Michihiro Kono

Long-term outcome in Japanese patients with lupus nephritis.

The objective of this study was to clarify the long-term outcome in patients with lupus nephritis (LN) according to the International Society of Nephrology and Renal Pathology Society classification. This retrospective analysis comprised 186 Japanese patients given a diagnosis of LN by renal specimen with a mean observation period of 12 years. Primary end point was defined as death or end-stage renal disease, and standardized mortality ratios were calculated. Five patients presented with histopathological class I, 62 with II, 21 with III or III+V, 73 with IV or IV+V and 25 with V. Fourteen deaths occurred, corresponding to an overall standardized mortality ratio of 3.59 (95% confidence interval 2.02–5.81, p < 0.0001). Kaplan-Meier analysis revealed a 10-year overall survival of 95.7%. Nephrotic proteinuria (≥3.5 g/day) at baseline was identified as an independent poor prognostic factor for overall survival in Cox regression analysis. Kaplan-Meier analysis revealed a 10-year renal survival as 94.3%. Male gender and nephrotic proteinuria at baseline were identified as independent poor prognostic factors for renal survival in Cox regression analysis. In conclusion, LN was associated with a 3.59-fold increase in mortality compared with the general population. Male gender and nephrotic proteinuria were predictive for poor renal outcome.

Decreased haptoglobin levels inversely correlated with pulmonary artery pressure in patients with pulmonary arterial hypertension: A cross-sectional study

Abstract We investigated the serum haptoglobin levels in patients with pulmonary arterial hypertension (PAH) based on the hypothesis that haptoglobin levels would reflect subclinical hemolysis due to microangiopathy in pulmonary arterioles. This cross-sectional study included 3 groups of patients attending Hokkaido University Hospital: PAH, chronic thromboembolic pulmonary hypertension (CTEPH), and connective tissue diseases (CTD) without PAH (CTD-non-PAH) group. Serum haptoglobin levels were measured by standardized turbidimetric immunoassay in all patients. Demographic data, laboratory results, right heart catheter, and echocardiographic findings were extracted from the medical records. Decreased haptoglobin levels were defined as below 19 mg/dL based on the 95th percentile of healthy controls. Thirty-five patients in PAH group including 11 with idiopathic PAH (IPAH) and 24 with CTD-associated PAH (CTD-PAH), 27 in CTEPH group, and 32 in CTD-non-PAH group were analyzed. Serum haptoglobin levels in PAH group (median 66 mg/dL) were significantly lower than those in CTEPH group (median 94 mg/dL, P = .03) and CTD-non-PAH group (median 79 mg/dL, P = .03). The prevalence of decreased haptoglobin levels was 26% in PAH group, 15% in CTEPH group, and 6% in CTD-non-PAH group. Serum haptoglobin levels had a significant negative correlation (r = −0.66, P < .001) with mean pulmonary artery pressure in PAH group, particularly in CTD-PAH subgroup (r = −0.74, P < .001), but no correlation in IPAH subgroup (r = −0.52, P = .13) and in CTEPH group (r = −0.17, P = .41). Follow-up cases of CTD-PAH showed lowering pulmonary artery pressure led to normalizing serum haptoglobin levels. Serum haptoglobin levels decreased in PAH patients and inversely correlated with pulmonary artery pressure in CTD-PAH patients, suggesting their potential as a surrogate marker for CTD-PAH.

Tocilizumab reduced production of systemic sclerosis-related autoantibodies and anti-cyclic citrullinated protein antibodies in two patients with overlapping systemic sclerosis and rheumatoid arthritis

