Risk loci involved in giant cell arteritis susceptibility: a genome-wide association study

BACKGROUND

Giant cell arteritis is an age-related vasculitis that mainly affects the aorta and its branches in individuals aged 50 years and older. Current options for diagnosis and treatment are scarce, highlighting the need to better understand its underlying pathogenesis. Genome-wide association studies (GWAS) have emerged as a powerful tool for unravelling the pathogenic mechanisms involved in complex diseases. We aimed to characterise the genetic basis of giant cell arteritis by performing the largest GWAS of this vasculitis to date and to assess the functional consequences and clinical implications of identified risk loci.

METHODS

We collected and meta-analysed genomic data from patients with giant cell arteritis and healthy controls of European ancestry from ten cohorts across Europe and North America. Eligible patients required confirmation of giant cell arteritis diagnosis by positive temporal artery biopsy, positive temporal artery doppler ultrasonography, or imaging techniques confirming large-vessel vasculitis. We assessed the functional consequences of loci associated with giant cell arteritis using cell enrichment analysis, fine-mapping, and causal gene prioritisation. We also performed a drug repurposing analysis and developed a polygenic risk score to explore the clinical implications of our findings.

FINDINGS

We included a total of 3498 patients with giant cell arteritis and 15 550 controls. We identified three novel loci associated with risk of giant cell arteritis. Two loci, MFGE8 (rs8029053; p=4·96 × 10-8; OR 1·19 [95% CI 1·12-1·26]) and VTN (rs704; p=2·75 × 10-9; OR 0·84 [0·79-0·89]), were related to angiogenesis pathways and the third locus, CCDC25 (rs11782624; p=1·28 × 10-8; OR 1·18 [1·12-1·25]), was related to neutrophil extracellular traps (NETs). We also found an association between this vasculitis and HLA region and PLG. Variants associated with giant cell arteritis seemed to fulfil a specific regulatory role in crucial immune cell types. Furthermore, we identified several drugs that could represent promising candidates for treatment of this disease. The polygenic risk score model was able to identify individuals at increased risk of developing giant cell arteritis (90th percentile OR 2·87 [95% CI 2·15-3·82]; p=1·73 × 10-13).

INTERPRETATION

We have found several additional loci associated with giant cell arteritis, highlighting the crucial role of angiogenesis in disease susceptibility. Our study represents a step forward in the translation of genomic findings to clinical practice in giant cell arteritis, proposing new treatments and a method to measure genetic predisposition to this vasculitis.

FUNDING

Institute of Health Carlos III, Spanish Ministry of Science and Innovation, UK Medical Research Council, and National Institute for Health and Care Research.

Declining Incidence of Systemic Lupus Erythematosus in Norway 1999-2017: Data From a Population Cohort Identified by International Classification of Diseases, 10th Revision Code and Verified by Classification

OBJECTIVE

The goal of this study was to provide complete, robust data on annual systemic lupus erythematosus (SLE) incidence rates over nearly two decades from the Southeast Norway area (2.9 million inhabitants) and assess accuracy of SLE-specific International Classification of Diseases (ICD) codes for SLE diagnosis.

METHODS

From administrative databases, we identified all cases International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coded as SLE during 1999 through 2017 in Southeast Norway. We manually reviewed the chart of every case ICD-10 coded as SLE to either confirm or reject SLE diagnosis. Using SLE classification criteria, we classified all cases with confirmed SLE. We estimated annual incidence rates of classified SLE, and subsets, defined by age at diagnosis, sex, and parental country of birth. The chi-square test was applied for linear time-trend analyses of incidence.

RESULTS

Among the 3,488 cases ICD-10 coded as SLE, chart reviews confirmed SLE diagnosis in 1,558 (45%), of which 797 had new-onset disease during 1999 through 2017. Annual SLE incidence rates fell during 1999 to 2017. The fall was most pronounced in female persons 50 to 59 years old at diagnosis, in whom incidence fell from 3.4 to 1.1 per 100,000 persons (P trend < 0.001). Concurrent ecological data from the study area showed a 74% reduction in prescriptions of menopausal hormone treatment. Accuracy of ICD-10 codes for incident SLE diagnosis was acceptable in juveniles and young adults (up to 20 years) but otherwise low.

CONCLUSION

In a presumably complete population-based cohort, we identified decreasing incidence of SLE, especially among female persons 50 to 59 years old. Although reasons for declining incidence are not clear, ecological data indicate a possible role of environmental factors, for example, menopausal hormone treatments.

B cell polygenic risk scores associate with anti-dsDNA antibodies and nephritis in systemic lupus erythematosus

OBJECTIVE

B cell function and autoantibodies are important in SLE pathogenesis. In this work, we aimed to investigate the impact of cumulative SLE B cell genetics on SLE subphenotype and autoantibody profile.

METHODS

Female patients with SLE (n=1248) and healthy controls (n=400) were genotyped using Illumina's Global Screening Array. Two polygenic risk scores (PRSs), one representing B cell genes and the other B cell activation genes, were calculated for each individual using risk loci for SLE in genes assigned to B cell-related pathways according to the Kyoto Encyclopedia of Genes and Genomes, Gene Ontology and Reactome Databases.

RESULTS

Double-stranded DNA (dsDNA) antibodies were more prevalent among patients with a high compared with a low SLE B cell PRS (OR 1.47 (1.07 to 2.01), p=0.018), and effect sizes were augmented in patients with human leucocyte antigen (HLA) risk haplotypes HLA-DRB1*03:01 and HLA-DRB1*15:01 (DRB1*03/15 -/- (OR 0.99 (0.56 to 1.77), p=0.98; DRB1*03/15 +/- or -/+ (OR 1.64 (1.06 to 2.54), p=0.028; and DRB1*03/15 +/+ (OR 4.47 (1.21 to 16.47), p=0.024). Further, a high compared with a low B cell PRS was associated with low complement levels in DRB1*03/15 +/+ patients (OR 3.92 (1.22 to 12.64), p=0.022). The prevalence of lupus nephritis (LN) was higher in patients with a B cell activation PRS above the third quartile compared with patients below (OR 1.32 (1.00 to 1.74), p=0.048).

CONCLUSIONS

High genetic burden related to B cell function is associated with dsDNA antibody development and LN. Assessing B cell PRSs may be important in order to determine immunological pathways influencing SLE and to predict clinical phenotype.

Persisting mortality gap in systemic lupus erythematosus; a population-based study on juvenile- and adult-onset SLE in Norway 1999-2022

OBJECTIVE

To estimate mortality and survival rates of systemic lupus erythematosus (SLE) in a contemporary, population-based setting and assess potential influences by time, sex, ethnicity, classification criteria and age at diagnosis.

METHODS

We assessed mortality and survival in the Nor-SLE cohort, which includes all chart-review confirmed SLE cases resident in Southeast Norway (population 2.9 million) 1999-2017. Study end was at death, emigration, or 1 October 2022. We defined juvenile SLE by age <16 years at diagnosis. For standardized mortality rate (SMR) estimates, we applied 15 population controls per case, all matched for age, sex, residency, and ethnicity. We analyzed survival by Kaplan-Meier and risk factors by cox regression.

RESULTS

The Nor-SLE cohort included 1558 SLE cases, of whom 749 were incident and met the 2019 European Alliance of Associations for Rheumatology and American College of Rheumatology (2019-EA) classification criteria. SMR was increased to 1.8 (95% CI 1.6-2.2) in incident adult-onset SLE but did not differ between females and males. Survival rates at 5-, 10-, 15 and 20-years were lower in incident adult-onset SLE than in matched controls. In multivariable analysis, lupus nephritis associated with decreased survival, while sex did not. Separate, long-term mortality analyses in the total Nor-SLE cohort showed that SMR peaked at 7.2 (95% CI 3.3-14) in juvenile-onset SLE (n = 93) and fell gradually by increasing age at SLE diagnosis.

CONCLUSION

This study shows persistence of a mortality gap between adult-onset SLE and controls at population level and provides indications of worryingly high mortality in juvenile-onset SLE.

Differential sensitivity of the 2020 revised comprehensive diagnostic criteria and the 2019 ACR/EULAR classification criteria across IgG4-related disease phenotypes: results from a Norwegian cohort

BACKGROUND

We investigated sensitivity of the 2020 Revised Comprehensive Diagnostic Criteria (RCD) and the 2019 ACR/EULAR classification criteria across the four identified IgG4-related disease (IgG4-RD) phenotypes: "Pancreato-Hepato-Biliary", "Retroperitoneum and Aorta", "Head and Neck-limited" and "Mikulicz' and Systemic" in a well-characterized patient cohort.

METHODS

We included adult patients diagnosed with IgG4-RD after comprehensive clinical assessment at Oslo University Hospital in Norway. We assigned patients to IgG4-RD phenotypes based on pattern of organ involvement and assessed fulfillment of RCD and 2019 ACR/EULAR classification criteria. Differences between phenotype groups were analyzed using one-way ANOVA for continuous variables, and contingency tables for categorical variables.

RESULTS

The study cohort included 79 IgG4-RD patients assigned to the "Pancreato-Hepato-Biliary" (22.8%), Retroperitoneum and Aorta" (22.8%) "Head and Neck-limited" (29.1%), and "Mikulicz' and Systemic" (25.3%) phenotype groups, respectively. While 72/79 (91.1%) patients in total fulfilled the RCD, proportion differed across phenotype groups and was lowest in the "Retroperitoneum and Aorta" group (66.7%, p < 0.001). Among the 57 (72.2%) patients meeting the 2019 ACR/EULAR classification criteria, proportion was again lowest in the "Retroperitoneum and Aorta" group (27.8%, p < 0.001).

CONCLUSION

The results from this study indicate that IgG4-RD patients having the "Retroperitoneum and Aorta" phenotype less often fulfill diagnostic criteria and classification criteria than patients with other IgG4-RD phenotypes. Accordingly, this phenotype is at risk of being systematically selected against in observational studies and randomized clinical trials, with potential implications for patients, caregivers and future definitions of IgG4-RD.

Identification of Novel Associations and Localization of Signals in Idiopathic Inflammatory Myopathies Using Genome-Wide Imputation

OBJECTIVE

The idiopathic inflammatory myopathies (IIMs) are heterogeneous diseases thought to be initiated by immune activation in genetically predisposed individuals. We imputed variants from the ImmunoChip array using a large reference panel to fine-map associations and identify novel associations in IIM.

METHODS

We analyzed 2,565 Caucasian IIM patient samples collected through the Myositis Genetics Consortium (MYOGEN) and 10,260 ethnically matched control samples. We imputed 1,648,116 variants from the ImmunoChip array using the Haplotype Reference Consortium panel and conducted association analysis on IIM and clinical and serologic subgroups.

RESULTS

The HLA locus was consistently the most significantly associated region. Four non-HLA regions reached genome-wide significance, SDK2 and LINC00924 (both novel) and STAT4 in the whole IIM cohort, with evidence of independent variants in STAT4, and NAB1 in the polymyositis (PM) subgroup. We also found suggestive evidence of association with loci previously associated with other autoimmune rheumatic diseases (TEC and LTBR). We identified more significant associations than those previously reported in IIM for STAT4 and DGKQ in the total cohort, for NAB1 and FAM167A-BLK loci in PM, and for CCR5 in inclusion body myositis. We found enrichment of variants among DNase I hypersensitivity sites and histone marks associated with active transcription within blood cells.

CONCLUSION

We found novel and strong associations in IIM and PM and localized signals to single genes and immune cell types.

Cardiac dysfunction in mixed connective tissue disease: a nationwide observational study

We aimed to identify cardiac function in patients with established mixed connective tissue disease (MCTD). This was a cross-sectional case-control study of well-characterised MCTD patients who had previously been included in a nationwide cohort. Assessments comprised protocol transthoracic echocardiography, electrocardiogram and blood samples. In patients only, we evaluated the findings of high-resolution pulmonary computed tomography and disease activity. We assessed 77 MCTD patients (mean age 50.5 ± 12.3 years) with a mean disease duration of 16.4 years, and 59 age- and sex-matched healthy controls (49.9 ± 11.7 years). By echocardiography, measures of left ventricular function, i.e. fractional shortening (38.1 ± 6.4% vs. 42.3 ± 6.6%, p < 0.001), mitral annulus plane systolic excursion (MAPSE) (13.7 ± 2.1 mm vs. 15.3 ± 2.3 mm, p < 0.001) and early diastolic velocity of the mitral annulus (e') (0.09 ± 0.02 m/s vs. 0.11 ± 0.03 m/s, p = 0.002) were subclinical and lower in patients than controls. Right ventricular dysfunction was found in patients assessed by tricuspid annular plane systolic excursion (TAPSE) (22.7 ± 4.0 mm vs. 25.5 ± 4.0 mm, p < 0.001). While cardiac dysfunction was not associated with pulmonary disease, e' and TAPSE were found to correlate with disease activity at baseline. In this cohort of MCTD patients, echocardiographic examinations demonstrated a higher frequency of cardiac dysfunction than in matched controls. Cardiac dysfunction was associated with disease activity at baseline, but was independent of cardiovascular risk factors and pulmonary disease. Our study indicates that cardiac dysfunction is part of the multi-organ affliction seen in MCTD.

Adipokine profile in long-term juvenile dermatomyositis, and associations with adipose tissue distribution and cardiac function: a cross-sectional study

OBJECTIVES

In long-term juvenile dermatomyositis (JDM), altered adipose tissue distribution and subclinical cardiac dysfunction have been described. Our aims were to compare adipokine levels in patients with JDM after long-term disease with controls, and explore associations between adipokines and (1) adipose tissue distribution and (2) cardiac function.

METHODS

The study cohort included 59 patients with JDM (60% female, mean age 25.2 years, mean disease duration 16.9 years), and 59 age/sex-matched controls. Updated Pediatric Rheumatology International Trials Organization criteria for clinically inactive JDM were used to stratify patients into active (JDM-active) or inactive (JDM-inactive) disease groups. Lipodystrophy was clinically assessed in all patients. In all study participants, we measured adipose tissue distribution by dual-energy X-ray absorptiometry and cardiac function by echocardiography. Serum adipokines (adiponectin, apelin-12, lipocalin-2, leptin, visfatin and resistin) were analysed using ELISA.

RESULTS

Patients with JDM had higher leptin levels compared with controls (p≤0.01). In JDM-active, apelin-12 and visfatin were higher compared with JDM-inactive (p≤0.05). In JDM-total and JDM-active, lower adiponectin correlated with lipodystrophy and total fat mass. Also, systolic dysfunction correlated with: lower adiponectin in JDM-total, JDM-inactive and JDM-active, and with lower apelin-12 in JDM-total and JDM-active and resistin in JDM-active (all p≤0.05). Lower adiponectin correlated with diastolic dysfunction in JDM-total and JDM-active.

