Type I interferon pathway activation across the antiphospholipid syndrome spectrum: associations with disease subsets and systemic antiphospholipid syndrome presentation

Introduction

While the type I interferon (IFN-I) pathway is crucial in autoimmunity, its role in antiphospholipid antibody (aPL)-positive subjects, including aPL carriers and antiphospholipid syndrome (APS) patients, is poorly understood. This study aims at characterizing IFN-I pathway activation within the spectrum of aPL-positive subsets.

Methods

A total of 112 patients [29 aPL carriers, 31 primary APS (PAPS), 25 secondary APS (SAPS), 27 systemic lupus erythematosus (SLE) patients without aPL, and 44 healthy controls (HCs)] were recruited. IFI6, IFI44, IFI44L, MX1, IFI27, OAS1, and RSAD2 gene expression was evaluated in whole blood, and a composite index (IFN score) was calculated.

Results

An overall activation of the IFN-I pathway was observed across the entire APS spectrum, with differences among genes based on the specific disease subset. The composite score revealed quantitative differences across subsets, being elevated in aPL carriers and PAPS patients compared to HCs (both p < 0.050) and increasing in SAPS (p < 0.010) and SLE patients (p < 0.001). An unsupervised cluster analysis identified three clusters, and correspondence analyses revealed differences in clusters usage across APS subsets (p < 0.001). A network analysis revealed different patterns characterizing different subsets. The associations between IFN-I pathway activation and clinical outcomes differed across APS subsets. Although no differences in gene expression were observed in systemic APS, the network analyses revealed specific gene-gene patterns, and a distinct distribution of the clusters previously identified was noted (p = 0.002).

Conclusion

IFN-I pathway activation is a common hallmark among aPL-positive individuals. Qualitative and quantitative differences across the APS spectrum can be identified, leading to the identification of distinct IFN-I signatures with different clinical values beyond traditional categorization.

Assessing the steroid-sparing effect of biological agents in randomized controlled trials for lupus: a scoping review

Prompt disease control of flares in patients with systemic lupus erythematosus (SLE) is a priority in treatment strategy planning. However, the long-term dosage-related collateral effects of glucocorticoids (GCs) have pushed researchers towards the identification and utilization of novel biological agents that could both induce and maintain low disease activity and remission, especially in the context of lupus nephritis (LN). This scoping review aims at assessing the current evidence of the potential steroid-sparing effect of biologic therapies by reviewing phase II and phase III randomized, placebo-controlled trials involving SLE/LN patients. A scoping review of the literature was carried out in accordance with PRISMA-ScR recommendations. Risk of bias was assessed through the utilization of the Cochrane Collaboration's tool for randomized controlled trials (RCTs). Eight RCTs met the inclusion criteria and were included in this analysis (treatment drug, 7 belimumab; 1 anifrolumab). Four studies showed a definite steroid-sparing effect (treatment drug, 3 belimumab; 1 anifrolumab), while in the remaining four RCTs, the steroid-sparing effect was not observed. When focusing on phase III trials, the overall quality of the studies resulted fair or good considering the risk of bias. However, a degree of heterogeneity of steroid regimen protocol (considering initial dosage, tapering and rescue treatment allowance) was observed. While a growing body of evidence is supporting the safety and efficacy of biological treatment in SLE, the evidence on their steroid-sparing effect remains scattered. Future research needs to pursue the identification of precise SLE clusters of patients who would benefit most from a specific treatment protocol with a definite steroid-sparing effect.

Deciphering the clinical significance of longitudinal antiphospholipid antibody titers

In antiphospholipid syndrome (APS), the risk of clinical manifestations increases with higher titers of antiphospholipid antibodies (aPL). Despite the adoption of aPL titers in the classification approach to aPL-positive subjects, the value of longitudinal monitoring of those titers in the follow-up is still debated, being well studied only in systemic lupus erythematosus (SLE). The literature suggests that the rate of aPL positivity decreases during follow-up in primary APS, estimating that seroconversion occurs in between 8.9 and 59% of patients over time. Negativisation of aPL occurs more frequently in asymptomatic aPL carriers than in patients with full-blown APS as well as in subjects with single aPL positivity or low aPL antibody titers. In patients with SLE, aPL typically behave fluctuating from positive to negative and back again in the course of follow-up. The few studies assessing the longitudinal course of aPL positivity with no associated systemic connective tissue disease reported a progressive decrement of aPL titers over time, in particular of antibodies against β2 glycoprotein I (antiβ2GPI) and cardiolipin (aCL) of IgG isotype. After a thrombotic event, aPL titers tend to decrease, as emerged from cohorts of both primary and secondary APS. Hydroxychloroquine has been identified as the most effective pharmacological agent to reduce aPL titers, with multiple studies demonstrating a parallel reduction in thrombosis rate. This review addresses available evidence on the significance of aPL titer fluctuation from clinical, therapeutic and pathogenic perspectives.

Pediatric Presentation of Antiphospholipid Syndrome: A Review of Recent Literature With Estimation of Local Prevalence

We aimed to investigate the epidemiology, the clinical and laboratory characteristics of the pediatric involvement of antiphospholipid syndrome (APS), by performing a review of the current evidence and reviewing local experience in the Northwest Italy. To achieve this, we performed a detailed literature search to identify articles describing clinical and laboratory characteristics of pediatric APS. In concomitance, we conducted a registry-based study collecting data from the Piedmont and Aosta Valley Rare Disease Registry including pediatric patients diagnosed with APS in the last 11 years. The literature review led to inclusion of six articles with a total of 386 pediatric patients (65% females, 50% with systemic lupus erythematosus (SLE) as concomitant diagnosis). Rates of venous and arterial thrombosis were 57 and 35%, respectively. "Extra-criteria manifestations" included mostly hematologic and neurologic involvement. Almost one-quarter of patients (19%) reported recurrent events and 13% manifested as catastrophic APS. A total of 17 pediatric patients (mean age 15.1 ± 2.8, 76% female) developed APS in the Northwest of Italy. In 29% of cases, SLE was a concomitant diagnosis. Deep vein thrombosis was the most frequent manifestation (28%) followed by catastrophic APS (6%). The estimated prevalence of pediatric APS in Piedmont and Aosta Valley Region is 2.5/100,000 people, whereas the estimated annual incidence is 0.2/100,000 inhabitants. In conclusion, clinical manifestations of pediatric APS seem to be more severe and with a high prevalence of noncriteria manifestations. International efforts are needed to better characterize this condition and to develop new specific diagnostic criteria to avoid missed/delayed diagnosis in children with APS.

2023 ACR/EULAR classification criteria in existing research cohorts: an international study

OBJECTIVE

Assessing the impact of the updated ACR/EULAR APS classification criteria to our research cohort.

METHODS

Consecutive patients who tested persistently positive for at least one aPL in the last three years were enrolled. The first APS Sydney index event was considered and computed for the comparison between Sydney and 2023 APS criteria. When computing the 2023 APS criteria, additional manifestations were also considered.

RESULTS

The cohort comprised 249 patients (185 with APS and 64 aPL carriers according to Sydney criteria). The 185 patients had as first index event VT in 55 cases (29.8%) AT in 63 (34%) and PM in 67 (36.2%). When applying the updated criteria, 90 subjects (48.7%) failed to reach the composite score of the new criteria. The percentage of thrombotic APS per Sydney criteria decreased from 47.3% to 34.9% because of high cardiovascular risk in 23 cases, IgM aPL profile in 6 cases and in 2 patients for both reasons. Patients with PM decreased from 26.9-3.2% (39 cases of recurrent early pregnancy loss and 20 of fetal losses). Consequently, the percentage of aPL carriers increased from 26% to 61%. When looking at the disease evolution at follow-up, 32 additional patients out of 90 (35.6%) fulfilled the new APS criteria, after developing additional clinical manifestation following index event.

CONCLUSION

When applying the new APS criteria to our research cohort, not negligible differences exist in patients' classification. A multidisciplinary approach will be mandatory to assess the impact into research and, ultimately, patient's care of new criteria.

The estimated prevalence of antiphospholipid antibodies and criteria-antiphospholipid syndrome in subjects with renal thrombotic microangiopathy

BACKGROUND

While the prevalence of antiphospholipid antibodies (aPL) in venous and arterial thrombotic events had already been estimated by previous studies, the prevalence of aPL in subjects with Thrombotic Microangiopathy (TMA) is still not fully elucidated. Thus, we conducted a systematic review to estimate the frequency of aPL in subjects with biopsy-proven renal TMA.

METHODS

We conducted in the PubMed database a search for English-language studies investigating the presence of aPL in subjects with biopsy-proven renal TMA from January 1985 to December 2022. Keywords used in the search included: 'antiphospholipid syndrome', 'antiphospholipid antibodies' and 'thrombotic microangiopathy'. Cohorts of HUS patients were excluded due to the risk of over-estimating the prevalence of aPL in these populations. The median frequency for positive aPL including anticardiolipin antibodies (aCL), antibodies against β2-glycoprotein-I (anti-β2GPI) and lupus anticoagulant (LA) was then calculated.

