) groups, comparison of conventional risk factors, cumulative clinical, serological and laboratory features

APO(-)(n=111)APO (+)(n=57)pAge35.1±6.734.9±5.9NSAge at conception30.6±5.628.9±4.2NSDisease duration (months)141.6±70166.9±87.9<0.05Chronic hypertension, n (%)6 (7)11 (19.6)<0.05Photosensitivity, n (%)86 (77.5)43 (75.4)NSMalar rash, n (%)66 (59.5)38 (66.7)NSOral ulcer, n (%)11 (9,9)6 (10.5)NSArthritis, n (%)77 (59.4)42 (73.7)NSSerositis, n (%)17 (15.3)13 (22.8)NSRenal, n (%)39 (35.1)30 (52.6)<0.05Hematologic, n (%)78 (70.3)40 (70.2)NSThrombocytopenia, n (%)37 (33.3)30 (52.6)<0.05AIHA, n (%)16 (14.4)14 (24.6)NSNeurologic, n (%)7 (6.3)9 (15.8)<0.05Anti-cardiolipin IgG, n(%)28 (25.2)18 (32.1)NSAnti-cardiolipin IgM, n (%)18 (16.2)18 (32.1)<0.05Lupus anticoagulant, n (%)26 (23.4)28 (49.1)<0.001Antiphospholipid syndrome, n (%)28 (25.2)30 (52.6)<0.001

(NS=not significant, APO=adverse pregnancy outcome, AIHA=autoimmune hemolytic anemia)

Disclosure of Interests: :

None declared

AB0486 ANALYSIS OF 89 PATIENTS WITH GIANT CELL ARTERITIS FROM TURKEY: PET-CT AS AN EMERGING METHOD FOR DIAGNOSIS AND HIGH FLARE RATE WITH STANDARD CARE

Background:

The prevalence of giant cell arteritis (GCA) in Turkey has been reported lower than other European countries and the information on clinical patterns, diagnostic modalities, treatment and prognosis of GCA are limited (1).

Objectives:

We aimed to analyse our GCA cohort from a large outpatient clinic for the last 20 years.

Methods:

Data of the GCA patients followed up at least for 6 months in our vasculitis clinic between 1998 and 2018 evaluated retrospectively according to EULAR 2018 GCA clinical research recommendations (2). Chi-square, students t-test, logistic regression analysis and Kaplan-Meier test were used for statistical analysis.

Results:

Eighty-nine patients with adequate follow-up data (64% female, mean age 67.9 ± 9.1) were analysed. Median follow up duration was 46 months (3-256) and mean time to diagnosis after presenting symptom (TTD) was 5,9±1,2 months (0-60). Polymyalgia rheumatica was found in 36 (40.4%) patients. The clinical findings of the patients are shown in Table-1. Mean TTD was longer in patients with acute vision loss (AVL) (11±4 vs. 4,8±1,1 months p=0.002). Mean CRP was 90,7±82 (8-343) mg/L and ESR was 103,7±25 (52-138) mm/h at the time of diagnosis. Mean age was lower (63±2 vs 69±1 p=0.01); mean CRP (141,8±107,3 vs. 76,6±67,9 mg/dL p=0.023) and ESR (120,8±25,1 vs. 99,3±24,3 mm/h p=0.004) was higher in patients without cranial symptoms (extracranial GCA group). PET-CT findings compatible with large vessel vasculitis were present in 64% (34/53). Sixteen of 19 (%84,2) patients in the extracranial GCA group had positive PET-CT. Temporal artery (TA) biopsy positivity was 64% (34/53). Sensitivity of ACR 1990 Criteria was 77,5% and GIACTA study inclusion criteria was 58,4% in this cohort at diagnosis. Fullfilment of GIACTA criteria was still present in 12 (13,5%) patients after six months of follow up. Treatment data was shown in table-2. Total flare rate was 34,8% and flare risk was lower in the extracranial GCA group (3/20 vs. 28/69 p=0.035 OR=0.78 %95 CI 0.64 – 0.96). Reduced survival was observed in cases diagnosed older than 65 years (168,8±23,9 vs 209±17,3 months p=0,015).

Conclusion:

The analysis of the largest single center cohort from Turkey confirmed that delayed diagnosis is associated with vision loss. A subgroup of patients without apparent cranial symptoms but positive PET-CT findings is delineated. These patients are younger, present with higher inflammatory response and fewer relapses. The sensitivity of ACR criteria in our cohort is less than 80%. High flare rate especially in GCA patients with cranial symptoms and GIACTA criteria fullfilment after 6 months of treatment in more than 10% of the patients show a need for for new treatment options.

References:

[1]Pamuk, O.N., et al.,Giant cell arteritis and polymyalgia rheumatica in northwestern Turkey: Clinical features and epidemiological data.Clin Exp Rheumatol, 2009.27(5): p. 830-3.

[2]Ehlers, L., et al.,2018 EULAR recommendations for a core data set to support observational research and clinical care in giant cell arteritis.Ann Rheum Dis, 2019.78(9): p. 1160-1166.

Table 1.

