Kuninobu Wakabayashi

Relevance of the CX3CL1/fractalkine-CX3CR1 pathway in vasculitis and vasculopathy

The clinical presentation of systemic vasculitis can vary widely and include skin disorders, neuropathy, eye symptoms, and systemic inflammation. The precise molecular mechanisms underlying this syndrome are not fully understood, but the importance of a chronic imbalance of the cytokines and chemokines involved in orchestrating inflammatory responses is now recognized. In similar fashion, atherosclerosis is now recognized to be a chronic inflammatory disease in which chemokines play important roles. In the current review, we discuss the involvement of CX3CL1, which is a unique member of the chemokine family, and its receptor, CX3CR1, in the pathogenesis of these vasculopathies.

Tacrolimus-induced lung injury in a rheumatoid arthritis patient with interstitial pneumonitis

A 74-year-old woman was experiencing rheumatoid arthritis complicated with interstitial pneumonitis (IP), and tacrolimus treatment was started. She presented with dyspnea. Chest X-ray and computed tomography (CT) showed ground-glass opacity and IP. Although tacrolimus was stopped, she died of respiratory failure. At autopsy, both the upper and lower lung fields showed usual IP and the organizing stage of diffuse alveolar damage. The former is common, but the latter is uncommon, suggesting tacrolimus may cause severe alveolar damage.

Synergistic induction of CX3CL1 by interleukin-1β and interferon-γ in human lung fibroblasts: involvement of signal transducer and activator of transcription 1 signaling pathways

CX3CL1 (fractalkine), a membrane-bound chemokine that induces both the adhesion and the migration of leukocytes, is involved in the recruitment of cells into tissues undergoing inflammatory responses. To explore the regulation of CX3CL1 in pulmonary inflammation and fibrosis, CX3CL1 expression in lung fibroblasts was examined. Normal human fibroblasts were obtained from Promocell (Lonza Walkersville Inc, Md) and were incubated in the presence or absence of various inflammatory stimuli. Culture supernatants were collected, and the soluble CX3CL1 levels were determined with an enzyme-linked immunosorbent assay. The expression of CX3CL1 mRNA transcripts in lung fibroblasts was assessed using quantitative TaqMan real-time polymerase chain reaction. Interleukin (IL)-1β or interferon (IFN)-γ individually induced negligible soluble CX3CL1 secretion by human lung fibroblasts after 24 h. However, the combination of IL-1β and IFN-γ induced dramatic increases in both soluble CX3CL1 protein and mRNA transcripts in a dose- and time-dependent manner. Synergistic up-regulation of cell-associated CX3CL1 protein also was observed after treatment with IL-1β and IFN-γ. The secretion and expression of lung fibroblast-derived CX3CL1 were markedly reduced by specific inhibitors of the STAT-1 transcription factor. These findings suggest that lung fibroblasts are an important cellular source of CX3CL1 and may play a role in pulmonary inflammation and fibrosis.

Elevated serum levels of macrophage migration inhibitory factor and their significant correlation with rheumatoid vasculitis disease activity

Macrophage migration inhibitory factor (MIF) is recognized to be an important mediator in several inflammatory disorders, including rheumatoid arthritis (RA) and vasculitis. To evaluate the role of MIF in rheumatoid vasculitis (RV), we determined serum levels of MIF by enzyme-linked immunosorbent assay in RA patients with and without vasculitis and assessed their relationship to disease activity. Serum was obtained from 95 RA patients during active disease states [49 without vasculitis, 35 with extra-articular manifestations without histologically proven vasculitis, and 11 with histologically proven vasculitis] and from 22 healthy individuals. Vasculitis disease activity was assessed using the Birmingham Vasculitis Activity Score (BVAS). MIF levels were significantly higher in RA patients than in controls. Moreover, MIF levels were significantly higher in RA patients with vasculitis than in those without vasculitic complications. In all RA patients, a statistically significant positive correlation was observed between serum MIF levels and each of the following: serum levels of C-reactive protein, rheumatoid factor, and thrombomodulin; and the erythrocyte sedimentation rate. In the RV group, the elevation of MIF levels correlated with the BVAS. Our findings suggest that MIF may serve as an additional serologic inflammatory marker of disease activity in RV, and it may be implicated in the pathogenesis of RV.

