POS0741 HISTOPATHOLOGIC PATTERNS OF LUPUS NEPHRITIS PREDICT THE RISKS OF MORTALITY- A SINGLE-CENTER RETROSPECTIVE STUDY

Background:

Lupus nephritis is a significant complication of systemic lupus erythematosus and is associated with increased risks of end-stage kidney disease and mortality.

Objectives:

The retrospective observational study aims to investigate which component of the National Institutes of Health activity and chronic indices of lupus nephritis can predict mortality.

Methods:

We identified 528 SLE patients with biopsy-proven lupus nephritis between 2006 and 2019. Two patients with class VI lupus nephritis were excluded, and a total of 526 patients were analyzed. Serum creatinine, urine protein-to-creatinine ratio (UPCR), and serologic markers for SLE disease activity were measured at the time of the renal biopsy. The histopathologic findings of renal biopsies were classified by utilizing the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification.

Results:

Among 526 patients enrolled, 64 expired, and 44 were female (68.8%, p=0.004). Class IV (± V) comprised the most (n= 39, 60.9%), followed by class V (n= 18, 29.7%). Lower eGFR was observed in the death group, compared with the survival group (median: 24.7 vs. 80.5, p<0.001). There were no significant differences in UPCR and serologic markers for SLE (dsDNA, C3, and C4). Total scores of chronicity index and the scores for each index were higher in the death group. Interestingly, although total scores of activity index in death and survival groups did not differ significantly, the scores for cellular crescents tended to be higher in the death group (1.38 ±1.77 vs. 0.72 ±1.24, p=0.002)

In the univariable analysis, age, male sex, eGFR, activity index scores, cellular crescents, chronicity index scores, and all CI components (global obsolete glomeruli, tubular atrophy, interstitial fibrosis, fibrous crescents) and tubulointerstitial nephritis were significantly associated with an increased risk of death. When patient characteristics and NIH activity/ chronicity indices were jointly examined in a multivariable analysis, fibrous crescents were significantly associated with increased risk of death in females (HR 5.23 [95% CI: 1.51, 18.09]) (Table 1). In males, the risks of death increased with cellular crescents (HR 1.73 [95% CI: 1.10, 2.73]) but decreased with global obsolete glomeruli (HR 0.12 [95% CI: 0.02, 0.91]).

Conclusion:

In this single-center observational study, fibrous crescents in females and cellular crescents in males were significantly associated with increased risks of mortality.

References:

[1]Doria A, Iaccarino L, Ghirardello A, et al. Long-term prognosis and causes of death in systemic lupus erythematosus. Am J Med 2006; 119: 700–706.

[2]Faurschou M, Starklint H, Halberg P, Jacobsen S. Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure. J Rheumatol. 2006;33(8):1563-1569.

[3]Chen YM, Hung WT, Liao YW, et al. Combination immunosuppressant therapy and lupus nephritis outcome: a hospital-based study. Lupus. 2019;28(5):658-666.

Table 1.

Logistic regression of predictors for mortality in patients with lupus nephritis

UnivariableMultivariable (Female)Multivariable (Male)HR95% CIp valueHR95% CIp valueHR95% CIp valueAge1.03(1.01-1.05)0.0021.02(0.98-1.07)0.2671.01(0.95-1.08)0.670Male sex2.10(1.23-3.55)0.006UPCR1.02(0.95-1.09)0.616eGFR0.97(0.96-0.99)<0.0010.99(0.96-1.00)0.1830.98(0.96-1.00)0.086Activity Index1.06(1.01-1.11)0.027Cellular crescents1.29(1.12-1.50)<0.0011.03(0.63-1.67)0.9171.73(1.10-2.73)0.017Chronicity Index1.16(1.07-1.26)<0.001global obsolete glomeruli1.37(1.08-1.76)0.0111.24(0.55-2.77)0.6060.12(0.02-0.91)0.040Tubular atrophy1.65(1.28-2.13)<0.0010.41(0.06-2.82)0.3624.77(0.30-75.32)0.267Interstitial fibrosis1.71(1.32-2.23)<0.0013.70(0.52-26.24)0.1911.37(0.07-27.40)0.837Fibrous crescents2.38(1.40-4.03)0.0015.23(1.51-18.09)0.0090.00(0-extremely large)0.989Tubulointerstitial nephritis1.70(1.03-2.80)0.037

Disclosure of Interests:

None declared

25 Cerebellar cognitive affective syndrome – a case report of diagnosis and management using selective serotonin and norepinephrine reuptake inhibitors

Objectives/aims

The objective of this case is to describe and report on a case of Cerebellar Cognitive Affective Syndrome (CCAS) which improved after the use of high dose venlafaxine therapy. To our knowledge, there are only a few case reports discussing on the effectiveness of various drug therapies in CCAS patients and none had reported on the use of Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI).