Systemic sclerosis (SSc) is a rare connective tissue disease, characterized by fibrosis in the skin and organs. There are many reports on the roles of interleukin 6 (IL-6) in the pathogenesis of SSc (1, 2). Recently, the efficacy of tocilizumab (TCZ), an anti-IL-6 receptor antibody, for skin sclerosis has been reported in a small case series in SSc (3), followed by a phase 2 trial of subcutaneous TCZ therapy showing the signal of reduction in skin stiffness (4). Here, we report two cases with rheumatoid arthritis (RA) accompanied by SSc successfully treated using TCZ, with reduction in the titres of autoantibodies related to both RA and SSc. Patient 1, a 25-year-old woman, presented with polyarthralgia and positive anti-cyclic citrullinated peptide antibodies (ACPAs), and was diagnosed as having RA. She was treated with methotrexate (MTX) and etanercept (ETN), resulting in clinical remission. At that time, she had no manifestations of SSc, although anti-nuclear antibodies (ANAs) with a speckled pattern and antitopoisomerase I antibodies (ATAs) were detected. Two years later, MTX was discontinued because she was planning for pregnancy. Shortly after that, skin stiffness rapidly developed in her both hands and forearms, with newly developed interstitial pneumonia. Then, she was diagnosed as having SSc complicated with RA. The 28-joint Disease Activity Score–erythrocyte sedimentation rate (DAS28-ESR) and modified Rodnan total skin score (RSS) were 2.92 and 25, respectively. She was treated with prednisolone (PSL) at 30 mg/day, intravenous cyclophosphamide (IVCY), and tacrolimus (TAC), which at first improved the clinical manifestations, but during PSL tapering, joint tenderness and skin sclerosis recurred. We administered TCZ concurrently with PSL and TAC, resulting in the rapid improvement of skin sclerosis and arthritis. After 1 year of TCZ treatment, the DAS28-ESR and RSS were decreased to 1.76 and 8, respectively. The titres of ACPAs and ATAs were also significantly decreased (Figure 1A). Patient 2, a 32-year-old man, developed small joint swelling, and was diagnosed as having RA with positive ACPAs. He also suffered from Raynaud’s phenomenon and skin sclerosis of both hands and forearms. ANAs with a speckled pattern and anti-U1 ribonucleoprotein antibodies (U1-RNP Abs) were detected. Computed tomography revealed mild interstitial pneumoniae, leading to a diagnosis of SSc. He was started with salazosulfapyridine and low dose of PSL, but 3 years later, he presented with fever lasting for several weeks and severe joint tenderness. PSL was increased to 20 mg/day, resulting in a good clinical response, but as PSL tapered, polyarthralgia recurred with extended skin sclerosis in his dorsal feet and his face. The DAS28-ESR became 6.92 and RSS increased to 14. Intravenous TCZ at 8 mg/kg/month was introduced, resulting in a rapid improvement of the polyarthralgia with a decrease in the DAS28-ESR to 1.1. Simultaneously, his skin lesions were dramatically improved, with RSS decreased to 5. The titres of ACPAs and U1-RNP Abs were also reduced after TCZ administration (Figure 1B). In our cases, the titres of ACPAs and ATAs or U1RNP Abs were decreased in accordance with clinical improvement during TCZ administration. Concerning the correlation between autoantibody production and TCZ, the titres of anti-aquaporin 4 antibodies (AQP4 Abs) were reduced by TCZ therapy in neuromyelitis optica spectrum disorder patients with good clinical response (5). Exogenous IL-6 promotes the survival of plasmablasts and their production of AQP4 Abs, whereas the blockade of IL-6 reduces the survival of plasmablasts in vitro (6). Iannone et al (7) reported that eight RA patients treated with TCZ had a significant decrease in ACPAs,; however, as far as we know, this is the first report following the reduction of ATA or U1-RNP Ab titres with TCZ therapy. The titres of ATAs have been reported to be stable over time; however, increment of the ATA level was associated with the development of new organ involvement (8). About 20% of SSc patients with ATAs lost the antibodies during the course of the disease and had a favourable outcome (9). 248 Scand J Rheumatol 2018;47:248–250

Clinical significance of plasma presepsin levels in patients with systemic lupus erythematosus

Abstract Objectives: Presepsin (PSEP: soluble CD14 subtype) is produced from bacteria-stimulated monocytes or neutrophils, thus recognized as a biomarker of sepsis. Aberrant functions in monocyte or neutrophils are increasingly recognized in systemic lupus erythematosus (SLE). We investigated whether plasma PSEP reflects disease activity in patients with SLE. Methods: This retrospective study comprised 35 patients with SLE and 72 with non-SLE autoimmune diseases who visited our facility during the period from August 2012 to September 2015. Plasma PSEP levels and laboratory data were compared between SLE and non-SLE. Clinical markers of SLE disease activity, including SLE disease activity index 2000 (SLEDAI-2K), serum complement concentrations and serum anti-ds-DNA antibodies were assessed in correlation with plasma PSEP levels. Results: Plasma PSEP levels in SLE were higher than those in non-SLE. This phenomenon holds true when comparing SLE and non-SLE patients in the absence of infection (p = .0008). Plasma PSEP levels in SLE patients negatively correlated with C3 (r = –0.4454, p = .0430), CH50 (r = –0.4502, p = .0406) and positively with SLEDAI-2K (r = 0.4801, p = .0237). Conclusion: Elevated plasma PSEP levels were correlated with disease activity of SLE, suggesting inappropriate monocyte or neutrophil activation in the pathophysiology of SLE exacerbation.