RESULTS

522 articles were identified through the literature search. Six studies, assessing the prevalence of aPL in 211 subjects with renal TMA, were retrieved. The overall aPL prevalence was estimated as 24.4% (range 22-56). The estimated prevalence of aCL (IgG/IgM), anti-β2GPI, (IgG/IgM) and LA was 4.0% (range 3-27), 4.0% (range 3-16) and 18.9% (range 13-25), respectively. APS was diagnosed in 16.3% (range 11-29) of the patients. Of note, a high level of heterogeneity was observed when comparing the reported aPL profiles for each study.

CONCLUSIONS

This comprehensive systematic analysis of studies investigating the prevalence of aPL in renal TMA showed that, despite the high heterogeneity of the included studies, aPL are present in about one case out of four renal-TMA cases.

Complement levels during the first trimester predict disease flare and adverse pregnancy outcomes in systemic lupus erythematosus: A network meta-analysis on 532 pregnancies

BACKGROUND

Complement levels have been proposed as candidate biomarkers of disease activity and obstetric risk in systemic lupus erythematosus (SLE) pregnancies, but their reliability has been questioned due to the physiologic fluctuations of complement during gestation. Thus, this network meta-analysis aimed at assessing the clinical significance of complement fluctuations in lupus pregnant women.

METHODS

Corresponding authors of 19 studies meeting inclusion criteria were invited to contribute with additional data including C3 and C4 levels [before pregnancy, at conception, in every trimester (T) and 3 months after delivery]; data were pooled together in a network meta-analysis.

RESULTS

A total of 532 lupus women from four studies were included in the analysis. In SLE women, C3 and C4 increased progressively during gestation: levels remained stable during T1 and peaked in T2 to decrease in T3. Patients with previous lupus nephritis (LN) and those who experienced flares during pregnancy had significantly lower mean levels of C3 and C4 at all timepoints. The lowest levels of complement were observed, particularly during T1, in patients with LN and gestational flare. Both reduction and the lack of increase of C3 and C4 levels at T1 versus conception were associated with gestational flares, particularly in LN patients. Pregnancies with flare had a statistically significant higher rate of maternal and fetal complications(60% versus 50.3%; p = 0.03).

CONCLUSIONS

Low complement levels, particularly in T1, were associated with a higher frequency of gestational flare. Either reduction or smaller increase of C3 and/or C4 levels, even within normal range, might predict flares especially in early gestation.

Thrombin generation assay and lupus anticoagulant synergically distinguish populations of patients with antiphospholipid antibodies

AIM

To apply thrombin generation assay (TGA) in a large cohort of antiphospholipid antibodies (aPL)-positive patients.

MATERIAL AND METHODS

108 patients were tested with TGA and lupus anticoagulant (LA) testing and divided according to their aPL profile. Briefly, 21 patients were positive for anti-phosphatidylserine (aPS)/prothrombin (PT) IgG/IgM (group1), 29 for anti-ß2-glycoprotein-I (aβ2GPI) and anti-cardiolipin (aCL) IgG/IgM (group2), 31 for aPS/PT, aβ2GPI and aCL IgG/IgM (group3), 27 for aPS/PT and/or aβ2GPI+aCL IgM at low-titres (group4). 31 healthy donors (HDs) and 24 controls treated with vitamin K antagonists (VKA) were included.

RESULTS

The most deranged TGA and LA profiles were observed in tetra-positive patients (group3) that differed significantly to the other groups, thus those with isolated, double or triple aPL-positivity. Moreover, when comparing the TGA profile of all antiphospholipid syndrome (APS) patients, aPL-carriers, HDs and VKA controls, we observed that the aPL+ patients (especially APS) showed a distinctive profile that allowed to distinguish them from the other groups with significantly higher tLag and tPeak, and lower Peak and area under the curve.When focusing on APS clinical manifestations, patients with a high-risk profile (group3) showed significant differences from those presenting low-titres aPL (group 4) regarding the number of venous events (p=0.04), recurrence of any thrombotic event (p=0.01), of arterial events (5 vs 0, p=0.02), the occurrence of TIA (p=0.04), DVT (p=0.02) and, when analysing extracriteria manifestations, of peripheral artery disease (p=0.04).

CONCLUSIONS

TGA seems a valuable approach to stratify aPL+ patients according to their risk profile. The differences among different populations of autoantibodies specificities could be considered a translational validation of the increased thrombotic risk of patients with triple or tetra aPL-positivity.

16th International congress on antiphospholipid antibodies task force report on antiphospholipid syndrome laboratory diagnostics and trends

Classification criteria for antiphospholipid syndrome (APS) require IgG or IgM isotypes of the anticardiolipin (aCL) antibodies, anti-β2 glycoprotein I (anti-β2GPI) antibodies, and/or the lupus anticoagulant (LA) to satisfy the laboratory disease definition. Over the past 20 years, non-criteria antiphospholipid antibodies (aPL) directed to other proteins of the coagulation cascade (i.e. prothrombin and/or phosphatidylserine-prothrombin complex) or to some domains of β2GPI have been proposed. This task force concentrated and reviewed the literature on data including aPS/PT, antibodies to domain 4/5 of β2GPI and the newly described antibodies to protein/HLA-DR complex. In addition, we discussed testing of LA in the 'new' oral anticoagulants' era and the value of triple positivity in the risk assessment of aPL. The conclusions were presented at a special session during the 16th International Congress on aPL, Manchester, UK, September 2019.

Thrombosis and APS: Lessons Learned from Another Black Swan Tale

Antiphospholipid syndrome (APS) is a chronic systemic autoimmune disease characterized by venous, arterial, and microvascular thromboses and/or recurrent pregnancy morbidity, that occur in the persistent presence of antiphospholipid antibodies (aPL). APS can present with a wide range of clinical manifestations often reffered as "extra-criteria". These features, although apparently less common, can severely impact patients' outcome. Here, we report the case of a patient with a newly diagnosed APS. He previously experienced a recurrence of venous thrombosis after discontinuation of anticoagulant therapy in association with cutaneous ulcerations as presenting symptoms. Interestingly, skin lesions did not improve with full anticoagulant treatment. Due to concomitant presence of thrombotic and microvascular involvement, immunomodulatory therapy with steroid pulses followed by intravenous injections of belimumab was started, with progressive and significant amelioration, leading to complete recovery. Following the presentation of the current case report, we highlight the importance of suspecting APS in young patients experiencing unprovoked thrombosis. We also emphasized the critical issue of testing aPL during anticoagulant treatment and focused on the need of aPL retesting in patients with positivity at high titers. We also highlight the double nature of aPL-mediated clinical manifestations. While most patients presented with pure thrombotic complications, one should always remember that APS is an autoimmune-mediated disease, which can benefit from alternative therapeutic approaches beyond anticoagulation.

Safety and efficacy of pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) in patients with glomerular diseases who received rituximab

Background

Patients on B-cell-depleting agents may have a suboptimal response to vaccination, placing them at a higher risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or suffering from a more severe prognosis. Indeed, available data on pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) in subjects with glomerular diseases (GDs) who received rituximab are limited.

Methods

We conducted a prospective study analysing the safety and efficacy of tixagevimab/cilgavimab for pre-exposure prophylaxis in patients with GDs who received rituximab in the previous 12 months. The rates of symptomatic infections and hospitalizations were compared with those for patients with GD treated with rituximab who refused to receive tixagevimab/cilgavimab.

Results

Tixagevimab/cilgavimab was administered to 22 patients (12 females, mean age 58.4 ± 19.6 years) with GD diagnoses including membranous nephropathy, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis and focal segmental glomerulosclerosis. No patient treated with tixagevimab/cilgavimab experienced symptomatic infection with SARS-CoV-2 during the follow-up (mean observation time of follow-up was 112 ± 23 days), while 11 of 28 controls (39.3%) reported a symptomatic infection (P = .0001), requiring hospitalization in 2 cases. Reported adverse events were mild, namely self-limiting headache [4], discomfort at the injection site [3], flu-like symptoms/myalgia [3] and fever [1]. No serious adverse events (e.g. cardiac events, anaphylaxis) were reported.

Conclusion

Pre-exposure prophylaxis with tixagevimab/cilgavimab seems safe and lowered the risk of symptomatic SARS-CoV-2 infection by ≈40% in vaccinated subjects with GD who received anti-CD20 therapy. Possible applications in the subset of patients who need immunosuppressive therapy, especially with rituximab, in a pandemic setting might be envisaged.

