Comparison of methotrexate and azathioprine as the first-line steroid-sparing immunosuppressive agents in patients with Takayasu's arteritis

BACKGROUND

Immunosuppressive (IS) agents are recommended for the first-line treatment of patients with active Takayasu's arteritis (TAK) together with glucocorticoids (GCs). However, there is limited data comparing the efficacy and outcomes of different IS agents for this purpose.

OBJECTIVES

In this study, we aimed to compare the outcomes of two most frequently used first-line IS agents, namely methotrexate (MTX) and azathioprine (AZA) in TAK patients.

METHODS

TAK patients who received any IS agent in addition to GCs as the initial therapy were included in this multicentre, retrospective cohort study. Clinical, laboratory and imaging data of the patients were assessed. In addition, a matched analysis (cc match) using variables 'age', 'gender' and 'diffuse aortic involvement' was performed between patients who received MTX or AZA as the first-line IS treatment.

RESULTS

We recruited 301 patients (F/M: 260/41, mean age: 42.2 ± 13.3 years) from 10 tertiary centres. As the first-line IS agent, 204 (67.8 %) patients received MTX, and 77 (25.6 %) received AZA. Less frequently used IS agents included cyclophosphamide in 17 (5.6 %), leflunomide in 2 (0.5 %) and mycophenolate mofetil in one patient. The remission, relapse, radiographic progression and adverse effect rates were similar between patients who received MTX and AZA as the first-line IS agent. Vascular surgery rate was significantly higher in the AZA group (23% vs. 9 %, p = 0.001), whereas the frequency of patients receiving ≤5 mg/day GCs at the end of the follow-up was significantly higher in the MTX group (76% vs 62 %, p = 0.034). Similarly, the rate of vascular surgery was higher in AZA group in matched analysis. Drug survival was similar between MTX and AZA groups (median 48 months, MTX vs AZA: 32% vs 42 %, p = 0.34). IS therapy was discontinued in 18 (12 MTX, 6 AZA) patients during the follow-up period due to remission. Among those patients, two patients had a relapse at 2 and 6 months, while 16 patients were still on remission at the end of a mean 69.4 (±50.9) months of follow-up.

CONCLUSIONS

Remission, relapse, radiographic progression and drug survival rates of AZA and MTX were similar for patients with TAK receiving an IS agent as the first-line f therapy. The rate of vascular surgery was higher and the rate of GC dose reduction was lower with AZA compared to MTX at the end of the follow-up.

Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

OBJECTIVES

This study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort.

METHODS

Patients from 31 centres in 10 countries were enrolled within 15 months of diagnosis and assessed annually. Five mutually exclusive disease activity states (DAS) were defined as (1) remission off-treatment: clinical (c) SLEDAI-2K=0, without prednisone/immunosuppressants; (2) remission on-treatment: cSLEDAI-2K=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; (3) LDA-Toronto Cohort (TC): cSLEDAI-2K≤2, without prednisone/immunosuppressants; (4) modified lupus LDA state (mLLDAS): SLEDAI-2K≤4, no activity in major organs/systems, no new activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants and (5) active: all remaining assessments.At each assessment, patients were stratified into the most stringent DAS fulfilled and the proportion of time in a DAS since cohort entry was determined. Annual DCs/ICs (2021 Canadian dollars) were based on healthcare use and lost workforce/non-workforce productivity over the preceding year.The association between the proportion of time in a DAS and annual DC/IC was examined through multivariable random-effects linear regressions.

RESULTS

1692 patients were followed a mean of 9.7 years; 49.0% of assessments were active. Remission/LDA (per 25% increase in time in a remission/LDA state vs active) were associated with lower annual DC/IC: remission off-treatment (DC -$C1372; IC -$C2507), remission on-treatment (DC -$C973; IC -$C2604,) LDA-TC (DC -$C1158) and mLLDAS (DC -$C1040). There were no cost differences between remission/LDA states.

CONCLUSIONS

Our data suggest that systemic lupus erythematosus patients who achieve remission, both off and on-therapy, and reductions in disease activity incur lower costs than those experiencing persistent disease activity.

Anti-KIF20B autoantibodies are associated with cranial neuropathy in systemic lupus erythematosus

BACKGROUND

Cranial neuropathies (CN) are a rare neuropsychiatric SLE (NPSLE) manifestation. Previous studies reported that antibodies to the kinesin family member 20B (KIF20B) (anti-KIF20B) protein were associated with idiopathic ataxia and CN. We assessed anti-KIF20B as a potential biomarker for NPSLE in an international SLE inception cohort.

METHODS

Individuals fulfilling the revised 1997 American College of Rheumatology (ACR) SLE classification criteria were enrolled from 31 centres from 1999 to 2011 and followed annually in the Systemic Lupus Erythematosus International Collaborating Clinics inception cohort. Anti-KIF20B testing was performed on baseline (within 15 months of diagnosis or first annual visit) samples using an addressable laser bead immunoassay. Logistic regression (penalised maximum likelihood and adjusting for confounding variables) examined the association between anti-KIF20B and NPSLE manifestations (1999 ACR case definitions), including CN, occurring over the first 5 years of follow-up.