Diversity of borderline pulmonary arterial pressure associated with systemic sclerosis: 3 case series

Abstract Mean pulmonary arterial pressure of 21 to 24 mmHg, called borderline pulmonary arterial pressure (BoPAP), may represent a pre-pulmonary arterial hypertension (PAH) condition but has not so far been indicated for specific PAH therapy. Despite the recent progress in PAH-targeted therapy, the prognosis of patients with systemic sclerosis (SSc)-associated PAH still remains poor. One of the possible strategies to improve the prognosis of those patients is the early detection and therapeutic intervention of pre-PAH conditions. We present three different clinical courses of BoPAP associated with SSc, which include successful treatment with bosentan and tocilizumab, an improvement following the treatment of interstitial lung disease, and spontaneous progression to fatal PAH, and suggest the efficacy of frequent follow-up examinations and therapeutic intervention for BoPAP in SSc patients.

Concerns about study on maternal H1N1 influenza vaccination and offspring mortality

We have three concerns about Ludvigsson and colleagues’ article on the association between maternal influenza A(H1N1)pdm09 vaccination during pregnancy and mortality in the offspring.1 Firstly, the authors defined exposure as vaccination during pregnancy. Accordingly, women who were vaccinated just before pregnancy were …

THU0043 AAA-ATPASE P97 Regulates Apoptotic and Autophagy-Associated Cell Death in Arthritis

Background Valosin containing protein (p97/VCP) is an ATPase implicated in the degradation of ubiquitin-labelled proteins through the proteasome. We recently described a resistance to apoptotic cell death induced by proteasome inhibition and a hypersensitivity to autophagy-associated cell death under conditions of severe endoplasmic reticulum (ER) stress in rheumatoid arthritis synovial fibroblasts (RASF) compared to osteoarthritis synovial fibroblasts. Objectives To investigate the role of p97 in apoptotic and autophagy-associated cell death in RASF and in in vivo arthritis model. Methods RASF were transfected with siRNA targeting p97 or treated with the selective p97 inhibitor DBeQ (5 μM). To induce cell death, RASF were treated with TRAIL (100 ng/ml) for 24 hours or the ER stress inducer thapsigargin (TG, 5 nM-5 μM) for 72 hours. 3-methyladenine (5 mM) was used as an autophagy inhibitor. The distribution and amount of poly-ubiquitinated proteins were evaluated by immunofluorescence and immunoblotting. Cell death was evaluated by flow cytometry using annexin V/ propidium iodide staining and a caspase-3 activity assay (NucView 488, Biotium). Collagen-induced arthritis (CIA) was induced in Lewis rats. Scrambled or p97 siRNA-atelocollagen complexes were injected into ankle joints of rats. CIA was scored according to paw thickness and ankle diameter. Bone erosion was assessed by micro-CT. Proliferation of fibroblasts in rat synovial tissue was quantified by immunolabeling for Hsp47. Results siRNA-mediated knockdown of p97 in RASF increased cell death induced by TRAIL (p=0.009, n=6), accompanied by caspase-3 activation. Both siRNA-mediated knockdown and inhibition of p97 in RASF boosted cell death induced by 5 μM TG, accompanied by a massive cytoplasmic vacuolization, the formation of poly-ubiquitinated protein aggregates and the accumulation of poly-ubiquitinated proteins, and cell death was inhibited by 3-methyladenine. Smaller amounts of TG (50 or 500 nM) induced a cytoplasmic vacuolization and the formation of poly-ubiquitinated protein aggregates in p97-inhibited RASF but not in control RASF. Intra-articular injection of p97 siRNA significantly suppressed CIA (p=0.002, n=6), bone erosion (p=0.02, n=6) and proliferation of synovial fibroblasts (p=0.004, n=6) in rats. Conclusions Our data indicate that the inhibition of p97 promotes both apoptotic and autophagy-associated cell death in RASF and suppresses CIA, bone erosion and proliferation of synovial fibroblasts in vivo. p97 may be a new potential target in the treatment of arthritis. References Kato M, et al. Arthritis Rheum 2014 Jan;66(1):40-8. Acknowledgements This work was supported by MHLW, MEXT, IMI-BT Cure, IAR Epalinges, euroTEAM. Disclosure of Interest None declared