Clinical characteristics

Systemic / Extracranial Findings78 (%87,6)Cranial Findings69 (%77,5)Opthalmologic Findings20 (%22,5)Fatigue72 (%80,9)Headache60 (%67,4)AVL16 (%18,8)Weight loss47 (%52,8)Jaw claudication33 (%37,1)Unilateral12 (%13,5)Arthralgia43 (%48,3)Scalp / TA Tenderness27 (%30,3)Bilateral4 (%4,5)Fever35 (%39,3)Decreased pulsation of TA11 (%12,4)Diplopia4 (%4,5)Arthritis13 (%14,6)CVE6 (%6,7)Vascular murmur3 (%3,4)Swollen TA6 (%6,7)Pericardial effusion2 (%2,2)Vertigo5 (%5,6)Extremity Claudication1 (%1,1)TABLE 2

Treatment data of GCA cohort

Initial glucocorticoid (GC) dosage (mg)46,7±20,1Pulse GC treatment%12,312nd month cumulative GC dosage (g)4,7±2,5MTX usage%63,3bDMARD usage%6,7Acetyl salicylic acid usage%51,7

Disclosure of Interests:

None declared

OP0274 CLINICAL ASPECTS, LABORATORY CHARACTERISTICS AND TREATMENT RESPONSES OF AA AMYLOIDOSIS: SINGLE CENTER EXPERIENCE WITH 163 PATIENTS

Background:

AA amyloidosis has been associated with uncontrolled chronic inflammatory diseases such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), inflammatory bowel disease (IBD) and hereditary periodic fever syndromes, and the most common cause is familial Mediterranean fever (FMF) in Turkey.

Objectives:

We herein aimed to evaluate clinical and laboratory characteristics and treatment responses of patients with AA amyloidosis retrospectively in a tertiary referral center.

Methods:

Study group was consisting of patients with biopsy proven AA amyloidosis, and their data were recorded from their charts. Treatment responses were categorized as follows:complete responsewas defined as no increase in serum creatinine and a proteinuria below 1gr/day;partial responseas 50% decrease in proteinuria; andstable disease as no significant change in serum creatinine and proteinuria. Progressive disease was defined as increase in serum creatinine and/or proteinuria under treatment.

Results:

173 patients were identified, and 10 patients with no biopsy result and/or missing data were excluded. A total of 163 patients (79 females, 84 males) were included in the study. Median age of patients was 45.4, and median age at diagnosis of amyloidosis was 33.5. Most common cause of amyloidosis was FMF (78.5%), followed by idiopathic cases (7.9%) and patients with AS (4.9%). A quarter (26%) of amyloidosis patients had a family history for AA amyloidosis, and 59% of patients with FMF had a family history of FMF. Amyloidosis was confirmed by renal biopsy in 76.1%, by gastrointestinal (GIS) biopsy in 11.7%, and by other biopsies in the remaining. Renal involvement was documented in 160 (98.2%) patients, while GIS involvement in 20.9%, heart in 13.5%, thyroid in 3.7% and bone marrow in 3.1%. In FMF patients, most common MEFV mutation was M694V (77.7%); and 66.7% of the patients had homozygous, 14.6% had compound heterozygous, and 18.7% heterozygous exon 10 variants. Mean age at diagnosis of amyloidosis was earlier in homozygotes (29.1) and compound heterozygotes (32.3) compared to heterozygotes (43.9) (p = 0.001). There was no difference in treatment responses, organ involvement, progression to end stage renal disease (ESRD) and mortality between monoallelic and biallelic exon 10 mutations (p = 0.42). While 44.3% (n = 70) of patients had chronic renal disease (CRD) at time of diagnosis, ESRD developed in 45.3% (n = 73) of patients. During follow-up, 55 patients underwent renal transplantation and recurrence of renal amyloidosis occurred in 24% of them. Mean creatinine and proteinuria levels at time of diagnosis were higher in patients with ESRD than those without ESRD (p <0.001, p = 0.03 respectively). Progression to ESRD was significantly higher in patients with GFR≤60 ml/min at time of admission (%14.5 vs %41.7, p=0.005, Figure 1). A total of 113 (70.2%) patients used biological agents, most commonly used biological agent was anakinra (n = 81). Canakinumab was used in 17 and other biological agents in 17 patients. Complete response was observed in 49.1%, partial response was observed in 6.2%, and progressive progression was observed in 21.7%. GIS and cardiac involvements were associated with progressive course (p <0.001) and increased mortality (p = 0.002, p <0.001, respectively), and overall mortality rate was 8.7%.

Figure 1

: Survival graphic of AA amyloidosis patients who developed ESRD according to their baseline GFR status

Conclusion:

Increased rate of ESRD and progression of amyloidosis findings in patients who presented with GFR<60 ml/min emphasize the importance of early diagnosis. Although mortality rate is very high in patients with AA amyloidosis due to FMF disease, it may be possible to reduce mortality with an effective treatment.

Disclosure of Interests:

None declared

THU0369 EVALUATION OF DIFFERENT CLASSIFICATION CRITERIA IN SYSTEMIC SCLEROSIS IN A TURKISH COHORT: THE IMPORTANCE OF NON-SKIN MANIFESTATIONS, SEROLOGY AND CAPILLAROSCOPY

Background:

Proximal scleroderma is the major criterion in both 1980 and 2013 classification criteria for sytemic scleroris (SSc). ACR(1980) criteria included digital lesions and bibasiler fibrozis, nonetheless ACR/EULAR(2013) criteria based on a scoring system including digital lesions, telangiectasia, abnormal nailfold video-capillaroscopy(NVC), PAH, Raynaud’s and specific autoantibodies.

Objectives:

We aimed to implement both criteria in a Turkish SSc kohort to evaluate the contribution of non-skin manifestations, NVC and autoantibodies.

Methods:

A consecutive hundred and thirty-nine (125 females) SSc patients diagnosed and evaluated by the same experts (YY, MI) with relevant NVC records and at least 6 months follow-up were included into the study. Classificaiton criteria were used retrospectively using a preformed database.

Results:

Characteristics of the SSc patients were summarized in table-1. The mean age, duration of Raynaud’s and non-Raynaud symptoms were 47.1±11.9, 8.9±7.9 and 5.7±5.8 years, respectively. Diffuse and limited cutaneous disease were diagnosed in 62(44.6%) and 60(43.2%) patients respectively. Asclerodermic disease was present in 17(12.2%) patients. ANA, anti-centromere and anti-Scl70(+) positivity was 80.5%, 18.0% and 37.4%, respectively.