RESULTS

Of the 1827 enrolled cohort members, baseline serum and 5 years of follow-up data were available on 795 patients who were included in this study: 29.8% were anti-KIF20B-positive, 88.7% female, and 52.1% White. The frequency of anti-KIF20B positivity differed only for those with CN (n=10) versus without CN (n=785) (70.0% vs 29.3%; OR 5.2, 95% CI 1.4, 18.5). Compared with patients without CN, patients with CN were more likely to fulfil the ACR haematological (90.0% vs 66.1%; difference 23.9%, 95% CI 5.0%, 42.8%) and ANA (100% vs 95.7%; difference 4.3%, 95% CI 2.9%, 5.8%) criteria. In the multivariate analysis adjusting for age at baseline, female, White race and ethnicity, and ACR haematological and ANA criteria, anti-KIF20B positivity remained associated with CN (OR 5.2, 95% CI 1.4, 19.1).

CONCLUSION

Anti-KIF20B is a potential biomarker for SLE-related CN. Further studies are needed to examine how autoantibodies against KIF20B, which is variably expressed in a variety of neurological cells, contribute to disease pathogenesis.

(18)F-fluorodeoxyglucose uptake by positron emission tomography in patients with IPAH and CTEPH

Pulmonary arterial hypertension (PAH) is driven by pathologies associated with increased metabolism such as pulmonary revascularization, vasoconstriction and smooth muscle cell proliferation in pulmonary artery wall. 18-fluorodeoxyglucose positron emission tomography (18FDG-PET) is an imaging technique sensitive to glucose metabolism and might be considered as a non-invasive method for diagnosis due to significant role of inflammation in idiopathic pulmonary artery hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH). The present study aimed to investigate the role of PET/CT imaging of patients with IPAH and CTEPH as an alternative diagnosis method. Demographic characteristics, FDG uptake in lungs, pulmonary artery and right ventricle (RV) of 17 patients (10 IPAH, 7 CTEPH), and 30 controls were evaluated. PET scanning, 6-min walk test, pro-BNP level, right heart catheterization of patients were performed both at the onsert and after 6-month PAH specific treatment. IPAH and CTEPH patients had significantly higher left lung FDG (p = 0.006), right lung FDG (p = 0.004), right atrial (RA) FDG (p < 0.001) and RV FDG (p < 0.001) uptakes than controls. Positive correlation was detected between the RV FDG uptake and the mean pulmonary artery pressure (mPAP) (r = 0.7, p = 0.012) and between the RA FDG uptake and the right atrial pressure (RAP) (r = 0.5, p = 0.02). Increased RV FDG and RA FDG uptakes predicts the presence of pulmonary hypertension and correlates with mPAP and RAP, respectively, which are important indicators in the prognosis of PAH. Further studies are required whether FDG PET imaging can be used to diagnose or predict the prognosis of pulmonary hypertension.

Multimodal imaging and genetic characteristics of autosomal recessive bestrophinopathy

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic significance of inflammation scores in malignant mesothelioma

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Characteristics and course of patients with AA amyloidosis: single centre experience with 174 patients from Turkey

OBJECTIVES

This study aimed to evaluate the clinical, laboratory and genetic characteristics and outcomes of patients with AA amyloidosis.

METHODS

Patients followed up in a tertiary referral centre in Turkey with the diagnosis of inflammatory rheumatic diseases and immunohistologically proven AA amyloidosis were included in the study and retrospectively analysed.

RESULTS

Among 184 patients with the diagnosis of AA amyloidosis, 174 (83 female, 91 male) were included in the analysis. The most common cause of AA amyloidosis was FMF (78.7%), and 91% of FMF-AA amyloidosis patients were carrying the p.M694V variant (74.1% homozygous). AA amyloidosis was identified earlier in patients with homozygous or compound heterozygous MEFV exon 10 variants compared with the heterozygous patients (27, 30 and 41 years, respectively). Patients with an estimated glomerular filtration rate <60 ml/min at admission had a higher frequency of progression to end-stage renal disease (P < 0.001). The overall mortality rate was 15.3% and it increased gradually in association with the amyloid burden (10% in patients with renal, 15% in renal + gastrointestinal and 43% in those with additional cardiac involvement). Renal findings responded completely to treatment in 31% of the patients, a partial response was observed in 4%, a stable course in 23.6% and progression in 38.5%. Amyloid storm was identified in nine patients and was found to be associated with increased mortality within 1 year.

CONCLUSION

FMF patients still constitute the majority of AA amyloidosis patients in Turkey. The MEFV genotype and associated inflammatory load may affect the age of onset of AA amyloidosis, and earlier diagnosis and stricter follow-up and treatment may delay progression of the disease.

Association Between Severe Nonadherence to Hydroxychloroquine and Systemic Lupus Erythematosus Flares, Damage, and Mortality in 660 Patients From the SLICC Inception Cohort

OBJECTIVE

The goals of this study were to assess the associations of severe nonadherence to hydroxychloroquine (HCQ), objectively assessed by HCQ serum levels, and risks of systemic lupus erythematosus (SLE) flares, damage, and mortality rates over five years of follow-up.

METHODS

The Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort is an international multicenter initiative (33 centers throughout 11 countries). The serum of patients prescribed HCQ for at least three months at enrollment were analyzed. Severe nonadherence was defined by a serum HCQ level <106 ng/mL or <53 ng/mL for HCQ doses of 400 or 200 mg/day, respectively. Associations with the risk of a flare (defined as a Systemic Lupus Erythematosus Disease Activity Index 2000 increase ≥4 points, initiation of prednisone or immunosuppressive drugs, or new renal involvement) were studied with logistic regression, and associations with damage (first SLICC/American College of Rheumatology Damage Index [SDI] increase ≥1 point) and mortality with separate Cox proportional hazard models.