CONCLUSION

After long-term disease, leptin levels were unfavourably regulated in patients with JDM compared with controls, and apelin-12 and visfatin in JDM-active versus JDM-inactive. We found associations between adipokines and both adipose tissue distribution and cardiac systolic function in all patients with JDM, which was most prominent in patients with active disease.

Effects of faecal microbiota transplantation on small intestinal mucosa in systemic sclerosis

OBJECTIVES

In systemic sclerosis (SSc), gastrointestinal tract (GIT) involvement is a major concern, with no disease-modifying and limited symptomatic therapies available. Faecal microbiota transplantation (FMT) represents a new therapeutic option for GIT-affliction in SSc, showing clinical promise in a recent controlled pilot trial. Here, we aim to investigate effects of FMT on duodenal biopsies collected from SSc patients by immunohistochemistry and transcriptome profiling.

METHODS

We analysed duodenal biopsies obtained pre- (week 0) and post-intervention (weeks 2 and 16) from nine SSc patients receiving intestinal infusion of FMT (n = 5) or placebo (n = 4). The analysis included immunohistochemistry (IHC) with a selected immune function and fibrosis markers, and whole biopsy transcriptome profiling.

RESULTS

In patients receiving FMT, the number of podoplanin and CD64-expressing cells in the mucosa were lower at week 2 compared to baseline. This decline in podoplanin- (r = 0.94) and CD64-positive (r = 0.89) cells correlated with improved patient-reported lower GIT symptoms. Whole biopsy transcriptome profiling from week 2 showed significant enrichment of pathways critical for cellular and endoplasmic reticulum stress responses, microvillus and secretory vesicles, vascular and sodium-dependent transport, and circadian rhythm. At week 16, we found enrichment of pathways mandatory for binding activity of immunoglobulin receptors, T-cell receptor complex, and chemokine receptor, as well as response to zinc-ions. We found that 25 genes, including Matrix metalloproteinase-1 were upregulated at both week 2 and week 16.

CONCLUSION

Combining selective IHC and unbiased gene expression analyses, this exploratory study highlights the potential for disease-relevant organ effects of FMT in SSc patients with GIT involvement.

Treatment Response to Tumor Necrosis Factor Inhibitors and Methotrexate Monotherapy in Adults With Juvenile Idiopathic Arthritis: Data From NOR-DMARD

OBJECTIVE

To compare the effectiveness of tumor necrosis factor inhibitors (TNFi) ± comedication and methotrexate (MTX) monotherapy between patients with adult juvenile idiopathic arthritis (JIA) and patients with rheumatoid arthritis (RA).

METHODS

Adult patients with JIA and RA were identified from the Norwegian Antirheumatic Drug Register (NOR-DMARD) register. Disease activity measurements at baseline, 3, 6, and 12 months were compared between patients with JIA and RA starting (1) TNFi and (2) MTX monotherapy, using age- and gender-weighted analyses. We calculated differences between JIA and RA in mean changes in Disease Activity Score in 28 joints (DAS28), Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI), among other disease activity measures. DAS28, CDAI, SDAI, and American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) remission rates at 3, 6, and 12 months, as well as 6- and 12-month Lund Efficacy Index (LUNDEX)-corrected rates, were calculated.

RESULTS

We identified 478 patients with JIA (TNFi/MTX monotherapy, n = 358/120) and 4637 patients with RA (TNFi/MTX monotherapy, n = 2292/2345). Patients with JIA had lower baseline disease activity compared to patients with RA across treatment groups. After baseline disease activity adjustment, there were no significant differences in disease activity change from baseline to 3, 6, and 12-months of follow-up between patients with JIA and RA for either treatment group. Twelve-month remission rates were similar between groups based on DAS28 (TNFi: JIA 55.2%, RA 49.5%; MTX monotherapy: JIA 45.3%, RA 41.2%) and ACR/EULAR remission criteria (TNFi: JIA 20.4%, RA 20%; MTX monotherapy: JIA 17%, RA 12.7%). Median drug survival (yrs) was similar for JIA and RA in both treatment groups (TNFi: JIA 1.2, RA 1.4; MTX monotherapy: JIA 1.3, RA 1.6).

CONCLUSION

TNFi and MTX monotherapy are effective in adult JIA, with similar effectiveness to that shown in RA.

Target organ expression and biomarker characterization of chemokine CCL21 in systemic sclerosis associated pulmonary arterial hypertension

Introduction

Systemic sclerosis (SSc) is a heterogenous disorder that appears to result from interplay between vascular pathologies, tissue fibrosis and immune processes, with evidence for deregulation of chemokines, which normally control immune trafficking. We recently identified altered levels of chemokine CCL21 in SSc associated pulmonary arterial hypertension (PAH). Here, we aimed to define target organ expression and biomarker characteristics of CCL21.

Materials and methods

To investigate target organ expression of CCL21, we performed immunohistochemistry (IHC) on explanted lung tissues from SSc-PAH patients. We assessed serum levels of CCL21 by ELISA and Luminex in two well-characterized SSc cohorts from Oslo (OUH, n=552) and Zurich (n=93) University hospitals and in 168 healthy controls. For detection of anti-CCl21 antibodies, we performed protein array analysis applying serum samples from SSc patients (n=300) and healthy controls. To characterize circulating CCL21 in SSc, we applied immunoprecipitation (IP) with antibodies detecting both full length and tailless and a custom-made antibody detecting only the C-terminal of CCL21. IP products were analyzed by SDS-PAGE/western blot and Mass spectrometry (MS).

Results

By IHC, we found that CCL21 was mainly expressed in the airway epithelial cells of SSc patients with PAH. In the analysis of serum levels of CCL21 we found weak correlation between Luminex and ELISA (r=0.515, p<0.001). Serum levels of anti-CCL21 antibodies were higher in SSc patients than in healthy controls (p<0.001), but only 5% of the SSc population were positive for anti-CCL21 antibodies in SSc, and we found no correlation between anti-CCl21 and serum levels of CCL21. By MS, we only identified peptides located within amino acid (aa) 23-102 of CCL21, indicating that CCL21 in SSc circulate as a truncated protein without the C-terminal tail.

Conclusion

This study demonstrates expression of CCL21 in epithelial lung tissue from SSc patients with PAH, and indicate that CCL21 in SSc circulates as a truncated protein. We extend previous observations indicating biomarker potential of CCL21, but find that Luminex is not suitable as platform for biomarker analyses. Finally, in vivo generated anti-CCL21 antibodies exist in SSc, but do not appear to modify serum CCL21 levels in patients with SSc-PAH.

Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis

OBJECTIVES

To compare limited, to a more extended ultrasound examination (anteromedial ultrasound, A2-ultrasound) to detect large vessels (LV) involvement in patients with newly diagnosed giant cell arteritis (GCA).

METHODS

Patients with new-onset GCA were included at the time of diagnosis. All patients were examined using limited ultrasound (ultrasound of the axillary artery as visualized in the axilla), and extended A2-ultrasound method (which also includes the carotid, vertebral, subclavian, and proximal axillary arteries), in addition to the temporal artery ultrasound.

RESULTS

One hundred and thirty-three patients were included in the study. All patients fulfilled the criteria according to a proposed extension of the 1990 American College of Rheumatology (ACR) classification criteria for GCA and had a positive ultrasound examination at diagnosis. Ninety-three of the 133 GCA patients (70,0%) had LV involvement when examined by extended A2-ultrasound, compared with only 56 patients (42,1%) by limited ultrasound (p< 0,001). Twelve patients (9.0%) had vasculitis of the vertebral arteries as the only LV involved. Five patients (3,8%) would have been missed as having GCA if only limited ultrasound was performed. Forty patients (30,0%) had isolated cranial GCA (c-GCA), 21 patients (15,8%) had isolated large vessel GCA (LV-GCA), and 72 patients (54,1%) had mixed-GCA.

CONCLUSION

Extended A2-ultrasound examination, identified more patients with LV involvement than limited ultrasound method. However, extended A2-ultrasound requires high expertise and high-end equipment and should be performed by ultrasonographers with adequate training.

Complement C4 Copy Number Variation is Linked to SSA/Ro and SSB/La Autoantibodies in Systemic Inflammatory Autoimmune Diseases

OBJECTIVE

Copy number variation of the C4 complement components, C4A and C4B, has been associated with systemic inflammatory autoimmune diseases. This study was undertaken to investigate whether C4 copy number variation is connected to the autoimmune repertoire in systemic lupus erythematosus (SLE), primary Sjögren's syndrome (SS), or myositis.

METHODS

Using targeted DNA sequencing, we determined the copy number and genetic variants of C4 in 2,290 well-characterized Scandinavian patients with SLE, primary SS, or myositis and 1,251 healthy controls.

RESULTS

A prominent relationship was observed between C4A copy number and the presence of SSA/SSB autoantibodies, which was shared between the 3 diseases. The strongest association was detected in patients with autoantibodies against both SSA and SSB and 0 C4A copies when compared to healthy controls (odds ratio [OR] 18.0 [95% confidence interval (95% CI) 10.2-33.3]), whereas a weaker association was seen in patients without SSA/SSB autoantibodies (OR 3.1 [95% CI 1.7-5.5]). The copy number of C4 correlated positively with C4 plasma levels. Further, a common loss-of-function variant in C4A leading to reduced plasma C4 was more prevalent in SLE patients with a low copy number of C4A. Functionally, we showed that absence of C4A reduced the individuals' capacity to deposit C4b on immune complexes.

CONCLUSION

We show that a low C4A copy number is more strongly associated with the autoantibody repertoire than with the clinically defined disease entities. These findings may have implications for understanding the etiopathogenetic mechanisms of systemic inflammatory autoimmune diseases and for patient stratification when taking the genetic profile into account.

POS1416 LONG-TERM OUTCOME OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE); DATA FROM THE LARGE POPULATION-BASED SOUTHEAST SLE COHORT (Nor-SLE)

Background

Population-based studies on Systemic Lupus Erythematosus (SLE) patients with a verified diagnosis is considered the gold standard to find true outcomes in SLE, but few population-based SLE cohorts have follow-up over 15 years [1]. Norway is among the few countries worldwide where social and structural factors facilitate the gathering of complete population-based cohorts in rare disease like SLE due to its healthcare organization.

Objectives

To examine long-term outcome of SLE in a population-based setting and determine if immediate cause of death differs between SLE patients and the general population.

Methods

The study included all SLE patients who were resident in the Southeast region of Norway during 1999 - 2017 and met the 1997 American College of Rheumatology classification criteria for SLE. All SLE diagnosis was confirmed by chart review. SLE patients and 15 controls for each case (matched by age, gender and ethnicity) were linked to the Norwegian Cause of Death Registry. We examined survival by means of Kaplan-Meyer estimates and used log rank test to test for differences. To estimate risk of death, we performed calculations of standard mortality rate (SMR) by dividing the number of deaths on the number of years observed. The excepted number of deaths referred to the number of deaths for the matched control group. All SLE cases were included in SMR. The 95 % confidence interval (CI) of SMR was calculated with Mid-P exact test. We defined immediate cause of death as the final event directly leading to death. An International Classification of Diseases 10th revision code of I00-99 or R96 classified as death from cardiovascular disease (CVD) (except pulmonary embolism and cerebral bleeding) and of infections A00-B99, J10-18, N39, M86 or U07.

Results

We identified 1298 SLE patients in the region, of whom 673 was incident cases; all captures within one year from diagnosis. Of the incident cases, 76 (11%) died during 8434 years of follow-up (Table 1). The five-, ten-, 15- and 20-year survival for incident SLE patients (controls) was respectively 98 (98), 94 (96), 87 (94) and 82 (88) % and differed significantly first after ten years of disease duration compared to controls. Figure 1 shows 20-year survival for incident SLE patients and matched controls; stratified by gender. SMR for all SLE cases was 2.3 (95 % CI 1.5. - 4.0); female SLE 2.5 (95 % CI 1.6 – 3.9) and male SLE 1.9 (95 % CI 1.3 – 2.2). The most common immediate cause of death in SLE patients was CVD; whereof myocardial infarction (21 %) was most frequent. SLE patients died more often of CVD than controls (29 % vs. 21 %, p = 0.01) and had a tendency to more infections (23 % vs. 18 %, p = 0.07), whereof pneumonia (58 %) was most frequent.

Table 1.

Patient demographics, follow-up time and number of deaths in the total Systemic Lupus Erythematosus (SLE) cohort and in incident SLE patients.

Total SLE cohortIncident SLEFemaleMalen = 1298n = 577n = 96Of European descent, n (%)1140 (88)472 (82)86 (90)Juvenile onseta, n (%)93 (7)31 (5)6 (6)LNb, n (%)470 (36)177 (30)49 (51)Cumulative ACR criteriac, µ (SD)5.4 (1.2)5.3 (1.2)5.1(1.1)Follow-up years, total1925261601217Deaths, n (%)282 (23)54 (9)22 (23)Age at diagnosis, years µ (SD)35.5 (15.7)37.4 (15.6)44 (17.9)Disease duration at death, years µ (SD)20.4 (12.5)9.6 (5.8)10.6 (10.5)

µ: mean, n: number, SD: standard deviation

a Diagnosed before age of 16 b Lupus Nephritis defined by 1999 American College of Rheumatology classification criteria for Systemic Lupus Erythematosus c1997 American Collee of Rheumatology classification criteria for Systemic Lupus Erythematosus

Conclusion

Mortality in SLE is substantially increased. Differences in survival compared to the general population only appear after ten years of disease duration. CVD was the most common immediate cause of death and more frequent in SLE patients.

References

[1]Reppe Moe, S., Haukeland, H., Molberg, Ø., & Lerang, K. (2021). Long-Term Outcome in Systemic Lupus Erythematosus; Knowledge from Population-Based Cohorts. J Clin Med, 10(19). doi:10.3390/jcm10194306

Disclosure of Interests

None declared

AB0597 FDG-PET/CT IN THE DIAGNOSE AND FOLLOW UP OF TAKAYASU VASCULITIS

Background

Takayasu vasculitis (TAK) is a chronic disease, where clinic and serological markers as CRP/ESR may fail to predict development of new vascular lesions in the disease course (1). Similarly, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) studies show conflicting results on the association between vessel uptake of FDG and clinical and laboratory finding. A study on new FDG-PET activity scoring system, PETVAS was newly published but has not been validated in other cohorts (2). To date there are limited data on FDG-PET/CT finding at time of diagnoses before treatment induction and 18-FDG uptake and development of new stenosis during follow up.

