Jill P. Buyon

Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus

OBJECTIVE The Systemic Lupus International Collaborating Clinics (SLICC) group revised and validated the American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) classification criteria in order to improve clinical relevance, meet stringent methodology requirements, and incorporate new knowledge regarding the immunology of SLE. METHODS The classification criteria were derived from a set of 702 expert-rated patient scenarios. Recursive partitioning was used to derive an initial rule that was simplified and refined based on SLICC physician consensus. The SLICC group validated the classification criteria in a new validation sample of 690 new expert-rated patient scenarios. RESULTS Seventeen criteria were identified. In the derivation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (49 versus 70; P = 0.0082) and had greater sensitivity (94% versus 86%; P < 0.0001) and equal specificity (92% versus 93%; P = 0.39). In the validation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (62 versus 74; P = 0.24) and had greater sensitivity (97% versus 83%; P < 0.0001) but lower specificity (84% versus 96%; P < 0.0001). CONCLUSION The new SLICC classification criteria performed well in a large set of patient scenarios rated by experts. According to the SLICC rule for the classification of SLE, the patient must satisfy at least 4 criteria, including at least one clinical criterion and one immunologic criterion OR the patient must have biopsy-proven lupus nephritis in the presence of antinuclear antibodies or anti-double-stranded DNA antibodies.

Mycophenolate Mofetil versus Cyclophosphamide for Induction Treatment of Lupus Nephritis

Recent studies have suggested that mycophenolate mofetil (MMF) may offer advantages over intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis, but these therapies have not been compared in an international randomized, controlled trial. Here, we report the comparison of MMF and IVC as induction treatment for active lupus nephritis in a multinational, two-phase (induction and maintenance) study. We randomly assigned 370 patients with classes III through V lupus nephritis to open-label MMF (target dosage 3 g/d) or IVC (0.5 to 1.0 g/m(2) in monthly pulses) in a 24-wk induction study. Both groups received prednisone, tapered from a maximum starting dosage of 60 mg/d. The primary end point was a prespecified decrease in urine protein/creatinine ratio and stabilization or improvement in serum creatinine. Secondary end points included complete renal remission, systemic disease activity and damage, and safety. Overall, we did not detect a significantly different response rate between the two groups: 104 (56.2%) of 185 patients responded to MMF compared with 98 (53.0%) of 185 to IVC. Secondary end points were also similar between treatment groups. There were nine deaths in the MMF group and five in the IVC group. We did not detect significant differences between the MMF and IVC groups with regard to rates of adverse events, serious adverse events, or infections. Although most patients in both treatment groups experienced clinical improvement, the study did not meet its primary objective of showing that MMF was superior to IVC as induction treatment for lupus nephritis.

Autoimmune-Associated Congenital Heart Block: Demographics, Mortality, Morbidity and Recurrence Rates Obtained From a National Neonatal Lupus Registry

OBJECTIVES The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus. BACKGROUND Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease. RESULTS The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS. CONCLUSIONS Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

The role of nitric oxide in the pathogenesis of preeclampsia

OBJECTIVE Nitric oxide, a potent vasodilator released by endothelial cells, inhibits platelet aggregation and adhesion to vascular endothelial surfaces. Because endothelial cell damage is considered pivotal in the pathogenesis of preeclampsia, this study was initiated to determine whether nitric oxide production is decreased in patients with preeclampsia. STUDY DESIGN Twenty-six patients with preeclampsia (as defined by a blood pressure > or = 140 mm Hg systolic or 90 mm Hg diastolic plus proteinuria, > or = 300 mg per 24 hours or > or = 2+ by dipstick, both occurring on two occasions > or = 4 hours apart) and 26 normotensive women with singleton gestations in the third trimester were studied. Because nitric oxide is spontaneously oxidized to both nitrite and nitrate, two analytic assays were used serially. Serum nitrite levels were initially determined with the Greiss reagent and subsequently analyzed with Escherichia coli nitrate reductase. RESULTS With the Greiss reagent alone the mean +/- SEM of serum nitrite level in 26 patients with preeclampsia was significantly decreased compared with 26 normotensive patients (3.46 +/- 1.43 mumol/L vs 4.65 +/- 0.85 mumol/L, p = 0.02). With the addition of the nitrate reductase enzyme of Escherichia coli the mean +/- SEM of serum nitrite level in 26 preeclamptic patients was again significantly decreased compared with 26 normotensive patients (20.04 +/- 1.25 mumol/L vs 27.38 +/- 2.23 mumol/L, p = 0.02). One patient with the syndrome of hemolysis, elevated liver enzymes, and low platelets demonstrated a concurrent decrease in serum nitrite over a 2-week period, emphasizing the relationship of nitric oxide to the pathophysiologic features of the syndrome. CONCLUSIONS Circulating levels of nitrite are decreased in patients with preeclampsia. These data support the concept that diminished nitric oxide synthesis contributes to the pathophysiologic changes seen in preeclampsia.

