F. Miranda

Flare, Persistently Active Disease, and Serologically Active Clinically Quiescent Disease in Systemic Lupus Erythematosus: A 2-Year Follow-Up Study

Objective Several indices have been proposed to assess disease activity in patients with Systemic Lupus Erythematosus (SLE). Recent studies have showed a prevalence of flare between 28–35.3%, persistently active disease (PAD) between 46%–52% and serologically active clinically quiescent (SACQ) disease ranging from 6 to 15%. Our goal was to evaluate the flare, PAD and SACQ rate incidence in a cohort of SLE patients over a 2-year follow-up. Methods We evaluated 394 SLE patients. Flare was defined as an increase in SLEDAI-2K score of ≥4 from the previous visit; PAD was defined as a SLEDAI-2K score of ≥4, on >2 consecutive visits; SACQ was defined as at least a 2-year period without clinical activity and with persistent serologic activity. Results Among the 95 patients eligible for the analysis in 2009, 7 (7.3%) had ≥1 flare episode, whereas 9 (9.4%) had PAD. Similarly, among the 118 patients selected for the analysis in 2010, 6 (5%) had ≥1 flare episode, whereas 16 (13.5%) had PAD. Only 1/45 patient (2.2%) showed SACQ during the follow-up. Conclusion We showed a low incidence of flare, PAD and SACQ in Italian SLE patients compared with previous studies which could be partly explained by ethnic differences.

Evaluation of the Patient Acceptable Symptom State (PASS) in Italian Patients Affected by Systemic Lupus Erythematosus: Association with Disease Activity Indices

Objectives The aim of this study was to evaluate the discriminant capability of the patient acceptable symptom state (PASS) according to disease activity, in a cohort of Italian patients affected by systemic Lupus erythematosus (SLE). Methods Consecutive SLE patients were enrolled. At each visit, the patients underwent a complete physical examination and the clinical/laboratory data were collected in a standardized, computerized, and electronically-filled form. The evaluation of serum complement C3 and C4 levels and determination of autoantibodies was obtained. Disease activity was assessed with the SLEDAI-2K and ECLAM, while chronic damage was measured with the SLICC. Finally, PASS was assessed in all patients by asking to answer yes or no to a single question. Results One hundred sixty-five patients were enrolled (M/F 12/153; mean age 40.4±11.8 years, mean disease duration 109.1±96.2 months). No patients refused to answer, suggesting the acceptability of PASS. A total of 80% of patients rated their state as acceptable. The patients with an acceptable status had significantly lower mean SLEDAI-2K and ECLAM scores than the others [1.8±2.7 versus 3.4±2.3(P=0.004); 0.7±0.9 versus 1.4±1.1(P=0.0027)]. No significant differences were observed when considering chronic damage, evaluated with SLICC. Conclusions In the clinical practice, SLE patients assessment performed by using complex disease activity indices such as SLEDAI-2K and ECLAM, could be time consuming. In our study, for the first time, we used PASS, a quick and easily comprehensible tool, to evaluate the patients’ status, this single question seems to be able to discriminate patients with different disease activity, especially when this is determined by musculoskeletal involvement.

The role of disease activity score 28 in the evaluation of articular involvement in systemic lupus erythematosus.

Objectives. To evaluate the application of Disease Activity Score 28 (DAS28) to assess joint involvement in Systemic Lupus Erythematosus (SLE). Methods. Sixty-nine SLE patients, complaining of joint symptoms, and 44 rheumatoid arthritis (RA) patients were enrolled. In SLE patients disease activity was assessed with SLEDAI-2K. DAS28 was calculated in all the patients. Results. Thirty SLE patients (43.5%) showed clinical signs of arthritis. Mean DAS28 was 4.0 ± 1.4, 22 patients (31.9%) had low disease activity, 29 (42.0%) moderate, and 18 (26.1%) high. We dichotomized SLE patients according to the presence (Group 1) or absence (Group 2) of articular involvement according to SLEDAI-2K: 56.3% of the patients of the second group had a moderate/high activity according to DAS28. We compared SLE patients with 44 RA patients (M/F 9/35, mean age 55.6 ± 14.5 years; mean disease duration 140.4 ± 105.6 months). No significant differences were found regarding the values of DAS28 between SLE and RA patients. On the contrary, the values of tender and swollen joint count were significantly higher in RA compared to SLE patients (P = 0.0002 and P = 0.0001, resp.). Conclusions. We suggest the use of the DAS28 in the assessment of joint involvement in SLE patients.