Objectives

The goal of this study was to see; 1) FDG-PET/CT uptake in newly diagnosed patients before any treatment start 2) FDG-PET/CT uptake and development of new vascular lesions during follow up magnetic resonance angiography (MRA) 3) assess PETVAS score before and after treatment induction.

Methods

All patients in a population-based TAK cohort with FDG-PET/CT at the time of diagnoses before treatment induction were identified. Disease activity was assessed with the NIH activity score (1). Patients had to have clinical, laboratory and MR-angiography prior to/or right after FDG-PET/CT and a minimum of one follow up MRA. The clinical report from the FDG-PET/CT and MRA were reviewed and arteries/aorta regions with reported pathological uptake and stenosis/aneurysm were registrated. Images were reviewed and uptakes in 16 arteries/aorta regions of interest (supraaortic arteries, aorta, iliaca and femoral arteries) scored from 0-3, where 0 represent no uptake, 1 less then liver, 2 same as liver and 3 higher than liver and finally summarized these to PETVAS score.

Results

Twenty-three patients fulfilled the study’s inclusion criteria. Twenty-one of the patients were females (91%) and twenty-two were European Caucasian. The mean age was 39.3 (SD 14) at the time of diagnose (Table 1). Five patients were in clinical and laboratory remission at diagnose (NIH=0). Correspondently, none of them had sign of active FDG vessel uptake at PET-CT. They had a median 7 in PETVAS (range 0-13). The remaining 17 patients had clinical active disease (NIH>1) at diagnoses. All 17 patients had uptake on PET/CT in at least one artery/aorta region. The mean PETVAS score at diagnosis was 21.5 (SD 8). At last imaging the patients had developed median 2 new lesions. All the arteries that developed new lesion had active uptake on the original PET/CT. Fourteen patients had FDG PET/CT after treatment start. The PETVAS score decreased from 22.4 (SD 8.7) to 10.7 (SD 6.8) after treatment start (p<0.001).

Table 1.PatientAge at pet 1NIH 0-4CrpPETVAS1PETVAS 2Treatment at PET211512016264233169predn 10 mg, mtx 15 mg3263207180predn 15 mg, INF434313187predn 2.5 mg, mtx 20 mg, INF54033173213predn 10 mg, mtx 156483122216predn 5 mg, mtx 207553593720predn 10 mg, mtx 1585431823525predn 5 mg, mtx 15921419133predn 5 mg, mtx 2010364145184predn 7.5 mg, mtx 17.5 mg1127433147predn 5 mg, mtx 22.5123947157predn 10 mg, mtx 22.5 mg13314752111predn 10 mg, mtx 25, INF14394802416predn 7.5 mg, mtx 20 mg156341063516predn 10 mg, mtx 2016224120201727426321

Conclusion

All patients with clinical active disease at diagnoses had pathological FDG uptake. Only arteries with increased FDG uptake in the vascular wall subsequently developed new lesion. The study also showed that the PETVAS score fell significantly after treatment induction.

References

[1]Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, et al. Takayasu arteritis. Annals of internal medicine. 1994;120(11):919-29. Epub 1994/06/01.

[2]Grayson PC, Alehashemi S, Bagheri AA, Civelek AC, Cupps TR, Kaplan MJ, et al. (18) F-Fluorodeoxyglucose-Positron Emission Tomography As an Imaging Biomarker in a Prospective, Longitudinal Cohort of Patients With Large Vessel Vasculitis. Arthritis & rheumatology (Hoboken, NJ). 2018;70(3):439-49. Epub 2017/11/18.

Disclosure of Interests

None declared

POS0925 HIGH LEVELS OF BOTH CCL2 AND CCL17 WERE ASSOCIATED WITH MORE SEVERE SSc-ILD

Background

Systemic sclerosis (SSc) carries a high risk for progressive interstitial lung disease (ILD). Several anti-inflammatory therapies have been used to treat SSc-ILD and recently the first antifibrotic therapy has been approved. Personalized treatment strategies are largely missing to date. The two chemokines, CCL2 (MCP-1) and CCL17 (TARC), have been shown to be markers of inflammation and fibrosis, respectively.

Objectives

To examine associations between ILD severity and serum levels of CCL2 and CCL17 in two different but complementary sources of biomaterial.

Methods

Sera from the prospective Oslo University Hospital SSc cohort (n=371) and healthy blood donor controls (HC; n=100) and lung tissue at the time of lung transplantation from UCLA SSc-ILD patients (n = 12) and healthy donors (n = 12) were analyzed for CCL2 and CCL17 by multiplex assays. CCL2 and CCL17 levels were defined in serum as high or low using 95% CI in HC sera as cut-off values. Paired pulmonary function tests and HRCT images were obtained at baseline and follow-up. ILD was diagnosed on HRCT and categorized by the extent of lung fibrosis as limited (<10%) or extensive (>10%) ILD. Cellular sources of CCL-2 and CCL-17 in lung tissues were determined by immunohistochemistry. Descriptive statistics were applied.

Results

CCL2 and CCL17 were increased in SSc in sera and in lung tissue compared to HC (Figure 1). High levels of CCL17 (>700 pg/ml) and CCL2 (>1000pg/ml) in sera were identified in 43/254 (17%) and 84/471(18%) of the SSc patients (Table 1 and Figure 1). High levels of both CCL17 and CCL2 were associated with lower FVC at baseline and higher extent of lung fibrosis on HRCT (Table 1). Of those with high CCL2 and CCL17, 67% had extensive lung fibrosis. Categorization of ILD into no ILD, limited or extensive ILD showed an association between high CCL17 levels and the extent of fibrosis (Table 1). Reactive epithelium and macrophages and plasma cells expressed TARC, while more AM and infiltrating mononuclear cells expressed CCL-2.

Conclusion

High levels of both CCL17 and CCL2 were associated with more severe ILD and expressed in end-stage kung tissue and may reflect an ongoing inflammatory and fibrotic processes in SSc-ILD. This may have an implication on treatment choices for SSc-ILD.

Disclosure of Interests

Imon Barua: None declared, Vyacheslav Palchevskiy: None declared, Håvard Fretheim Shareholder of: non-financial support from GSK and

Actelion, outside the submitted work.,, Consultant of: Consultant of: Personal fees from Bayer and non-financial support from GSK and Actelion, outside the submitted work.,, Henriette Didriksen: None declared, Torhild Garen: None declared, Trond Mogens Aaløkken: None declared, Stephen Samuel Weigt: None declared, Øyvind Molberg: None declared, John Belperio: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche,, Consultant of: Actelion, ARXX therapeutics, Bayer, Janssen,, MSD, Lilly, Roche, Boehringer-Ingelheim, Medscape.,,, Grant/research support from: Boehringer Ingelheim

POS0065 INTERSTITIAL LUNG DISEASE ASSOCIATED WITH PRIMARY SJÖGREN’S SYNDROME IS FREQUENTLY PROGRESSIVE

Background

Interstitial lung disease (ILD) in primary Sjögren’s syndrome (pSS) has been reported to be present in 10-15% of patients, but pSS-ILD behavior over time is not well characterized.

Objectives

Assess the pattern of ILD in pSS, its disease behavior and factors associated with disease progression in a well-characterized pSS-ILD cohort.

Methods

All pSS patients from the Oslo University Hospital (OUH) were included if ILD was diagnosed on HRCT. Clinical characteristics, lung function tests including forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) and ILD pattern on HRCT assessed by a radiologist were evaluated. We determined ILD progression, defined as absolute FVC decline >5% or absolute DLCO decline >10% over 12 +/-6 months and increasing extent of ILD on HRCT over the observation period. Factors associated with disease progression were chosen based on expert opinion. Descriptive analyses were conducted

Results

Of 702 pSS patients followed at OUH, we identified 60 pSS patients with ILD with 33 (55%) having follow-up at 12 months (Table 1). Patients with pSS-ILD were characterized by high number of males (18%) and by frequent other extra-pulmonary organ involvement (48%) (Table 1). Mean time from pSS diagnosis to ILD diagnosis was 7.4 years. In 67% ILD was diagnosed after pSS, in 13% simultaneously, in 11% before pSS diagnosis and in 9% unknown. In total, 28 (47%) were diagnosed with lymphocytic interstitial pneumonia (LIP) and 32 (53%) with reticular pattern on HRCT. Over mean follow-up of 10.9 months (SD 4.2), 7/33 (21%) showed a FVC >5% decline, 9/32 (28%) a DLCO >10% decline and 12 (36%) had at least one of these defined lung function declines on standard of care treatment. Treatment was registered as ever used and by any indication. Over an observation period of 15.4 (SD 10.6) years, 27/47 (45%) showed any ILD progression on HRCT. HRCT pattern was not associated with risk of >10% DLCO decline or ILD progression on HCRT. >5% FVC decline occurred more frequently in patients with reticular pattern compared to LIP (6/17 (35%) vs 1/16 (6%), p=0.041). Factors significantly associated with ILD progression on lung function included higher baseline FVC (99% (SD16.4) vs 87% (SD14.9), p=0.032), higher DLCO (81% (SD13.1) vs 67% (SD17.4), p=0.020), increased CRP (2/10 (20%) vs 0/16 (0%), p=0.045) and presence of polyneuropathy (2/9 (22%) vs 1/17 (6%), p=0.045).

Table 1.

Clinical characteristics, demographics and outcome of pSS with ILD

pSS-ILD(n=60)Age at pSS diagnosis, y (SD)50 (21.9)Time from pSS to ILD diagnosis, y (SD)7.4 (8.9)Male sex, n (%)11 (18)Anti-SSA AB, n/50 (%)46 (92)Increased CRP, n/47 (%)7 (15)Low complements, n/49 (%)5 (10)Extra-pulmonary involvement, n/46 (%)22 (48)Deceased, n (%)10 (17)Pulmonary involvementFVC% predicted (SD)91 (18.7)FVC decline>5%, n/33 (%)7 (21)DLCO% predicted (SD)70 (20.7)DLCO decline >10%, n/32 (%)9 (32)ILD progression on HRCT, n/47 (%)27 (45)Treatment during follow upRituximab, n (%)11 (18)Any other immunosuppressive, n (%)20 (33)Hydroxychloroquine, n (%)16 (27)Nintedanib, n (%)1 (2)Lung transplant, n (%)1 (2)

Conclusion

A substantial number of patients with pSS-ILD progressed during the time of observation. This highlights the importance of close monitoring and active consideration of treatment options in pSS-ILD. Recommendations for disease management including screening, diagnosis, disease monitoring and treatment for pulmonary involvement in pSS are lacking to date, but are highly needed.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Håvard Fretheim Consultant of: Bayer, Grant/research support from: Jansen, Phuong Phuong Diep Speakers bureau: Boehringer Ingelheim, Karoline Lerang: None declared, Helena Andersson: None declared, Øyvind Midtvedt: None declared, Torhild Garen: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim and Roche, Grant/research support from: Boehringer Ingelheim and Roche, Trond M Aaløkken Speakers bureau: Boehringer Ingelheim, Øyvind Palm: None declared, Øyvind Molberg: None declared

POS0215 PHENOTYPES AND DISEASE CHARACTERISTICS OF IgG4-RELATED DISEASE IN NORWAY

Background

Milestones in the field of IgG4-related disease (IgG4-RD) include the 2011 Comprehensive Diagnostic Criteria (CDC) (1), the 2019 ACR/EULAR classification criteria (2), and the recent identification of four distinct clinical phenotypes (3). Performance of the criteria and phenotypic disease expression in Scandinavian populations are largely unknown.

Objectives

Describe disease characteristics, phenotypes, and performance of the 2011 CDC and 2019 ACR/EULAR classification criteria in patients with IgG4-RD in Norway.

Methods

Consenting, adult patients with a clinical diagnosis of IgG4-RD, seen at the Department of Rheumatology, Oslo University Hospital were included. Two experts (JV, ØMi) assigned patients to phenotypes (”Pancreato-Hepato-Biliary”, “Retroperitoneum and Aorta”, “Head and Neck-Limited” or “Mikulicz and Systemic”) based on pattern of organ involvement. Fulfillment of the CDC and classification criteria were assessed. Disease activity and damage were scored with the IgG4-RD responder index (IgG4-RD RI). We used descriptive statistics.

Results

We identified 60 patients with IgG4-RD (Table 1). Clinical characteristics were as expected, with approximately equal number of patients in each phenotype group. Of all patients diagnosed by expert opinion, 42 (70%) fulfilled the ACR/EULAR classification criteria. Reasons for not fulfilling the criteria were (i) failure to meet the inclusion criterium (n = 3) due to “atypical” organ involvement: tonsils (n = 1), nasal cavity (n = 1); coronary artery (n = 1); (ii) presence of ≥ 1 exclusion criterium (n = 5): fever (n = 1), leukopenia (n = 1), thrombocytopenia (n = 1), positive anti-MPO-ANCA (n = 3), anti-SSA (n = 1) and/or anti-RNP (n = 1) antibody; and (iii) score < 20 points (n = 10). In the latter group, 8 (80%) were not biopsied, and 1 (10%) had only performed fine needle biopsy. Among the patients not meeting the inclusion criterium or having ≥ 1 exclusion criteria, 1 (33%) and 4 (80%) scored ≥ 20 points, respectively. Of all patients, 56 (93%) fulfilled CDC, with 32 (53%), 10 (17%) and 14 (23%) patients characterized as “definite”, “probable” and “possible” IgG4-RD, respectively. Of the 18 patients not fulfilling the ACR/EULAR classification criteria, 15 (83%) fulfilled CDC (4 “definite”, 3 “probable”, 8 “possible”). Of the 4 patients not fulfilling CDC, 1 fulfilled the ACR/EULAR classification criteria.