Congenital heart block: development of late-onset cardiomyopathy, a previously underappreciated sequela.

OBJECTIVE We report 16 infants with complete congenital heart block (CHB) who developed late-onset dilated cardiomyopathy despite early institution of cardiac pacing. BACKGROUND Isolated CHB has an excellent prognosis following pacemaker implantation. Most early deaths result from delayed initiation of pacing therapy or hemodynamic abnormalities associated with congenital heart defects. METHODS A multi-institutional study was performed to identify common clinical features and possible risk factors associated with late-onset dilated cardiomyopathy in patients born with congenital CHB. RESULTS Congenital heart block was diagnosed in utero in 12 patients and at birth in four patients. Ten of 16 patients had serologic findings consistent with neonatal lupus syndrome (NLS). A pericardial effusion was evident on fetal ultrasound in six patients. In utero determination of left ventricular (LV) function was normal in all. Following birth, one infant exhibited a rash consistent with NLS and two had elevated hepatic transaminases and transient thrombocytopenia. In the early postnatal period, LV function was normal in 15 patients (shortening fraction [SF] = 34 +/- 7%) and was decreased in one (SF = 20%). A cardiac pacemaker was implanted during the first two weeks of life in 15 patients and at seven months in one patient. Left ventricular function significantly decreased during follow-up (14 days to 9.3 years, SF = 9% +/- 5%). Twelve of 16 patients developed congestive heart failure before age 24 months. Myocardial biopsy revealed hypertrophy in 11 patients, interstitial fibrosis in 11 patients, and myocyte degeneration in two patients. Clinical status during follow-up was guarded: four patients died from congestive heart failure; seven required cardiac transplantation; one was awaiting cardiac transplantation; and four exhibited recovery of SF (31 +/- 2%). CONCLUSIONS Despite early institution of cardiac pacing, some infants with CHB develop LV cardiomyopathy. Patients with CHB require close follow-up not only of their cardiac rate and rhythm, but also ventricular function.

Circulating endothelial cells Biomarker of vascular disease

Recent research has recognised new populations of non-hematopoietic cells in the blood. One of these, circulating endothelial cells (CECs), often defined by the expression of membrane glycoprotein CD146, are rarely found in the blood in health, but raised numbers are present in a wide variety of human conditions, including inflammatory, immune, infectious, neoplastic and cardiovascular disease, and seem likely to be evidence of profound vascular insult. An additional population are endothelial progenitor cells, defined by the co-expression of endothelial and immaturity cell surface molecules and also by the ability to form colonies in vitro. Although increased numbers of CECs correlate with other markers of vascular disease, questions remain regarding the precise definition, cell biology and origin of CECs. For example, they may be damaged, necrotic or apopototic, or alive, and could possess procoagulant and/or proinflammatory properties. However, since these cells seem to be representative of in situ endothelium, their phenotype may provide useful information. Indeed, whatever their phenotype, there is growing evidence that CECs may well be a novel biomarker, the measurement of which will have utility in various clinical settings related to vascular injury. Despite this promise, progress is impeded by the diversity of methodologies used to detect these cells. Accordingly, results are sometimes inconclusive and even conflicting. Nevertheless, increased CECs predict adverse cardiovascular events in acute coronary syndromes, suggesting they may move from being simply a research index to having a role in the clinic. The objective of the present communication is to condense existing data on CECs, briefly compare them with progenitor cells, and summarise possible mechanism(s) by which they may contribute to vascular pathology.

Molecular definition and sequence motifs of the 52-kD component of human SS-A/Ro autoantigen.