Methods

We describe a 55-year-old male with a history of partially excised grade 1 left cerebellar haemangioblastoma in 2005 followed by Gamma Knife in 2006.

Unfortunately, he suffered a recurrence in 2018 requiring embolisation of the haemangioblastoma followed with surgery to resect the tumour. He presented to our specialist neuropsychiatric unit following episodes of new acute unprovoked behavioural changes after surgery. During these episodes, he would become verbally abusive, refuse to engage in any rehab activity, refuse any oral intake, become sexually disinhibited, and experience distressing hallucinations. On the neuropsychiatric ward, he continued to have episodes of severe emotional regulation difficulties. There were no obvious triggers identified and it was noted that the peaks and troughs in his behaviour lasted for a few days before self-resolving and did not follow any particular pattern. In between these episodes, the patient was pleasant, engaging in physiotherapy, and conversed normally with staff.

Results

He scored a total of 4 out of 10 on the CCAS-scale. A diagnosis of CCAS was concluded given the extensive history of cerebellar injury, nature of presenting complain, and his CCAS-scale score. He was started on high dose SNRI (Venlafaxine XL 150 mg BD). On repeating the CCAS-scale after being on SNRI for 4 months, his score was worse at 6 out of 10. However, we observed a decrease in the frequency, duration, and severity of behavioural change after commencement of SNRI. He benefited greatly from physiotherapy on the ward however despite our best efforts functional independence was not regained. He had to be transferred with the aid of 2 members of staff and mobilises with the aid of an electronic wheelchair.

Conclusions

CCAS is a complex disease and the management is yet to be agreed on by the neuropsychiatry community. Our case report illustrated the therapeutic benefit of venlafaxine in the treatment of severe emotional regulation difficulties associated with resection of a cerebellar haemangioblastoma. Furthermore, patients with cerebellar injuries should be managed in a multi-disciplinary manner with input from neurology, neuropsychiatry, neuropsychology, occupational therapist, and physiotherapist.

AB0379 IS MYCOPHENOLATE SODIUM (MYFORTIC) SIMILARLY EFFECTIVE AS MYCOPHENOLATE MOFETIL (CELLCEPT) IN TREATMENT OF LUPUS NEPHRITIS? EXPERIENCE FROM NON-MEDICAL SWITCHING REAL WORLD DATA IN TAIWAN

Background:

Lupus nephritis is the most important predictive factor of morbidity and mortality in SLE. Though Mycophenolate mofetil is recommended for induction and maintenance treatment of class III, IV V lupus nephritis, it is not approved by US or Taiwan FDA (TFDA). In previous reports of kidney transplantation, no efficacy differences were observed between mycophenolate sodium (Myfortic) and mycophenolate mofetil (Cellcept). However, no clinical trial was conducted to compare these two widely-used mycophenolic acid derivatives in lupus nephritis. In December, 2016, TFDA approved Mycophenolate sodium in treatment of lupus nephritis. For reimbursement issue, patients treated with mycophenolate mofetil were non-medically switched to mycophenolate sodium in Taiwan.

Objectives:

To compare the treatment efficacy of mycophenolate mofetil and mycophenolate sodium in lupus nephritis patients with non-medical switching.

Methods:

Between 2016 and 2018, a retrospective observational study enrolled 50 biopsy-proven LN patients in Taichung Veterans General Hospital, Taiwan. All these patients were initially treated with Cellcept for at least one year. Treatment response was evaluated by urinalysis and daily urine protein one year before and after switching to Myfortic.

Results:

Before switching, 72% patients were classified as responder if complete remission or partial remission were achieved, while 28% patients were categorized as non-responders (Table 1). After switching to Myfortic, 75% of the responder group achieved or maintained complete remission or partial response. In for non-responder group, 85.7% exhibited complete remission or partial response (Table 2). We did not observe new safety signals after switching.