Table 1.All (60)Pancreato-Hepato-Biliary (14)Retroperitoneum and aorta (12)Head and Neck-Limited (17)Mikulicz and Systemic (17)Male, n (%)44 (73)11 (79)9 (75)10 (59)14 (82)Caucasian, n (%)52 (87)14 (100)11 (92)13 (77)14 (82)Age at diagnosis, years (SD)60 (14)66 (9)64 (10)50* (17)61 (11)Time from onset to diagnosis, years (SD)2 (3)2 (3)2 (4)1 (1)4 (5)Serum IgG4, g/L (SD) (n=51)8 (9)5 (5)3 (2)7 (5)16* (13)Elevated baseline serum IgG4, n (%) (n=51)44 (86)9 (69)10 (91)11 (92)14 (93)CRP, mg/dL (SD)11 (26)4 (7)36* (52)9 (17)5 (4)ESR, mm/h (SD)35 (32)16 (11)63* (36)29 (29)39 (30)Eosinophilia, n (%) (n=46)17 (37)2 (22)06 (38)9 (64)CDC definite, n (%)32 (53)10 (71)3 (25)8 (47)11 (65)CDC probable, n (%)10 (17)3 (21)1 (8)5 (29)1 (6)CDC possible, n (%)14 (23)06 (50)4 (24)4 (24)ACR/EULAR classification criteria, n (%)42 (70)13 (93)5 (42)8 (47)16 (94)Number of involved organs (SD)Active, all4 (2)3 (2)2 (2)3 (1)6* (2)Active, symptoms2 (1)2 (1)1 (0)2 (1)3* (1)Active, urgent1 (1)1 (1)1 (1)0* (0)1 (1)Damage2 (1)2* (1)1 (1)1 (1)2* (2)IgG4-RD RI (SD)10 (5)9 (4)7 (4)7 (3)15* (4)

*p < 0,05 by one-way ANOVA

Conclusion

Despite expected clinical characteristics, phenotype distribution and fulfilment of CDC in our cohort, the performance of the ACR/EULAR classification criteria was lower than expected, especially in the “Retroperitoneum and Aorta” and “Head and Neck-Limited” phenotypes. This may have important implications for the comparability across studies and inclusion in future clinical trials.

References

[1]Umehara et al. Mod Rheumatol. 2012;22(1):21-30.

[2]Wallace et al. Ann Rheum Dis. 2020;79(1):77-87.

[3]Wallace et al. Ann Rheum Dis. 2019;78(3):406-412

Disclosure of Interests

Jens Vikse Speakers bureau: Novartis, Consultant of: Novartis, Jupiter Life Science Consulting, Øyvind Midtvedt: None declared, Øyvind Molberg: None declared, Bjørg Tilde Svanes Fevang: None declared, Øyvind Palm: None declared, Torhild Garen: None declared, Katrine Brække Norheim: None declared, Gunnstein Bakland: None declared, Marianne Wallenius: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

POS1366 RITUXIMAB IN IgG4-RD: AN OPEN-LABEL NON-RANDOMIZED OBSERVATIONAL STUDY

Background

IgG4-related disease (IgG4-RD) is a rare, heterogenous and potentially severe disease. An open-label trial demonstrated efficacy of rituximab (RTX) in IgG4-RD [1]. Recently, four distinct phenotypes of IgG4-RD were identified [2]. There is a paucity of studies investigating RTX efficacy across these phenotypes.

Objectives

Investigate efficacy and safety of RTX in IgG4-RD and segregated by phenotypes.

Methods

This is an open-label non-randomized single center observational study. All patients with IgG4-RD (diagnosed by expert opinion) at the Oslo University Hospital treated with ≥ 1 dose of RTX with 12 months follow-up were included. Two experts (JV, ØMi) assigned patients to phenotypes. Glucocorticoid (GC) treatment was allowed. We measured disease activity by the IgG4-RD Responder Index (IgG4-RD RI) at baseline, 6 months, and 12 months. We defined a composite primary outcome consisting of two measures; (i) reduced disease activity (i.e., ≥2 points improvement in IgG4-RD RI from baseline and/or IgG4-RD RI score 0 at follow-up), and (ii) no disease flares (i.e., no ≥2 points worsening of IgG4-RD RI and no need to increase GC dose) at 6 months. Secondary outcomes were (a) reduced disease activity at months 6 or 12, (b) remission (IgG4-RD RI score 0 and GC dose ≤ 7.5 mg) at 6 or 12 months and (c) safety. Descriptive statistics were applied.

Results

We included 40 patients, of which 30 (75%) were male and 35 (88%) Caucasian. Mean age and disease duration at time of first RTX infusion was 58 and 3 years, respectively. Seventeen of the 40 patients (43%) received RTX as add-on therapy (following GC for > 3 months), while 13 (33%) received RTX as upfront combination therapy with GC, and 10 (25%) received RTX as upfront monotherapy. All 40 patients received an infusion of 1000 mg RTX at study baseline (dose 1A at week 0) and 39 of these 40 patients (98%) received a second RTX infusion (dose 1B) at week 2. Additional infusions of 500-1000 mg RTX were administered at weeks 26 (dose 2A) and 28 (dose 2B) in 24 (60%) and 7 (18%) patients, respectively. The composite primary endpoint was met by 31/40 patients (78%). Reduced disease activity at 6 and 12 months were seen in 34 (87%) and 35 (90%) patients, respectively. Fifteen patients (38%) were in remission at 6 months, and 22 (56%) were in remission at 12 months. “Retroperitoneum and Aorta” showed lowest response rates, while “Head and Neck-Limited” had the highest rate of flares (Table 1). Mild infusion reaction occurred in 8 (20%) patients. Hypogammaglobulinemia was observed in 4 (10%). Infection requiring hospitalization occurred in 6 (15%), including one fatal infection which was the only death in the study period.

Table 1.All40 (100)Pancreato-Hepato-Biliary9 (23)Retroperitoneum and Aorta 6* (15)Head and Neck-Limited 14 (35)Mikulicz and Systemic 11 (28)Baseline (n=40)Male, n (%)30 (75)8 (89)5 (83)8 (57)9 (82)Caucasian (%)35 (88)9 (100)6 (100)12 (86)8 (73)Age, years (SD)58 (14)63 (9)66 (3)49 (18)60 (11)Disease duration, years (SD)3 (4)4 (3)3 (4)2 (2)5 (6)2019 ACR/EULAR classification criteria (%)28 (70)8 (89)3 (50)6 (43)11 (100)IgG4-RD RI at diagnosis (SD)10 (6)10 (5)7 (4)7 (3)17 (4)IgG4-RD RI at RTX 1A, (SD)8 (6)9 (4)5 (4)6 (4)12 (7)6 months (n=39)*IgG4-RD RI (SD)2 (2)3 (3)2 (2)1 (1)1 (2)Primary outcome, n (%) (n=40)31 (78)9 (100)3 (50)9 (64)10 (91)Reduced disease activity, n (%)34 (87)9 (100)3 (60)12 (86)10 (91)Remission, n (%)15 (38)4 (44)06 (43)5 (46)Flare, n (%)3 (8)003 (21)012 months (n=39)*IgG4-RD RI (SD)1 (1)1 (1)0 (1)1 (1)1 (2)Reduced disease activity, n (%)35 (90)9 (100)4 (80)12 (86)10 (91)Remission, n (%)22 (56)7 (78)3 (60)7 (50)5 (45)Flare, n (%)4 (10)1 (11)1 (20)2 (14)0

*One patient died shortly after 1A, and is not included in secondary efficacy outcomes

Conclusion

In our observational study, RTX appears safe and effective in IgG4-RD, with the highest response in patients with Pancreato-Hepato-Biliary phenotype. Relatively low remission rates across all phenotypes indicate an unmet need for improved treatment.

References

[1]Carruthers MN et al. Ann Rheum Dis. 2015;74(6):1171-1177.

[2]Wallace ZS et al. Ann Rheum Dis. 2019;78(3):406-412.

Disclosure of Interests

Jens Vikse Speakers bureau: Novartis, Consultant of: Novartis, Jupiter Life Science Consulting, Øyvind Midtvedt: None declared, Øyvind Molberg: None declared, Bjørg Tilde Svanes Fevang: None declared, Øyvind Palm: None declared, Torhild Garen: None declared, Katrine Brække Norheim: None declared, Gunnstein Bakland: None declared, Marianne Wallenius: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

Serum markers of cardiac complications in a systemic sclerosis cohort

Primary cardiac involvement is one of the leading causes of mortality in systemic sclerosis (SSc), but little is known regarding circulating biomarkers for cardiac SSc. Here, we aimed to investigate potential associations between cardiac SSc and candidate serum markers. Serum samples from patients of the Oslo University SSc cohort and 100 healthy controls were screened against two custom-made candidate marker panels containing molecules deemed relevant for cardiopulmonary and/or fibrotic diseases. Left (LV) and right ventricular (RV) dysfunction was assessed by protocol echocardiography, performed within three years from serum sampling. Patients suspected of pulmonary hypertension underwent right heart catheterization. Vital status at study end was available for all patients. Descriptive analyses, logistic and Cox regressions were conducted to assess associations between cardiac SSc and candidate serum markers. The 371 patients presented an average age of 57.2 (± 13.9) years. Female sex (84%) and limited cutaneous SSc (73%) were predominant. Association between LV diastolic dysfunction and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) (OR 0.41, 95% CI 0.21-0.78, p = 0.007) was identified. LV systolic dysfunction defined by global longitudinal strain was associated with angiopoietin 2 (ANGPT2) (OR 3.42, 95% CI 1.52-7.71, p = 0.003) and osteopontin (OPN) (OR 1.95, 95% CI 1.08-3.52, p = 0.026). RV systolic dysfunction, measured by tricuspid annular plane systolic excursion, was associated to markers of LV dysfunction (ANGPT2, OPN, and TRAIL) (OR 1.67, 95% CI 1.11-2.50, p = 0.014, OR 1.86, 95% CI 1.25-2.77, p = 0.002, OR 0.32, 95% CI 0.15-0.66, p = 0.002, respectively) and endostatin (OR 1.86, 95% CI 1.22-2.84, p = 0.004). In conclusion, ANGPT2, OPN and TRAIL seem to be circulating biomarkers associated with both LV and RV dysfunction in SSc.

Gastrointestinal symptom severity and progression in systemic sclerosis

OBJECTIVES

To evaluate the severity and evolution of patient-reported gastrointestinal tract (GIT) symptoms in systemic sclerosis (SSc) patients, assess predictive factors for progression and determine the impact of standard of care treatment.

METHODS

SSc patients from the Leiden and Oslo cohorts were included. We assessed clinical data and patient-reported GIT symptoms measured by the validated University of California, Los-Angeles Gastrointestinal-tract (UCLA-GIT) score at baseline and annually. GIT severity and progression was determined. Logistic regression was applied to identify risk factors associated with baseline GIT symptom severity. Linear mixed-effect models were applied to assess progression in GIT symptom burden and to identify predictive factors. We repeated all analysis in patients with early disease (inception cohort) to exclude the effect of longstanding disease and increase insights in development of GIT symptom burden early in the disease course.

RESULTS

We included 834 SSc patients with baseline UCLA GIT scores, 454 from Leiden and 380 from Oslo. In the total cohort, 28% reported moderate-severe GIT symptoms at baseline, with increased risk for severity conferred by ACA, smoking and corticosteroid use, while use of calcium channel blockers appeared protective. In the inception cohort, 23% reported moderate-severe GIT symptoms at baseline, with increased risk for females and with smoking. Over time, symptom burden increased mainly for reflux/bloating. Female sex and ACA predicted GIT symptom progression.

CONCLUSION

High GIT symptom burden is present early in SSc disease course. Both for prevalence and for progression of GIT symptom burden, female sex and smoking were identified as risk factors.

Contribution of Rare Genetic Variation to Disease Susceptibility in a Large Scandinavian Myositis Cohort

OBJECTIVE

Idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of complex autoimmune conditions characterized by inflammation in skeletal muscle and extramuscular compartments, and interferon (IFN) system activation. We undertook this study to examine the contribution of genetic variation to disease susceptibility and to identify novel avenues for research in IIMs.

METHODS

Targeted DNA sequencing was used to mine coding and potentially regulatory single nucleotide variants from ~1,900 immune-related genes in a Scandinavian case-control cohort of 454 IIM patients and 1,024 healthy controls. Gene-based aggregate testing, together with rare variant- and gene-level enrichment analyses, was implemented to explore genotype-phenotype relations.

RESULTS

Gene-based aggregate tests of all variants, including rare variants, identified IFI35 as a potential genetic risk locus for IIMs, suggesting a genetic signature of type I IFN pathway activation. Functional annotation of the IFI35 locus highlighted a regulatory network linked to the skeletal muscle-specific gene PTGES3L, as a potential candidate for IIM pathogenesis. Aggregate genetic associations with AGER and PSMB8 in the major histocompatibility complex locus were detected in the antisynthetase syndrome subgroup, which also showed a less marked genetic signature of the type I IFN pathway. Enrichment analyses indicated a burden of synonymous and noncoding rare variants in IIM patients, suggesting increased disease predisposition associated with these classes of rare variants.

CONCLUSION

Our study suggests the contribution of rare genetic variation to disease susceptibility in IIM and specific patient subgroups, and pinpoints genetic associations consistent with previous findings by gene expression profiling. These features highlight genetic profiles that are potentially relevant to disease pathogenesis.

Body composition in longstanding juvenile dermatomyositis; Associations with disease activity, muscle strength and cardiometabolic measures

OBJECTIVE

To (i) compare body composition parameters in patients with longstanding juvenile dermatomyositis (JDM) and controls and (ii) explore associations between body composition and disease activity/inflammation, muscle strength, health-related quality of life (HRQL) and cardiometabolic measures.

METHODS

In a cross-sectional study, we included 59 patients (median disease duration 16.7 y; median age 21.5 y) and 59 age- and sex-matched controls. Active/inactive disease were defined by the PRINTO criteria. Body composition was assessed by total body dual-energy absorptiometry (DXA), inflammation by hs-CRP and cytokines, muscle strength by manual muscle test (MMT-8), HRQL by 36-item short form survey physical component score (SF-36 PCS) and cardiometabolic function by echocardiography (systolic and diastolic function) and serum-lipids.

RESULTS

DXA analyses revealed lower appendicular lean mass index (ALMI) (reflecting limb skeletal muscle mass), higher body fat percentage (BF%) and higher android: gynoid fat ratio (A: G ratio) (reflecting central fat distribution) in patients than controls, despite similar BMI. Patients with active disease had lower ALMI and higher BF% than those with inactive disease; lower ALMI and higher BF% were associated with inflammation (elevated monocyte attractant protein-1 (MCP-1) and hs-CRP). Lower ALMI was associated with reduced muscle strength; higher BF% was associated with impaired HRQL. Central fat distribution (higher A: G ratio) was associated with impaired cardiac function and unfavorable serum-lipids.

CONCLUSION

: Despite normal BMI, patients with JDM, especially those with active disease, had unfavorable body composition, which was associated with impaired HRQL/muscle strength and cardiometabolic function. The association between central fat distribution and cardiometabolic alterations is a novel finding in JDM.