Twelve patients (8.6%) could not be classified as SSc by both criteria; 5 with Raynaud’s+specific antibodies (2 anti-centromere+, 2 anti-Scl70+), 4 with Raynaud’s+puffy hands+NC abnormalities, 2 with Raynaud’s+telangiectasia and a patient with Raynaud’s+sclerodactyly. Nineteen (13.7%) patients could not be classified as SSc according to ACR (1980) can be classsified according to ACR/EULAR (2013) (table-1 and -2).

The sensitivity for ACR/EULAR (2013) and ACR (1980) criteria were found to be 91,4% vs 75,5%; 98.4% vs 96.8% in diffuse cutaneous SSc, 98.3% vs 68.3% in limited cutaneous SSc and 47.1 vs 23.5% in asclerodermic SSc, respectively.

Table 1.

The sensitivity for ACR (1980) and ACR/EULAR (2013) classification criteriain SSc

ACR/EULAR (2013) +ACR/EULAR (2013)-totalACR (1980)+1080108ACR (1980)-191231total12712139Table 2.

SSc patients fulfilling ACR (1980) and/or ACR/EULAR (2013) criteria

ACR/EULAR (2013)ACR (1980)Classified n=127Not classified n=12+Prox scleroderma+87+Puffy hands294+Sclerodactyly+1121+Digital ulcers + +Pitting scars62 72+Telangiectasia862+Nailfold capillaroscopy974 Normal9 Early173 Active40 Late501+PAH12+Interstitial lung Disease +60+Raynaud’s12012+SSc- specific antibodies795

Conclusion:

The sensitivity of ACR/EULAR (2013) criteria was shown to be higher than ACR (1980) criteria in our Turkish SSc cohort with established cases. Although in diffuse cutaneous subgroup, the sensitivity was >%96 for both criteria, in limited cutaneous subgroup, the sensitivity was preserved for ACR/EULAR(2013) while apparently decreased for ACR(1980) criteria (<%70). The sensitivity for both of the two sets were lowest in the asclerodermic group. In SSc patients with limited or no skin involvement, non-skin manifestations, NVC findings and spcific serology should be carefully sought. Some of these patients could not be classified by the current criteria.

Disclosure of Interests:

None declared

AB0461 ANCA-ASSOCIATED VASCULITIS: CLINICAL FEATURES, RELAPSE, ORGAN DAMAGE AND SURVIVAL IN 197 PATIENTS

Background:

ANCA-associated vasculitis (AAV) is a multisystemic autoimmune disease with high mortality and morbidity.

Objectives:

We aimed to present the long-term follow-up results of our cohort.

Methods:

Data of patients who fulfilled Chapell Hill Consensus Criteria and followed up at least 6 months between 1999-2019 were analyzed. A standard form including vasculitis damage index (VDI) was used. Multivariable analysis was performed by using logistic regression.

Results:

Long-term data was available for 197 patients (%53.8 female) from 208 patient records. Mean age at diagnosis was 49.4 years and mean follow-up was 80.7 months. Granulomatosis with polyangiitis (GPA); microscopic polyangiitis (MPA), eosinophilic GPA (EGPA) were 117 (64.5%), 52 (26.4%), 17 (8.6%), respectively. Relapses are observed in 31.6% of patients. Disease relapses were higher in GPA compared to MPA and EGPA (p = 0.014). Relapse rate was higher in patients withs.aureuscarriage (p = 0.037). Cyclophosphamide (CYC) (76.6%) was most commonly used drug for induction, whereas azathioprine (57.3%) was used mostly in maintenance. In multivariate analysis relapse was found to be associated with maintenance treatment with rituximab (p <0.001), venous thrombosis (p=0.046) and serious infection (p<0.004). There was no significant association between relapse and mortality. Five-year survival rates were 98.5% for GPA, 88.5% for MPA and 100% for EGPA. Nineteen patients died during follow-up (9.6%). In univariate analysis mortality were high in MPA patients. Low hemoglobin and increased creatinine at baseline, subglottic stenosis, polyneuropathy, and cerebrovascular events (CVE) were associated with increased mortality. In multivariable analysis, mortality was associated with CVE (p=0.047) and anti-MPO positivity (p=0.014). Malignancy was developed in 9 patients (M / F: 7/2; two lung, three bladder, one cervix, one thyroid papillary, one kidney and one of unknown primary). There was no association between malignancy and cumulative dose of CYC. Venous thromboembolism was developed in 12 (6 %) and avascular necrosis (AVN) was detected in 30 patients (15.4%). Most (88.7%) patients developed damage during follow-up. Mean VDI score was 2.6 and VDI score was found to be higher in GPA (p= 0.035). There was no association between VDI score and mortality.

Conclusion:

In our AAV cohort, GPA was most frequent. Although survival was improved, permanent organ damage was detected in the majority of patients. Relapse and organ damage were found to be increased in patients with GPA. Relapses are frequent and maintenance with rituximab could not prevent relapses. Also relapses were associated with venous thrombosis and severe infections. Patients should be screened for malignancies especially of the genitourinary tract.

Table 2.

Damage findings of AAV patients according to VDI

Organ/systemNumber(%)Steroid myopathy23 (%11.7)Osteoporosis31 (%15.9)AVN30 (%15.4)Cataract30 (%15.4)Partial loss of vision6 (%3.1)Blindness (one eye)2 (%1)Subglottic stenosis9 (%4.5)Hearing loss18 (%9.1)Nasal septum perforation21 (%10,7)Chronic nasal crusting9 (%4,6)Chronic ashtma28 (%14,2)Chronic dispnea1 (%0,5)Hypertension60 (%30,5)Coronary artery disease / Angioplasty10 (%5,1)Cardiomyopathy6 (%3)Valvular heart disease5 (%2,5)Myocardial infarction7 (%3,6)Deep vein thrombosis12 (%6)Chronic renal failure (GFR <50 ml/min)51 (%26)End stage renal disease22 (%10.8)Cerebrovascular accident9 (%4,4)Peripheric neuropathy39 (%19.8)Malignancy9 (%4.5)Diabetes mellitus24 (%12.2)Gonadal failure2 (%1)Figure 3.