New Frontiers in Autoimmune Diagnostics: A Systematic Review on Saliva Testing

(1) Background: Immunological laboratory testing is known to be complex, and it is usually performed in tertiary referral centers. Many criticalities affect diagnostic immunological testing, such as limited availability, the need for specifically trained laboratory staff, and potential difficulties in collecting blood samples, especially in the most vulnerable patients, i.e., the elderly and children. For this reason, the identification of a new feasible and reliable methodology for autoantibody detection is urgently needed. (2) Methods: We designed a systematic review to investigate the available literature on the utilization of saliva samples for immunological testing. (3) Results: A total of 170 articles were identified. Eighteen studies met the inclusion criteria, accounting for 1059 patients and 671 controls. The saliva collection method was mostly represented by passive drooling (11/18, 61%), and the most frequently described methodology for antibody detection was ELISA (12/18, 67%). The analysis included 392 patients with rheumatoid arthritis, 161 with systemic lupus erythematosus, 131 with type 1 diabetes mellitus, 116 with primary biliary cholangitis, 100 with pemphigus vulgaris, 50 with bullous pemphigoids, 49 with Sjogren syndrome, 39 with celiac disease, 10 with primary antiphospholipid syndromes, 8 with undifferentiated connective tissue disease, 2 with systemic sclerosis, and 1 with autoimmune thyroiditis. The majority of the reviewed studies involved adequate controls, and saliva testing allowed for a clear distinction of patients (10/12 studies, 83%). More than half of the papers showed a correlation between saliva and serum results (10/18, 55%) for autoantibody detection, with varying rates of correlation, sensitivity, and specificity. Interestingly, many papers showed a correlation between saliva antibody results and clinical manifestations. (4) Conclusions: Saliva testing might represent an appealing alternative to serum-based testing for autoantibody detection, considering the correspondence with serum testing results and the correlation with clinical manifestations. Nonetheless, standardization of sample collection processing, maintenance, and detection methodology has yet to be fully addressed.

The [Formula: see text] channel of proton-proton scattering in new chiral effective field theory power counting

In this paper, the chiral effective field theory is used to investigate the spin singlet channel [Formula: see text], of proton-proton (pp) scattering according to the new suggested power counting. For this purpose, the pp zero scattering amplitude is reproduced by inserting one pion exchange at leading order (LO) and the Coulomb interaction between protons at next-to-leading order (NLO). This leads to a systematic improvement up to NLO compared to the result obtained from Nijm93 potential model.

Health inequalities and social determinants of health: The role of syndemics in rheumatic disease

A syndemic is the co-existence of two or more health problems (including both social and biological features) that adversely influence each other with negative consequences on disease outcomes and perpetuation of inequalities. The syndemic approach can be applied to better understand the course of rheumatic musculoskeletal diseases (RMD) involving the study of adverse biological pathways and social determinants of health (SDH) all under the same framework. Identifying if a syndemic exists within RMDs may include investigating the synergic interactions between comorbidity (e.g., diabetes, obesity, chronic kidney diseases) and the concomitant of other adverse conditions (e.g., drug non-adherence, substance abuse), along with SDHs such as low household income, unemployment, low education, limited access to health care, as well as racial/ethnic discrimination. For decades, the understanding of RMDs progression has been based on causality, rather than investigating the kaleidoscopic web of connections that can potentially influence a disease course. The co-existence of health burdens in vulnerable populations, including those with RMD, specifically in certain socioeconomic groups, calls for new ways and strategies of thinking to improve our understanding of risk factors and co-morbidities to offer tailored interventions for clinical medicine and public health policy.

Chasing the Zebra: a case of membranous-like Glomerulopathy with SSA/RO52 deposits and no overt connective tissue disease

BACKGROUND

The nature of the deposits in immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits (MGMID) remains still to be elucidated.

CASE PRESENTATION

We present a case of 33-year-old woman developing a continuous asymptomatic proteinuria (0.8-1 g/24 h) with no overt connective tissue diseases. She tested positive at high titers for SSA antibodies (Ro52 838 UI/mL, Ro60 2716 UI/mL) and at the kidney biopsy histological findings were compatible with an immune-mediated glomerulonephritis with a membranous pattern and masked IgG-Kappa deposits. Also, we demonstrated a positive immunohistochemistry staining for anti-Ro52-SSA antibodies, with a granular positivity in mesangium and along rare glomerular capillaries. To date, only one case of a patient with overt diagnosis of Sjögren's syndrome with MGMID has been described but a pathogenic role for SSA and SSB antibodies has never been proven.

CONCLUSIONS

In this case, we described for the first time by immunohistochemistry a Ro52+ granular positivity in the mesangium and glomerular capillaries, potentially paving the way for a better understanding of MGMID.

Finding the Needle in the Haystack: Serological and Urinary Biomarkers in Behçet's Disease: A Systematic Review

Urinary and serological markers play an essential role in the diagnostic process of autoimmune diseases. However, to date, specific and reliable biomarkers for diagnosing Behçet's disease (BD) are still lacking, negatively affecting the management of these patients. To analyze the currently available literature on serological and urinary BD biomarkers investigated in the last 25 years, we performed a systematic literature review using the Population, Intervention, Comparison, and Outcomes (PICO) strategy. One hundred eleven studies met the eligibility criteria (6301 BD patients, 5163 controls). Most of them were retrospective, while five (5%) were prospective. One hundred ten studies (99%) investigated serological biomarkers and only two (2%) focused on urinary biomarkers. One hundred three studies (93%) explored the diagnostic potential of the biomolecules, whereas sixty-two (56%) tested their effect on disease activity monitoring. Most articles reported an increase in inflammatory markers and pro-oxidant molecules, with a decrease in antioxidants. Promising results have been shown by the omics sciences, offering a more holistic approach. Despite the vast number of investigated markers, existing evidence indicates a persistent gap in BD diagnostic/prognostic indices. While new steps have been taken in the direction of pathogenesis and disease monitoring, international efforts for the search of a diagnostic marker for BD are still needed.

The role of bacteria and viruses in Behçet syndrome: Should we move towards new paradigms?

The etiological complexity of Behçet syndrome (BS), an immune-mediated rare form of vasculitis characterized by multi-organ involvement, is still elusive due to an incomplete understanding of the synergy between genetic susceptibility, environmental triggers, and an abnormal immune response. Long-standing theories regarding the origins of BS include the involvement of infectious organisms supporting an aberrant immunological response through different mechanisms, including molecular mimicry. Additionally, it has been demonstrated that the BS phenotypes are linked to oral and gut microbiome dysbiosis, which is a dynamic reservoir of millions of microbes containing proteins and metabolites that can mimic the autoantigens. Infections, including viral pathogens, could potentially trigger the inflammation and symptoms of BS. In this review, we aim to describe the available evidence on the cross-talk between BS and infections in order to discuss potential clinical implications and possible therapeutic targets.

"How we treat" clinical dilemmas in antiphospholipid syndrome: A case-based approach

Antiphospholipid syndrome (APS) is an autoimmune condition characterized by thrombosis (arterial, venous, and microvascular) and/or pregnancy morbidity occurring in subjects persistently positive for antiphospholipid antibodies (aPL). While the APS classification criteria are being currently updated to improve homogeneity in clinical research, patients who seek medical treatment often have a variety of laboratory and clinical characteristics that may not completely fulfill the classification criteria for overt APS. Those cases might represent a challenge in terms of treatment and overall management. We aim to present a collection of challenging scenarios of patients who tested positive for aPL and to discuss available literature to guide the therapeutic strategies.

Clinical-pathological characteristics of renal injuries identify different clusters in patients with antiphospholipid antibodies

Introduction

Significant heterogeneity still exists in the nomenclature of renal involvement in antiphospholipid syndrome (APS).

Methods

We applied a hierarchical cluster analysis to determine subgroups of patients according to clinical, laboratory, and renal histology characteristics in a cohort of subjects with confirmed antiphospholipid antibodies (aPL) positivity and biopsy proven aPL-related renal injuries. Kidney outcomes were then assessed at 12 months.

Results

A total of 123 aPL-positive patients were included in the study (101 [82%] female, 109 [88.6%] with systemic lupus erythematosus [SLE], 14 (11.4%) with primary APS [PAPS]). Three clusters were identified. Twenty-three patients (18.7%) were included in the first cluster (cluster 1), characterized by a higher prevalence of glomerular capillary and arteriolar thrombi and fragmented red blood cells in the subendothelial space. Cluster 2 included 33 patients (26.8%) and showed a higher prevalence of fibromyointimal proliferative lesions as seen in hyperplastic vasculopathy. Cluster 3 was the largest (67 patients, mainly with SLE) and was characterized by higher prevalence of subendothelial edema, of both glomerular capillaries and arterioles.

Conclusion

Three different clusters of patients with aPL and renal injuries emerged from our study as follows: the first, with the worst renal prognosis, was associated with features of thrombotic microangiopathy (TMA), thrombosis, triple aPL positivity and higher adjusted Global APS Score (aGAPSS) values; the second, characterized by hyperplastic vasculopathy with an intermediate prognosis, was seen more frequently in patients with cerebrovascular manifestations; and the third, more benign in terms of outcomes and with no overt association with thrombotic features, was characterized by endothelial swelling in concomitant lupus nephritis (LN).