AB0377 Efficacy of tacrolimus combination therapy during the maintenance phase of systemic lupus erythematosus

Background In Japan, a placebo-controlled clinical trial of tacrolimus for lupus nephritis was performed to investigate the efficacy and safety of this agent. Based on the results obtained, administration of tacrolimus at an oral dose of 3 mg/day was approved for the treatment of lupus nephritis. Objectives The aim of this study was to prospectively evaluate the efficacy and safety of tacrolimus (TAC) combination therapy during the maintenance phase of systemic lupus erythematosus (SLE). TAC was added to the existing therapy if the clinical symptoms worsened and/or if there was a decrease in the serum complements titer because it allowed for a decrease in the dose of prednisolone (PSL). Methods From 2009 to 2012, 38 patients were included in the study period for 1 year. TAC combination therapy (dosage range: 1 mg to 5 mg once daily) was given if there was worsening of any mild manifestations of active SLE, such as arthritis, skin eruptions, or asymptomatic nephritis, and/or if there was a decrease in the serum complement titer (C3c). This study reviewed the SLE Disease Activity Index (SLEDAI) score, the dosage of PSL, the serum levels of C3c, the anti-dsDNA titers and proteinuria. Results Twenty-eight patients were treated with TAC combination therapy and showed symptom improvement with the following results: 1) the dosage of PSL was reduced from 11.7 ± 5.6 to 8.2 ± 4.2 (mg/day) (P<0.001), 2) the serum C3c concentration increased from 74.7 ± 21.9 to 86.4 ± 17.8 (mg/dl) (P=0.006), 3) the anti-dsDNA titer decreased from 39.6 ± 68.0 to 24.8 ± 49.1 (U/ml) (P<0.001) and 4) the SLEDAI score improved from 6.2 ± 3.7 to 2.6 ± 2.3 (P<0.001). Of note, the components of the SLEDAI with the greatest levels of improvement included headache (decreased from 7 patients to 1 patient), arthritis (from 3 patients to no patients), rash (from 6 patients to 2 patients), alopecia (from 5 patients to no patients), mucosal ulcer (from 2 patients to no patients) and fever (from 5 patients to 1 patient). Although the occurrence of proteinuria decreased from 46.0 ± 95.7 to 30.7 ± 74.2 (mg/dl) upon administration of TAC combination therapy, the difference was not significant (P=0.23). However, 8 patients treated with TAC combination therapy did not show disease improvement nor had worsening SLE. In addition, 2 patients discontinued therapy due to an adverse effect: muscle cramp or rhabdomyolysis. No patients presented abnormal urinalysis, progression to renal failure, or became a candidate for dialysis therapy. Conclusions TAC combination therapy was clinically useful in the maintenance phase of SLE. Disclosure of Interest None Declared

Correction to: ADAM-17 is expressed in the inflammatory myopathy and is involved with interstitial lung disease

The original version of this article, unfortunately, contained errors. Figure citation, caption, image and updated sentence in the Result section are now presented correctly in this article.

THU0064 ADAM-10 as a tocilizumab treatment predictive factor in rheumatoid arthritis

Background A disintegrin and metalloproteinases (ADAMs) are a family of transmembrane and secreted proteins. ADAM-10 has been reported to be the enzyme responsible for the release of a number of chemokines and cytokine receptors. We have shown that ADAM-10 is overexpressed on rheumatoid arthritis (RA) synovial tissue endothelial cells (ECs) and lining cells compared with osteoarthritis and normal tissues. We also demonstrated that ADAM-10 mediates EC migration and tube formed. Objectives In order to demonstrate for ADAM-10 in clinical side, we focused on ADAM-10 as predictive factor for treatment with biologics in RA. Methods The serum was collected from patients before the initial treatment with biological therapies. Fifteen patients were treated with adalimumab (ADA), and 20 patents were treated with tocilizumab (TCZ). ADAM-10 and fractalkine/CX3CL1 were measured by enzyme-linked immunosorbent assay at 0, 12, 24 and 54 weeks. Clinical disease activity was evaluated by clinical disease activity index (CDAI). Following biological therapies, we defined biologic-responders as patients whose DAS28 scores decreased by more than 1.2 at 24 weeks. ADAM-10 baseline was also compared between responders and nonresponders at 24 weeks. Results There were no significant differences were observed in the mean age, gender ratio, dosages of predonisolone and methotraxate between ADA and TCZ groups. In ADA group, baseline DAS28 for the 15 patients was 4.8±0.3 (2.5–7.2). On the other hands, baseline DAS28 for the 20 patients was 4.8±0.3 (2.5–6.8) in TCZ group. There were no differences between ADA and TCZ groups. RA patients with an insufficient response to ADA or TCZ showed highly significant improvement of DAS28 after 12 weeks (2.9±0.3 and 2.2±0.4, respectively), and 24 weeks (2.5±0.4 to 2.2±0.2, respectively). ADAM-10 highly correlates with CDAI, and fractalkine/CX3CL1. Serum ADAM-10 levels were no remarkable change after treatment with ADA despite decrease of disease activity of RA. On the other hand, serum ADAM-10 levels in patients who were treated with TCZ were significantly diminished following successful treatment and clinical improvement (baseline 408±88 pg/ml and 54 weeks 138±51 pg/ml, p<0.05). Univariate logistic regression analysis, baseline of DAS28 (ESR), baseline of CDAI, and ADAM-10 were selected as significant variables for improvement of DAS28 (ESR) at 24 weeks. Multiple regression analysis showed that ADAM-10 was only identified as independent predictive variable for improvement of DAS28 (ESR) at 24 weeks. ADAM-10 baseline in TCZ responder was significantly higher than TCZ nonresponders at 24 weeks (620±134 pg/ml and 109±25 pg/ml, respectively, p<0.05). Conclusions This study indicates that ADAM-10 is correlated with RA disease activity, and is higher in TCZ responders. These results suggest that ADAM-10 may be a predictor of treatment effectiveness for RA with TCZ. Disclosure of Interest None declared