Cumulative Relapse Rate: Hazard ratio of patients treated with Rituximab versus Azathioprine (Log Rank: p<0.001)

Disclosure of Interests:

None declared

THU0349 THE RELATIONSHIP BETWEEN DISEASE ACTIVITY AND SEVERITY IN SYSTEMIC SCLEROSIS: A PROSPECTIVE ANALYSIS OF 278 PATIENTS

Background:

Evaluating disease activity and severity in systemic sclerosis (SSc) is crucial to define the patients who are candidate for treatment options.

Objectives:

We aimed to investigate the relationship between disease activity and severity in SSc in a large cohort.

Methods:

This is a cross-sectional prospective analysis of 278 (253 females) patients fulfilling ACR/EULAR (2013) classification criteria for SSc. Disease activity and severity were calculated seperately for cutaneous subsets (EscSG and Medsger). The patients were grouped as inactive if EscSG score=0, mildly active if EscSG score>0<3, active if EscSG score≥3.

Results:

The mean age, duration of Raynaud’s and non-Raynaud features were 48.5±13.1, 12.1±9.8 and 8.3±7.5 years respectively. Characteristics of the SSc patients were summarized in table-1.

Ninety-three (34%) and 151(54%) patients were evaluated as having active and mildly active disease. Only 34(12%) patients had inactive disease. The patients with diffuse cutaneous involvement (dcSSc) who were active had higher modified Rodnan Skin score(mRSS) and severity scores of general, skin and joint-tendon involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin compared to those with inactive disease (table-2).The patients with limited cutaneous involvement (lcSSc) who were assessed as having active disease had higher mRSS and higher severity scores of general, skin, peripheral vascular, lung, joint-tendon and gastrointestinal involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin, lung, joint-tendon and gastrointestinal involvements compared to those with inactive disease (table-2).

Conclusion:

One third of our cohort was found to have active disease despite treatment and only 12% had inactive disease. Skin involvement and severity of different organs were shown to be higher in patients with active disease in both cutaneous subsets, together with severity of lung, peripheral vascular and gastrointestinal involvements in active lcSSc. LcSSc and dcSSc patients who had mildly active disease also had severe disease similar to those with active patients. Disease activity and severity should be assessed as separate measurements to highlight the course of the disease and may guide to the management of patients with SSc.

Disclosure of Interests:

None declared

AB0485 INVESTIGATION OF PERMANENT ORGAN DAMAGE IN GIANT CELL ARTERITIS: DISEASE FLARES ARE ASSOCIATED WITH INCREASED DAMAGE SCORES

Background:

Development of organ damage is a major concern in patients with systemic vasculitis. Treatment may also contribute to this important outcome. Scoring systems has been developed to evaluate organ damage in systemic vasculitis and specifically for large vessel vasculitis (1).

Objectives:

We aimed to investigate permanent organ damage and determining factors in our giant cell arteritis GCA cohort.

Methods:

Organ damage detected at the time of diagnosis and / or follow-up and irreversible for at least 3 months in GCA patients followed up between 1998-2018 were recorded by using Vasculitis Damage Index (VDI) and Vascular Vasculitis Damage Index (LVVID) fom patient records of our vasculitis clinic. In the statistical evaluation, chi-square, students t-test and logistic regression analysis were used.

Results:

Eighty-nine patients (64% women, mean age 67.9 ± 9.1) included in the study, the mean follow-up duration was 61.6 ± 58.6 months. All organ damage findings according to both VDI and LVVID are shown in table-1. In this cohort, cardiovascular damage items and diabetes mellitus were prevalent at baseline. At least one damage item was present in 53 (59,5%) according to VDI; 54 (%60,7) according to LVVID and agreement was high between two damage indices (kappa=0.97). Forty-seven of patients (52%) had a damage item presumably with contribution of GC treatment e.g. locomotor system findings, hypertension, diabetes and cataract; 12 (13,5%) had damage items related to disease (total or partial vision loss, ischemic optical neuropathy). Mean time to diagnosis after initial symptoms was longer in patients with permanent vision loss (10,2±4,3 vs. 5,2±1,2 months p=0.006). The presence of damage was associated with flares in univariate and multivariate analysis (29/54 vs. 2/35 p<0,001 OR=19 %95 GA 4,2– 87,9). All patients who had a flare during the first year (n = 15) developed signs of damage at follow-up. No association was found between the development of organ damage and the age of diagnosis, the time between first complaint and diagnosis, presence of cranial, ophthalmologic findings, PET-CT positivity, cumulative steroid dose, and DMARD use.

Conclusion:

In our study, permanent organ damage was analysed by using diffrerent indices. In this patient population baseline cardiovascular damage and diabetes mellitus were frequent as expected but information for osteoporosis was lacking. More than half of the patients had damage and significant part of the present items was considered due to corticosteroid treatment. The most common damage item developed was osteoporosis. There was a very good agreement between the two indices, despite few specific items in LVVID. The striking relationship of disease flare with damage and frequency of visual problems despite treatment indicate the necessity of new treatment strategies.

References:

[1]Kermani, T.A., et al.,Evaluation of damage in giant cell arteritis.Rheumatology (Oxford), 2018.57(2): p. 322-328.

Disclosure of Interests: :

None declared

FRI0160 THE CORRELATION BETWEEN PREGNANCY, DISEASE ACTIVITY AND ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Patients with systemic lupus erythematosus (SLE) can present with acute disease flares/exacerbations during pregnancy and postpartum period.1These flares can cause adverse pregnancy outcomes (APO).