Serum Biomarkers of Renal Fibrosis: A Systematic Review

Chronic kidney disease (CKD) is a widely diffuse pathological condition which deeply impacts upon an affected patient's quality of life and its worldwide rate is predicted to further rise. The main biological mechanism underlying CKD is renal fibrosis, a non-reversible process representing, for the affected system, a point of no return of tissue damage and dysfunction, deeply reducing the possible therapeutic strategies at the disposal of physicians. The best tool clinicians can use to address the extent of renal fibrosis at any level (glomeruli, tubule-interstitium, vasculature) is kidney biopsy that, despite its overall safety, remains an invasive procedure showing some shortcomings. Thus, the identification of novel non-invasive renal fibrosis biomarkers would be of fundamental importance. Here, when systematically reviewing the available evidence on serological biomarkers associated with renal fibrosis evaluated in patients suffering from CKD in the last five years, we found that despite the presence of several promising biomarkers, the level of observed evidence is still very scattered. Probably, the use of multiple measures capable of addressing different aspects involved in this condition would be the most suitable way to capture the high complexity characterizing the renal fibrotic process, having consequently a great impact on clinical practice by maximizing prevention, diagnosis, and management.

Renal involvement as a unique manifestation of hemophagocytic syndrome

Renal-limited hemophagocytic syndrome (HPS) is a rare clinical setting characterized by abnormal activation of the immune system. Fever associated with pancytopenia, hepatosplenomegaly with liver dysfunction, and hypofibrinogenemia are usually observed in HPS. From a histological level, the presence of non-malignant macrophages infiltrating bone marrow and organs represents the hallmark of this condition. Non-malignant macrophages are associated with phagocytizing activities involving other blood cells. While primary HPS is usually associated with inherited dysregulation of the immune system, secondary HPS usually occurs in the context of infection or is linked to a neoplastic process. Clinical presentation varies and can potentially lead to life-threatening settings. While renal involvement has frequently been reported, however, detailed descriptions of the kidney manifestations of HPS are lacking. More critically, the diagnosis of HPS is rarely supported by renal biopsy specimens. We report four rare cases of biopsy-proven renal-limited HPS in patients presenting with acute kidney injury (AKI). The available evidence on this topic is critically discussed in light of the possible emergence of an autonomous entity characterized by an isolated kidney involvement.

Circulating immune-complexes of IgG/IgM bound to B2-glycoprotein-I associated with complement consumption and thrombocytopenia in antiphospholipid syndrome

Background

Antiphospholipid syndrome (APS) is a multisystemic autoimmune disorder characterized by thrombotic events and/or gestational morbidity in patients with antiphospholipid antibodies (aPL). In a previous single center study, APS-related clinical manifestations that were not included in the classification criteria (livedo reticularis, thrombocytopenia, leukopenia) were associated with the presence of circulating immune-complexes (CIC) formed by beta-2-glycoprotein-I (B2GP1) and anti-B2GP1 antibodies (B2-CIC). We have performed a multicenter study on APS features associated with the presence of B2-CIC.

Methods

A multicenter, cross-sectional and observational study was conducted on 303 patients recruited from six European hospitals who fulfilled APS classification criteria: 165 patients had primary APS and 138 APS associated with other systemic autoimmune diseases (mainly systemic lupus erythematosus, N=112). Prevalence of B2-CIC (IgG/IgM isotypes) and its association with clinical manifestations and biomarkers related to the disease activity were evaluated.

Results

B2-CIC prevalence in APS patients was 39.3%. B2-CIC-positive patients with thrombotic APS presented a higher incidence of thrombocytopenia (OR: 2.32, p=0.007), heart valve thickening and dysfunction (OR: 9.06, p=0.015) and triple aPL positivity (OR: 1.83, p=0.027), as well as lower levels of C3, C4 and platelets (p-values: <0.001, <0.001 and 0.001) compared to B2-CIC-negative patients. B2-CIC of IgM isotype were significantly more prevalent in gestational than thrombotic APS.

Conclusions

Patients with thrombotic events and positive for B2-CIC had lower platelet count and complement levels than those who were negative, suggesting a greater degree of platelet activation.

Detection of Autoantibodies in Saliva as New Avenue for the Diagnosis and Management of Autoimmune Patients

(1) Background: Autoimmune diseases are characterized by autoantibodies directed to a large number of antigenic targets and are measured using serum as sample matrix. Although serum is a very common specimen type, it comes with certain drawbacks. Most importantly, it depends on venous puncture and requires medical personnel for sampling. This is of particular importance in light of the limited healthcare access of patients with autoimmune diseases during the COVID-19 pandemic. Consequently, alternative sample matrices are being explored for the measurement of autoantibodies. Our study aimed to establish the feasibility of measuring autoantibodies in saliva samples using a novel and highly sensitive method for the detection of autoantibodies. (2) Methods: A total of 48 serum/saliva pairs were collected and tested using a novel particle-based multi-analyte technology (PMAT) system for the presence of a wide range of autoantibodies. (3) Results: A high level of correlation was observed between the results obtained with serum and saliva (Spearman’s rho = 0.725). Study participants clearly preferred saliva over serum sampling as part of the usability assessment. (4) Conclusions: Saliva represents a promising alternative sample matrix for the detection of autoantibodies. The usability study showed a clear preference of saliva over serum as a sample matrix.

POS1448 DICKKOPF HOMOLOG 3 (DKK3) AS A PROGNOSTIC MARKER IN LUPUS NEPHRITIS: A PROSPECTIVE MONOCENTRIC EXPERIENCE

Background

Lupus nephritis (LN) is a major cause of mortality/morbidity in patients affected by systemic lupus erythematosus (SLE). Reliable prognostic markers, especially related to the degree of interstitial fibrosis, are still lacking and renal biopsy still represents the gold standard. Recent data suggests a role of Dickkopf homolog 3 (DKK3) as a marker of tissue fibrosis in different diseases, however its role in autoimmune diseases still needs to be elucidated.

Objectives

To investigate DKK3 serum levels in SLE patients with and without LN, assessing its changes in relation to kidney function, flares and interstitial renal fibrosis, as well as its association with the IFN signature.

Methods

132 SLE patients, 57 of whom diagnosed with LN, were included in this study, as well as 50 healthy donors. DKK3 and Myxovirus resistance protein 1 (MxA) were measured in serum samples, using enzyme-linked immunosorbent assays. Biopsies were evaluated for glomerular involvement, interstitial renal fibrosis and tubular atrophy according to 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification and the revised 2018 version. Patients were followed-up for at least 36 months.

Results

DKK3 serum levels were significantly higher in patients with biopsy-proven LN when compared to those without (median[min-max]: 215ng/ml [81-341] vs 21.1ng/ml [1-69], p<0.01). When focusing on patients with LN, DKK3 levels resulted to be associated with the presence of chronic kidney disease (OR: 4.31[C.I. 2.01-6.61] per DKK3 doubling, p<0.01), higher chronicity index at biopsy (OR: 1.75[C.I. 1.59-2.13] per DKK3 doubling, p<0.01) and flares rate (OR: 1.45[C.I. 1.1-5.71] per DKK3 doubling, p<0.044). DKK3 levels correlated with the IFN signature as expressed by MxA (correlation coefficient: 0.71, p<0.037).

Conclusion

While kidney biopsy remains the gold standard for diagnostic and prognostic assessment in LN, DKK3 could represent an additional useful prognostic tool to monitor SLE patients and eventually to guide therapeutic choices.

Disclosure of Interests

None declared

AB1433 ASSESSING THE CARDIOVASCULAR RISK IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: QRISK AND GAPSS SCORES HEAD TO HEAD

Background

Cardiovascular diseases (CVDs) represent one of the most life-threatening conditions that can affect SLE patients. Assessing the potential CVD risk of these patients is still a challenge and an important aspect in the clinical practice. Recently the QRISK3 score has attempted to encompass for SLE augmented thrombotic risk by adding items (such as corticosteroid use) that are missing in traditional CVD risk scores.

Objectives

To apply and compare the QRISK3 and the adjusted Global AntiPhospholipid Syndrome Score (aGAPSS), a validated score to assess CVD and overall thrombotic risk in aPL positive patients, in a cohort of SLE patients with and without a concomitant diagnosis of APS.

Methods

25-85 years old patients attending San Giovanni Bosco Hospital (Turin) during a period of 6 months (Sep 2019 – Feb 2020) with a confirmed diagnosis of SLE (2019 ACR/EULAR classification criteria) and/or a diagnosis of SAPS (Sidney criteria) were included in the study. QRISK3 has been calculated using the official online calculator (https://qrisk.org/). aGAPSS has been calculated using the validated point values based on aPL profile and independent risk factors: aCL=5, aβ2GPI=4, LA=4, aPS/PT=3, hyperlipidemia=3, hypertension=1.