Kidney Expression of Toll Like Receptors in Lupus Nephritis: Quantification and Clinicopathological Correlations

Objective. The study aimed at locating and quantifying Toll Like Receptor (TLR) 3, 7, 8, and 9 expression in kidney of patients with lupus nephritis (LN) and correlating them with clinicopathological features. Methods. Kidney sections from 26 LN patients and 4 controls were analyzed by immunohistochemistry using anti-human TLR3, TLR7, TLR8, and TLR9 polyclonal antibodies; the number of TLR-positive nuclei/mm2 was evaluated on digitalized images. Results. Compared to controls, LN showed a significantly higher amount of glomerular and tubulointerstitial TLR9 (p = 0.003 and p = 0.007), whole and tubulointerstitial TLR3 (p = 0.026 and p = 0.031), and a higher tubulointerstitial TLR7 (p = 0.022). TLR9 positively correlated with activity index (p = 0.0063) and tubular TLR7 with chronicity index (p = 0.026). TLR9 positively correlated with Renal-SLEDAI (p = 0.01). Conclusions. This is the first study quantifying kidney expressions of TLRs in LN patients; the results show an overexpression of TLR3, TLR7, and TLR9 and demonstrate a correlation with clinicopathological indices supporting a role of these mediators in the pathogenesis of LN.

AB0512 Nasal Carriage of Staphylococcus Aureus in Patients with Systemic Lupus Erythematosus: Cause or Effect?

Background Staphylococcus aureus (SA) is a commensal bacterium which can be isolated mostly in the anterior nares. In immunosuppressive patients, SA could cause various infections, ranging from minor skin infections to severe pneumonia. Data from literature reported a prevalence of SA nasal carriage of about 25% in healthy subjects (HS). Patients affected by Wegeners granulomatosis and Rheumatoid Arthritis showed significantly higher rates of SA nasal colonisation compared with HS. In contrast, there are no studies concerning the patients with Lupus Erythematosus Systemic (SLE). Objectives We aimed to analyse the prevalence of SA nasal carriers in a cohort of SLE patients. Secondly, we evaluated the correlations between the presence of nasal colonization and clinical, laboratory and therapeutical features. Methods We enrolled 84 SLE patients (ACR criteria 1997, M/F 6/78; mean age 41.3±12.2 years, mean disease duration 141.5±102.6 months) and 154 HS blood donors, enrolled as control group. At each visit, SLE patients underwent a complete physical examination and the clinical/laboratory data were collected in a standardized, computerized, and electronically-filled form. The evaluation of serum complement C3 and C4 levels and determination of autoantibodies was obtained. Disease activity was assessed with the SLEDAI-2K. All the SLE patients and HS received a nasal swab in both anterior nares; the swabs were sent to microbiological laboratory for isolation and identification of SA. Results SA nasal colonization prevalence was 23.8% in SLE patients and 28.6% in HS (P=NS). None of the detected SA were Methicillin-resistant. We analysed SLE patients according with the presence (N=20, group 1) or the absence (N=64, group 2) of the nasal colonization. Group 1 patients showed a significant higher frequency of renal involvement compared with group 2 (15.0% vs 3.1%; P=0.0009). Moreover, the presence of anti-dsDNA, RNP, SSA and SSB antibodies was significantly higher in group 1 (P<0.0001, P=0.03, P=0.005, P=0.03, respectively). Finally, although without reaching significant differences, group 1 patients showed higher mean values of SLEDAI-2K and flare number in the previous 12 months compared with group 2. Conclusions In the present study we analysed the prevalence of SA nasal colonization in SLE patients, showing similar results in SLE patients and HS control group. Interestingly, in SLE patients the nasal colonization was associated with a more active disease, as demonstrated by higher values of disease activity indices, most frequent renal involvement and positivity for several autoantibodies. This association could be explained by two different hypothesis: first, the presence of SA nasal colonization could act as trigger for autoimmune process, perpetuating inflammatory condition. The second hypothesis suggests that the more active disease, requiring more aggressive immunosuppressant treatment, could facilitate the development of the nasal colonization. Further studies are needed to better clarify the relationship between SLE and SA. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4226

FRI0705 Progression of chronic damage in systemic lupus erythematosus patients after 5-year follow-up: data from a large monocentric cohort