Objectives:

In this study, our pregnant SLE cohort, which was under medical surveillance of both our Rheumatology and Gynecology and Obstetrics departments was analyzed. We intended to determine the effects of pregnancy on disease activity and the correlation between disease flares and adverse pregnancy outcomes.

Methods:

168 pregnancy data involving 136 patients with SLE meeting the ACR criteria were examined. Cumulative clinical, laboratory and serological parameters were described and disease activity and flares were calculated using SLEDAI-2K disease activity index during preconceptional six month period, during all trimesters of pregnancy, and during postpartum six month period. Patients with low lupus disease activity scores (LLDAS) during each of these periods were identified. Fetal/neonatal death, premature birth due to preeclampsia, eclampsia or HELLP syndrome, neonates small for gestational age were determined as adverse pregnancy outcomes. Relationship of APO with disease activity was studied and patients with APO were compared to patients without APO.

Results:

Mean SLEDAI-2K scores was 1.3±2.2 (0-16) during preconceptional six month period, 1.3±2.6 (0-16) during conception period, 1.7±3.2 (0-22) during first trimester, 1.4±2.7 (0-16) during second trimester, 1.5±3.3 (0-20) during third trimester and 3.5±5.4 (0-26) during postpartum six month period. Mean postpartum six month period SLEDAI-2K score was higher compared to the mean pregnancy SLEDAI-2K score (p<0.05). LLDAS was sustained in 79% of all pregnancies. 19% of pregnancies resulted in flares. 42% of these flares were severe and 58% were mild or moderate. 49% of severe flares occurred during the postpartum six month period and this percentage was significantly higher compared to each trimester (p<0.05). Most of the flares during pregnancy and postpartum period had mucocutaneous (37%), renal(35%) and hematological(25%) involvement.

APO was observed in 34% of pregnancies (n=57). APO (+) group was characterized by significantly longer disease duration and higher disease activity in all periods compared to APO (-) group (142±70 vs 170±88 months, p<0.05). In APO (-) group, the proportion of patients with severe disease activity during all pregnancy periods and postpartum period was significantly low (%18 vs 35, p<0.05), while the proportion of patients with sustained LLDAS was much higher (%88 vs 70).

Conclusion:

Postpartum six-month period appears to have the highest risk for disease flares during SLE pregnancies. Disease activity during pregnancy increases the risk of APO. Patients with sustained LLDAS have significantly lower APO rates. In order to achieve a positive pregnancy outcome and lower maternal morbidity, regular follow up of patients during pregnancy and postpartum period by Rheumatology and Gynecology and Obstetrics Departments is necessary.

References:

[1]Eudy AM, et al. Ann Rheum Dis 2018;0:1–6. doi:10.1136/annrheumdis-2017-212535

Disclosure of Interests:

None declared

SAT0261 FEATURES AND RISK FACTORS OF SERIOUS INFECTIONS IN ANCA ASSOCIATED VASCULITIS: LONG TERM FOLLOW UP OF 186 PATIENTS

Background:

Serious infections (SI) are one of the main complications in patients with ANCA associated vasculitis (AAV).

Objectives:

We planned to investigate the prevalence, features and risk factors of SI in our AAV cohort during follow-up.

Methods:

Outpatient and hospital data of patients diagnosed with granulomatous polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatous polyangiitis (eGPA) between 1999 and 2019 according to Chapel Hill Consensus Criteria and followed up at least 6 months in our vasculitis clinic were evaluated. Development of sepsis, requirement for intravenous (IV) antibiotherapy and / or hospitalization during infection episodes were considered as SI. Chi-square, student’s t-test and logistic regression analysis were used for statistical analysis.

Results:

Study was conducted with 186 (53.6% female) patients with adequate follow-up data. Mean age of diagnosis was 54.3±14,5 (23-79), mean follow-up duration was 86,4 ± 54,3 (6-251) months. Number of GPA, MPA and eGPA patients were 132 (71%), 42 (22,5%) and 12 (6,5%), respectively. IV cyclophosphamide (CYC) was used in 148 (79,6%), azathioprin in 105 (56,5%), rituximab (RTX) in 69 (%37,1), methotrexate in 29 (15,6%) and mycophenolate mofetil in 14 (7,5%) patients. Number of patients developed SI was 66 (34.7%), total SI episode was 86, patients who had multiple episodes was 15. All SI is shown in Table-1. Bacterial pneumonia was the most common diagnosis and 26 of SI (30.2%) were considered as opportunistic (systemic viral, parasite, fungus) infections. Thirty-one of patients developed SI (40,7%) in the first year after diagnosis. SI were observed more frequently in the presence of major organ involvement (kidney, lung, neurological) (65/173 vs. 1/13 p = 0.02 OR = 8.7 95% CI 1.06-64.4). Diffuse alveolar hemorrhage (DAH) was associated with SI in multivariate analysis (12/52 vs. 0/34 p=0.007 OR=1.6 95% CI 1.3-1.96). Cumulative CYC dose was significantly higher in patients with SI (14,2±21 vs. 8.2±13.9 p=0.045). During maintenance, patients treated with RTX had significantly more SI (18/53 vs. 17/99 p=0.19 OR=3,3 95% CI 1,55- 7,07). Hypogammaglobulinemia (HIgG) (IgG<700 mg/dL) was present in 12 (14%) SI episodes. HIgG was associated with SI in RTX-treated patients (5/13 vs. 7/47 p=0.03 OR=4.2, CI=1-16.5). Hospitalization need for SI was 65%. Disease flares (34/128 vs. 32/62 p = 0.001 %95 CI = 2.9 95% CI 1.6-5.6) and organ damage presence were more common (64/65 vs. 109/125 p = 0.01 95% OR= 8.9 95% CI 1.1-68.9) in patients with a history of SI in multivariate analysis. SI was confirmed as cause of death in three cases.