RESULTS

Of the 1,849 cohort participants, 660 patients (88% women) were included. Median (interquartile range) serum HCQ was 388 ng/mL (244-566); 48 patients (7.3%) had severe HCQ nonadherence. No covariates were clearly associated with severe nonadherence, which was, however, independently associated with both flare (odds ratio 3.38; 95% confidence interval [CI] 1.80-6.42) and an increase in the SDI within each of the first three years (hazard ratio [HR] 1.92 at three years; 95% CI 1.05-3.50). Eleven patients died within five years, including 3 with severe nonadherence (crude HR 5.41; 95% CI 1.43-20.39).

CONCLUSION

Severe nonadherence was independently associated with the risks of an SLE flare in the following year, early damage, and five-year mortality.

Assessing the Costs of Neuropsychiatric Disease in the Systemic Lupus International Collaborating Clinics Cohort Using Multistate Modeling

OBJECTIVE

To estimate direct and indirect costs associated with neuropsychiatric (NP) events in the Systemic Lupus International Collaborating Clinics inception cohort.

METHODS

NP events were documented annually using American College of Rheumatology definitions for NP events and attributed to systemic lupus erythematosus (SLE) or non-SLE causes. Patients were stratified into 1 of 3 NP states (no, resolved, or new/ongoing NP event). Change in NP status was characterized by interstate transition rates using multistate modeling. Annual direct costs and indirect costs were based on health care use and impaired productivity over the preceding year. Annual costs associated with NP states and NP events were calculated by averaging all observations in each state and adjusted through random-effects regressions. Five- and 10-year costs for NP states were predicted by multiplying adjusted annual costs per state by expected state duration, forecasted using multistate modeling.

RESULTS

A total of 1,697 patients (49% White race/ethnicity) were followed for a mean of 9.6 years. NP events (n = 1,971) occurred in 956 patients, 32% attributed to SLE. For SLE and non-SLE NP events, predicted annual, 5-, and 10-year direct costs and indirect costs were higher in new/ongoing versus no events. Direct costs were 1.5-fold higher and indirect costs 1.3-fold higher in new/ongoing versus no events. Indirect costs exceeded direct costs 3.0 to 5.2 fold. Among frequent SLE NP events, new/ongoing seizure disorder and cerebrovascular disease accounted for the largest increases in annual direct costs. For non-SLE NP events, new/ongoing polyneuropathy accounted for the largest increase in annual direct costs, and new/ongoing headache and mood disorder for the largest increases in indirect costs.

CONCLUSION

Patients with new/ongoing SLE or non-SLE NP events incurred higher direct and indirect costs.

Treatment of systemic sclerosis-associated digital ulcers: recommendations of the Turkish Society for Rheumatology

OBJECTIVES

Digital ulcers (DUs) are associated with a significant burden in systemic sclerosis (SSc) by leading to severe pain, physical disability, and reduced quality of life. This effort aimed to develop recommendations of the Turkish Society for Rheumatology (TRD) on the management of DUs associated with SSc.

METHODS

In the first meeting held in December 2020 with the participation of a task force consisting of 23 rheumatologists the scope of the recommendations and research questions were determined. A systematic literature review was conducted by 5 fellows and results were presented to the task force during the second meeting. The Oxford system was used to determine the level of evidence. The preliminary recommendations were discussed, modified, and voted by the task force and then by members of TRD via e-mail invitation allowing personalised access to a web-based questionnaire [SurveyMonkey®].

RESULTS

A total of 23 recommendations under 7 main headings were formulated covering non-pharmacological measures for the prevention of DUs and pharmacological treatments including vasodilators, anti-aggregants, antibiotics, wound care, pain control, and interventions including sympathectomy, botulinum toxin, and surgery. Risk factors, poor prognostic factors, prevention of DU and adverse effects of medical treatments were reported as 4 overarching principles.

CONCLUSIONS

These evidence-based recommendations for the management of SSc-associated DUs were developed to provide a useful guide to all physicians who are involved in the care of patients with SSc, as well as to point out unmet needs in this field.

Sex influence on outcomes of patients with systemic sclerosis-associated interstitial lung disease: a EUSTAR database analysis

OBJECTIVE

Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in systemic sclerosis (SSc) patients. We aimed to investigate the impact of sex on SSc-ILD.

METHODS

EUSTAR SSc patients with radiologically confirmed ILD and available percentage predicted forced vital capacity (%pFVC) were included. Demographics and disease features were recorded. A change in %pFVC over 12 months (s.d. 6) (cohort 1) was classified into stable (≤4%), mild (5-9%) and large progression (≥10%). In those with 2-year longitudinal %pFVC (cohort 2), the %pFVC change at each 12-month (s.d. 6) interval was calculated. Logistic regression analyses [odds ratio (OR) and 95% CI] and Cox proportional hazards models adjusted for age and %pFVC were applied.