Table 2.

Laboratory features

Non-responder (N=14)Responder*(N=36)Total (n=50)pvalueAge31.12±11.4832.58±9.390.660Female23(88.5%)20(76.9%)43(82.7%)0.465Daily urine protein (g)4.44±4.404.43±3.810.835Creatine (mg/dl)1.44±0.921.22±1.160.212Renal pathology class0.649III6(23.1%)4(15.4%)10(19.2%)III+V2(7.7%)4(15.4%)6(11.5%)IV16(61.5%)15(57.7%)31(59.6%)IV+V2(7.7%)3(11.5%)5(9.6%)

*complete remission and partial remission.

Table 1.

Comparative analysis of 328 SLE patients with and without lupus fatigue

Initial treatment with CellceptNon-responderResponderp valueNon-medical switch to Myfortic0.705Non-responder2(14.3)9(25)Responder12(85.7)27(75)

Conclusion:

This real-world data indicated similar efficacy of Cellcept and Myfortic. Further prospective study is needed to confirm our findings.

Disclosure of Interests:

None declared

P2816Antithrombotic strategy for patients with anticoagulation indication undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials

Background

A significant proportion of patients having acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI) have indications for long-term anticoagulation such as atrial fibrillation. Their optimal antithrombotic strategy despite recent randomised trials. We meta-analysed outcomes comparing dual versus triple, and non-vitamin K oral anticoagulants (NOAC) versus vitamin K oral anticoagulants (VKA) antithrombotic regimens.

Methods

MEDLINE, Embase and Cochrane databases were searched for original randomised trials with relevant search terms. Two authors evaluated these studies for inclusion and extracted data pooling bleeding and cardiovascular events.

Results

The search yielded 308 articles, with 19 full-texts reviewed and 4 randomised trials totalling 6,029 patients included. Dual antithrombotic strategies were associated with significant reductions in TIMI major and minor bleeding (odds ratios 0.55, 95% confidence interval 0.36–0.83), and other bleeding endpoints including all, major, minor and intracranial bleeding (odds ratios 0.45–0.62, all P<0.05), compared with triple antithrombotic strategies in four trials, with no differences in mortality, myocardial infarction, stroke, stent thrombosis or composite cardiovascular events (odds ratio 0.79–1.13, all P>0.05). NOAC regimens were associated with significant reductions in TIMI major and minor bleeding odds ratio 0.49 (0.37–0.65), as well as major, minor and intracranial bleeding (odds ratios 0.29–0.52, all P<0.05), but again no differences in mortality or all cardiovascular endpoints (odds ratios 0.98–1.49, all P>0.05).

Conclusion

Antithrombotic strategies involving dual instead of triple agents, and NOAC instead of VKA had significantly less bleeding without increasing mortality and cardiovascular events, and are therefore preferred options in patients undergoing PCI who also require long-term anticoagulation.

P5548Hypertrophic cardiomyopathy and exercise restrictions: time to let the shackles off?

Introduction

Physical activity is well known to have many health benefits. However, patients with hypertrophic cardiomyopathy (HCM) might carry an increased risk of sudden cardiac death (SCD) during physical activity. This threat has to be considered in the risk versus benefit analysis of physical activity versus a more sedentary lifestyle. Current guidelines focus primarily on what level of activity should be entirely excluded and what level is considered safe. However, it does not quantify nor qualify the amount of physical activity which should actively be undertaken. We aimed to analyse current evidence in attempt to answer this question.

Method

For this review, we focused on non-athletes who made up the majority of HCM patients. However, we found that majority of the current evidence were geared towards athletes. In total, we analysed 27 papers.

Results

Obesity is a well documented aetiology of many diseases and patients with HCM have been observed to have higher BMI. When considering physical activity of patients with HCM, both patients and current guidelines tend to focus on avoidance of risk and restriction of exercise. This is understandable given the consequence of SCD in HCM patients. A retrospective review of 78 patients found that at the time of cardiac catastrophe, 46 of them were engaged in sedentary activities. This is further backed up by a UK study which found only 35 of 185 patients died during exertion. A meta-analysis of 3449 non-athletes found only 7.8% had SCD caused by HCM. These results suggest that prescribed exercise can be safe in non-athletes.