Serum SS-A/Ro autoantibodies are commonly found in patients with Sjogrens syndrome, systemic lupus erythematosus, neonatal lupus, and subacute cutaneous lupus. Two proteins of 60 and 52 kD have been described as targets for these autoantibodies. To define the 52-kD component unambiguously, cDNA clones were isolated from human HepG2 and MOLT-4 cell cDNA libraries. The identity of cDNA was established by (a) the specificity of the antibody affinity purified from the recombinant protein, (b) the reactivity of the purified recombinant protein with prototype SS-A/Ro sera in immunoblot and ELISA, and (c) two-dimensional gel comigration of MOLT-4 cell 52-kD protein and the recombinant protein. A 1.9-kb cDNA encoded the complete 52-kD protein containing 475 amino acids (Mr 54,082). Putative zinc-finger domains and a leucine zipper motif were identified in the amino-terminal half of the 52-kD protein, implicating its possible association with DNA/RNA. Sequence homology detected between the 52-kD protein and human ret transforming protein, and mouse T cell gene expression down-regulatory protein rpt-1, may provide leads to the functional role of the 52-kD protein in addition to the possibility that these proteins might constitute members of a subfamily of finger proteins.

Autoantibody-Associated Congenital Heart Block: Outcome in Mothers and Children

Congenital heart block was first reported by Morquio [1] in 1901 and was diagnosed antepartum in 1945 by Plant and Steven [2]. This dysfunction of the conducting system can occur in association with structural heart disease such as atrioventricular septal defects, left atrial isomerism, and abnormalities of the great arteries [3]; with tumors such as mesotheliomas [4]; or as an isolated defect. Although malformation of the conducting system can result in isolated congenital heart block [3], an important advance in the description and understanding of congenital heart block came in the 1970s with the observation that mothers of these infants frequently had autoimmune diseases [5-7] and that, in particular, many maternal sera contained antibodies to SSA/Ro ribonucleoproteins [8, 9]. Other neonatal abnormalities affecting the skin, liver, and blood elements were also associated with anti-SSA/Ro antibodies in the maternal and fetal circulation and are now grouped under the heading of neonatal lupus syndromes [10, 11]. Neonatal lupus was so termed because the cutaneous lesions of the neonate resembled those seen in systemic lupus erythematosus [12, 13]. The neonatal lupus syndrome is considered to result from the transplacental passage of maternal autoantibodies into the fetal circulation resulting in damage to the otherwise normally developing heart. An inflammatory phase of cardiac injury has been noted in utero with decreased ventricular function and pericarditis [14]. This may resolve or the newborn may have congestive heart failure in addition to congenital heart block. Major cardiac anatomic abnormalities rarely occur in autoimmune-associated congenital heart block [15]. To date, congenital heart block is irreversible. However, the noncardiac manifestations of the neonatal lupus syndrome are transient, resolving at about 6 months of life, coincident with the disappearance of maternal autoantibodies from the neonatal circulation [13]. Although reports of additional patients with congenital heart block reinforced the relation of the neonatal lupus syndrome with antibodies to the 52-kd and 60-kd SSA/Ro proteins and to the 48-kd SSB/La proteins, the associated maternal clinical status and prognosis remained poorly defined. In 1987, McCune and colleagues [16] assessed the health status of mothers and children with transient and permanent manifestations of the neonatal lupus syndrome in a follow-up study of 21 families. The average follow-up was 4.5 years (range, 0.25 to 9.5 years). All mothers eventually developed symptoms of a rheumatic disease. Fourteen children had congenital heart block. Three died in the neonatal period and 5 of the living children required pacemakers. Of 13 children born after the child with the neonatal lupus syndrome, 2 had congenital heart block and 1 had cutaneous disease. In the last several years, our laboratory evaluated the sera of 60 mothers whose children had congenital heart block and 5 women currently carrying fetuses with heart block, who were from the continental United States, Canada, and Europe [17, 18]. Given the limited clinical data available, a follow-up study of this extensive group was initiated to address the long-term outcome of these mothers and their children. Moreover, this study evaluated whether maternal autoantibodies to the 52-kd SSA/Ro, 60-kd SSA/Ro, or 48-kd SSB/La proteins (as determined by enzyme-linked immunosorbent assay [ELISA] or immunoblot) were associated with the clinical prognosis of the mother or her child. Methods Collection of Clinical Data Since 1985, sera from 60 mothers of children with congenital heart block and from 5 women currently carrying fetuses with heart block were analyzed at the Hospital for Joint Diseases, New York University School of Medicine. Several women were followed at the Hospital for Joint Diseases or were referred for their care after congenital heart block was diagnosed. In other cases, we were contacted by the womens physicians because of our known interest in this condition. Two serum samples were obtained early in pregnancies that were later complicated by congenital heart block. Other mothers were referred through the Sjogren Syndrome Foundation or the Lupus Foundation of America. The affected births occurred during 1970 to 1992. Any woman whose