RESULTS

A total of 1136 male and 5253 female SSc-ILD patients were identified. Males were significantly younger, had a shorter disease duration, had a higher prevalence of CRP elevation and frequently had diffuse cutaneous involvement. In cohort 1 (1655 females and 390 males), a higher percentage of males had stable ILD (74.4% vs 69.4%, P = 0.056). In multivariable analysis, disease duration and %pFVC [OR 0.99 (95% CI 0.98, 0.99) and OR 0.97 (95% CI 0.95, 0.99), respectively] in males and age, %pFVC and anti-centromere [OR 1.02 (95% CI 1.00, 1.04), OR 0.97 (95% CI 0.96, 0.98) and OR 0.39 (95% CI 0.245, 0.63), respectively] in females were associated with large progression. The 1-year mortality rate was higher in males (5.1% vs 2.5%, P = 0.013). In cohort 2 (849 females and 209 males), a higher percentage of females showed periods of large progression (11.7% vs 7.7%, P = 0.023), the percentage of patients with none, one or two periods of worsening was not different. The overall death rate was 30.9% for males and 20.4% in females (P < 0.001). In the survival analysis, male sex was a predictor of mortality [OR 1.95 (95% CI 1.66, 2.28)].

CONCLUSIONS

Male SSc-ILD patients have a poorer prognosis and sex-specific predictors exist in SSc-ILD.

Machine learning identifies clusters of longitudinal autoantibody profiles predictive of systemic lupus erythematosus disease outcomes

OBJECTIVES

A novel longitudinal clustering technique was applied to comprehensive autoantibody data from a large, well-characterised, multinational inception systemic lupus erythematosus (SLE) cohort to determine profiles predictive of clinical outcomes.

METHODS

Demographic, clinical and serological data from 805 patients with SLE obtained within 15 months of diagnosis and at 3-year and 5-year follow-up were included. For each visit, sera were assessed for 29 antinuclear antibodies (ANA) immunofluorescence patterns and 20 autoantibodies. K-means clustering on principal component analysis-transformed longitudinal autoantibody profiles identified discrete phenotypic clusters. One-way analysis of variance compared cluster enrolment demographics and clinical outcomes at 10-year follow-up. Cox proportional hazards model estimated the HR for survival adjusting for age of disease onset.

RESULTS

Cluster 1 (n=137, high frequency of anti-Smith, anti-U1RNP, AC-5 (large nuclear speckled pattern) and high ANA titres) had the highest cumulative disease activity and immunosuppressants/biologics use at year 10. Cluster 2 (n=376, low anti-double stranded DNA (dsDNA) and ANA titres) had the lowest disease activity, frequency of lupus nephritis and immunosuppressants/biologics use. Cluster 3 (n=80, highest frequency of all five antiphospholipid antibodies) had the highest frequency of seizures and hypocomplementaemia. Cluster 4 (n=212) also had high disease activity and was characterised by multiple autoantibody reactivity including to antihistone, anti-dsDNA, antiribosomal P, anti-Sjögren syndrome antigen A or Ro60, anti-Sjögren syndrome antigen B or La, anti-Ro52/Tripartite Motif Protein 21, antiproliferating cell nuclear antigen and anticentromere B). Clusters 1 (adjusted HR 2.60 (95% CI 1.12 to 6.05), p=0.03) and 3 (adjusted HR 2.87 (95% CI 1.22 to 6.74), p=0.02) had lower survival compared with cluster 2.

CONCLUSION

Four discrete SLE patient longitudinal autoantibody clusters were predictive of long-term disease activity, organ involvement, treatment requirements and mortality risk.

Efficacy and safety of interleukin-1 blockers in kidney transplant recipients with familial Mediterranean fever: a propensity score-matched cohort study

Background

Data on use of IL-1 blockers in kidney transplant recipients (KTRs) with familial Mediterranean fever (FMF) are very limited. We aimed to evaluate the efficacy and safety of anakinra and canakinumab in the transplantation setting.

Methods

In this retrospective cohort study, we included KTRs suffered from AA amyloidosis caused by FMF and treated with anakinra or canakinumab (study group, n = 36). Using propensity score matching, we selected 36 patients without FMF or amyloidosis from our database of 696 KTRs as the control group. Primary outcomes were patient and graft survival. Biopsy-confirmed graft rejection, changes in eGFR, hsCRP, erythrocyte sedimentation rate (ESR), proteinuria, and number of monthly attacks were secondary outcomes.

Results

All KTRs with FMF began IL-1 blocker therapy with anakinra and nine (25%) were switched to canakinumab. Overall death was more frequent in study group (19.4% vs 0%) (p = 0.005); however, overall graft loss was comparable between study (27.8%) and control groups (36.1%) (p = 0.448). Five- and 10-year graft survival rates were significantly higher in study group (94.4% and 83.3%, respectively) than control group (77.8% and 63.9%, respectively) (p = 0.014 and p&lt;0.001, respectively). Rejections were numerically lower in study group (8.3% vs 25%), but it did not reach to statistical significance (p = 0.058). When compared to pre-treatment period, with IL-1 blockers, number of attacks per month (p&lt;0.001), eGFR (p = 0.004), hsCRP (p&lt;0.001) and ESR (p = 0.026) levels were lower throughout the follow-up; whereas proteinuria levels were not.

Conclusions

Anakinra and canakinumab are effective in KTRs suffering from FMF; however, mortality rate may be of concern.