A cross-sectional study of 187 HCM patients with left ventricular hypertrophy investigated if a history of vigorous exercise was associated with adverse events including ventricular arrhythmias. It found that vigorous exercise was not associated with ventricular arrhythmias. Saberi et al conducted the first randomised controlled trial (RCT) designed to investigate the effect of prescribed training in HCM patients. 136 patients were randomised into a normal activity group and a 16 week prescribed moderate- intensity training group. At 16 weeks, there was an absolute increase of 6% in the mean change in peak oxygen consumption (peak VO2) between the groups. This was an important finding as the HF-ACTION trial found that every 6% increase in peak VO2 was associated with an 8% lower risk for cardiovascular mortality.

Modified Mitchell's classification

Conclusion

Current guidelines on exercise for patients with HCM are very restrictive. The recommendations for level of exercise are focused on prohibition rather than encouraging a safe and sensible level of exercise. RESET-HCM is the first RCT of its kind which successfully shows that carefully guided exercise is not only safe but can also be beneficial for patients. With more studies targeting the role of exercise and activity in these patients, it is only a matter of time before our focus switches from restricting activity to sensible exercise prescription.

Combination immunosuppressant therapy and lupus nephritis outcome: a hospital-based study

Lupus nephritis (LN) is the leading cause of mortality in lupus patients. This study aimed to investigate the treatment outcome and renal histological risk factors of LN in a tertiary referral center. Between 2006 and 2017, a retrospective observational study enrolled 148 biopsy-proven LN patients. After propensity score matching, 75 cases were included for further analysis. The classification and scoring of LN were assessed according to the International Society of Nephrology/Renal Pathology Society. Treatment response was evaluated by daily urine protein and urinalysis at two years after commencing induction treatment and the development of end-stage renal disease (ESRD). In total, 50.7% patients achieved complete remission (CR) or partial remission (PR), while 49.3% patients were categorized as nonresponders. Therapeutic responses in terms of CR/PR rates were associated with Systemic Lupus Erythematosus Disease Activity Index scores (odds ratio (OR): 1.34, 95% confidence interval (CI): 1.12-1.60, p = 0.001). Moreover, higher baseline creatinine levels (hazard ratio (HR): 2.10, 95% CI: 1.29-3.40, p = 0.003), higher renal activity index (HR: 1.30, 95% CI: 1.07-1.58, p = 0.008) and chronicity index (HR: 1.40, 95% CI: 1.06-1.85, p = 0.017) predicted ESRD. Among pathological scores, cellular crescents (HR: 4.42, 95% CI: 1.01-19.38, p = 0.049) and fibrous crescents (HR: 5.93, 95% CI: 1.41-24.92, p = 0.015) were independent risk factors for ESRD. In conclusion, higher lupus activity was a good prognostic marker for renal remission. Renal histology was predictive of ESRD. Large-scale prospective studies are required to verify the efficacy of mycophenolate in combination with azathioprine or cyclosporine in LN patients.

De novo satellited 21q associated with corpus callosum dysgenesis, colpocephaly, a concealed penis, congenital heart defects, and developmental delay

De novo satellited 21q associated with corpus callosum dysgenesis, colpocephaly, a concealed penis, congenital heart defects, and developmental delay: We present clinical and cytogenetic data on an infant with de novo satellited 21 q. A 3-month-old boy was found to have microcephaly, developmental delay, hypertelorism, down-slanting palpebral fissures, large low-set ears, a prominent nose, a broad philtrum, a concealed penis, interventricular septal defects, corpus callosum dysgenesis, colpocephaly, ventriculomegaly, and a de novo karyotype of 46,XY,21qs. Standard Ag-NOR staining and FISH studies confirmed a satellite and a deletion on the long arm of a chromosome 21. Quantitative-fluorescent polymerase chain reaction using the polymorphic small tandem repeat markers specific for chromosome 21 determined a maternal origin of the deletion and the breakpoint between D21S156 (21q22.1) (present) and D21S53 (21q22.3) (absent), centromeric to the known minimal holoprosencephaly critical region, D21S13-21qter. The present case provides evidence of the correlation of a distal region of chromosome 21 to the phenotypic effects of monosomy 21.