Background The prevention of chronic damage represents one of the most important target in the management of patients affected by Systemic Lupus Erythematosus (SLE). About 50% of patients develop chronic damage, especially in the early disease phase, due to disease activity, treatment adverse events and comorbidities. Longitudinal studies demonstrated a progressive increase of damage, evaluated by using SLICC Damage Index (SDI). Objectives Moving from these evidences, we aimed at evaluating the progression of chronic damage in a monocentric SLE cohort with at least 5-year follow-up and identifying the factors associated with damage progression. Methods We analyzed 658 SLE patients diagnosed according to the ACR 1997 revised criteria, referring to a dedicated outpatient clinic. For the present analysis, we evaluated only patients with a minimum follow-up of 5 years and at least one visit per year. Clinical and laboratory data were collected in a standardized, computerized and electronically-filled form, including demographics, past medical history, comorbidities and concomitant treatments. In all patients, chronic damage was determined by using SDI, with the evaluation of 12 organ systems. Disease activity was evaluated by SLEDAI-2K. Furthermore, we calculated the number of flares during the follow-up, defined as an increase in SLEDAI-2K score ≥4 from the previous visit, with a minimum interval of 2 months between visits. Results According with the inclusion criteria, we analyzed data deriving from 198 SLE patients (17 M/181 F, mean±SD age 46.8±12.1 years, mean±SD disease duration 131±99.7 months). At the first visit 60 patients (30.3%) showed SDI>0; in particular SDI=1 was identified in 65%, SDI=2 in 18.3%, SDI=3 in 10%, SDI=4 in 6.7%). At baseline, the presence of chronic damage was significantly associated with age (P<0.0001) and disease duration (P=0.001). After 5 years, we registered the progression of chronic damage in 69 patients (34.8%), with a significant increase of SDI values (baseline: median SDI 0.0, IQR 0–1; follow-up SDI: median 0 IQR 0–2, P=0.009). SDI progression resulted significantly more frequent in subjects with damage at baseline (55.0%) in comparison with free-damage patients (26.1%, P=0.0001, Fisher exact test). The progression of chronic damage was significantly associated with neuropsychiatric involvement (P=0.01), disease activity in terms of number of flares during the 5-year follow-up (P=0.001), concomitant anti-phospholipid syndrome (P=0.02) and arterial hypertension (P=0.001). Conclusions In our study, we observed a progression of chronic damage in almost 30% of SLE patients after 5 years. In particular, the presence of previous chronic damage seem to be a risk factor for new damage development. Moreover, the lack of disease control and the presence of comorbidities allows damage progression. Taken together, the results of this study underline the need of a better management of SLE patients in order to prevent damage accrual. Disclosure of Interest None declared

AB0135 Plasmatic and urinary endothelial microparticles are increased in patients with lupus nephritis

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease presenting with a wide array of clinical manifestations and incompletely understood pathogenesis. SLE is characterized by alterations in both the innate and adaptive immune system ultimately leading to the loss of immunologic tolerance and occurrence of autoantibodies against nuclear material. Lupus nephritis is one of the most severe features of SLE determining an increase in morbidity e mortality rates. Renal biopsy still represent a fundamental diagnostic and prognostic tool for LN. Therefore, non-invasive surrogate biomarkers of active LN are urgently needed. Circulating, heterogeneous subcellular microparticles (MPs) are released from cells and platelets constitutively and upon cellular activation or apoptosis. Such MPs may reflect the state of their parental cells and tissues, and could serve as markers of pathology. Particularly in SLE, MPs are potential biomarkers and triggers of autoimmunity. Recent studies have demonstrated increased levels of plasmatic EMPs in patients with SLE active disease and their reduction after treatment. Objectives The aim of this study was to investigate plasmatic and urinary levels of endothelial microparticles in a cohort of SLE patients with and without renal involvement compared to healthy controls. Methods Consecutive SLE patients and sex- and age-matched HC were included in the study. MPs were isolated from plasma and urine and characterized by flow cytometry using AnxV (a probe that binds to the exposed phosphatidilserine - PS) and antibodies against surface markers endothelial cells (CD31+CD41-). Mann-Whitney and Spearman correlation tests were used. A p value <0.05 was considered statistically significant. Results Sixty SLE patients (55F:5M, age 41,7±9.6 Y disease duration 149±112 months) and 29 healthy controls were studied. Twenty-eight patients had renal involvement.The total number of plasmatic MPs was lower in SLE patients than HC (p=0.001). In contrast there was no significant difference in levels of EMPs between the two groups. When the patients were divided according to renal involvement, the patients with active lupus nephritis (A-LN) showed lower plasmatic level of EMPs in comparison to inactive LN (I-LN) (p=0.01), while the patients with I-LN had higher levels of EMPs than HC (p=0.002). There was no significant difference of total urinary level of MPs between SLE patients and HC. Urinary levels of EMPs were higher in SLE and in lupus nephritis patients than HC. Conclusions The results of the present study show increased urinary and plasmatic levels of EMPs in patients with lupus nephritis in remission. Circulating EMPs have been considered as a potential biomarker of endothelial activation and damage in several autoimmune disorders, and higher EMP levels have been detected in patients with vasculitis and associated with disease activation. According to our results, plasmatic EMPs levels are higher in inactive LN patients than in healthy donors. These results may suggest a potential role of EMP as a biomarker of lupus nephritis Disclosure of Interest None declared