Conclusion:

Long-term follow-up results of a single center cohort of AAV patients revealed that approximately one third of patients developed SI, most frequently in the first year of treatment. During the maintenance period, the risk of SI continues. Cumulative CYC dosage and maintanence with RTX is associated with SI, especially in patients who developed hIgG. Major organ involvement, disease flares and organ damage are significant risk factors for SI. In this regard, protection measures (vaccination, prophylaxis) should be reviewed and the quality of follow-up should be improved.

Table 1.

Serious infections in AAV patients.

BACTERIALNFUNGALNVIRALNPROTOZOANNPneumonia37PJP7Zoster Zona3Intramuscular abscess (Nocardiosis)1Urinary Tract Infection (UTI)8Aspergilloma1CMV Pneumonia1Gr (-) sepsis2Invasive Fungal Infection3CMV Colitis1Perianal abscess2Candida Eosephagitis4CMV Gastritis1Intraabdominal abscess2Candidemia2HSV Eosephagitis1Catheter infection2UTI1Sellulitis1Fungal otitis1Orbital sellulitis1Maxillary sinüs abscess1Mastoiditis1Prosthesis infection1Septic artrhitis1Lung tuberculosis1

Disclosure of Interests:

None declared

SAT0346 THE EFFICACY AND SAFETY OF RITUXIMAB IN 27 CASES OF TREATMENT RESISTANT SYSTEMIC SCLEROSIS WITH SEVERE DISEASE ASSESSED BY ACTIVITY SCORES

Background:

Treatment options for systemic sclerosis (SSc) remain limited especially in severe skin, lung and musculoskeletal involvements. B-cell targeted therapy with anti-CD20 Rituximab (RTX), is widely available, reports from case series are encouraging as a a rescue therapy and might have an improving effect on organ involvement in SSc.

Objectives:

We aimed to retrospectively analyze the efficacy and safety of rituximab (RTX) courses in patients with severe systemic sclerosis who were refractory to standard immunosuppressive treatment.

Methods:

Twenty-seven SSc patients fulfilling ACR/EULAR classification criteria (2013) who received RTX treatment due to acive disease despite treatment with immunosuppresives were analyzed. Disease activity was evaluated by using EScSG/EUSTAR activity scores prior to and after RTX treatment. Disease severity was also assessed at baseline by Medsger’s index.

Results:

The demographics and characteristics of SSc patients were as follows: the median age of 50 (30-70), duration of Raynaud’s 10 (3-26) and non-Raynaud symptom 8.5 (3-18) years and summarised in table 1. RTX was given as a single cycle (2 infusions of 1000 mg) in 12 cases, 2 cyles in 5 cases, ≥3 cyles in 10 cases. DMARDs were prescribed in 19 (73%) patients (14 MMF, 5 MTX) concomitantly with RTX. The main RTX indications were skin and lung involvement (n=9), skin and arthritis (n=6), skin(n=5), lung (n=3), myositis (n=2), cardiac involvement (n=1) and digital vasculopathy (n=1). Medsger severity score was 7.39±3.091(3-13) at baseline.

Table 1.

Prevelance of Characteristics of SSc Patients

n(%)female/male25 /2diffuse/limited cutaneous SSc22 (81.5) / 5 (19,2)Clinical Characteristicssynovitis / flexion contractures12(44,4) / 10 (37,1)tendon friction rubs / myositis7 (26,9) / 4 (15,4)renal crisis1 (3,8)GI involvement19 (69,2)lung involvement16 (61,5)SerologyANA23 (85,2)Anti-Scl70 / Anti-sentromer16(61,5) / 1(3,8)Anti-Ro6 (22,2)Previous ImmunosuppressivesCYC / MMFAZA / MTX Low dose steroids19 (73,1) / 19 (73,1) 12 (46,2) / 16 (61,5) 27 (100)

Disease activity and severity scores prior to and after RTX were summarised table 2. Disease activity scores were improved after RTX in patients who had a median follow-up period of 1 year (0,5-5 years). After RTX treatment, according to EscSG /EUSTAR scores 13 (%46.2) and 10 (%34.6) patients out of 26 were assessed as inactive.

Table 2.

Disease activity scores prior to and after RTX treatment

Prior to RTX (n=26)After RTX (n=18)median Δ Change (n=18)EscSG activity score4,89±1,82 (2,0-9,0)2,37±1,10 (0,50-4,50)-2,00 (P<0,001)EUSTAR activity score4,57±2,68(1,0-10,0)2,30±2,15 (0,0-7,25)-2,00 (P=0,002)

There were severe infecions in 4 patients (Pneumonia in 2, infected digital ulcers in 2) and an episode of sinusitis in one during treatment period. One patient was deceased because of pneumonia and sepsis after the first cycle of RTX.

Conclusion:

In our SSc cohort, RTX treatment was used in severe patients, who had predominantly diffuse cutaneous disease with lung and joint involvements, severe vasculopathy and anti-Scl-70 positivity. Concomitant DMARDs were used in three-forth of the patients in addition to RTX cycles. Disease activity scores that assessed retrospectively were shown to be improved after RTX and 37-48% of the cases were assessed as inactive by using activity scores. Serious infections like pneumonia and infected digital ulcers were observed in 14,8% of cases during the follow-up. The addition of RTX treatment can be effective in selected patients with active disease despite immunosuppressive therapy.

Disclosure of Interests:

None declared

SAT0238 VALIDATION OF THE ADJUSTED GLOBAL ANTIPHOSPHOLIPID SYNDROME SCORE AND CORRELATION WITH EXTRA-CRITERIA MANIFESTATIONS

Background:

Adjusted global antiphosholipid syndrome score (aGAPSS) is the simplified version GAPSS that was recently developed to assess thrombotic risk by the consideration of antiphospholipid antibody (aPL) profile and conventional cardiovascular risk factors.