serum contained anti-SSA/Ro antibodies alone or in association with anti-SSB/La antibodies (as shown in our laboratory) and whose child (or fetus) had congenital heart block was initially included in the study. Each woman was sent an explanatory letter and a questionnaire. We also attempted to contact all mothers by telephone to confirm and expand information obtained in the questionnaire. Information was sought about the mothers health at the time of birth of the affected child and her health during the ensuing years. Emphasis was placed on organ system involvement characteristic of a rheumatic disease. Specifically included were questions seeking evidence of dry eyes or mouth, cutaneous lesions, sun sensitivity, cardiac or pulmonary disease, arthritic complaints, and renal or central nervous system disease. Medications used during the affected pregnancy were identified as were any intercurrent illnesses. A family history of rheumatic tissue disease or cardiac abnormalities was also sought. Information about subsequent pregnancies was obtained as was medical and developmental history of the affected child(ren), specifically the presence of heart failure and pacemaker placement. Further information was obtained from the attending rheumatologist, primary care physician, or pediatrician; available medical charts were reviewed. Eight of the 65 women could not be contacted by mail or telephone and were excluded. Sufficient information to confidently describe initial maternal characteristics was obtained for 57 women; follow-up status could be assessed in 52 of these women (5 are currently pregnant with affected fetuses) and in 55 affected children. In 8 of these 52 women, a telephone interview was not done because the woman had moved and could not be located or because either the woman or her physician was hesitant to release the telephone number. In all these patients, the information was confirmed by the primary physician or the patients medical records or both and was thus included in the study. Mothers classified as having systemic lupus erythematosus met at least four of the criteria from the American College of Rheumatology (formerly the American Rheumatism Association) [19]. Mothers were categorized as having the Sjogren syndrome if sicca complaints were present in the absence of other characteristics of a rheumatic disease whether or not objective documentation existed of salivary or lacrimal gland hypofunction or of lymphocytic infiltration in these glands. None of these mothers met criteria for other rheumatic diseases. Undifferentiated autoimmune syndromes were diagnosed in those patients with features of a rheumatic disease who did not have prominent sicca complaints and did not meet criteria for systemic lupus erythematosus. Characterization of Maternal Antibody Responses to SSA/Ro and SSB/La Enzyme-linked immunosorbent assays were done as described using commercially purified SSA/Ro from bovine spleen and SSB/La antigens from rabbit thymus (Immunovision, Springdale, Arkansas) [17]. SSA/Ro at 5 g/mL or SSB/La at 10 g/mL in 0.05 M sodium bicarbonate with sodium carbonate at pH 9.2 were incubated in 96-well ELISA plates overnight at 4 C. The ELISA plates were blocked with 1% bovine serum albumin in phosphate-buffered saline with 0.05% Tween, were incubated with sera diluted 1:1000 in phosphate-buffered saline with 0.05% Tween followed by incubation with F(ab)2 goat anti-human IgG alkaline phosphatase conjugate (Sigma St. Louis, Missouri), and were developed with disodium p-nitrophenyl phosphate in diethanolamine buffer. Results are expressed as the optical absorbance at 405 nm minus that of the reagent blank. A result was considered positive if it was greater than 2 SD above the value obtained for normal healthy donors. Immunoblot was done as described [20]. Briefly, the cell line MOLT4 was used as the source of antigen. Proteins were separated by electrophoresis and were electrotransferred to nitrocellulose. The nitrocellulose strips were incubated in phosphate-buffered saline containing 0.05% Tween 20 and 3% nonfat milk followed by incubation with a 1:100 dilution of sera. Protein A-(Iodine-125) was used to detect the bound human immunoglobulins. Statistical Analysis Comparisons between groups were calculated using the Fisher exact test. P values (two-tailed) less than 0.05 were considered to be significant. Results Demographic Characteristics and Clinical Status of the Women Thirty-nine (68%) of the 57 women were white, 12 (21%) were black, and 6 (11%) were Hispanic. Ages ranged from 19 to 38 years. Most lived in the eastern United States, although many were from other areas of the country. One woman was from Canada, and 10 were from northern Europe. At the time of identification of heart block either at birth or in utero, 23 (40%) of the 57 mothers were asymptomatic (mean age, 27.1 years), 15 (26%) had systemic lupus erythematosus (mean age, 30.1 years), 11 (19%) had an undifferentiated autoimmune syndrome (mean age, 27.7 years), and 8 (14%) had the Sjogren syndrome (mean age, 27.7 years). The specific clinical characteristics of all mothers with an undifferentiated autoimmune syndrome (initially or on follow-up) are included in Table 1 and Table 2. Of the 10 patients categorized with the Sjogren syndrome (initially or on follow-up), 6 had symptomatic dry eyes and mouth in the absence of objective criteria, 2 had dry eyes and mouth and an abnormal salivary gland biopsy, 1 had dry eyes and mouth and a positive Schirmer test, and 1 had dry eyes and mouth and keratoconjunctivitis sicca. Unlike for systemic lupus erythematosus, no universally accepted diagnostic cr