Results

The analysis included a cohort of 142 SLE patients: 34 SAPS (23.9%) and 108 SLE patients without APS (76.1%), with a mean age of 48±12.9 (SAPS=51.6±12.8/SLE without APS=46.9±12.8). Table 1 summarizes patients characteristics. When focusing on cerebrovascular/coronary events, we found a statistical significance with respect to aGAPSS (pt with event =10.1±6.2 vs pt without event=5.8±6.1; p=0.007), but not QRISK3. Also, a significant association was observed between the occurrence of these events and high risk aGAPSS: p=0.03 for aGAPSS≥8, p=0.01 for aGAPSS ≥9, p=0.008 for aGAPSS ≥10. Moreover, the aGAPSS but not the QRISK3 resulted to strongly correlate with the occurrence of any thrombotic event, both at the uni- and multivariate analysis (univariate: pt with event =8.17±7.1 vs pt without event= 5.41±5.6; p=0.012 / multivariate: p=0.009). The same was observed for gender: male gender resulted to correlate with the occurrence of any thrombotic event at both uni- and multivariate analysis (p=0.017 and p=0.03, respectively). Finally, when focusing on aPL profile, regardless the diagnosis, we found a statistical significance only with respect to aGAPSS (aPL+ =9.6±6.3 vs aPL- = 4.1±5.1; p<0.001).

Table 1.

Demographic and clinical features of the patients included in the study.

Conclusion

By encompassing factors that can contribute to CVD development in complex/autoimmune diseases, QRISK3 has been shown to be more accurate than traditional risk score in predicting SLE patients CVD risk. Nonetheless, the results of this analysis showed how the aGAPSS still seems to be the most valuable tool for this purpose when facing SLE patients. Moreover, the significance observed when focusing on patients’ aPL profile, suggests that adding this item to the QRISK3 could be a useful strategy to improve the management.

References

[1]Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. BMJ. 2017 May 23;357:j2099. doi: 10.1136/bmj.j2099.

[2]Radin M, Sciascia S, Erkan D, et al. The adjusted global antiphospholipid syndrome score (aGAPSS) and the risk of recurrent thrombosis: Results from the APS ACTION cohort. Semin Arthritis Rheum. 2019 Dec;49(3):464-468. doi: 10.1016/j.semarthrit.2019.04.009.

Disclosure of Interests

None declared

AB1283 HOW TO COUNSEL A WOMAN WITH BEHÇET’S DISEASE: RESULTS FROM A MONOCENTRIC COHORT OF WOMEN DIAGNOSED DURING CHILDBEARING AGE

Background

Patients with autoimmune diseases require appropriate pregnancy counceling, as their disease can negatively impact both maternal and fetal outcomes. In regards to Behçet’s disease (BD), although commonly diagnosed during the childbearing age, only few studies focused on its impact on gestation, with contradictory results.

Objectives

We aimed to collect new data on BD and its impact on pregnancy by designing a single-center cohort study, reporting the pregnancy and maternal outcomes in BD patients attending the Multidisciplinary Centre for Immunopathology and Rare Diseases at Giovanni Bosco Hospital (Turin, Italy).

Methods

We retrospectively included 26 women diagnosed with BD followed at our center. Out of 26 patients, data from 33 pregnancies in 16 women were collected. Ten patients were never pregnant. Table 1 shows the demographical and clinical characteristics and the pregnancy outcomes of the enrolled patients.

Table 1.

Clinical characteristics and pregnancy outcome of the Behçet’s disease patients enrolled in the study.

Patients(tot=31)Nulliparous; n (%)10/26 (38,46%)Primigravida; n (%)16/26 (61,54%)DemographicsAge at BD diagnosis; mean± S.D.40,56±11,42Age at first pregnancy; mean ± S:D.24,86 ± 6,56Clinical characteristics of BDOral ulcers; n (%)26/26 (100 %)Genital ulcers; n (%)21/26 (80,76%)Folliculitis; n (%)15/26 (57,69%)Erythema nodosum; n (%)6/26 (23,08%)Ocular manifestations; n (%)11/26 (42,31%)HLA B-51+; n (%)13/26 (50%)Pregnancy outcomeRate of live births; n (%)27/33 (81,81%)Any complications; n (%)12/33(36,36%) Early miscarriage before 10 weeks of gestation; n (%)6/33 (18,18%) Gestational diabetes; n (%)3/33 (9,09%) Placental abruption; n (%)2/33 (6,06%) Vaginal bleeding before 20 weeks of gestation; n (%)1/33 (3,03%)Worsening of oral and genital ulcerations; n (%) *2/ 11 (18%)

* This information was available only for 11/33 pregnancies.

BD – Behçet’s disease

S.D – Standard deviation

Results

All included patients fulfilled the international criteria for BD (1), with a median age at the time of diagnosis of BD and first pregnancy of 40,56±11,42 and 24,86±6,86 respectively. The frequency of clinical manifestations was oral ulcers (100%), genital ulcers (80,76%), erythema nodosum (23,08%), folliculitis (57,69%), ocular manifestations (42,31%) and HLA B-51+ (50%), respectively.

The overall rate of live births was 81,81% (27/33). Twelve women experienced pregnancy complications (36,36%), in particular we report one case of vaginal bleeding before 20 weeks of gestation, six miscarriages before the 10th week of gestation, three cases of gestational diabetes and two placental abruptions. Among the analyzed pregnancies, a worsening of oral and genital ulcerations was observed in the 18% of them, while in the remaining cases a subjective amelioration of aphtosis and other concurrent symptoms was reported by the patients. No systemic flare, worsening of ocular complications and VTE was reported during pregnancy and in the post-partum period.

Conclusion

The results of our study highlight an overall favorable rate of life births in BD women and a positive rate of disease remission in pregnancy. Currently, the studies focusing on pregnancy outcomes in BD are scarce, however it might be appropriate to give a specialized counseling to a BD woman planning for a pregnancy and follow these patients with a multidisciplinary approach.

References

[1]Chan T-M, Meng &, Chiou J, Kuo C-F. Adverse pregnancy outcomes in women with Behçet’s disease: population-based registry linkage study in Taiwan. Available from: https://doi.org/10.1007/s10067-021-05688-6

[2]Davatchi F, Assaad-Khalil S, Calamia KT, Crook JE, Sadeghi-Abdollahi B, Schirmer M, et al. The International Criteria for Behçet’s Disease (ICBD): A collaborative study of 27 countries on the sensitivity and specificity of the new criteria. J Eur Acad Dermatology Venereol [Internet]. 2014 Mar [cited 2021 May 1];28(3):338–47. Available from: https://pubmed.ncbi.nlm.nih.gov/23441863

Disclosure of Interests

None declared

POS0507 TAILORING ORAL THERAPY IN RHEUMATOID ARTHRITIS: THE TuTOR APP

Background

Medication non-adherence has a significant impact on the health and well-being of individuals with chronic diseases. Indeed, with respect to important risk factors of Rheumatoid Arthritis (RA), such as cardiovascular risk factors, it is known that up to 50% of patients will stop taking medication for these conditions during the first year of prescription [1].

Objectives

To support the management of RA patients treated with Tofacitinib, we designed the TuTOR (Tailoring Tofacitinib Oral therapy in Rheumatoid arthritis) Mobile App.

Methods

A prospective-controlled study evaluated the impact of TuTOR App on medical adherence in 20 RA patients, that began treatment with Tofacitinib jointly with the App. We used a crossover design alternating Paper-Diary and TuTOR App, with monthly clinical assessments.

Results

Seventeen patients with RA (mean age at inclusion 59±13yrs; 88% females) the study. A statistically significant decrease of DAS28 was observed since the first month of therapy with Tofacitinib (mean DAS28 at baseline 3.9±1 vs. 1° month 3.1±1, p=0.0016). Similarly, Numerical Rating Scale(NRS) of perceived activity of disease (5.8±2.1 vs.3.7±2.5, p=0.02), and subjective fatigue (6.1±2.3 vs 4.3±2.6; p=0.01) progressively decreased. No differences were reported in DAS28 and in all the NRS between the use of the TuTOR App and the Paper-Diary. A significant decrease was observed also in HAQ during the follow-up (baseline 1.38±1.11 vs.six months 0.83±0.9; p=0.01).

Most of the patients (82%) when filling out the self-reporting questionnaires preferred the TuTOR App in helping them to remember to take the pills. Further 82% of patients used the TuTOR App regularly (vs.53% Paper-Diary) and 76% of patients would use it in the future (vs.53% Paper-Diary). Three patients suspended the therapy with Tofacitinib due to gastrointestinal intolerance.

Conclusion

Both digital- and paper-devices can help maximize the adherence to therapy, leading to an improvement in disease’s activity, highlighting the need of supports for medication adherence.