Small intestinal biopsy findings consistent with celiac disease in patients with idiopathic inflammatory myopathy: Review of existing literature

BACKGROUND

Case reports have described patients with idiopathic inflammatory myopathies (IIM) and a concurrent diagnosis of celiac disease (CeD) for whom the muscle inflammation (myositis) component of IIM improves after the patients start standard treatment with gluten-free diet (GFD). A connection between IIM and CeD is not commonly recognized.

AIM

In this first systematic review of the topic, we aimed to explore all peer-reviewed publications of IIM cases and concomitant small intestinal biopsy findings consistent with CeD, published after 1975.

METHODS

Systematic literature searches were performed in MEDLINE, PubMed, and EMBASE, supplemented by screening of references and non-systematic searches via Google and Google Scholar.

RESULTS

Altogether 30 cases published between 1976 and 2017 were uncovered. Information about gastrointestinal symptoms prior to CeD diagnosis was available for 19 patients, with 6/19 (32%) reporting no GI symptoms. CeD-related serological data were available in 23/30 patients. Endomysial antibodies were present in 10/18 (56%), while only 2/9 (22%) had antibodies against tissue transglutaminase. Serum antibodies to native gliadin were present in 16/18 (89%). Clinical effects of a GFD on the IIM were reported for 24 patients, with signs of improvement in 14/24 (58%), including three patients with otherwise therapy-resistant inclusion body myositis. Longitudinal follow-up data available from the published studies indicated that 7/24 (29%) remained in clinical IIM remission with GFD as the sole therapeutic intervention.

CONCLUSION

In the IIM cases presented here, duodenal biopsy findings consistent with celiac disease was sometimes present without classical CeD symptoms or positive traditional CeD serology, and in the majority of cases, the IIM improved after introduction of a gluten-free diet. While extra vigilance towards CeD in IIM patients seems warranted, there is need for more research to clarify if GFD has effects on organ systems other than the small intestine in patients with IIM and small intestinal biopsy findings consistent with CeD.

Safety and efficacy of faecal microbiota transplantation by Anaerobic Cultivated Human Intestinal Microbiome (ACHIM) in patients with systemic sclerosis: study protocol for the randomised controlled phase II ReSScue trial

INTRODUCTION

In the multisystem inflammatory disorder systemic sclerosis (SSc), gastrointestinal tract (GIT) affliction is highly prevalent. There are no known disease modifying therapies and the negative impact is substantial. Aiming for a new therapeutic principle, and inspired by recent work showing associations between gut microbiota changes and GIT symptoms in SSc, we performed a pilot study on faecal microbiota transplantation (FMT) with the single-donor bacterial culture 'Anaerobic Cultivated Human Intestinal Microbiome (ACHIM)'. Motivated by positive pilot study signals, we designed the ReSScue trial as a phase II multicentre, placebo-controlled, randomised 20-week trial to evaluate safety and efficacy on lower GIT symptoms of FMT by ACHIM in SSc.

METHODS AND ANALYSES

We aim to include 70 SSc participants with moderate to severe lower GIT symptoms, defined by the validated patient-reported University of California Los Angeles Scleroderma Clinical Trial Consortium GIT 2.0 2.0 questionnaire. The trial includes three parts. In part A1 (induction phase) lasting from week 0 to week 12, participants will be randomised 1:1 to repeat infusions of 30 mL ACHIM or placebo at week 0 and 2 by gastroduodenoscopy. In part A2, which is an 8-week subsequent maintenance phase, all study participants will receive 30 mL ACHIM at week 12 and followed until week 20 on continued blind. In part B, which will last until the last participant completes part A2, the participants will be followed through a maximum 16-week extended monitoring period, for longer-term data on safety and intervention effects. Primary endpoint is change from baseline to week 12 in UCLA GIT subscale scores of diarrhoea or bloating, depending on the worst symptom at baseline evaluated separately for each patient. Secondary endpoints are safety measures and changes in UCLA GIT scores (total, diarrhoea and bloating).

ETHICS AND DISSEMINATION

This protocol was approved by the Northern Norwegian Committee for Medical Ethics. Study findings will be published.

TRIAL REGISTRATION NUMBER

NCT04300426; Pre-results.

PROTOCOL VERSION

V.3.1.

Variants in BANK1 are associated with lupus nephritis of European ancestry

The genetic background of lupus nephritis (LN) has not been completely elucidated. We performed a case-only study of 2886 SLE patients, including 947 (33%) with LN. Renal biopsies were available from 396 patients. The discovery cohort (Sweden, n = 1091) and replication cohort 1 (US, n = 962) were genotyped on the Immunochip and replication cohort 2 (Denmark/Norway, n = 833) on a custom array. Patients with LN, proliferative nephritis, or LN with end-stage renal disease were compared with SLE without nephritis. Six loci were associated with LN (p < 1 × 10⁻⁴, NFKBIA, CACNA1S, ITGA1, BANK1, OR2Y, and ACER3) in the discovery cohort. Variants in BANK1 showed the strongest association with LN in replication cohort 1 (p = 9.5 × 10⁻⁴) and proliferative nephritis in a meta-analysis of discovery and replication cohort 1. There was a weak association between BANK1 and LN in replication cohort 2 (p = 0.052), and in the meta-analysis of all three cohorts the association was strengthened (p = 2.2 × 10⁻⁷). DNA methylation data in 180 LN patients demonstrated methylation quantitative trait loci (meQTL) effects between a CpG site and BANK1 variants. To conclude, we describe genetic variations in BANK1 associated with LN and evidence for genetic regulation of DNA methylation within the BANK1 locus. This indicates a role for BANK1 in LN pathogenesis.

POS0867 ALTERATION OF DUODENAL HISTOLOGY IN SYSTEMIC SCLEROSIS PATIENTS AFTER FECAL MICROBIOTA TRANSPLANTATION

Background:

Systemic sclerosis (SSc) is a complex autoimmune, multi-organ disease with gastro-intestinal tract (GIT) involvement significantly contributing to comorbidity. While understanding of mechanisms behind SSc-related GIT disease is incomplete, recent work shows that altered gut microbiota (dysbiosis) is present in many patients and associates with specific GIT symptoms. Intending to improve dysbiosis, we set up the controlled ReSScue pilot trial, where fecal microbiota transplantation (FMT) was conducted by duodenal infusions of Anaerobic Cultivated Human Intestinal Microbiome (ACHIM) or placebo. The results indicated that FMT by ACHIM induced short-term improvement on patient reported GIT symptoms, as evaluated by the validated UCLA GIT score (1). Duodenal biopsies were taken before and after FMT to assess potential effects of ACHIM on small intestinal mucosa.

Objectives:

Assessment of duodenal histology and GIT symptoms before and after FMT by ACHIM compared to placebo.

Methods:

In this explorative study, we assessed duodenal biopsies collected prior to first FMT (week 0), prior to second FMT (week 2) and at study end (week 16) from ReSScue trial patients who either received ACHIM (n=5) or placebo (n=4). To examine potential effects of FMT on the duodenal mucosa, we performed immunohistochemistry (IHC) staining on paraffin-embedded tissue samples using the following markers: Sirius red (SIR) for collagen fibers and monoclonal antibodies against gp38 (podoplanin, as marker for lymphatic vessels and fibroblasts), CD38 (as preliminary marker for adaptive immune cells) and CD64 (as preliminary marker for innate immune cells). We determined staining per area in the individual tissue slides for each marker using ImageJ Fiji. The mean total UCLA GIT score for the patients were calculated at week 0, 2 and 16, as well as the mean staining per area of the duodenum biopsies at week 0, 2 and 6 for all the markers. Finally, correlations between mean staining per area and mean total UCLA GIT score were assessed for ACHIM and placebo patient groups by Pearson correlation (r).

Results:

All nine patients included in the pilot trial were female and had limited cutaneous SSc. Groups receiving ACHIM and placebo had comparable disease duration (1). We found that relative change in staining per area for SIR from week 0 to week 2 differed between the ACHIM group and the placebo group (Figure 1A, left panel). Similar changes were observed for anti-gp38, anti-CD38 and anti-CD64 (left panel in Figures 1B-D). Strong correlations were found between mean total UCLA GIT score and the mean staining per area of the markers SIR (r=0.98), anti-gp38 (r=0.94), anti-CD34 (r=0.85) and CD64 (r=0.93) in the ACHIM group (Figure 1, A-D). In the placebo group, there was no correlation between the UCLA GIT score and anti-gp38 (r=0.22) and anti-CD64 (r=0.21), however, a strong correlation were observed to SIR (r=0.86) and anti-CD38 (r=0.92) staining (Figure 1A-D, right panel).

Conclusion:

This explorative data set indicates different effects of FMT by ACHIM and placebo on the duodenal mucosa of SSc patients with GIT affection. Interestingly, we observed correlations between mucosal markers and improved patient reported GIT symptoms in the ACHIM group.

References:

[1]Fretheim H, Chung BK, Didriksen H, Bækkevold ES, Midtvedt Ø, Brunborg C, et al. Fecal microbiota transplantation in systemic sclerosis: A double-blind, placebo-controlled randomized pilot trial. PLoS One. 2020;15(5):e0232739.

Figure 1.

Relative staining per area in ACHIM and placebo group (left panel) and correlation between total UCLA GIT score and staining ratios at time point 0, 2 and 16 weeks in patients receiving ACHIM and placebo (right panel).

Acknowledgements:

We will like to thank Maria Comazzi for all the work she have done with the IHC stainings

Disclosure of Interests:

Henriette Didriksen Speakers bureau: Travel bursary - GSK

Travel bursary and speaker - Actelion, Noemi Strahm: None declared, Øyvind Molberg: None declared, Håvard Fretheim Speakers bureau: Received travel bursaries from Actelion, and remuneration from Bayer., Torhild Garen: None declared, Øyvind Midtvedt: None declared, Oliver Distler Speakers bureau: Actelion, Kymera Therapeutics, Mitsubishi Tanabe Pharma, Abbvie, Acceleron, Alexion, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Corbus Pharmaceuticals, Drug Development International Ltd, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Kymera Therapeutics, Lilly, Novartis, Pfizer, Topadur and UCB, Grant/research support from: Boehringer Ingelheim, Beyer, Gabriela Kania: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Roche, Bayer, Merck Sharp & Dohme, Lilly, ARXX and Medscape, Grant/research support from: Boehringer Ingelheim

AB0433 STUDY DESIGN FOR THE RANDOMISED CONTROLLED PHASE II ReSScue TRIAL: SAFETY AND EFFICACY OF FAECAL MICROBIOTA TRANSPLANTATION BY ANAEROBIC CULTIVATED HUMAN INTESTINAL MICROBIOME (ACHIM) IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Gastro-intestinal tract (GIT) symptoms is highly prevalent in patients with systemic sclerosis (SSc). The GIT-symptoms impact on the quality of life is significant, and available treatment alternatives are limited. Recently published articles show associations between gut microbiota changes and GIT-symptoms in SSc. We, therefore, performed a successful feasibility trial on faecal microbiota transplantation (FMT) in SSc patients using the single-donor bacterial culture “Anaerobic Cultivated Human Intestinal Microbiome (ACHIM)”. Based on the promising results from the feasibility trial, we aim to evaluate the safety and efficacy of FMT by ACHIM in SSc patients. (NCT04300426)

Objectives:

To design a clinical trial that explores the safety and efficacy of FMT in SSc patients.

Methods:

The ReSScue trial is a phase II, placebo-controlled, randomised 20-week, multicentre trial. The trial comprises three parts. In the induction phase (A1) lasting from week 0 to week 12, participants are randomised 1:1 to repeat infusions of 30 ml ACHIM or placebo at week 0 and 2 by gastro-duodenoscopy. In the maintenance phase (A2), all study participants will receive 30 ml ACHIM at week 12 and are followed continued blinded until week 20.

For longer-term data on intervention effects and safety, the participant will be followed for a maximum extended monitoring period of 16 weeks (part B).

The primary endpoint is change from baseline to week 12 in UCLA GIT scores on bloating or diarrhoea, depending on the worst symptom at baseline evaluated separately for each patient. Secondary endpoints are changes in UCLA GIT scores (bloating, diarrhoea and total) and safety measures.

Results:

We aim to enrol 70 SSc patients based on the power calculations for the primary endpoint “change in worst symptom from baseline to week 12”, with a considered drop out rate of 10%. This number of patients is expected to give a power of 80% of detecting a change in mean (p=0.05, two-sided) of -5.0 (or higher) if the relating standard deviation is 0.70 or lower. The patient screening started in September 2020, and we expect the study to be completed in May 2022.

Conclusion:

The ReSScue-study is to our knowledge the first FMT-study in SSc. This trial will assess the safety and efficacy of FMT in SSc patients with lower GI-symptoms, possibly leading to a novel treatment approach in SSc patients.

Disclosure of Interests:

Håvard Fretheim Grant/research support from: Received travel bursaries from Actelion, and remuneration from Bayer., Imon Barua: None declared, Vikas Sarna: None declared, Maylen N Carstens: None declared, Oliver Distler Speakers bureau: Below, Consultant of: Below, Grant/research support from: OD has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx, Baecon Discovery, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos NV, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Italfarmaco, iQone, Kymera, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Dinesh Khanna Consultant of: Abbvie, Actelion/Janssen, Acceleron Pharma, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, GSK, Horizon Pharmaceuticals, Mitsubishi Tanabe Pharma, Pfizer, Roche, Sanofi, United Therapeutics. DK is chief medical officer of Eicos Sciences, Inc., Grant/research support from: Abbvie, Actelion/Janssen, Acceleron Pharma, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, GSK, Horizon Pharmaceuticals, Mitsubishi Tanabe Pharma, Pfizer, Roche, Sanofi, United Therapeutics. DK is chief medical officer of Eicos Sciences, Inc., Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Boehringer Ingelheim, Øyvind Midtvedt Shareholder of: Son of owner of ACHIM., Henriette Didriksen Speakers bureau: Travel bursary - GSK, Alvilde Dhainaut: None declared, Anna-Kristine H Halse: None declared, Gunnstein Bakland: None declared, Inge Christoffer Olsen: None declared, Maiju E Pesonen: None declared, Øyvind Molberg: None declared, Anna-Maria Hoffmann-Vold Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Medscape, Merck Sharp & Dohme, Lilly and Roche., Grant/research support from: Actelion, ARXX, Bayer, Boehringer Ingelheim, Medscape, Merck Sharp & Dohme, Lilly and Roche.