Objectives:

The aim of this study was to evaluate the validity of the aGAPSS in predicting thrombosis and extra-criteria manifestations in our antiphospholipid syndrome (APS) cohort.

Methods:

Ninety-eight patients with APS were classified according to clinical manifestations as vascular thrombosis (VT), pregnancy morbidity (PM) or both (VT+PM). The aGAPSS was calculated as defined before. Arterial hypertension and hyperlipidemia definitions were made according to the ESC/ESH ve NCEP/ATP III guidelines, respectively.

Results:

Demographic, laboratory and clinical characteristics of patients are summarized in table-1. Mean aGAPSS was calculated as 10.2 ± 3.8. Significantly higher aGAPSS values were seen in VT (n=58) and VT+PM (n=29) compared to PM (n=11) (mean aGAPSS 10.6 ± 3.7 vs 7.3 ± 2.9, P=0.005; 10.5 ± 4 vs 7.3 ± 2.9, P=0.01, respectively). AUC demonstrated that aGAPSS values ≥ 10 had the best diagnostic accuracy for thrombosis (figure-1). Higher aGAPPS values were also associated with recurrent thrombosis (mean aGAPSS 11.5 ± 3.7 vs 9.9 ± 3.6, P=0.04). Regarding extra-criteria manifestations, patients with livedo reticularis (n=11) and APS nephropathy (n=9) had significantly higher aGAPSS values (mean aGAPSS 12.9 ± 3.4 vs 9.9 ± 3.7, P=0.02; 12.4 ± 2.9 vs 10 ± 3.8, P=0.04, respectively).

Conclusion:

Our results suggest that patients with higher aGAPSS values are at higher risk for developing vascular thrombosis (either single or recurrent) and extra-criteria manifestations, especially livedo reticularis and APS nephropathy.

Table-1.

Demographic, laboratory and clinical characteristics of patients.

PAPS (n=42)n(%)SLE/APS (n=56)n(%)PFemale36 (85.7)47 (83.9)0.52Age, years (mean±SD)44.6 (11.6)40.8 (10.1)0.42Disease duration, years (mean±SD)10 (8.8)9.7 (7.1)0.16Thrombosis35 (83.3)52 (92.9)0.12•Arterial24 (68.6)34 (65.4)0.47•Venous19 (54.3)26 (50)0.43•Recurrent15 (42.9)22 (42.3)0.56Pregnancy morbidity20 (47.6)20 (35.7)0.16•<10 weeks, ≥ 3 abortions5 (25)4 (20)0.5•≥ 10 weeks, ≥ 1 abortion14 (70)15 (75)0.5•Pre-eclampsia/eclampsia3 (15)5 (25)0.34•<34 weeks, ≥ 1 premature birth1 (5)5 (25)0.09Convensional risk factors•Arterial hypertension17 (40.5)35 (62.5)0.02•Hyperlipidemia21 (50)26 (46.4)0.41•Diabetes mellitus3 (7.1)3 (5.4)0.51•Obesity19 (45.2)16 (28.6)0.07•Smoking12 (28.6)18 (32.1)0.43aPL profile•LA29 (69)48 (85.7)0.04•aCL IgG/IgM31 (73.8)28 (52.8)0.03•aβ2GPI IgG/IgM22 (56.4)27 (52.9)0.45•Triple positive14 (33.3)17 (30.4)0.46Figure 1.

ROC curve according to cut-off aGAPSS value: 10 (AUC: 0.71, sensitivity: 0.52, specificity: 0.91, positive predictive value: 0.98, negative predictive value: 0.19, p-value: 0.01).

Disclosure of Interests:

None declared

Serum and urine TNF-like weak inducer of apoptosis, monocyte chemoattractant protein-1 and neutrophil gelatinase-associated lipocalin as biomarkers of disease activity in patients with systemic lupus erythematosus

OBJECTIVES

TNF-like weak inducer of apoptosis (TWEAK), monocyte chemoattractant protein-1 (MCP-1) and neutrophil gelatinase-associated lipocalin (NGAL) are proinflammatory cytokines/chemokines that are considered as potential biomarkers reflecting disease activity in systemic lupus erythematosus (SLE). In this study, we aimed to investigate the association of serum (s) and urine (u) levels of TWEAK, MCP-1 and NGAL with disease activity in both renal and extra-renal SLE.

METHODS

Thirty active patients with SLE (15 renal and 15 extra-renal) were recruited. Thirty-one inactive patients with SLE (16 renal and 15 extra-renal), 14 patients with ANCA-associated vasculitis (AAV) all of whom had active renal involvement and 20 healthy volunteers were selected as control groups. Serum and urine levels of TWEAK, MCP-1 and NGAL were tested using ELISA.

RESULTS

Serum and urine levels of TWEAK and NGAL were significantly higher in the active SLE group compared to the inactive SLE group (sTWEAK p = 0.005; uTWEAK p = 0.026; sNGAL p < 0.001; uNGAL p = 0.002), whilst no significant differences regarding serum and urine MCP-1 levels were observed (p = 0.189 and p = 0.106, respectively). uTWEAK (p = 0.237), sMCP-1 (p = 0.141), uMCP-1 (p = 0.206), sNGAL (p = 0.419) and uNGAL (p = 0.443) levels did not differ between patients with active renal and extra-renal SLE. Serum TWEAK was higher in patients with active renal SLE (p = 0.006). There were no differences between active renal SLE and active renal AAV. Levels of all biomarkers were correlated with the SLE Disease Activity Index.

CONCLUSION

sTWEAK, uTWEAK, sNGAL and uNGAL are biomarkers showing disease activity in SLE. However, our results implicate that these biomarkers may not be specific for SLE, and can be elevated in patients with active renal involvement of AAV.

Study of Flare Assessment in Systemic Lupus Erythematosus Based on Paper Patients

Objective

To determine the level of agreement of disease flare severity (distinguishing severe, moderate, and mild flare and persistent disease activity) in a large paper‐patient exercise involving 988 individual cases of systemic lupus erythematosus.