References

[1]BJ van den B, HE Z, CH van den E. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert Rev Clin Immunol 2012;8:337–351. Available at: https://pubmed.ncbi.nlm.nih.gov/22607180/. Accessed July 13, 2021.

Table 1.

Baseline demographic and clinical characteristics of the patients enrolled in the study, who completed follow-up. RA – Rheumatoid Arthritis

Patients with RA(N=17)DEMOGRAPHICSAge (mean ± S.D.)59,4 ± 13,5Sex (n; %)M (2; 11,8), F (15; 88,2)Etnicity (caucasian; n; %)16; 94Etnicity (Hispanic; n; %)1; 6CLINICAL CHARACTERISTICSAge at diagnosis (mean ± S.D.)44,7±14,47Follow-up length (years; mean ± S.D.)6,33± 5,17Positive Rheumatoid Factor (n; %)17; 100Positive Anti-Cyclic citrullinated peptides (n;%)15; 88.2Structural articular damage at radiography (n; %)11; 7Figure 1.

Decrease of disease activity assessed by DAS28 in the paper-diary and TuTOR App groups.

Disclosure of Interests

Massimo Radin Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Marta Arbrile: None declared, Irene Cecchi Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Alice Barinotti: None declared, Simone Baldovino: None declared, Elisa Menegatti: None declared, Daniela Rossi Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Savino Sciascia Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer)., Dario Roccatello Grant/research support from: The study is supported by the Investigator-Initiated Research Studies Grant—CREARE (Pfizer).

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

POS0092 HETEROGENEITY OF THE TYPE I INTERFERON SIGNATURE AMONG ANTIPHOSPHOLIPID SYNDROME PATIENTS: A CLUSTER AND CORRESPONDENCE ANALYSIS APPROACH

Background

Type I Interferons (IFN) are central players in the pathogenesis, disease activity and evolution of several autoimmune conditions. To date, a limited number of evidences is available on the specific role of IFN activation in antiphospholipid antibodies (aPL) positive patients, including aPL carriers, primary antiphospholipid syndrome (PAPS) and those APS subjects who presented with an associated autoimmune disease (secondary APS, SAPS), such as systemic lupus erythematosus (SLE).

Objectives

The aim of this study was to evaluate the differential expression of IFN stimulated genes (ISG) among different subsets of aPL positive subjects and SLE patients.

Methods

For the purpose of the study, a total of 112 patients attending the San Giovanni Bosco Hospital (Turin, Italy) were enrolled, including 31 PAPS, 25 SAPS, 27 SLE patients without aPL, 29 aPL carriers (mean age 48.3±13.3 years, 76% female)1,2. Nineteen subjects were also recruited as healthy controls (HCs). Complete demographic, clinical, and laboratory data were collected at the time of the inclusion. Gene expression was evaluated by RT-PCR in whole blood for the following genes: IFI6, IFI44, IFI44L, MX1,IFI27, OAS1 and RSAD2. Normalized gene expression levels (Z-scores) were averaged into a global IFN signature (IFN score). Differences were measured by Kruskal-Wallis tests and associations among genes were studied by cluster and correspondence analyses. Correlations among genes were plotted by network analyses.

Results

An overall activation of ISG was noted across APS subsets, but certain differences were noted among genes. Whereas some ISG were already upregulated in the aPL positive group compared to HC (IFI44, IFI44L, MX1, IFI27, OAS1 and RSAD2, all p<0.050), other ISG were only in increased SLE (IFI6), MX1 differed between SLE and SAPS, and IFI27 and OAS1 showed differences between PAPS and SAPS. The composite IFN score revealed quantitative differences in the IFN pathway activation across APS subsets, being elevated in aPL carriers/PAPS groups compared to HCs (both p<0.050) and increasing in SAPS (p<0.010) and SLE (p<0.001) groups. Network analyses (Figure 1A) revealed qualitative differences in the gene-gene correlation networks: (i) weaker structures were found in HCs and aPL carriers, compared to stronger and higher-degree networks in SAPS and SLE groups; and (ii) the influence of each node was different across groups. Unsupervised cluster analysis identified 3 clusters (I to III) based on ISG patterns (Figure 1B). Clusters usage differed among APS subsets, thus correlating clinical status (Figure 1C). Distinct groups of ISG positively correlate to aPS/PT IgG titre in aPL carriers and PAPS groups (all rho>0.500), whereas no associations were retrieved in SAPS or SLE. No associations with previous thrombotic events were observed in any subset, although IFN composite score and several ISG correlate with the number of thrombotic recurrences under anticoagulation (all rho>0.400). No associations with GAPSS were observed.

Figure 1.

Conclusion

An overall IFN pathway activation has been observed in aPL positive patients and across all APS subsets. Qualitative and quantitative differences across the APS spectrum can be identified, leading to the identification of distinct IFN signatures with different clinical value.

References

[1]Miyakis S, et al. J Thromb Haemost (2006). 2. Aringer M, et al. Arthritis Rheumatol (2019).

Disclosure of Interests

None declared

AB0458 DISEASE ACTIVITY AT CONCEPTION PREDICTS LUPUS FLARE UP TO 2 YEARS AFTER BIRTH: A MULTICENTRE LONG TERM FOLLOW-UP STUDY

Background

Systemic lupus erythematosus (SLE) often affects women in their childbearing years, and pregnancy may affect SLE disease activity during pregnancy and post-partum (1,2). Limited data assessing the likelihood and characteristics of SLE activity in an extended time period post-partum which may be relevant as patients may wish further pregnancies exist.

Objectives

To assess predicting factors that might influence SLE disease activity in women in an extended follow-up period of 2 years after giving birth and clinical assessment every three months.

Methods

The study was design as an international retrospective, data-driven case collection study, enrolling 119 women with a first birth and with a strictly monitored follow-up period of 2 years.

Results

Table 1 shows pregnancy outcomes of all pregnancies. When considering disease manifestations, joint involvement was present in 80% of patients, acute cutaneous in 64%, haematological in 54%and renal in 41%; 75% of patients were positive for anti-dsDNA, 49% for anti-ENA and 37% for anti-Ro/SSA positive. The mean SLE disease activity index 2000(SLEDAI-2k) at diagnosis was 13.5±6.8 and at first birth was 2.8±4.4.

Table 1.

Pregnancy outcomes of all pregnancies and relative breastfeeding data

Pregnancy CharacteristicsAll (214)%OutcomesLive births16979Miscarriages3717.3Stillbirths83.7Maternal and Foetal ComplicationsPrematurity3918.2Pre-eclampsia2310.7HELLP syndrome41.9Placental Infarction125.6Breastfeeding (all pregnancies)Any breastfeeding (n, %)10964.5*Exclusive breastfeeding (n, %)8751.5*Breastfeeding (after first birth)Any breastfeeding (n, %)8773.1**Any breastfeeding duration (months) (m±sd)10.29±10.04Exclusive breastfeeding*** (n, %)6252.1**Exclusive breastfeeding*** duration (months) (m±sd)6.07±6

*Percentages are calculated considering viable babies (total= 169)

**Percentages are calculated considering first birth (total= 119)

***Exclusive breastfeeding was defined as feeding infants only breast milk

At follow-up, 51.3% of patients had at least one flare after a mean time after birth of 9±6.3 months(mean flare per patient 0.94±1.1). The most frequent flare manifestations were joint involvement(48%), followed by renal(33%), cutaneous(28%) and haematologic(20%).

Patients with remission of disease(SLEDAI-2K=0; no clinical or laboratory manifestations of SLE) at conception had significantly lower rates of flares than those not in remission (18/49–37% vs. 43/70–61%;p=0.008) (Figure 1).

Figure 1.

Flare proportion: Survival Curve based on remission status at conception of the patients included in the study.

Patients who experienced a flare during pregnancy (17 patients), when compared to those who did not, had higher rates of flares during follow-up (76% vs. 47%, respectively, p=0.019), lower time for first flare (4.4±2.3 months vs. 10.3±6.5, respectively, p<0.001), lower rate of remission of disease at conception (12% vs. 46%, respectively, p<0.001), lower rates of SLEDAI 2K at conception (5.9±5.6 vs. 2.3±4, respectively, p<0.001) and lower rates of exclusive breastfeeding (24% vs. 57%, respectively, p=0.009).

Remission of disease and flares during pregnancy remained significantly associated with the development of flares during follow-up after multivariate analysis.

Conclusion

Remission at conception can influence SLE disease positively, even at long-term. Planned pregnancy counseling is fundamental when managing SLE patients.

References

[1]Tincani A, Nalli C, Khizroeva J, Bitsadze V, Lojacono A, Andreoli L, et al. Autoimmune diseases and pregnancy. Best Pract Res Clin Endocrinol Metab 2019;33.

[2]Clowse MEB, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum 2005;52:514–521.