OP0174 SUBCLINICAL INTERSTITIAL LUNG DISEASE IS FREQUENT AND PROGRESSES ACROSS DIFFERENT CONNECTIVE TISSUE DISEASES

Background:

Based on the argument that symptoms define disease, physicians commonly apply the terms “preclinical” or “subclinical” disease to describe patients with disease-related findings but no accompanying symptoms for connective tissue disease associated interstitial lung disease (CTD-ILD). The term subclinical frequently applies to patients with mild ILD changes on high resolution chest tomography (HRCT), normal forced vital capacity (FVC), and without respiratory symptoms. Previous work in systemic sclerosis (SSc)-ILD did show that patients with even minor extent of ILD at baseline often progressed and had increased mortality risk, suggesting that it is not appropriate to define these patients as “subclinical.”

Objectives:

To identify the prevalence of subclinical ILD across CTD diagnoses, and assess the rate of progression of lung fibrosis compared to CTD without ILD and with clinical ILD.

Methods:

All CTD patients, including SSc, anti-synthetase syndrome (ASS) and mixed connective tissue disease (MCTD) from the Oslo University Hospital diagnosed before 2015 and assessed for the presence of ILD by HRCT were included. The year 2015 was chosen to secure an observation time of at least five years from ILD diagnosis to study end on 01.01.2021 or time of death. All patients fulfilled the respective CTD classification criteria. Subclinical ILD was defined as an ILD extent <5% by semi-quantitative assessment of baseline HRCT, preserved lung function with FVC >80% predicted and without respiratory symptoms. Clinical ILD was defined as >5% extent of ILD or <5% extent of ILD on HRCT with respiratory symtoms or FVC<80%. The outcome was ILD progression, defined as increasing extent of ILD from basline to follow-up HRCT by semi-quantitative assessment. Vital status was available in all patients and mortality was evaluated. Descriptive statistical analyses were conducted and time to ILD progression determined by Kaplan-Meier estimates.

Results:

We identified 525 CTD patients, including 296 with SSc, 135 with MCTD and 94 with ASS who had conducted a baseline HRCT. Of these, 227 (43%) had no ILD, 67 (13%) subclinical and 231 (44%) clinical ILD (Table). Of the 67 subclinical ILD patients, 45 (15%) had SSc, 13 (10%) MCTD and 9 (10%) ASS of thespecific cohorts. Over a median time of 4.5 years between baseline and follow-up HRCT, 95/395 (24%) showed progression of ILD, including 72 (26%) SSc and 23 (19%) MCTD patients. Disease progression frequently occurred in both subclinical ILD (38%) and clinical ILD (51%) patients (Figure). Age, gender, underlying CTD, and baseline lung function were not predictive for the progression of lung fibrosis. Progression was too infrequent to allow for meaningful multivariable regression analyses. After a median observation period of 12 years, 153 (29%) of the patients died. The 1-, 5- and 10-year survival rates in those without ILD, subclinical and clinical ILD were 97%/97%/99%, 88%/91%/82%, and 82%/85%/68% (p<0.001), respectively.

Table 1.

Clinical characteristics, demographics and outcome

No ILD (n=227)Subclinical ILD (n=67)Clinical ILD (n=231)Age, y (SD)50 (15.4)51 (14.4)52 (15.3)Male sex, n (%)89 (39)22 (33)111 (48)Deceased, n (%)50 (22)12 (18)91 (39)Observation period, y median (range)13.7 (18.6)13.9 (17.9)11.5 (17.1)FVC% (SD)97 (18.6)99 (17.9)81 (20.9)FVC decline% (SD)-0.70 (11.1)-0.81 (16.5)-1.61 (15.9)DLCO% (SD)73 (19.4)73 (16.9)55 (17.4)Extent of ILD% (SD)0 (0)2.3 (1.5)19.3 (16.8)ILD progression% (SD)0.08 (1.0)3.1 (6.2)3.6 (9.9)ILD progressors, n (%)3 (2)20 (38)72 (51)Figure 1.

Time to ILD progression in CTD without ILD, with subclinical and clinical ILD

Conclusion:

Subclinical ILD is frequently present across CTDs and progresses over time in a substantial subgroup of patients, comparable to patients with clinical ILD. Our findings question the terms sub- and preclinical ILD, which may potentially lead to a suboptimal “watchful waiting management strategy”. Monitoring all CTD patients with any ILD is of high importance to identify disease progression early.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Roche, Merck Sharp & Dohme, Lilly and Medscape, Consultant of: Actelion, Boehringer Ingelheim, Bayer, ARXX, and Medscape, Grant/research support from: Boehringer Ingelheim, Helena Andersson: None declared, Silje Reiseter: None declared, Håvard Fretheim Consultant of: Actelion, Bayer., Imon Barua: None declared, Torhild Garen: None declared, Øyvind Midtvedt: None declared, Ragnar Gunnarsson: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim and Roche, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Trond M Aaløkken: None declared, Øyvind Molberg: None declared

Interaction between the STAT4 rs11889341(T) risk allele and smoking confers increased risk of myocardial infarction and nephritis in patients with systemic lupus erythematosus

Objective

To investigate how genetics influence the risk of smoking-related systemic lupus erythematosus (SLE) manifestations.

Methods

Patients with SLE (n_{discovery cohort}=776, n_{replication cohort}=836) were genotyped using the 200K Immunochip single nucleotide polymorphisms (SNP) Array (Illumina) and a custom array. Sixty SNPs with SLE association (p<5.0×10⁻⁸) were analysed. Signal transducer and activator of transcription 4 (STAT4) activation was assessed in in vitro stimulated peripheral blood mononuclear cells from healthy controls (n=45).

Results

In the discovery cohort, smoking was associated with myocardial infarction (MI) (OR 1.96 (95% CI 1.09 to 3.55)), with a greater effect in patients carrying any rs11889341 STAT4 risk allele (OR 2.72 (95% CI 1.24 to 6.00)) or two risk alleles (OR 8.27 (95% CI 1.48 to 46.27)).

Smokers carrying the risk allele also displayed an increased risk of nephritis (OR 1.47 (95% CI 1.06 to 2.03)). In the replication cohort, the high risk of MI in smokers carrying the risk allele and the association between the STAT4 risk allele and nephritis in smokers were confirmed (OR 6.19 (95% CI 1.29 to 29.79) and 1.84 (95% CI 1.05 to 3.29), respectively).

The interaction between smoking and the STAT4 risk allele resulted in further increase in the risk of MI (OR 2.14 (95% CI 1.01 to 4.62)) and nephritis (OR 1.53 (95% CI 1.08 to 2.17)), with 54% (MI) and 34% (nephritis) of the risk attributable to the interaction. Levels of interleukin-12-induced phosphorylation of STAT4 in CD8+ T cells were higher in smokers than in non-smokers (mean geometric fluorescence intensity 1063 vs 565, p=0.0063).

Lastly, the IL12A rs564799 risk allele displayed association with MI in both cohorts (OR 1.53 (95% CI 1.01 to 2.31) and 2.15 (95% CI 1.08 to 4.26), respectively).

Conclusions

Smoking in the presence of the STAT4 risk gene variant appears to increase the risk of MI and nephritis in SLE. Our results also highlight the role of the IL12−STAT4 pathway in SLE-cardiovascular morbidity.

Association of Lymphangiogenic Factors With Pulmonary Arterial Hypertension in Systemic Sclerosis

OBJECTIVE

Pulmonary arterial hypertension (PAH) is a major complication in systemic sclerosis (SSc), a disease marked by vascular and lymphatic vessel abnormalities. This study was undertaken to assess the role of the lymphangiogenic factors vascular endothelial growth factor C (VEGF-C) and angiopoietin 2 (Ang-2) and the soluble forms of their respective cognate receptors, soluble VEGF receptor 3 (sVEGFR-3) and soluble TIE-2, in patients with SSc, and to evaluate their predictive ability as markers for PAH development in SSc.

METHODS

In this cohort study, we used multiplex bead assays to assess serum levels of lymphangiogenic factors in 2 well-characterized SSc cohorts: an unselected identification cohort of SSc patients from Oslo University Hospital (n = 371), and a PAH-enriched validation cohort of SSc patients from Zurich University Hospital and Oslo University Hospital (n = 149). As controls for the identification and validation cohorts, we obtained serum samples from 100 healthy individuals and 68 healthy individuals, respectively. Patients in whom SSc-related PAH was identified by right-sided heart catheterization (RHC) in both cohorts were studied in prediction analyses. PAH was defined according to the European Society of Cardiology/European Respiratory Society 2015 guidelines for the diagnosis and treatment of PAH. Associations of serum levels of lymphangiogenic factors with the risk of PAH development were assessed in logistic regression and Cox regression analyses. Associations in Cox regression analyses were expressed as the hazard ratio (HR) with 95% confidence interval (95% CI).

RESULTS

In the identification cohort, SSc patients had lower mean serum levels of VEGF-C and higher mean serum levels of Ang-2 compared to healthy controls (for VEGF-C, mean ± SD 2.1 ± 0.5 ng/ml in patients versus 2.5 ± 0.4 ng/ml in controls; for Ang-2, mean ± SD 6.1 ± 7.6 ng/ml in patients versus 2.8 ± 1.8 ng/ml in controls; each P < 0.001); these same trends were observed in SSc patients with PAH compared to those without PAH. The association of serum VEGF-C levels with SSc-PAH was confirmed in the PAH-enriched RHC validation cohort. For prediction analyses, we assembled all 251 cases of SSc-PAH identified by RHC from the identification and validation cohorts. In multivariable Cox regression analyses adjusted for age and sex, the mean serum levels of VEGF-C and sVEGFR-3 were predictive of PAH development in patients with SSc (for VEGF-C, HR 0.53 [95% CI 0.29-0.97], P = 0.04; for sVEGFR-3, HR 1.21 [95% CI 1.01-1.45], P = 0.042).

CONCLUSION

These findings support the notion that lymphangiogenesis is deregulated during PAH development in SSc, and indicate that VEGF-C could be a promising marker for early PAH detection in patients with SSc.

Impact of baseline clinical and radiological features on outcome of chronic rhinosinusitis in granulomatosis with polyangiitis

BACKGROUND

Granulomatosis with polyangiitis (GPA) causes a recurring inflammation in nose and paranasal sinuses that clinically resembles chronic rhinosinusitis (CRS) of other aetiologies. While sinonasal inflammation is not among the life-threatening features of GPA, patients report it to have major negative impact on quality of life. A relatively large proportion of GPA patients have severe CRS with extensive damage to nose and sinus structures evident by CT, but risk factors for severe CRS development remain largely unknown. In this study, we aimed to identify clinical and radiological predictors of CRS-related damage in GPA.

METHODS

We included GPA patients who had clinical data sets from time of diagnosis, and two or more paranasal sinus CT scans obtained ≥12 months apart available for analysis. We defined time from first to last CT as the study observation period, and evaluated CRS development across this period using CT scores for inflammatory sinus bone thickening (osteitis), bone destructions, and sinus opacifications (here defined as mucosal disease). In logistic regression, we applied osteitis as main outcome measure for CRS-related damage.

RESULTS

We evaluated 697 CT scans obtained over median 5 years observation from 116 GPA patients. We found that 39% (45/116) of the GPA patients remained free from CRS damage across the study observation period, while 33% (38/116) had progressive damage. By end of observation, 32% (37/116) of the GPA patients had developed severe osteitis. We identified mucosal disease at baseline as a predictor for osteitis (odds ratio 1.33), and we found that renal involvement at baseline was less common in patients with severe osteitis at last CT (41%, 15/37) than in patients with no osteitis (60%, 27/45).

CONCLUSIONS

In this largely unselected GPA patient cohort, baseline sinus mucosal disease associated with CRS-related damage, as measured by osteitis at the end of follow-up. We found no significant association with clinical factors, but the data set indicated an inverse relationship between renal involvement and severe sinonasal affliction.

Longitudinal Characterisation of the Gastrointestinal Tract Microbiome in Systemic Sclerosis

Objectives

To evaluate changes in microbial composition and the evolution of gastrointestinal tract (GIT) symptoms in systemic sclerosis (SSc).

Methods

Adult SSc patients provided stool specimens every 3 months over the course of 1 year. Participants completed the University of California, Los Angeles (UCLA) GIT 2.0 questionnaire to assess GIT symptom severity at each stool collection. The microbiota from these samples were determined by Illumina HiSeq 2500 16S ribosomal RNA sequencing (Illumina, Inc., San Diego, California, USA). Mixed effect models evaluated changes in GIT symptoms and microbial composition over time.

Results

Among 19 patients with SSc (female; 89.5%; median age: 51.3 years), the median disease duration was 7 years and the baseline total GIT 2.0 score was 0.7 (standard deviation: 0.6). The majority of participants (63%) provided at least four stool samples over the course of the 12-month study. Patients with longer disease durations had increased GIT symptoms over the course of the study. There was no difference in the course of GIT symptoms over time between patients with limited versus diffuse cutaneous disease. The relative abundances of specific genera did not change over time within individual subjects. After controlling for age, sex, ethnicity, disease duration, and SSc subtype (i.e., limited versus diffuse), low abundance of Bacteroides was associated with increased GIT symptoms over time.

Conclusion

This study is the first to have longitudinally characterised the lower GIT microbiome in SSc patients and demonstrated relative stability of genera abundance over the course of 1 year. The findings provide additional evidence that specific genera are associated with SSc-GIT symptoms and warrant further evaluation in larger SSc studies.

Molecular pathways in patients with systemic lupus erythematosus revealed by gene-centred DNA sequencing

Objectives

Systemic lupus erythematosus (SLE) is an autoimmune disease with extensive heterogeneity in disease presentation between patients, which is likely due to an underlying molecular diversity. Here, we aimed at elucidating the genetic aetiology of SLE from the immunity pathway level to the single variant level, and stratify patients with SLE into distinguishable molecular subgroups, which could inform treatment choices in SLE.

Methods

We undertook a pathway-centred approach, using sequencing of immunological pathway genes. Altogether 1832 candidate genes were analysed in 958 Swedish patients with SLE and 1026 healthy individuals. Aggregate and single variant association testing was performed, and we generated pathway polygenic risk scores (PRS).

Results

We identified two main independent pathways involved in SLE susceptibility: T lymphocyte differentiation and innate immunity, characterised by HLA and interferon, respectively. Pathway PRS defined pathways in individual patients, who on average were positive for seven pathways. We found that SLE organ damage was more pronounced in patients positive for the T or B cell receptor signalling pathways. Further, pathway PRS-based clustering allowed stratification of patients into four groups with different risk score profiles. Studying sets of genes with priors for involvement in SLE, we observed an aggregate common variant contribution to SLE at genes previously reported for monogenic SLE as well as at interferonopathy genes.