Methods

A total of 988 individual lupus case histories were assessed by 3 individual physicians. Complete agreement about the degree of flare (or persistent disease activity) was obtained in 451 cases (46%), and these provided the reference standard for the second part of the study. This component used 3 flare activity instruments (the British Isles Lupus Assessment Group [BILAG] 2004, Safety of Estrogens in Lupus Erythematosus National Assessment [SELENA] flare index [SFI] and the revised SELENA flare index [rSFI]). The 451 patient case histories were distributed to 18 pairs of physicians, carefully randomized in a manner designed to ensure a fair case mix and equal distribution of flare according to severity.

Results

The 3‐physician assessment of flare matched the level of flare using the 3 indices, with 67% for BILAG 2004, 72% for SFI, and 70% for rSFI. The corresponding weighted kappa coefficients for each instrument were 0.82, 0.59, and 0.74, respectively. We undertook a detailed analysis of the discrepant cases and several factors emerged, including a tendency to score moderate flares as severe and persistent activity as flare, especially when the SFI and rSFI instruments were used. Overscoring was also driven by scoring treatment change as flare, even if there were no new or worsening clinical features.

Conclusion

Given the complexity of assessing lupus flare, we were encouraged by the overall results reported. However, the problem of capturing lupus flare accurately is not completely solved.

The quantitative assessment of alterations in lens transparency after transconjunctival 27-gauge microincision vitrectomy surgery

PurposeTo evaluate the baseline and post-vitrectomy lens densitometry values by a Scheimpflug camera in eyes with epiretinal membrane that were treated with 27-G microincision vitrectomy surgery (MIVS) without tamponade and to compare the results with those in fellow healthy eyes.Patients and methodsProspective case series. The lens densitometry measurements of 24 patients, who underwent 27-G MIVS without any tamponade for the treatment of epiretinal membrane, were taken preoperatively and on the first week, first month, and third month postoperatively with Pentacam HR-Scheimpflug imaging system.ResultsThe mean lens densitometry values at Zone 1 and average lens densitometry values significantly increased in the study eyes on the first month when compared with the preoperative values (P=0.011, P=0.033, respectively). Additionally, there were statistically significant differences regarding the mean lens densitometry values of Zone 1 and Zone 2, and also average lens densitometry values between the preoperative and third month postoperative values (P=0.003, P=0.021, P=0.009, respectively). However, the densitometry values of fellow eyes were similar at preoperatively and all the postoperative follow-up periods (P>0.05 for all).ConclusionsThis study suggests that 27-G MIVS might cause post-surgical lens density changes even in early postoperative months and vitreous may play an important role in protecting the transparency of the lens.

Crab claw pattern on corneal topography: pellucid marginal degeneration or inferior keratoconus?

PurposeTo evaluate the topographic, tomographic, and densitometric properties of patients with pellucid marginal degeneration (PMD) and inferior keratoconus.Patients and methodsRetrospective, comparative case series. Forty-seven eyes of 32 patients with crab claw patterns were identified from 2751 patients with corneal ectasia. They were divided into two groups, inferior keratoconus and PMD, based on clinical findings. The topographic, tomographic, and densitometric measurements were analyzed.ResultsPMD was detected in 11 eyes of eight patients (mean age 50.2±11.1 years), and inferior keratoconus was detected in 36 eyes of 24 patients (mean age 34.7±10.1 years). The control group consisted of 40 patients (33.1±4.6 years). The thinnest corneal point and maximum anterior and posterior elevation points were located lower in the PMD than in the inferior keratoconus (P<0.01). In the PMD, all deviation indices were higher than the controls (P<0.01), whereas the deviation indices, except Dt (P=0.960), were lower than the inferior keratoconus (P<0.01). The densitometry values of PMD were significantly higher than those of the controls in all zones and layers (P<0.01) and significantly higher than the densitometry values of inferior keratoconus in the 6-10 and 10-12 mm zones (P<0.05).ConclusionThere is a higher probability of a patient with crab claw pattern on the topography of having inferior keratoconus than having PMD. Therefore, analyzing only the anterior corneal surface is not sufficient in differential diagnosis. Tomographic and densitometric evaluations may facilitate the differential diagnosis.

Factor XIII Val34Leu polymorphism does not contribute to the prevention of thrombotic complications in patients with antiphospholipid syndrome

The effect of thrombophilic mutations in the development of thrombosis in patients with antiphospholipid syndrome (APS) has been extensively investigated. Factor XIII (FXIII) Val34Leu polymorphism is a newly described polymorphism which is located in the three amino acids away from the thrombin activation site of the FXIII-A subunit. It has been reported that the Leu allele decreases the risk of both arterial and venous thrombosis. In the present study, we examined the associationbetween the FXIII Val34Leu polymorphismand the developmentof thrombosisin patients with APS. Sixty APS patients with arterial and venous thrombosis, 22 antiphospholipid antibody (aPLA) positive patients with first trimester abortus and/or thrombocytopenia,126 healthy controls, and 60 healthy subjects who were age- and sex-matched with thrombotic APS group were included into the study. FXIII Leu allele frequencies in the APS patients with thrombosis, aPLA-positive patients without thrombosis, healthy controls, and matched controls were 13.3, 16, 19.5, and 18.3%, respectively. When we compared Leu allele frequencies between APS patients with thrombosis and aPLA-positive patients without thrombosis, healthy controls or matched controls, we could not find any difference (x 2, P 0.43, and P 0.09, P 0.67, respectively). Our results showed that the FXIII Leu allele has no protectiveeffect in the developmentof thrombosis in APS.

Anti-C1q antibodies in systemic lupus erythematosus

OBJECTIVE

Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study.

METHODS

Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA.

RESULTS

Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01).

CONCLUSIONS

Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.