SAT0085 Study of Prognostic Factors Associated with Death from Pneumocystis Pneumonia Complicated by Collagen Diseases

Background Corticosteroids and immunosuppressant are now widely used as a treatment for collagen diseases, and complications of pneumocystis pneumonia (PCP) have become a problem. Objectives We study prognostic factors associated with death from PCP complicated by collagen diseases. Methods We conducted a retrospective analysis on the basis of the medical records of 38 patients with PCP complicated by collagen diseases. For background factors, age, gender, baseline diseases, medications at the time of hospital admission (dose of steroids, immunosuppressant), the presence of complications (respiratory diseases, diabetes, chronic kidney disease), smoking history, trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis were studied. For laboratory data, CBC (including lymphocyte count), serum LDH, albumin, creatinine, CRP, KL-6, SP-D, IgG level, IgA, IgM, (1,3)-β-D-glucan, arterial blood gas, and sputum PCP-DNA (tested by PCR) at the time of hospital admission were investigated. The eGFR was calculated using creatinine value, age, and gender. We also studied treatment methods after hospitalization (TMP-SMX use, change from TMP-SMX to pentamidine, pulsed-steroid therapy, intratracheal intubation, managing in ICU) and hospitalization period. Results In laboratory data, the group of non-survivors had a higher creatinine (0.88±0.38 mg/dl vs. 1.16±0.38, p=0.045), a lower albumin (3.13±0.50 g/dl vs. 2.71±0.38, p=0.031), a higher CRP (7.8±7.0 mg/dl vs. 18.9±8.8, p=0.014), a lower IgA (274±108 mg/dl vs. 174±54, p=0.013), a higher serum SP-D (173±106 vs. 285±285, p=0.047), and a lower PaO2/FiO2 (P/F) ratio (268±99 mmHg vs. 147±98, p=0.025). For sputum PCP (by PCR), all patients were positive in the group of non-survivors, but only 18 out of 31 survivors (58%) were positive. All patients in the group of non-survivors underwent pulsed-steroid therapy, but it was assumed that the therapy was performed in order to treat severe respiratory failure because the patients who resulted in death had a low P/F ratio and severely poor respiratory status. On the other hand, as background factors, there was no significant difference. Conclusions We newly identified prognostic factors associated with death from PCP, which are a low serum albumin and cholinesterase at the time of PCP diagnosis, decreased pulmonary diffusing capacity, and significantly high rate of intratracheal intubation and managing in ICU; in this study, male, older age, a high serum creatinine, a high CRP, a low IgA, a high SP-D, a low P/F ratio, and sputum PCP positive (by PCR) were newly identified as the poor prognostic factors. Disclosure of Interest None declared

AB0329 A Study on Characteristics of Rheumatoid Arthritis Patients Achieving HAQ Remission with 6 Months of Biologic Treatment