Disclosure of Interests

None declared

Dickkopf Homolog 3 (DKK3) as a Prognostic Marker in Lupus Nephritis: A Prospective Monocentric Experience

Background: The gold standard for diagnosis of lupus nephritis (LN) is still represented by renal biopsy, and serological prognostic biomarkers are still lacking. Dickkopf homolog-3 (DKK3) has been suggested as a marker of tissue fibrosis in different conditions; however, its role in autoimmune diseases needs to be elucidated. Here, we investigated the prognostic role of DKK3 in systemic lupus erythematosus (SLE) patients with and without LN, assessing its changes in relation to kidney function, flares, and interstitial fibrosis. Methods: Overall, 132 SLE patients (57 with LN) were included and prospectively followed up for at least 36 months. DKK3 was measured in serum at baseline. Biopsies were evaluated for glomerular involvement, interstitial fibrosis, and tubular atrophy. Results: Patients with biopsy-proven LN had significantly higher levels of DKK3 than those without (median [min−max]: 215 ng/mL [81−341] vs. 21.1 ng/mL [1−69], p < 0.01). DKK3 levels were associated with prevalent chronic kidney diseases (OR: 4.31 [C.I. 2.01−6.61] per DKK3 doubling, p < 0.01), higher chronicity index at biopsy (1.75 [1.51−2.77] per DKK3 doubling, p < 0.01), and flares rate (OR: 1.45 [C.I. 1.1−5.71] per DKK3 doubling, p < 0.044). Conclusions: While kidney biopsy still represents the gold standard for diagnostic and prognostic assessment in LN, DKK3 could represent an additional prognostic tool to monitor SLE patients and guide therapeutic choices.

OP0002 LOW COMPLEMENT LEVELS IN THE FIRST TRIMESTER PREDICT DISEASE FLARE IN SLE PREGNANCY: A NETWORK META-ANALYSIS ON 532 PATIENTS

Background

The complement system is a key-player in the pathogenesis of systemic lupus erythematosus (SLE); its decreases correlate with disease activity and precedes flare. Since synthesis of complement proteins increase during gestational course, it is debated whether complement levels exert a prognostic role in pregnant women with SLE.

Objectives

We performed a network meta-analysis to assess the prognostic role of complement in pregnant SLE women, to evaluate the possible role of complement fluctuations during pregnancies.

Methods

Data from available prospective studies (Jan 2002-Dec 2020) investigating pregnancies in at least 50 SLE patients, excluding miscarriages before 12 weeks, were pooled together. After a systematic literature search, corresponding authors of 19 retrieved studies meeting inclusion criteria were invited to contribute with additional data, including complement levels [6 months before pregnancy, at conception, 1st trimester (T1), 2nd trimester (T2), 3rd trimester (T3) and 3 months after delivery].

Results

A total of 532 SLE women from four eligible studies were included in the analysis [1-4]. Lupus Nephritis (LN) was diagnosed in 237 patients (44.5%) and Antiphospholipid Syndrome in 68 (12.8%). A total of 170 patients (32%) experienced a flare during pregnancy, defined as need of new Immunosuppressants or increase of prednisone > 9 mg/day.

Patients with LN had significantly lower mean levels of complement (C3 at conception; C3 at T1; C3 after 3 months of delivery; C4 at all timepoints except for C4 at T3). SLE patients who experienced flares during pregnancy had significantly lower mean levels of complement (all timepoints for both C3 and C4). Table 1 shows the mean C3 and C4 levels in different timepoints according to diagnosis and flare during pregnancy. The lowest levels of complement were observed in patients with a concomitant diagnosis of LN and presence of flare, particularly during the T1 (Figure 1). Nevertheless, both in LN and flare groups the lowest levels of C3 and C4 were documented at T1.

Table 1.

Complement levels at the different timepoints according to diagnosis or presence of flare (bold results are statistically significant)

Patients with LN(237)Patientswithout LN (295)Patients with Flare (170)Patients without Flare (362)Patients with LN and Flare (73)Patients with LN and without Flare (164)C3 6 months before pregnancy (mean ±SD)90.7±18.694.1±25.285.6±19.195.6±23.375 ±17.999.1±12.5C3 conception (mean ±SD)96.1±13.991.1±1395.3±19.591.8±9.197 ±21.695.6±7.1C3 1sttrimester (mean ±SD)84.6±32.298.4±14.178.3±22.8100.5±20.756.8 ±19.997.2±28.7C3 2ndtrimester (mean ±SD)108.5±21108.3±12.294.16±13.4115.7±12.387.5 ±10.9118.6±16.8C3 3rdtrimester (mean ±SD)105.5±15.7108.2±19.198.97±18.6111.4±1698.1 ±12.6109.1±15.8C3 3 months after delivery (mean ±SD)93.4±12103.1±15.492.4±15.7102.6±13.490.5 ±10.894.8±12.3C4 6 months before pregnancy (mean ±SD)15.7±5.514.1±2.811.8±3.916.5±3.310.5±3.418.4±4.2C4 conception (mean ±SD)15.4±4.113.9±2.813.3±3.215.7±3.411±1.317.8±3C4 1sttrimester (mean ±SD)15±7.816.3±2.812.5±5.917.5±4.29.3±7.617.9±6.2C4 2ndtrimester (mean ±SD)17.7±4.718.7±4.215.5±4.319.8±3.713.6±4.119.6±3.5C4 3rdtrimester (mean ±SD)17.8±4.417.5±5.115.7±5.818.6±415.8±4.818.8±3.9C4 3 months after delivery (mean ±SD)16.2±4.319.8±6.914.9±3.920±6.413.3±3.117.6±4Figure 1.

Complement Levels during time in patients with Lupus Nephritis and presence, or absence, of flare.

Conclusion

In this prospective large cohort of SLE patients low C3/C4 levels, particularly in T1, were associated with a higher frequency of flare. Lowering levels of complement, especially in T1, even within normal range might alert the treating clinicians in predicting disease course and consequently avoid flares, especially in LN.

References

[1]Saavedra MÁ et al. Int J Rheum Dis 2020

[2]Moroni G et al. J Autoimmun 2016

[3]Rodrigues BC et al. Lupus 2019

[4]Borella E et al. Immunol Res 2014

Disclosure of Interests

None declared

Clinical Delphi on aPLnegativization: report from the from the APS Study Group of the Italian Society for Rheumatology (SIR-APS)

The rate of antiphospholipid antibodies (aPL) negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion. Evaluate the clinical approach and level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario. Experts of SIR-APS were contacted using a survey methodology. A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost full consensus exist among experts in some clinical settings, including: a) the role of aPL negativization in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%); b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of "extra criteria" aPL antibodies testing before pondering VKA suspension (93%). A substantial agreement exists among expert on how to define aPL negativization. VKA suspension should be embraced with extreme caution, particularly in case of previous thrombotic events and/or triple aPL positivity. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for "extra criteria" is ruled out.

Quality of life measures in Systemic Lupus Erythematosus: A systematic review

In this study we systematically investigated the health-related quality of life (HRQoL) tools, which have been most often used over the last five years to evaluate the QoL in patients with systemic lupus erythematosus (SLE), focusing on their items and applications. A detailed literature search was conducted: the inclusion criteria were as follows: 1) studies including at least 50 patients; 2) studies including at least 25 patients with SLE; 3) quality of life testing with validated measures. The systematic review was based on 119 studies for a total of 32,449 SLE patients and 3092 controls. A total of 35 different patients-reported quality of life measures, applied in cohorts of patients with SLE, were retrieved with the 36-item Medical Outcome Short Form (SF-36) (63 studies of 119 =52.95%), Lupus Quality of Life (LupusQoL) (17 studies =14.3%) and Lupus Patient-Reported Outcome (LupusPRO) (12 studies =10%) being the most commonly used tools. Overall, this systematic review of the literature indicated that quality of life in patients with SLE appears to be poor and generally lower compared to both the general population and patients with other chronic conditions, as was shown by a few studies that used SF-36 and LupusPRO. The use of HRQoL scoring in SLE is gaining increasing interest and is used both in randomized controlled trials and in real-life. Future efforts are needed to improve the understanding of the impact of the disease burden on quality of life from the patient’s perspective.

Open-label, prospective, phase II descriptive pilot trial of belimumab therapy for refractory and/or non-criteria manifestations of antiphospholipid syndrome: study protocol

OBJECTIVES

To evaluate the safety and tolerability of belimumab given for 24 months in patients persistently positive for antiphospholipid antibodies (aPL) with clinical features attributable to aPL [refractory and/or non-criteria manifestations of the antiphospholipid syndrome (APS)].