Comparison of treatment with fluorinated glucocorticoids to the natural history of autoantibody-associated congenital heart block: Retrospective review of the research registry for neonatal lupus

OBJECTIVE To compare intervention with fluorinated glucocorticoids to the natural history of untreated congenital heart block (CHB) with respect to conduction abnormalities, associated effusions, ascites, and hydrops fetalis, and the requirement for a pacemaker. METHODS Records of all mothers enrolled in the Research Registry for Neonatal Lupus were reviewed. The cohort includes 47 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, and their 50 offspring with CHB, in whom at least 4 echocardiograms were performed after in utero diagnosis. In 28 pregnancies, mothers received dexamethasone 4-9 mg/day for 3-19 weeks or betamethasone 12-24 mg/week for >6 weeks (group A). In 22 pregnancies, fluorinated steroids were not used (group B). RESULTS Third-degree block was present in 21 fetuses in group A and 18 fetuses in group B; none were reversible despite steroid treatment. Three fetuses in group A and 2 in group B progressed from second-degree block, alternating with third-degree block, to permanent third-degree block at birth and postnatally. Of 4 fetuses in group A with second-degree block at presentation, all reverted to first-degree block by birth; 2 remain so at age 4 years, 1 alternates between first-degree and second-degree block at 2 years, and the fourth is in second-degree block at age 4 years. Of 2 fetuses in group B with second-degree block at presentation, both progressed to permanent third-degree block postnatally. Initial echocardiographic evaluation revealed pericardial effusions in 13 group A versus 4 group B fetuses, pleural effusions in 2 group A versus 0 group B, ascites in 8 group A versus 0 group B (P < 0.007), hydrops fetalis in 8 group A versus 0 group B (P < 0.007), and intrauterine growth restriction in 1 group A versus 1 group B. Pericardial effusions resolved and reappeared in both groups. Steroid therapy was most effective in the resolution of pleural effusions (2 of 2), ascites (6 of 8), and hydrops fetalis (5 of 8). Oligohydramnios ensued in 9 group A and 2 group B fetuses. Although fetuses in group A had more complications at presentation than those in group B, there were no significant differences in the duration of pregnancy (35.7 weeks versus 37.0 weeks), the number of deaths (4 versus 1), final degree of heart block, or requirement for a pacemaker (14 versus 11). CONCLUSION While prospective trials are needed, these data suggest that fluorinated steroids should be considered for fetuses with incomplete block or hydropic changes. Serial echocardiograms are recommended to monitor fetal progress. It remains to be determined whether third-degree block is reversible if therapy is initiated immediately upon detection.

Lupus anticoagulant activity of autoimmune antiphospholipid antibodies is dependent upon beta 2-glycoprotein I.

It has been reported that antiphospholipid autoantibodies do not recognize phospholipid alone, but rather the plasma protein beta 2-glycoprotein I (beta 2GPI), or a beta 2GPI-phospholipid complex. In vitro beta 2GPI binds to anionic phospholipids and inhibits the prothrombinase activity of procoagulant membranes. In light of the fact that lupus anticoagulants, a type of antiphospholipid antibody, have similar anticoagulant properties, the relationship of beta 2GPI to lupus anticoagulant activity was investigated. IgG from patients with autoimmune diseases or syphilis were tested for anticardiolipin reactivity and lupus anticoagulant activity in the presence and absence of beta 2GPI. As expected, anti-cardiolipin reactivity associated with autoimmune disease was beta 2GPI dependent. In contrast, IgG from a patient with syphilis recognized cardiolipin alone and binding was inhibited by beta 2GPI. Autoimmune antiphospholipid antibodies prolonged the dilute Russell viper venom time of normal plasma, but had no effect on beta 2GPI-depleted plasma. Antiphospholipid antibodies associated with syphilis had no anticoagulant effect. RP-1, an anti-beta 2GPI mAb, had anticoagulant effects similar to those of autoimmune antiphospholipid antibodies. These data demonstrate that antiphospholipid autoantibodies exert lupus anticoagulant activity via an interaction with beta 2GPI. These antibodies and RP-1 appear to amplify the anticoagulant effect of beta 2GPI itself.