Conclusions

Our results show that pathway risk scores have the potential to stratify patients with SLE beyond clinical manifestations into molecular subsets, which may have implications for clinical follow-up and therapy selection.

Multidimensional tracking of phenotypes and organ involvement in a complete nationwide systemic sclerosis cohort

OBJECTIVE

SSc is a severe, heterogeneous multi-organ disease where population-based estimates on phenotypic spectrum, overall disease burden and societal impact are largely missing. Here the objective was to provide the first-ever complete national-level data on phenotype and major organ afflictions in SSc.

METHODS

A stepwise strategy was applied to find and characterize every SSc patient resident in Norway from 2000 to 2012. First we identified every case in the country registered with an International Classification of Diseases, Tenth Revision code for SSc (M34). Next we manually reviewed all cases coded as M34 to determine whether they met the 1980 ACR and/or 2013 ACR/EULAR classification criteria for SSc and could be included in the Norwegian SSc cohort (Nor-SSc). Finally, all disease features from SSc onset to study end were reviewed.

RESULTS

The Nor-SSc cohort included 815 SSc patients. The mean age at diagnosis was 53 years, with 84% females and 77% limited cutaneous SSc. The estimated incidence increased from 4 per million in 2000 to 13 per million in 2012. We identified high cumulative frequencies of internal organ involvement, coexistence of multiple organ afflictions across disease subsets and autoantibody status and stable frequencies of pulmonary arterial hypertension across haemodynamic definitions, but indications of referral-related differences in pulmonary hypertension detection rates across the study area.

CONCLUSION

This nationwide cohort study provides new, unbiased evidence for a high disease burden in SSc patients of Caucasian descent and indicates the existence of hurdles preventing equality of assessment across the SSc population.

THU0348 ALTERED IMMUNE RECOGNITION OF SPECIFIC GUT BACTERIA BY IMMUNOGLOBULINS IN EARLY SYSTEMIC SCLEROSIS

Background:

Gastrointestinal tract (GIT) involvement is highly prevalent in systemic sclerosis (SSc) and associates with GIT symptoms that are present early and progress over time. Changes in gut microbiota are often reported in inflammatory disease settings but whether GIT symptoms associate with altered immune recognition of specific gut bacteria in early SSc is unknown.

Objectives:

Here, we profiled Ig coating patterns of gut bacteria in early disease from two well-characterized SSc cohorts to determine if the pattern and extent of bacterial immunoglobulin (Ig) coating differs in early SSc.

Methods:

We collected fecal material from early SSc patients (<36 months from time of diagnosis) at Oslo and Lund University Hospitals and from healthy age and gender matched controls (HC). To assess whether adaptive immunity was triggered against gut microbiota in early disease, we sorted and sequenced IgA, IgM and IgG coated bacteria from fecal samples by flow cytometry and performed 16s rRNA sequencing to compare the relative Ig coating of early SSc patients to HC. Data was resolved to the family level, rarefied to 5101 reads and converted to relative abundance. Taxonomic profiles, relative abundance, IgA, IgM and IgG coating patterns and extent of Ig coating were assessed. Unadjusted p-values <0.05 were defined as significant.

Results:

We included 50 SSc patients (26 from Oslo, 24 from Lund) with early SSc and 9 gender and age matched HC. Mean age of SSc patients at time of inclusion was 53 years, mean time since diagnosis was 13 months; 82% were female, 61% had limited cutaneous SSc and 43% were anti-centromere antibody positive. In all, 82% were treatment naïve while 18% had received either cyclophosphomide or mycophenolate mofetil immunosuppressants. We found increased relative abundance of IgA coated Desulfovibrionaceae in both SSc cohorts compared to HC and increased IgM and IgG coating of Veillonellaceae and Streptococcaceae (Figure 1). All of these bacteria have previously been associated with other autoimmune diseases or pro-inflammatory status; Desulfovibrionaceae to immune activation in the gut, and Veillonellaceae and Streptococcaceae to other chronic inflammatory and fibrotic conditions. While abundance of IgA coated Desulfovibrionaceae was higher in cyclophosphomide or mycophenolate mofetil-treated SSc patients than untreated patients, Veillonellaceae and Streptococcaceae were not affected by treatment. A lower abundance of IgA and IgM coated Akkermansiaceae; and IgM and IgG coated Bifidobacteriaceae was detected in treated compared to treatment naïve early SSc patients (Figure 2).

Conclusion:

We find the pattern and extent of Ig coating to inflammatory-associated gut bacteria differs between treatment-naïve, early SSc patients treated with cyclophosphomide or mycophenolate mofetil and HC which suggests immunosuppressive treatments may modify gut microbiota in SSc. Overall these findings support the involvement of altered immune recognition of specific gut bacteria in early SSc.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Kristofer Andréasson: None declared, Simen Hyll Hansen: None declared, Simon Midtvedt: None declared, Håvard Fretheim: None declared, Henriette Didriksen Consultant of: Actelion, Torhild Garen: None declared, Espen Bækkevold: None declared, Øyvind Midtvedt: None declared, Roger Hesselstrand: None declared, Brian K Chung: None declared, Øyvind Molberg: None declared

SAT0348 CLINICAL SPECTRUM TIME COURSE OF ANTISYNTHETASE SYNDROME PATIENTS POSITIVE FOR ANTICENTROMERE ANTIBODIES

Background:

ASSD is characterized by antisynthetase antibodies (ARS) and the triad arthritis/myositis/Interstitial Lung Disease (ILD). ASSD and systemic sclerosis (SSc) may share features, like Raynaud’s phenomenon (RP), capillaroscopic alterations, and also some SSc specific autoantibodies.

Objectives:

To evaluate the characteristics of ASSD + for anticentromere antibodies (ACA).

Methods:

Retrospective analysis of clinical and laboratory characteristics of ACA + ASSD. Patients were identified in an established international cohort, randomly matched 1:1 for sex, age, disease duration and ARS positivity with a group of ACA - ASSD.

Results:

18 ACA + ASSD (15 females, 83%, 15 anti-Jo1, 2 anti-PL7, 1 anti-PL12 ARS) patients were identified. In comparison to ACA - group, no differences were observed in disease clinical presentation and evolution. Though, 9 ACA + patients (50%) satisfied the ACR/EULAR 2013 classification criteria for SSc and only 1 in ACA - group (p=0.007) (Table 1).

An incomplete ASSD (lack of at least one triad finding) was observed in 15 patients in both ACA + and – group (p=1). Among these patients, 13 ACA + and 11 ACA – developed de-novo triad finding during disease course (p=0.651). In ACA + group, a de-novo arthritis was observed in 4 patients (vs 1, p=0.565), a de-novo myositis in 8 (vs 5, p=1), and a de-novo ILD in 7 (vs 10, p=1). The prevalence of complete forms was similar between ACA + and – group at both disease onset (3 vs 3, 17%, p=1) and last follow-up, (10 vs 11, 56% vs 61%, p=1). Of note, only 1 patient (6%) for each group died (p=1).

Conclusion:

The clinical spectrum time course of ACA+ and - ASSD is similar, even when ACA + patients could be classified as SSc. By considering the high prevalence of arthritis and myositis we observed, we suggest that ACA+ patients with arthritis and myositis, should be tested for ARS antibodies even when an ASSD is not clearly suspected.

References:

[1]Mirrakhimov AE. Curr Med Chem 2015;22:1963–75

[2]Cavagna L. J Clin Med 2019;8:E2013

[3]Sebastiani M. J Rheum 2019:46:279-84

[4]van den Hoogen F. Ann Rheum Dis 2013;72:1747-55

Table 1.

Patients characteristics. IQR, interquartile range; ILD, interstitial Lung Disease; SSc, systemic sclerosis

ACA+ (18)ACA - (18)pAge (years) at disease onset (median, IQR)47 (37-63)47 (39-63)0.834Disease duration (months) (median, IQR)81 (62-169)77 (58-165)0.486anti Ro52antibody (%)12(67)11 (61)1Arthritis onset10 (56)13 (72)0.489Arthritis last follow-up (%)14 (78)14 (78%)1Myositis onset (%)7 (39)11 (61)0.318Myositis last follow-up (%)15 (83)16 (89)1ILD onset (%)9 (50)6 (33)0.5ILD last follow-up (%)16 (89)16 (89)1Complete form onset (%)3 (17)3 (17)1Complete form last follow-up (%)10 (56)11 (61)1Raynaud phenomenon (%)13 (72)9 (50)0.305Mechanic’s hands (%)6 (33)7 (38)1Teleangectasias (%)2 (11)0 (0)0.486Cutaneous sclerosis (%)510.177Acral ulcers (%)1 (6)0 (0)1Scleroderma pattern at NVC8 (44)7 (39)1Pulmonary arterial hypertension (%)3 (17)2 (11)12013 ACR/EULAR SSc classification criteria9 (50)1 (6)0.007

Disclosure of Interests:

Giovanni Zanframundo: None declared, Gianluca Sambataro: None declared, Veronica Codullo: None declared, Alessandro Biglia: None declared, Emanuele Bozzalla Cassione: None declared, Elena Bravi: None declared, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Marco Fornaro: None declared, Konstantinos Triantafyllias: None declared, Alberto Pesci: None declared, Paola Tomietto: None declared, Øyvind Molberg: None declared, Salvatore Scarpato: None declared, Reinhard Voll: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Carlomaurizio Montecucco: None declared, Lorenzo Cavagna: None declared

THU0327 EFFECT OF IMMUNOSUPPRESSIVE MEDICATION ON GASTRO-INTESTINAL INVOLVEMENT IN SYSTEMIC SCLEROSIS PATIENTS STRATIFIED FOR DISEASE DURATION

Background:

Gastrointestinal tract (GIT) involvement is associated with high morbidity in systemic sclerosis (SSc) but the data on its impact from unselected and well characterized SSc cohorts are scarce. Currently, the effect of immunosuppressive (IS) treatment on GIT involvement is largely unknown.

Objectives:

To evaluate the severity and worsening of GIT involvement in two prospective SSc cohorts. To assess factors associated with severity of GIT involvement, stratified for disease duration. To evaluate effect of IS treatment on worsening of GIT involvement.

Methods:

All SSc patients fulfilling the 2013 SSc classification criteria from two SSc cohorts were evaluated. Incident SSc was defined as disease duration since first symptom non-Raynaud < 24 months at first presentation. GIT involvement was assessed by the UCLA GIT 2.0 score at baseline and after one year to assess worsening of GIT involvement. Worsening was defined as change > minimal clinical important difference for total score and for each of the seven subdomains. GIT involvement was defined as present if the patients reported symptoms resulting in a score of ≥0.01 and was segregated into mild ≥0.01 (<0.5 or for fecal incontinence and distention/bloating <1.01), moderate (≥0.5 or for fecal incontinence and distention/bloating ≥1.01) or severe GI symptoms (> 1.01 or for distension/bloating > 1.61 or for fecal soiling > 2.01). Logistic regression was applied to identify risk factors associated with GIT involvement at baseline. The effect of IS treatment on worsening on each of the subdomains after one year was evaluated with logistic regression, with adjustment for baseline disease duration and severity.

Results:

In total, 834 SSc patients were included; 236 (28%) had incident disease (table 1). Incident cases (IC) showed comparable severity of GIT involvement compared to non-incident cases (NIC) except for significantly less severe reflux and distension/bloating (figure 1). Logistic regression showed female sex (OR 8.5(1.1-36.01)) and smoking (OR 2.9(1.2-7.3)) to be associated with GIT severity at baseline in IC; in NIC anti-centromere antibody (OR 1.7(1.3-2.2)) was additionally associated with GIT severity. The use of IS at baseline did not associate with GI severity at baseline. In total n = 685 (82% never had IS treatment (83% NIC, 81% IC); of these 258 (38%) started with IS after baseline assessment (52% IC, 32% NIC, p =0.02). When comparing change of GIT involvement after one year between those who started IS and those who did not, worsening of GI symptoms occurred more frequently in patients who started IS treatment (figure 2), but notably, patients in this group were also more frequently anti-topoisomerase positive, had ILD, and diffuse disease subset compared to the patients without IS treatment; age and sex were comparable. In the logistic regression with adjustment for disease duration and severity, there were no significant associations between IS treatment and worsening on GIT involvement.

Conclusion:

Regardless disease duration, about 1/3 of all SSc patients had moderate-severe GIT involvement. Disease duration and treatment initiation with IS did not have a significant influence on worsening of GIT involvement.

Table:

Baseline characteristicsNon-inception cohort(n=598)Inception cohort(n=236)Female, n(%)504 (85)180 (76)Age, mean(SD)55 (13)56 (14)Disease duration non Raynaud-Phenomenon, median (IQR)8.8 (4.8-14.4)0.7 (0.3-1.2)Diffuse cutaneous subset, n(%)119 (20)67 (28)Interstitial lung disease, n(%)233 (39)71 (30)Anti-centromere, n(%)296 (50)96 (41)Immunosuppresive treatment at baseline, n(%)102 (17)44 (19))Duration of treatment at baseline in years, mean (SD)4.1 (4.8)1.2 (2.9)Methotrexate, n(%)54 (9)24 (10)Mycophenolate mofetil, n(%)25 (4)13 (6)Hydroxycholoquine, n(%)20 (3)7 (3)Cyclofosfamide, n(%)1 (1)10 (4)Azathioprine, n(%)11 (2)2 (1)Corticosteroids, n(%)58 (10)27 (11)

Acknowledgments:

NA

Disclosure of Interests:

Nina van Leeuwen: None declared, Håvard Fretheim: None declared, Øyvind Molberg: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Jeska de Vries-Bouwstra: None declared, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche

THU0331 INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: DECLINE IN FORCED VITAL CAPACITY DOES NOT PREDICT FURTHER PROGRESSION IN THE FOLLOWING PERIOD

Background:

In systemic sclerosis (SSc) patients with interstitial lung disease (ILD) approximately 30% show progressive ILD. It is unknown whether a progressive ILD period is followed by further lung function decline. In clinical practice, treatment is frequently initiated after observation of lung function decline over 6-12 months and lung function stabilization at follow up is often interpreted as treatment effect.

Objectives:

Assess the predictive ability of lung function decline over 12 months for further deterioration adjusted for known risk factors for ILD and treatment in two large and well characterized SSc cohorts.