Interferon-inducible Mx1 protein is highly expressed in renal tissues from treatment-naïve lupus nephritis, but not in those under immunosuppressive treatment

Abstract Objectives: The aim of this study was to clarify the consequences of Mx1, one of the IFN-inducible proteins, in the peripheral blood as well as in renal tissues in patients with systemic lupus erythematosus (SLE). Patients and methods: Mx1 protein concentrations in (PBMCs) from 18 SLE patients mostly in their stable disease status, 11 IgA nephropathy (IgAN) patients, 5 ANCA-associated vasculitis (AAV) patients and 16 healthy controls were measured using enzyme-linked immunosorbent assay (ELISA). Mx1 expression in renal specimens from 18 patients with lupus nephritis (LN), 18 with IgAN and 10 with AAV were evaluated using immunohistochemistry. Results: Mx1 protein concentrations in lysates of PBMCs were significantly higher in SLE patients compared with those in other three groups. Mx1-positive area in renal tissues was significantly dominant in both glomeruli and renal tubules of LN compared with other renal diseases. Renal Mx1 protein levels were lower in LN after immunosuppressive treatment, compared with those from immunosuppressant-naïve patients. Conclusion: Mx1 levels were upregulated in lupus peripheral blood even when their disease activities were stable. On the other hand, Mx1 was highly expressed in kidneys from patients with LN before treatment, which was decreased after immunosuppressive treatment. These results suggest that Mx1 is a potential marker for the diagnosis of SLE in the peripheral blood and also for the activity of lupus nephritis in the kidney.

Decreased Expression of Serine/Arginine-Rich Splicing Factor 1 in T Cells From Patients With Active Systemic Lupus Erythematosus Accounts for Reduced Expression of RasGRP1 and DNA Methyltransferase 1

T cells from systemic lupus erythematosus (SLE) patients have reduced protein levels of RasGRP1, a guanine nucleotide exchange factor for Ras, and increased transcript of alternatively spliced (AS) forms lacking exon 11. Serine/arginine‐rich splicing factor 1 (SRSF1) binds pre–messenger RNA (pre‐mRNA) to regulate AS forms of several genes, including CD3ζ in SLE T cells. This study was undertaken to assess whether SRSF1 controls the expression of RasGRP1 in T cells from patients with SLE.

Ectopic RASGRP2 (CalDAG-GEFI) expression in rheumatoid synovium contributes to the development of destructive arthritis

Objectives Rheumatoid arthritis (RA) is an autoimmune polyarthritis, in which fibroblast-like synoviocytes (FLS) play a key role in cartilage and bone destruction through tumour-like proliferation and invasiveness. Considering still unsatisfactory remission rate in RA even under treatment with biological disease-modifying antirheumatic drugs, novel therapeutic strategy for treatment-resistant RA is still awaited. In this study, we analysed the expression and function of Ras guanine nucleotide-releasing proteins (RASGRPs), guanine exchange factors for small GTPase Ras, in FLS as a potential therapeutic target for RA. Methods The expression of RASGRPs mRNA was quantified by a real-time PCR assay in FLS isolated from synovial tissue samples. RASGRP2 protein was also evaluated immunohistochemically. Then, we transiently transfected FLS with RASGRP2 expression vector and assessed their proliferation, adhesion, migration and invasion by cellular functional assays and downstream signalling activation using immunoblot. Finally, the therapeutic effect of RASGRP2 silencing was evaluated in type-II collagen-induced arthritis rats. Results RASGRP2 was abundantly expressed in FLS from RA synovium, whereas scarcely found in those from osteoarthritis. Expression of RASGRP2 in RA-FLS was enhanced by transforming growth factor-beta. RASGRP2 activated RAP-1, subsequently affecting nuclear factor kappa-light-chain-enhancer of activated B cells pathway and actin dynamics in FLS. RASGRP2-overexpressed FLS had increased abilities of adhesion, migration and interleukin (IL)-6 production. Silencing of RASGRP2 using the intra-articular injection of Rasgrp2-specific siRNAs dampened experimental arthritis in rats by inhibiting pannus formation. Conclusions RASGRP2 was identified to be involved in the pathogenesis of RA by promoting adhesion, migration and IL-6 production from FLS, proposed as a potential novel non-immunosuppressive therapeutic target for RA.