Background Biologic agents are highly effective for rheumatoid arthritis (RA); however, not all cases achieve HAQ remission. Although previous studies have reported the prognostic factors, there is no report on predictive factors for HAQ remission. Objectives To study predictive factors for HAQ remission, which is one of the treatment goals in RA, after using biologic agents for 6 months. Methods The subjects were 333 RA patients treated with biologic agents for 6 months. The following patients characteristics were investigated: age, gender, the number of previous drugs, disease duration, the type of biologic agents, baseline steroid dosage, MTX dosage, serum RF, MMP-3, ACPA, TNF-α, and IL-6. For evaluation we used SDAI for RA disease activity, HAQ for ADL, Short Form (SF)-36 for QOL, and Hamilton Depression Rating Scale (HAM-D) or Self-rating depression scale (SDS) for depression status. HAQ remission was defined by HAQ0.5 after 6 months of treatment. The subjects were divided into two groups: patients with HAQ0.5 and patients with HAQ >0.5 at 6 months, and a retrospective study was conducted. 101 patients were excluded from the study due to loss to 6-month follow-up, and a total of 232 patients were analyzed. Results Compared with a group of RA patients without HAQ remission (n=68), a group of patients with HAQ remission (n=164) had younger age (54.8±15.2 vs. 61.8±13.3, p=0.0011), lower baseline steroid dosage (3.4±3.7mg vs. 4.5±3.5mg, p=0.037), lower serum MMP-3 (196±234 ng/ml vs. 321±551, p=0.047), lower SDAI (22.5±13.4 vs. 32.1±12.9, p<0.001), lower HAQ (0.39±0.51 vs. 1.08±0.54, p<0.001), higher SF-36 (p<0.05 in all categories), lower SDS (40.4±9.9 vs. 43.5±9.2, p=0.033), and lower HAM-D (5.0±4.3 vs. 8.4±5.0, p<0.001). On the other hand, there was no significant difference on the types of biologic agents, the order of drugs used in the treatment, gender, MTX dosage, disease duration, serum RF, ACPA, TNF-α, and IL-6. Conclusions It was suggested that RA patients with lower disease activity, lower dosage of steroid, younger age, lower serum MMP-3, higher ADL and QOL, and lower depression scores at baseline are more likely to achieve HAQ remission with biologic treatment. Disclosure of Interest Y. Miwa Grant/research support from: Astellas Pharm Inc., Mitsubishi Tanabe Pharma Corporation, AbbVie CK, Pfizer Japan Inc., Chugai Pharmaceutical Co., Ltd., and Eizai Co., Ltd., R. Takahashi: None declared, N. Yajima: None declared, K. Wakabayashi: None declared, T. Tokunaga: None declared, S. Ishii: None declared, A. Nishimi: None declared, T. Kasama: None declared, K. Oh: None declared, Y. Toyoshima: None declared, K. Inagaki: None declared

AB0493 Tacrolimus Therapy for Systemic Lupus Erythematosus with or without Renal Involvement during the Maintenance Phase

Background In Japan, a placebo-controlled clinical trial was undertaken to investigate the efficacy and safety of tacrolimus (TAC) for lupus nephritis. To our knowledge, there has been no previous comparison of systemic lupus erythematosus (SLE) with and without renal involvement in the context of TAC treatment. Objectives The aim of this study was to prospectively evaluate the efficacy and safety of TAC combination therapy for SLE with (Group A) or without (Group B) renal involvement during the maintenance phase. Methods From 2009 to 2013, 38 patients were examined in a single-hospital, prospective cohort study over a one-year period. If manifestations of mild active SLE, such as arthritis, skin eruptions, or asymptomatic nephritis, worsened and/or decreasing titers of serum complement (C3c) were observed, TAC combination therapy (from 1 mg to 5 mg once daily) was administered (e.g., TAC was added to the patients existing treatment regimen, and the dosage of prednisolone (PSL) was decreased). Scores on the SLE disease activity index (SLEDAI); PSL dosage; and serum levels of creatinine, C3c, anti-dsDNA titers, and proteinuria were measured. Evidence of renal involvement was detected by laboratory tests: proteinuria was defined as >0.5 g/day, and cellular debris were detected on urinalysis or pathological findings of lupus nephritis by renal biopsy. The main outcome was the efficacy of SLE treatment”. In this study, Welchs t-test, Fishers exact probability test and repeated measures ANOVA were used for statistical analysis. Results The dosage of PSL was reduced, the serum concentration of C3c increased, titers of anti-dsDNA antibodies decreased and SLEDAI scores improved in both groups (p<0.05). In particular, the following symptoms improved by the SLEDAI: headache (from 7 patients to 1 patient), arthritis (from 3 patients to 0 patients), rash (from 6 patients to 2 patients), alopecia (from 5 patients to 0 patients), mucosal ulcers (from 2 patients to 0 patients), and fever (from 5 patients to 1 patient). According to an analysis by repeated measures ANOVA, serum C3c levels improved from 66.9±16.7 to 83.5±14.2 mg/dl (p=0.021) in Group A, and proteinuria improved from 0.09±0.25 to 0.0±0.0 g/g Cr in Group B. There were no significant differences between Groups A and B in terms of age, sex, disease duration, rate of ACE/ARB use or the rate of statin use before TAC treatment. Two patients discontinued treatment as a result of an adverse effect: muscle cramp or rhabdomyolysis. No patients experienced complications with adverse effects of abnormal urinalysis, and none progressed to renal failure or became candidates for dialysis. Conclusions TAC combination therapy is a useful alternative treatment for SLE despite the presence or absence of renal involvement. Disclosure of Interest K. Otsuka: None declared, Y. Miwa Grant/research support: astellas, N. Oguro: None declared, Y. Miura: None declared, S. Ishii: None declared, S. Seki: None declared, H. Furuya: None declared, R. Yanai: None declared, R. Takahashi: None declared, K. Wakabayashi: None declared, T. Isozaki: None declared, N. Yajima: None declared, T. Kasama Grant/research support: astellas DOI 10.1136/annrheumdis-2014-eular.1627