METHODS

In this investigator-initiated, single-centre, open-label, prospective, phase II descriptive pilot trial, belimumab will be administered in 15 patients attending San Giovanni Bosco Hospital (Turin) showing refractory and/or non-criteria manifestations of APS. Subjects will receive belimumab 10 mg/kg intravenously (in addition to their ongoing APS treatment) with regimen at 0, 2, 4 weeks and every 4 weeks thereafter (up to week 104). Study endpoints determined at 4, 16, 24, 36, 52 and 104 weeks will include: primary (safety and adverse events) and secondary outcomes, such as changes in clinical outcomes (recurrent thromboses, thrombocytopenia, haemolytic anaemia, cardiovascular events, skin ulcer, aPL-related nephropathy and cognitive dysfunction), laboratory outcomes (routine tests, aPL, ENA and anti-dsDNA tests, thrombin generation assay, interferon-signature analysis, lymphocytes immunophenotyping, BLyS determination) and QoL evaluation.

RESULTS

Study endpoints determined at 4, 16, 24, 36, 52 and 104 weeks will include: primary (safety and adverse events) and secondary outcomes, such as changes in clinical outcomes (recurrent thromboses, thrombocytopenia, haemolytic anaemia, cardiovascular events, skin ulcer, aPL-related nephropathy and cognitive dysfunction), laboratory outcomes (routine tests, aPL, ENA and anti-dsDNA tests, thrombin generation assay, interferon-signature analysis, lymphocytes immunophenotyping, BLyS determination) and QoL evaluation.

CONCLUSIONS

Targeting B-cells is emerging as an appealing strategy for patients with APS. Preliminary observations showed aPL negativisation after starting therapy with belimumab. The clinical relevance of these findings will be investigated in this prospective study. If confirmed, the current 'anti-thrombotic' approach to APS patients could be complemented, at least in selected cases, with an 'immunomodulatory' strategy.

Vedolizumab for the Management of Refractory Behçet's Disease: From a Case Report to New Pieces of Mosaic in a Complex Disease

Objectives

When treating Behçet’s disease (BD), anti-tumor necrosis factor (TNF)-α agents have become a second-line therapy when conventional immunosuppressive drugs have failed. However, in the case of failure of treatment with anti-TNFα drugs, further options are limited. Based on previous reports of the efficacy of vedolizumab (VDZ) in inflammatory bowel diseases, we decided to administer VDZ to treat a patient with intestinal BD.

Methods

We present the case of a 49-year-old female patient with BD. Her clinical manifestations included erythema nodosum, oro-genital ulcers, positive Pathergy test, positive HLA-B51, and biopsy-proven intestinal BD. The patient was unsuccessfully treated with conventional immunosuppressive and several biological agents.

Results

Treatment with VDZ was started intravenously at a dose of 300 mg at 0, 2, and 6 weeks and then every 4 weeks.

After the second dose of VDZ, the patient reported a marked improvement of intestinal BD and a concomitant amelioration of arthralgia, erythema nodosum lesions and aphthosis. Clinical remission was achieved at 6 months after starting VDZ.

Conclusion

VDZ might represent a valid option to treat patients with BD who are non-responsive to standard treatments or anti-TNFα agents, particularly, those cases with intestinal involvement.

Prognostic and Diagnostic Values of Novel Serum and Urine Biomarkers in Lupus Nephritis: A Systematic Review

INTRODUCTION

While renal biopsy remains the gold standard for diagnosing lupus nephritis (LN), the prognostic and diagnostic role of non-invasive biomarkers for LN is currently debated.

METHODS

Available studies published in last 5 years (2015-2020) assessing the diagnostic and prognostic value of urinary and/or serological biomarkers in subjects with LN were analyzed in this systematic review.

RESULTS

Eighty-five studies were included (comprehending 13,496 patients with systemic lupus erythematosus [SLE], 8,872 LN, 487 pediatric LN, 3,977 SLE but no LN, 160 pediatric SLE but no LN and 7,679 controls). Most of the studies were cross-sectional (62; 73%), while 14 (17%) were prospective. In sixty studies (71%), the diagnosis of LN was biopsy-confirmed. Forty-four out of 85 (52%) investigated only serological biomarkers, 29 studies (34%) tested their population only with urinary biomarkers, and 12 (14%) investigated the presence of both. Outcome measures to assess the clinical utility of the analyzed biomarkers were heterogeneous, including up to 21 different activity scores, with the SLEDAI (in 60%) being the most used. Despite some heterogeneity, promising results have been shown for biomarkers such as urinary monocyte chemoattractant protein, urinary adiponectin, and urinary vascular cell adhesion protein 1.

DISCUSSION/CONCLUSION

While serum and urine biomarkers have the potential to improve diagnostic and prognostic pathways in patients with LN, the vast heterogeneity across studies severely limits their applicability in current clinical practice. With the kidney biopsy still representing the gold standard, future efforts should focus on harmonizing study inclusion criteria and outcomes, particularly in clinical trials, in order to improve comparability and facilitate the implementations of available biomarkers into the daily practice.

Relativistic nucleon-nucleon potentials in a spin-dependent three-dimensional approach

The matrix elements of relativistic nucleon–nucleon (NN) potentials are calculated directly from the nonrelativistic potentials as a function of relative NN momentum vectors, without a partial wave decomposition. To this aim, the quadratic operator relation between the relativistic and nonrelativistic NN potentials is formulated in momentum-helicity basis states. It leads to a single integral equation for the two-nucleon (2N) spin-singlet state, and four coupled integral equations for two-nucleon spin-triplet states, which are solved by an iterative method. Our numerical analysis indicates that the relativistic NN potential obtained using CD-Bonn potential reproduces the deuteron binding energy and neutron-proton elastic scattering differential and total cross-sections with high accuracy.

Psychosocial burden in young patients with primary anti-phospholipid syndrome: an Italian nationwide survey (The AQUEOUS study)

OBJECTIVES

The AQUEOUS (Anti-phospholipid syndrome: a QUEstionnaire for yOUng patientS) study aimed to assess how the diagnosis of primary anti-phospholipid syndrome (PAPS) affects the psychosocial status of young patients.

METHODS

Subjects with PAPS aged 18-45 years were invited to compile an ad hoc designed questionnaire and the Short Form-12 to assess quality of life (QoL).

RESULTS

Ninety-two patients (83.7% females) were recruited in 10 Italian centres. Vascular and obstetric manifestations were equally represented. Nearly half of the patients perceived the need for psychological support, 89.2% when considering women after pregnancy complications. Social activities and working efficiency were reduced in APS patients, also intimacy was threatened. In all cases, fatigue appeared to be the main determinant. PAPS affected family planning, due to fears of treatment side-effects, disease hereditariness, inability to care for the newborn child. Fertility appeared to be conserved: the median time to pregnancy was 2 months; assisted reproduction techniques were pursued by 5 women. Our survey documented significantly lower rates of hospitalisation and learning disabilities in 51 children born after APS diagnosis as compared to 48 children born before. PAPS patients displayed lower QoL in physical and, to a greater extent, mental scores compared to the general Italian population. Both components were significantly lower in women and in patients with fatigue.

CONCLUSIONS

The AQUEOUS study assessed for the first time the unmet needs of young PAPS patients, enabling the development of a future "youth-focused" strategy to reduce disease burden.

Cerebrovascular events in patients with isolated anti-phosphatidyl-serine/prothrombin antibodies

The interest of extra-criteria antiphospholipid antibodies is growing, especially in patients negative for conventional antibodies. In this study we aimed to assess the clinical utility of anti-phosphatidyl-serine/prothrombin antibodies (aPS/PT) testing in patients negative for Beta2-Glycoprotein 1(β2GPI)-dependent tests, for identifying antiphospholipid syndrome (APS) patients that developed cerebrovascular events (CVE). When screening APS patients attending our center, out of 119 aPS/PT IgG/IgM-positive patients, thus patients negative for aβ2GPI and aCL, 42 patients (35%) tested negative for β2GPI-dependent tests and were tested with thrombin generation assay (TGA). Ten patients (24%), with isolated aPS/PT IgG/IgM, had a history of CVE. Lupus anticoagulant (LA)-positive test was more frequently observed in patients with CVE (8/22 vs. 2/20; p = 0.045). Out of the 10 patients who experienced CVE, 3 patients were aPS/PT IgG positive (all LA positive), and 8 patients were aPS/PT IgM positive (6/8 LA positive). One patient was positive for both aPS/PT IgG and IgM. LA-positive patients had only high titers of aPS/PT IgG/IgM, all of them being ≥ 80 U/ml, while the 2 LA-negative patients were aPS/PT IgM positive with medium titers [40-60 U/ml]. LA-positive patients had significantly altered TGA profile when compared to those who were LA negative, considering all TGA parameters. LA-positive patients had significantly higher tLag (8.4 ± 3.3 min vs. 6.6 ± 1.8 min; p = 0.046), higher tPeak (14 ± 4.3 min vs. 11 ± 2.7 min; p = 0.015) and lower Peak (207 ± 152 nM vs. 356.3 ± 104.7 nM; p < 0.001) and lower AUC (2109.7 ± 1006.9 nM vs. 2772.5 ± 776.8 nM; p = 0.033). The use of aPS/PT might be of help in identifying patients with CVE and APS, as also confirmed by TGA testing.