Methods:

Patients with SSc-ILD by HRCT, fulfilling SSc classification criteria, from the Oslo and Zurich University Hospital were included. The first period with three consecutive annual forced vital capacity (FVC) measurements (i.e. at 0, 12 and 24 months, +/- 3 months) was used. Lung function decline was assessed by absolute changes in FVC% predicted. Moderately progressive ILD was defined as FVC decline of >5-<10% and significantly progressive ILD as FVC decline ≥10% in 12 months. Candidate predictors by experts (including SSc subtype, autoantibodies, disease duration, baseline and FVC decline in the first period, extent of lung and skin (mRSS) fibrosis, CRP, reflux, tendon friction rubs, O2 desaturation, dyspnea) for FVC decline in the second period were tested using logistic regression analysis. Treatment included low dose corticosteroids, mycophenolate mofetil; and other immunosuppressive treatment (cyclophosphamide, Rituximab and Tocilizumab).

Results:

In total, 240 SSc-ILD patients met the inclusion criteria (table). Of these 69 (29%) SSc-ILD patients showed progressive ILD in the first 12 months period; 34 (14%) with moderate (5-10%) and 35 (15%) with significant FVC decline (≥10%). Independent of FVC changes in the first period, 77 (32%) showed progressive ILD in the second period; 44 (18%) moderate and 33 (14%) significant FVC decline. Only 21 (9%) SSc-ILD patients had two progressive periods, and 115 (48%) were stable in the two 12 month’s periods; all independent of treatment. In multivariable logistic regression, progressive ILD in the first period (moderate, significant or combined FVC decline) was not predictive for progression in the following period. Of all applied risk factors, only mRSS was significantly predictive for further FVC decline, also when adjusted for age, gender and treatment (OR 1.03, 95%CI 1.00-1.08, p=0.035).

Conclusion:

Decline of FVC in one 12 months period did not predict further ILD progression in the following 12 months independent of treatment. These results have important clinical implications. Firstly, a decline of lung function in one period seems not to be the right indicator for initiating treatment. Secondly, stabilization of lung function under treatment initiated after ILD progression cannot necessarily be interpreted as a treatment response on the individual patient level.

Table:

First periodBoth periodsSSc-ILD (n=240)ILD progression (n=69)ILD progression (n=21)Stable ILD (n=115)Age, years (SD)48 (14.7)49 (13.8)50 (14.3)46 (15.3)Male, n (%)57 (24)18 (26)5 (24)27 (24)Disease duration yrs, mean (SD)10.2 (11.4)9.8 (10.2)8.8 (11.0)10.8 (12.3)Disease duration <3 years, n (%)68 (28)22 (32)8 (38)29 (25)Diffuse cutaneous SSc, n (%)95 (40)30 (44)11 (52)43 (27)Anti-topoisomerase I Ab, n (%)84 (35)27 (40)9 (43)42 (37)mRSS, mean (SD)10 (9.3)11 (10.2)16 (13.0)8 (8.3)CRPml, mean (SD)3.6 (7.2)3.3 (6.2)4.4 (9.1)3.1 (5.1)GERD, n (%)148 (62)44 (64)15 (74)70 (61)FVC % predicted90 (20.3)90 (21.9)92 (21.7)89 (19.3)DLCO% predicted64 (17.9)64 (16.6)70 (11.3)65 (17.5)Lung fibrosis >20%, n (%)55 (23)16 (23)4 (19)27 (24)Mycophenolate Mofetil, n (%)47 (20)15 (22)5 (24)23 (20)Other immunosuppression, n (%)79 (33)22 (32)9 (43)42 (37)Corticosteroids, n (%)62 (26)18 (26)8 (38)28 (24)

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Håvard Fretheim: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Mike Durheim Grant/research support from: BI, Consultant of: BI, Speakers bureau: BI, Øyvind Midtvedt: None declared, Mike O. Becker: None declared, Rucsandra Dobrota: None declared, Øyvind Molberg: None declared, Suzana Jordan: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

Physical Fitness in Patients With Oligoarticular and Polyarticular Juvenile Idiopathic Arthritis Diagnosed in the Era of Biologics: A Controlled Cross-Sectional Study

OBJECTIVE

To perform a comprehensive evaluation of and identify correlates for physical fitness in consecutive patients with juvenile idiopathic arthritis (JIA) who have been diagnosed in the era of biologics and to compare the results with those obtained in healthy controls.

METHODS

The study cohort included 60 patients with JIA (50 girls) ages 10-16 years and 60 age- and sex-matched controls. The JIA group included 30 patients with persistent oligoarticular JIA and 30 patients with extended oligoarticular or polyarticular disease. Measures of physical fitness included cardiorespiratory fitness (CRF) by peak oxygen uptake (Vo_2peak ) during a continuous graded treadmill exercise test, muscle strength by isokinetic and isometric knee and hand grip evaluations, and bone mineral density (BMD) and body composition by dual-energy x-ray absorptiometry. Physical activity was assessed by accelerometry.

RESULTS

Forty-two percent of the patients were being treated with biologic drugs. Patients with JIA demonstrated lower muscle strength and total body BMD compared to controls, but there were no differences in CRF and body composition. Physical fitness was comparable between the persistent oligoarticular and extended oligoarticular/polyarticular-JIA groups. In patients with JIA, we identified associations between higher vigorous physical activity and higher CRF and muscle strength, but did not find any association between physical fitness and disease variables.

CONCLUSION

In this cohort of patients with JIA, we found suboptimal muscle strength and BMD compared to controls, but no differences in CRF and body composition. Vigorous physical activities appeared important for optimizing muscle strength and CRF in patients with JIA; the importance of such activities should be highlighted in patient education.

Impact of Paranasal Sinus Surgery in Granulomatosis With Polyangiitis: A Longitudinal Computed Tomography Study

OBJECTIVES/HYPOTHESIS

Severe chronic rhinosinusitis (CRS) in patients with granulomatosis with polyangiitis (GPA) failing medical therapies can be treated with paranasal sinus surgery. Whether this surgery protects from progressive sinonasal damage remains unknown. Here, we aimed to analyze time-dependent relations between sinus surgeries and computed tomography (CT) imaging features in the CRS of GPA.

STUDY DESIGN

Longitudinal observational study.

METHODS

We assessed CRS features including bone thickening by global osteitis scoring scale, bone erosions, and mucosal thickening by Lund-Mackay scores in serial paranasal sinus CT scans (742 CT scans in total) from a cohort of 127 well-characterized GPA patients. Data on sinonasal surgical procedures were from a mandatory national registry and from chart review. We defined the time from baseline CT to last CT as the study observation period in each patient. Datasets were analyzed by linear mixed models.

RESULTS

We found that 23/127 cohort patients had one or more paranasal sinus surgical procedures, and 96% of these (22/23) had osteitis by CT after surgery. In patients with nasal surgery alone or no surgery, we identified osteitis in 7/11 (64%) and 45/93 (48%), respectively. During the observation period of a median of 5 years, 38 patients had progression of their sinus osteitis, with the highest annual osteitis progression rates observed around the time of surgery.

CONCLUSIONS

In this cohort, paranasal sinus surgery was associated with prevalence, severity, and progression rate of sinus osteitis, indicating that sinus surgery does not reduce the bone damage development in the CRS of GPA.

LEVEL OF EVIDENCE

4 Laryngoscope, 130: E460-E468, 2020.

Left Ventricular Diastolic Dysfunction Predicts Mortality in Patients With Systemic Sclerosis

BACKGROUND

Primary cardiac affection is common and is a major cause of death in systemic sclerosis (SSc), but there are knowledge gaps regarding the effect of cardiac dysfunction on mortality.

OBJECTIVES

The purpose of this study was to evaluate diastolic function in a large, unselected SSc cohort and assess the effect of diastolic dysfunction (DD) on mortality.

METHODS

SSc patients followed prospectively at the Oslo University Hospital from 2003 to 2016 with available echocardiographies and matched control subjects were included. DD was assessed by echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Pulmonary hypertension (PH) was diagnosed by right heart catheterization. Vital status was available for all patients. Cox regression analyses with hazards ratios (HRs) were conducted.

RESULTS

Diastolic function was assessed in 275 SSc patients at baseline and in 186 patients at follow-up. At baseline, 46 of the 275 SSc patients (17%) were diagnosed with DD and 195 (71%) had normal diastolic function. After a median follow-up of 3.4 years (interquartile range: 1.6 to 6.2 years), the proportion of DD increased from 17% to 29%. During follow-up, 57% of patients with DD at baseline died, compared with 13% of patients with normal diastolic function. At baseline, 86 patients had performed right heart catheterization, and 43 were diagnosed with PH; of these 60% deceased. In multivariable Cox regression analyses, DD was a stronger predictor of death (HR: 3.7; 95% CI: 1.69 to 8.14; c-index 0.89) than PH (HR: 2.0; 95% CI: 1.1 to 3.9; c-index 0.84).

CONCLUSIONS

DD is frequent in SSc, and the presence of DD is associated with high mortality. DD exceeds PH with respect to predicting mortality.

Systolic Dysfunction in Systemic Sclerosis: Prevalence and Prognostic Implications

Objective

Primary cardiac involvement is presumed to account for a substantial part of disease-related mortality in systemic sclerosis (SSc). Still, there are knowledge gaps on the evolution and total burden of systolic dysfunction in SSc. Here we evaluated prospective left ventricular (LV) and right ventricular (RV) systolic function in an unselected SSc cohort and assessed the burden of systolic dysfunction on mortality.

Methods

From the Oslo University Hospital cohort, 277 SSc patients were included from 2003-2016 and compared with healthy controls. Serial echocardiographies were reevaluated in order to detect change in systolic function. Right heart catheterization was performed on patients suspected of pulmonary hypertension. Descriptive and regression analyses were conducted.

Results

At baseline, LV systolic dysfunction by ejection fraction less than 50%, or a global longitudinal strain greater than -17.0%, was found in 12% and 24%, respectively. RV systolic dysfunction measured by tricuspid annular plane systolic excursion (TAPSE) less than 17 mm was evident in 10%. Follow-up echocardiography was performed after a median of 3.3 years (interquartile range [IQR] 1.5-5.6). At follow-up, LV systolic function remained stable, whereas RV function evaluated by TAPSE deteriorated (mean 23.1 to 21.7 mm, P = 0.005) equaling a 15% prevalence of RV systolic dysfunction. RV systolic function predicted mortality in multivariable models (hazard ratio 0.41, 95% confidence interval [CI] 0.19-0.90, P value 0.027), whereas LV systolic function lost predictive significance when adjusted for TAPSE.

Conclusion

In this unselected and prospective study, systolic dysfunction of the LV and RV was a frequent complication of SSc. LV systolic function remained stable across the observation period, whereas RV function deteriorated and predicted mortality.

Focused HLA analysis in Caucasians with myositis identifies significant associations with autoantibody subgroups

Objectives

Idiopathic inflammatory myopathies (IIM) are a spectrum of rare autoimmune diseases characterised clinically by muscle weakness and heterogeneous systemic organ involvement. The strongest genetic risk is within the major histocompatibility complex (MHC). Since autoantibody presence defines specific clinical subgroups of IIM, we aimed to correlate serotype and genotype, to identify novel risk variants in the MHC region that co-occur with IIM autoantibodies.

Methods

We collected available autoantibody data in our cohort of 2582 Caucasian patients with IIM. High resolution human leucocyte antigen (HLA) alleles and corresponding amino acid sequences were imputed using SNP2HLA from existing genotyping data and tested for association with 12 autoantibody subgroups.

Results

We report associations with eight autoantibodies reaching our study-wide significance level of p<2.9×10^–5. Associations with the 8.1 ancestral haplotype were found with anti-Jo-1 (HLA-B*08:01, p=2.28×10^–53 and HLA-DRB1*03:01, p=3.25×10^–9), anti-PM/Scl (HLA-DQB1*02:01, p=1.47×10^–26) and anti-cN1A autoantibodies (HLA-DRB1*03:01, p=1.40×10^–11). Associations independent of this haplotype were found with anti-Mi-2 (HLA-DRB1*07:01, p=4.92×10^–13) and anti-HMGCR autoantibodies (HLA-DRB1*11, p=5.09×10^–6). Amino acid positions may be more strongly associated than classical HLA associations; for example with anti-Jo-1 autoantibodies and position 74 of HLA-DRB1 (p=3.47×10^–64) and position 9 of HLA-B (p=7.03×10^–11). We report novel genetic associations with HLA-DQB1 anti-TIF1 autoantibodies and identify haplotypes that may differ between adult-onset and juvenile-onset patients with these autoantibodies.

Conclusions

These findings provide new insights regarding the functional consequences of genetic polymorphisms within the MHC. As autoantibodies in IIM correlate with specific clinical features of disease, understanding genetic risk underlying development of autoantibody profiles has implications for future research.

Assessing the relative impact of lupus nephritis on mortality in a population-based systemic lupus erythematosus cohort

OBJECTIVE

There is limited knowledge on the relative impact of lupus nephritis (LN) on morbidity and mortality in population-based systemic lupus erythematous (SLE) cohorts. Here, the primary aim was to compare mortality rates between patients with and without LN in a population-based SLE cohort.

METHODS

The study cohort included all SLE patients resident in the city of Oslo during 1999-2008. Follow-up time was median 14 (0-15) years. Presence of LN was defined according to the 1987 American College of Rheumatology classification criteria for SLE. LN class was determined by renal biopsy. Data on kidney function, including presence of end-stage renal disease (ESRD), were obtained from patient charts. Standardized mortality ratios (SMRs) were estimated by comparing deaths in the SLE cohort with age- and gender-matched population controls.

RESULTS

We found that 98/325 SLE patients (30%) developed LN, 92% of whom had occurrence within the first five years from disease onset. Incidence rate of ESRD was 2.3 per 1000 patient-years. A total of 56 deaths occurred during the study period, corresponding to an overall SMR in the SLE cohort of 2.1 (95% confidence interval (CI) 1.2-3.4). Estimated SMR for LN patients was 3.8 (95% CI 2.1-6.2), and for SLE patients without LN it was 1.7 (95% CI 0.9-2.7).

CONCLUSION

In this population-based SLE cohort, we found that LN was associated with increased morbidity and mortality, whereas SLE patients who did not develop LN had good overall prognoses regarding survival.

Distinct phenotype of CD4+ T cells driving celiac disease identified in multiple autoimmune conditions

Combining HLA-DQ-gluten tetramers with mass cytometry and RNA sequencing analysis, we find that gluten-specific CD4+ T cells in the blood and intestines of patients with celiac disease display a surprisingly rare phenotype. Cells with this phenotype are also elevated in patients with systemic sclerosis and systemic lupus erythematosus, suggesting a way to characterize CD4+ T cells specific for disease-driving antigens in multiple autoimmune conditions.