Retinal toxicity in a multinational inception cohort of patients with systemic lupus on hydroxychloroquine

OBJECTIVE

To evaluate hydroxychloroquine (HCQ)-related retinal toxicity in the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort.

METHODS

Data were collected at annual study visits between 1999 and 2019. We followed patients with incident SLE from first visit on HCQ (time zero) up to time of retinal toxicity (outcome), death, loss-to-follow-up or end of study. Potential retinal toxicity was identified from SLICC Damage Index scores; cases were confirmed with chart review. Using cumulative HCQ duration as the time axis, we constructed univariate Cox regression models to assess if covariates (ie, HCQ daily dose/kg, sex, race/ethnicity, age at SLE onset, education, body mass index, renal damage, chloroquine use) were associated with HCQ-related retinal toxicity.

RESULTS

We studied 1460 patients (89% female, 52% white). Retinal toxicity was confirmed in 11 patients (incidence 1.0 per 1000 person-years, 0.8% overall). Average cumulative time on HCQ in those with retinal toxicity was 7.4 (SD 3.2) years; the first case was detected 4 years after HCQ initiation. Risk of retinal toxicity was numerically higher in older patients at SLE diagnosis (univariate HR 1.05, 95% CI 1.01 to 1.09).

CONCLUSIONS

This is the first assessment of HCQ and retinal disease in incident SLE. We did not see any cases of retinopathy within the first 4 years of HCQ. Cumulative HCQ may be associated with increased risk. Ophthalmology monitoring (and formal assessment of cases of potential toxicity, by a retinal specialist) remains important, especially in patients on HCQ for 10+ years, those needing higher doses and those of older age at SLE diagnosis.

Remission and low disease activity (LDA) prevent damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

OBJECTIVE

To determine the independent impact of different definitions of remission and low disease activity (LDA) on damage accrual.

METHODS

Patients with ≥2 annual assessments from a longitudinal multinational inception lupus cohort were studied. Five mutually exclusive disease activity states were defined: remission off-treatment: clinical Systemic Lupus Erythematosus Disease Activity Index (cSLEDAI)-2K=0, without prednisone or immunosuppressants; remission on-treatment: cSLEDAI-2K score=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; low disease activity Toronto cohort (LDA-TC): cSLEDAI-2K score of ≤2, without prednisone or immunosuppressants; modified lupus low disease activity (mLLDAS): Systemic Lupus Erythematosus Disease Activity Index-2K score of 4 with no activity in major organ/systems, no new disease activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants; active: all remaining visits. Only the most stringent definition was used per visit. Antimalarials were allowed in all. The proportion of time that patients were in a specific state at each visit since cohort entry was determined. Damage accrual was ascertained with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Univariable and multivariable generalised estimated equation negative binomial regression models were used. Time-dependent covariates were determined at the same annual visit as the disease activity state but the SDI at the subsequent visit.

RESULTS

There were 1652 patients, 1464 (88.6%) female, mean age at diagnosis 34.2 (SD 13.4) years and mean follow-up time of 7.7 (SD 4.8) years. Being in remission off-treatment, remission on-treatment, LDA-TC and mLLDAS (per 25% increase) were each associated with a lower probability of damage accrual (remission off-treatment: incidence rate ratio (IRR)=0.75, 95% CI 0.70 to 0.81; remission on-treatment: IRR=0.68, 95% CI 0.62 to 0.75; LDA: IRR=0.79, 95% CI 0.68 to 0.92; and mLLDAS: IRR=0.76, 95% CI 0.65 to 0.89)).

CONCLUSIONS

Remission on-treatment and off-treatment, LDA-TC and mLLDAS were associated with less damage accrual, even adjusting for possible confounders and effect modifiers.

Longitudinal analysis of ANA in the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort

OBJECTIVES

A perception derived from cross-sectional studies of small systemic lupus erythematosus (SLE) cohorts is that there is a marked discrepancy between antinuclear antibody (ANA) assays, which impacts on clinicians' approach to diagnosis and follow-up. We compared three ANA assays in a longitudinal analysis of a large international incident SLE cohort retested regularly and followed for 5 years.

METHODS

Demographic, clinical and serological data was from 805 SLE patients at enrolment, year 3 and 5. Two HEp-2 indirect immunofluorescence assays (IFA1, IFA2), an ANA ELISA, and SLE-related autoantibodies were performed in one laboratory. Frequencies of positivity, titres or absorbance units (AU), and IFA patterns were compared using McNemar, Wilcoxon and kappa statistics, respectively.

RESULTS

At enrolment, ANA positivity (≥1:80) was 96.1% by IFA1 (median titre 1:1280 (IQR 1:640-1:5120)), 98.3% by IFA2 (1:2560 (IQR 1:640-1:5120)) and 96.6% by ELISA (176.3 AU (IQR 106.4 AU-203.5 AU)). At least one ANA assay was positive for 99.6% of patients at enrolment. At year 5, ANA positivity by IFAs (IFA1 95.2%; IFA2 98.9%) remained high, while there was a decrease in ELISA positivity (91.3%, p<0.001). Overall, there was >91% agreement in ANA positivity at all time points and ≥71% agreement in IFA patterns between IFA1 and IFA2.

CONCLUSION

In recent-onset SLE, three ANA assays demonstrated commutability with a high proportion of positivity and titres or AU. However, over 5 years follow-up, there was modest variation in ANA assay performance. In clinical situations where the SLE diagnosis is being considered, a negative test by either the ELISA or HEp-2 IFA may require reflex testing.