FRI0027 Tnf expression on microparticles from rheumatoid arthritis patients mediates endothelial cell fate in vitro

Background Microparticles (MPs) are small membrane vesicles released by many cell types under physiological conditions or pathological situations. Increased levels of MPs have been reported in patients with autoimmune diseases, such as Rheumatoid Arthritis (RA) (1) which is characterized by an accelerated atherosclerosis. TNF, a key cytokine involved in the pathogenesis of RA, has been associated to RA atherosclerosis (2). Moreover, MPs could also have a role in endothelial dysfunction contributing to atherosclerosis in RA patients. Objectives The aim of this study was: 1) to evaluate TNF expression on RA-MPs. 2) to estimate the effects of serum RA-MPs on endothelial apoptosis and autophagy before and after in vivo and in vitro treatment with Etanercept. Methods 15 RA patients were recruited from the Department of Rheumatology Sapienza University of Rome at baseline (T0) and after three months of therapy (T3) with Etanercept. A fasting blood sample was collected and centrifuged two times to obtain platelet-poor plasma rich in MPs. The resulting plasma was stained with Ab anti-TNF and analized by flow cytometry. In vitro effects of serum RA-MPs on endothelium were evaluated using human umbilical vein cell line EA.hy926. Cells were treated with RA-MPs purified at T0 and T3 and with RA-MPs in vitro treated with Etanercept. At the end of experiments apoptosis and autophagy were evaluated. Apoptosis was analyzed by flow cytometry using a FITC-conjugated annexin V and propidium iodide apoptosis detection kit; autophagy was analyzed by western blot for the expression level of the autophagic marker LC3-II. Results Our results showed that MPs purified from RA patients at T0 expressed TNF on their surface and this expression decreased after three months of treatment with Etanercept (p=0.04). Moreover, serum RA-MPs at T0 significantly increased, in a dose-dependent manner, both apoptosis and autophagy levels in the human umbilical vein cell line EA. hy926 (p=0.005 and p=0.02, respectively versus untreated cells). After three months of treatment with Etanercept, RA-MPs were not able to significantly change these parameters.Finally, in vitro studies showed that RA-MPs treated with Etanercept significantly decreased surface expression of TNF and were no longer able to modulate apoptosis and autophagy in EA.hy926 cells. Conclusions Our data demonstrate that serum RA-MPs express TNF on their surface. Moreover, both in vivo and in vitro treatment with Etanercept interfere with the ability of MPs to significantly modulate apoptosis and autophagy of endothelial cells by decreasing surface expression of TNF. References Beyer C and Pisetsky DS.The role of microparticles in the pathogenesis of rheumatic diseases. Nat. Rev. Rheumatol. 2010;6:21–9. Feldmann M, Brennan FM, Foxwell BM and Maini RN.The role of TNF alpha and IL-1 in rheumatoid arthritis Curr. Dir. Autoimmun. 2001;3:188–99. Disclosure of Interest None declared

SAT0241 Early response to belimumab in sle-related joint involvement evaluated by ultrasonographic assessment