Effect of Ground-Based Walk Training in Pulmonary Hypertension

This study aimed to determine the effect of ground-based walking training on exercise capacity, physical activity, quadriceps muscle strength, and quality of life (QoL) in patients with pulmonary hypertension. A total of 24 patients were included in the study. Patients were randomly assigned to 2 groups as the walking group or the control group. The walking group participated in 30-minute supervised ground-based walking training 2 days/week for 8 weeks. Also, they walked unsupervised at least 1 day/week. The control group received no intervention. The number of weekly steps taken in both groups was recorded using a pedometer. In addition to the sociodemographic and clinic characteristics of the patients, the endurance shuttle walk test, incremental shuttle walk test, and 6-minute walk test were used for the evaluation of exercise capacity, and an activity monitor and pedometer for physical activity, a dynamometer for quadriceps muscle strength, and emPHasis-10 for QoL. After 8 weeks, endurance capacity, maximal exercise capacity, and the number of steps significantly improved in the walking group (p <0.05). The 6-minute walk distance, physical activity, quadriceps muscle strength, and QoL were similar in both groups (p >0.05). The results of the study showed that ground-based walking could improve endurance capacity, maximal exercise capacity, and the number of steps. Quadriceps muscle strength also improved in the walking group. No adverse effects were reported during the training period. Ground-based walking training can be performed safely in patients with pulmonary hypertension.

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

Background

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

Objectives

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

Methods

We used the Ion Torrent platform for deep sequencing.

Results

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

Conclusion

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

References

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

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

Table 1.

Characteristics of SSc-ILD Patients Receiving Nintedanib

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

Advers Events during Nintedanib Treatment in SSc-ILD patients

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

Conclusion

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

References

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

Table 1.

The new screening tool

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

Conclusion

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

Conclusion

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

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

p1: AA-a and FMF

p2: AA-a and cirrhosis

p3: AA-a and chronic liver disease

p4: AA-a and HC

p5: FMF and HC

p6: AA-a and AL-a

*Median, interquartile of range

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

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

Conclusion

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

Table 1.

Factors associated with vascular events in pts with AAV

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

*mean±std dev

Ɨ n, %

ĸmedian, interquartile range

. OR: Odds ratio

Figure 1.

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

Log-rank: p=0.039

References

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

Table 1.

Serum and urine levels of biomarkers across study groups.

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

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

Conclusion

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

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

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

Conclusion

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

Table 1.

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

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

#estimated glomerular filtration rate

p1: G2-G1

p2: G3-G1

p3: G2-G3

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

Figure 1.

Comparison of survival rate between G3 and G1

Log-Rank: p=0.007

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

Table 1.

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

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

*median; IQR Ɨ n, %

Conclusion

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

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

We used the Ion Torrent platform for deep sequencing.

Results

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

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

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

Conclusion

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

Disclosure of Interests

None declared

AB0610 Development of Malignancy in Patients with ANCA-associated Vasculitis

Background

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

Objectives

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

Methods

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

Results

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

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

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

Table 1.

Factors associated with malignancy in pts with AAV

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

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

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

Figure 1.

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

Log-Rank: p=0.035

Conclusion

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

References

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

Disclosure of Interests

None declared

FC063: Serum and Urine Galectin-9, Ip-10 and Siglec-1 as Biomarkers of Disease Activity in Patients with Systemic Lupus Erythematosus Compared to Anca-Associated Vasculitis: A Longitudinal Study

BACKGROUND AND AIMS

Galectin-9, interferon-inducible protein-10 (IP-10) and sialoadhesin (SIGLEC-1) are considered as potential biomarkers reflecting disease activity in patients with systemic lupus erythematosus (SLE). In this study, we aimed to investigate the association of serum and urine galectin-9, IP-10 and SIGLEC-1 with disease activity in patients with SLE. Also, we compared the results with ANCA-associated vasculitis (AAV) to test the specificity of the biomarkers.

METHOD

A total of 63 patients with active SLE (31 renal and 32 extrarenal) were included in the study. A total of 30 patients with inactive SLE (15 renal and 15 extrarenal), 17 with renal active AAV and 32 healthy volunteers were selected as control groups. Serum (s) and urine (u) levels of galectin-9, IP-10 and SIGLEC-1 were tested using ELISA. Urine levels of biomarkers were normalized by urine creatinine.

RESULTS

Of 142 participants, 109 (76.7%) were female and median age was 36 (28.75–48) years. Groups were comparable with regard to sex and age distribution except for AAV. In AAV group, seven patients (41.1%) were female and median age was 60 (48–65.5) years. Proliferative lupus nephritis (LN) (class III/III + V and IV/IV + V) were found in 22 patients with active renal SLE (70.9%), while 6 patients (19.3%) had pure class V and 3 (9.7%) had class II LN. Levels of sIP-10, uIP-10, sGalectin-9 and uSIGLEC-1 were significantly higher in the active SLE group compared to the inactive SLE group (sIP-10; P = 0.046, uIP-10; P &lt; 0.001, sGalectin-9; P = 0.031 and uSIGLEC-1; P = 0.006); however, no differences were detected in the comparison of uGalectin-9 and sSIGLEC-1 between these two groups (uGalectin-9; P = 0.180 and sSIGLEC-1; P = 0.699). sIP-10 (P &lt; 0.001), uIP-10 (P = 0.029) and uGalectin-9 (P &lt; 0.001) were significantly higher in patients with active SLE compared to AAV (Table 1). Serum and urine galectin-9, IP-10 and SIGLEC-1 did not differ between patients with active renal and extrarenal SLE. Levels of sIP-10, uIP-10 and uSIGLEC-1 were correlated with SLE Disease Activity Index (SLEDAI). ROC analyses confirmed that sIP-10, uIP-10, sGalectin-9 and uSIGLEC-1 discriminated disease activity in SLE (Figure 1). Serum and urine levels of all biomarkers were retested in 41 of 63 patients (65%) with active SLE after a median treatment of 8 (5–22.5) months. At the time of the second tests, there was a significant decrease in disease activity as measured by SLEDAI [2 (0–4)] compared to the time of the first tests [10 (6–15.5)]. Comparison of sGalectin-9 levels between the sample at the time of active disease and remission showed a very significant decline (P &lt; 0.001). uGalectin-9, sIP-10 and uSIGLEC-1 also decreased after treatment; however, the difference was not statistically significant.

CONCLUSION

sIP-10, uIP-10, sGalectin-9 and uSIGLEC-1 are associated with disease activity in SLE. None is able to discriminate active renal from active extrarenal disease. sIP-10 and uIP-10 are specific for active SLE compared to renal active AAV. sGalectin-9 may be a valuable biomarker to monitor response after treatment for active disease.

Funded by Scientific Research Projects Coordination Unit of Istanbul University. Project number: TSA-2019–34 218.

The relationship between serum A proliferation-inducing ligand and B-cell activating factor levels with disease activity and organ involvement in systemic lupus erythematosus

Objectives

We aim to investigate the association between serum B-cell activating factor (BAFF) and A proliferation-inducing ligand (APRIL) levels with disease activity and clinical findings in SLE patients.

Methods

Seventy-nine patients with SLE and 27 healthy controls were included into the study. Serum BAFF and APRIL levels were measured by using ELISA. In 19 patients with active disease at the time of the assessment, BAFF/APRIL levels were reassessed after 6 months of follow-up and disease activity was evaluated by using SLEDAI-2K. The relationship between renal histopathology index scores and lupus nephritis (LN) classes with serum BAFF/APRIL levels was examined in 16 patients who had recent renal involvement and underwent biopsy during the study.

Results

Although both BAFF/APRIL levels were higher in patients with SLE compared to the control group ( p < 0.001), no correlation was found between BAFF/APRIL levels and SLEDAI scores. Serum BAFF levels were higher in patients with renal disease activity ( p = 0.01), and there was a significant correlation between APRIL levels and proteinuria (r = 0.42, p = 0.02). A weak inverse correlation was observed between BAFF and C3 levels (r = 0.25, p = 0.02). No correlation was found between BAFF/APRIL levels and renal SLEDAI scores, renal histopathology, activity, and chronicity index scores. In the active disease group after treatment, there was no significant change in serum BAFF levels, but a significant increase in serum APRIL levels was observed.

Conclusion

These results suggest that both cytokines are involved in the pathogenesis of SLE and that serum BAFF can be valuable as a biomarker in SLE especially in patients with renal activity.

Flares after hydroxychloroquine reduction or discontinuation: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

OBJECTIVES

To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance.

METHODS

We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). We evaluated person-time contributed while on the initial HCQ dose ('maintenance'), comparing this with person-time contributed after a first dose reduction, and after a first HCQ discontinuation. We estimated time to first flare, defined as either subsequent need for therapy augmentation, increase of ≥4 points in the SLE Disease Activity Index-2000, or hospitalisation for SLE. We estimated adjusted HRs (aHRs) with 95% CIs associated with reducing/discontinuing HCQ (vs maintenance). We also conducted separate multivariable hazard regressions in each HCQ subcohort to identify factors associated with flare.

RESULTS

We studied 1460 (90% female) patients initiating HCQ. aHRs for first SLE flare were 1.20 (95% CI 1.04 to 1.38) and 1.56 (95% CI 1.31 to 1.86) for the HCQ reduction and discontinuation groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts.

CONCLUSIONS

SLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.

Impact of glucocorticoids on the incidence of lupus-related major organ damage: a systematic literature review and meta-regression analysis of longitudinal observational studies

OBJECTIVE

In systemic lupus erythematosus (SLE), disease activity and glucocorticoid (GC) exposure are known to contribute to irreversible organ damage. We aimed to examine the association between GC exposure and organ damage occurrence.

METHODS

We conducted a literature search (PubMed (Medline), Embase and Cochrane January 1966-October 2021). We identified original longitudinal observational studies reporting GC exposure as the proportion of users and/or GC use with dose information as well as the occurrence of new major organ damage as defined in the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. Meta-regression analyses were performed. Reviews, case-reports and studies with <5 years of follow-up, <50 patients, different outcomes and special populations were excluded.

RESULTS

We selected 49 articles including 16 224 patients, 14 755 (90.9%) female with a mean age and disease duration of 35.1 years and of 37.1 months. The mean follow-up time was 104.9 months. For individual damage items, the average daily GC dose was associated with the occurrence of overall cardiovascular events and with osteoporosis with fractures. A higher average cumulative dose adjusted (or not)/number of follow-up years and a higher proportion of patients on GC were associated with the occurrence of osteonecrosis.