Background Belimumab (BLM), a fully human monoclonal antibody directed against B lymphocyte stimulator (BLyS), is currently the only biological drug approved for the treatment of active Systemic Lupus erythematosus (SLE) patients not responding to standard of care. Data from RCTs and observational studies have demonstrated its efficacy, especially in patients with joint involvement. Focusing on this specific manifestation, the response has been also demonstrated by using Disease Activity Score on 28 joints (DAS28) (1). No data are available about the response to BLM in terms of synovitis, assessed by ultrasonography (US). Objectives In the present 6-months longitudinal study, we evaluated the response to BLM in SLE patients treated for joint involvement, by using clinimetric indices and US assessment. Methods SLE patients starting BLM in the period between August 2013 and December 2016 were prospectively examined. The present analysis was restricted to patients requiring BLM for joint involvement. A complete physical examination and US assessment were performed at baseline (T0) and after 3 (T3) and 6 months (T6). At each time, we assessed the global disease activity by Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) and the joint involvement activity by DAS28. US evaluation of 12 joints (I-V metacarpophalangeal, I-V proximal interphalangeal, wrist and knee bilateral) was performed to identify inflammatory features (synovial effusion and hypertrophy, power Doppler) according to the OMERACT definitions. These elementary lesions were scored according to a semi-quantitative scale (0=absent, 1=mild, 2=moderate and 3=severe) and a total score, corresponding to the patients inflammatory status (0–216) was obtained by their sum. Results Moving from 35 SLE patients starting BLM, 14 (14 female; mean age±SD 48.4±8.6 years; mean disease duration±SD 255.4±124.2 months) were treated for prevalent joint involvement. At baseline, the mean DAS28±SD was 4.5±1.1, the mean SLEDAI-2K±SD was 6.1±1.5 and the mean daily prednisone±SD was 7.8±3.5 mg. After 3 months of treatment we observed a significant reduction in mean DAS28 (3.1±0.8 vs 4.5±1.1, P=0.007) and in mean SLEDAI-2K (3.5±2.1 vs 6.1±1.5, P=0.003) compared to baseline. The mean daily prednisone significantly decreased at T6 (4.7±1.4 vs 7.8±3.5 mg, P=0.03) while the rest of the therapy remained stable for 6 months. Of note, the mean total US score significantly decreased at T3 compared to T0 (13.7±24.4 vs 22.2±22.6, P=0.001). This result was maintained in 12 patients (85.7%) after 6 months with a statistically significant difference compared to T0 (7.9±6.6 vs 22.2±22.6, P=0.003) (Figure 1). Conclusions The results of the present study demonstrated the efficacy of BLM in SLE-related joint involvement, evaluated by SLEDAI-2K and DAS28, confirming previous data reported in the scientific literature. For the first time, we demonstrated an early response to BLM as proved by the reduction of the total US synovitis score after 3 months, reflecting the improvement of the joint inflammatory status. References Iaccarino L et al. Effects of Belimumab on Flare Rate and Expected Damage Progression in Patients With Active Systemic Lupus Erythematosus. Arthritis Care Res. 2017; 69:115–123. Disclosure of Interest None declared

AB0132 Antiphospholipid syndrome patients show an altered profile of endothelial progenitor cells and endothelial microparticles

Background Antiphospholipid Syndrome (APS) is an autoimmune disease characterized by recurrent thromboembolic events and pregnancy morbidity associated to the presence of specific serum antibodies directed against membrane phospholipids and proteic co-factors (1). Endothelial dysfunction represents the earlier and reversible stage of subclinical atherosclerosis that characterizes these patients. An altered profile of endothelial progenitor cells (EPCs) and endothelial microparticles (EMPs) could promote endothelial damage (2). Few studies suggested that EMP release is stimulated by circulating anti-phospholipids (aPL). A previous study on EPC reservoir in 7 APS patients showed no difference compared to healthy subjects. Objectives Our aim was to evaluate circulating EPCs and EMPs in primary APS patients (PAPS). Methods We studied primary APS patients with previous thromboembolic events and sex and age-matched healthy controls (HC). Circulating EPCs was identified by flow cytometry analysis as CD34+/KDR+ positive cells isolated from peripheral blood mononuclear cells (PBMCs); EMPs was obtained by centrifugation of whole blood and quantified by flow cytometry (CD31+/CD41a-). Data were expressed a s mean±standard deviation or median (interquartile range) when appropriate; correlations between EPC and EMP levels with aPL were investigated by Spearman test. P values <0.05 were considered statistically significant. Results We enrolled 12 PAPS patients (mean age 44±12 years) and 12 HC. Compared to HC, PAPS patients showed a lower EPC percentage (0.01±0.006% vs 0.04±0.003%, p=0.0008) and a higher EMP number (104±80 MPs/microliter vs 20±8, p<0.0001). EMPs number positively correlated with anticardiolipin and antibeta2 glicoprotein I, both IgM and IgG (p<0.05 and r>0.7 for all correlations). Conclusions The results of this study suggest that endothelial cells, activated by circulating aPL, release EMPs that can perpetuate the endothelial damage. Moreover, our cohort of APS patients has a reduced number of circulating EPC that could contribute to the impairment of endothelial repair. Both the chronic endothelial damage and the lack of an efficient repair could contribute to the progression of atherosclerosis in PAPS patients. References Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RH, DE Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A,Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definiteantiphospholipid syndrome (APS). J. Thromb. Haemost. 2006 Feb;4:295–306. Bartoloni E, Alunno A, Bistoni O, Caterbi S, Luccioli F, Santoboni G, Mirabelli G, Cannarile F, Gerli R. Characterization of circulating endothelial microparticles and endothelial progenitor cells in primary Sjögrens syndrome: new markers of chronic endothelial damage? Rheumatology (Oxford). 2015 Mar;54:536–44. Disclosure of Interest None declared