CONCLUSIONS

We confirm associations of GC use with three specific damage items. In treating patients with SLE, our aim should be to maximise the efficacy of GC and to minimise their harms.

2021 DORIS definition of remission in SLE: final recommendations from an international task force

Objective

To achieve consensus on a definition of remission in SLE (DORIS).

Background

Remission is the stated goal for both patient and caregiver, but consensus on a definition of remission has been lacking. Previously, an international task force consisting of patient representatives and medical specialists published a framework for such a definition, without reaching a final recommendation.

Methods

Several systematic literature reviews were performed and specific research questions examined in suitably chosen data sets. The findings were discussed, reformulated as recommendations and voted on.

Results

Based on data from the literature and several SLE-specific data sets, a set of recommendations was endorsed. Ultimately, the DORIS Task Force recommended a single definition of remission in SLE, based on clinical systemic lupus erythematosus disease activitiy index (SLEDAI)=0, Evaluator’s Global Assessment <0.5 (0–3), prednisolone 5 mg/day or less, and stable antimalarials, immunosuppressives, and biologics.

Conclusion

The 2021 DORIS definition of remission in SLE is recommended for use in clinical care, education, and research including clinical trials and observational studies.

Chronic oxcarbazepine intoxication in a patient with primary antiphospholipid syndrome on maintenance haemodialysis

WHAT IS KNOWN AND OBJECTIVE

Oxcarbazepine (OXC) is an antiepileptic drug. Patients suffering from chronic kidney disease with an estimated glomerular filtration rate below 30 ml/min/1.73 m² require dose adjustments for OXC.

CASE SUMMARY

A 31-year-old man was admitted with a history of diplopia, ataxia and dizziness attacks that had disappeared after a regular haemodialysis sessions for three months. Medical history was remarkable for primary antiphospholipid syndrome (APS). However, no signs of new-onset APS-related neurological involvement were present. Then, it was revealed that the patient had been using 2400 mg/day of OXC for four months, despite the prescription of half of this dose. Serum OXC level was 50 mcg/ml (reference: 3-35 mcg/ml) before a regular haemodialysis session. All symptoms disappeared in a few days after reducing to 1200 mg/day and never recurred.

WHAT IS NEW AND CONCLUSION

We reported a chronic OXC intoxication in a patient on maintenance haemodialysis. To the best of our knowledge, it is the first chronic OXC intoxication case in the literature. It could be related to episodic removal of OXC and its metabolites via haemodialysis. Consequently, dose modification of drugs is a pivotal point in haemodialysis patients. Chronic drug intoxications must be kept in mind in haemodialysis patients with unexplained symptoms.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

Conclusion:

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

Graphic 1.

Distribution of damage according to organs/systems in hospitalized patients

References:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

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

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

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

Conclusion:

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

Disclosure of Interests:

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

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

Conclusion:

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

References:

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

Table 1.

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

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

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

Table 1.

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

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Demographic, clinical and laboratory characteristics of clusters

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

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

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

Conclusion:

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

Figure 1.

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

Table 1.

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

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Demographic features and laboratory findings of the participants

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

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

Table 1.

Clinical characteristics, laboratory findings and treatment responses of patients

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

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

References:

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

Table 1.

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

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

s.c:subcutaneous

Figure 1.

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Figure 1.

Performance Among Patients with Each Domain

Conclusion:

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

Table 1.

Diagnostic estimates of screening tools in different studies

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

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

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Table 1.

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

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

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

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

Table 1.

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

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

Conclusion:

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

References:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Characteristics of SSc patients with PAH

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

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

Table 2.

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

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

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

Conclusion:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

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

Conclusion:

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

*the first two authors contributed equally

Disclosure of Interests:

None declared.

Neuropsychiatric Events in Systemic Lupus Erythematosus

OBJECTIVES

To determine predictors for change in neuropsychiatric (NP) event status in a large, prospective, international, inception cohort of SLE patients METHODS: Upon enrollment and annually thereafter, NP events attributed to SLE and non-SLE causes and physician determined resolution were documented. Factors potentially associated with onset and resolution of NP events were determined by time-to-event analysis using a multistate modelling structure.

RESULTS

NP events occurred in 955/1,827 (52.3%) patients and 592/1910 (31.0%) unique events were attributed to SLE. For SLE NP events multivariate analysis revealed positive associations with male sex, concurrent non-SLE NP events excluding headache, active SLE and corticosteroids. There was a negative association with Asian race/ethnicity, post-secondary education, and immunosuppressive or anti-malarial drugs. For non-SLE NP events, excluding headache, there was a positive association with concurrent SLE NP events and negative associations with African and Asian race/ethnicity. NP events attributed to SLE had a higher resolution rate than non-SLE NP events, with the exception of headache that had comparable resolution rates. For SLE NP events, multivariate analysis revealed resolution was more common with Asian race/ethnicity and for central/focal NP events. For non-SLE NP events resolution was more common with African race/ethnicity and less common with older age at SLE diagnosis.

CONCLUSIONS

In a large and long-term study of the occurrence and resolution of NP events in SLE we identified subgroups with better and worse prognosis. The course of NP events differs greatly depending on their nature and attribution.