Tang Fl

Clinical significance of increased CD4+CD25-Foxp3+T cells in patients with new-onset systemic lupus erythematosus

Objective: To investigate the expressions of Foxp3 and CD25 on CD4+ T cells from patients with new-onset systemic lupus erythematosus (SLE) and assess their clinical significance. Methods: 10 patients with active (systemic lupus erythematosus Disease Activity Index (SLEDAI) ⩾10) and 11 with inactive (SLEDAI ⩽5) new-onset SLE as well as 11 healthy volunteers were enrolled. The expressions of CD25, Foxp3 and CD127 on CD4+ T cells were analysed by flow cytometry. Proliferation assays were performed on isolated CD4+CD25+ or CD4+CD25− T cells, or both. Results: There was no significant difference in the number of CD4+CD25+Foxp3+ T cells in subjects with either active or inactive SLE compared with normal controls (p>0.05). Moreover, the suppressive capacity of CD4+CD25+ T cells in patients with new-onset lupus was not impaired as measured by the ability to inhibit proliferation of CD4+CD25− T cells. Interestingly, CD4+CD25−Foxp3+ T cells in new-onset lupus (2.97–10.94%) were significantly more frequent than in normal controls (1.01–3.62%) (p<0.01), and correlated positively with the titres of anti-dsDNA antibodies (p = 0.029). Few of these cells expressed CD127. Treatment with glucocorticoids and cyclophosphamide reduced CD4+CD25−Foxp3+ T cells in 8 of 10 patients with active disease. Conclusions: There was a significant increase in CD4+CD25−Foxp3+ T cells in patients with new-onset SLE that correlated with anti-dsDNA titres, whereas no alteration in either the percentage or function of CD4+CD25+Foxp3+ T cells was observed.

Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis (TRIFRA): a randomised, controlled clinical trial

Objectives To compare the efficacy and safety of Tripterygium wilfordii Hook F (TwHF) with methotrexate (MTX) in the treatment of active rheumatoid arthritis (RA). Methods Design: a multicentre, open-label, randomised controlled trial. All patients were assessed by trained investigators who were unaware of the therapeutic regimen. Intervention: 207 patients with active RA were randomly allocated (1:1:1) to treatment with MTX 12.5 mg once a week, or TwHF 20 mg three times a day, or the two in combination. At week 12, if reduction of the 28-joint count Disease Activity Score (DAS28) was <30% in the monotherapy groups, the patient was switched to MTX+TwHF. The primary efficacy point was the proportion of patients achieving an American College of Rheumatology (ACR) 50 response at week 24. Results 174/207 (84.1%) patients completed 24 weeks of the trial. In an intention-to-treat analysis, the proportion of patients reaching the ACR50 response criteria was 46.4% (32/69), 55.1% (38/69) and 76.8% (53/69), respectively, in the MTX, TwHF and MTX+TwHF groups (TwHF vs MTX monotherapy, p=0.014; MTX+TwHF vs MTX monotherapy, p<0.001). Similar statistically significant patterns at week 24 were found for ACR20, ACR70, clinical Disease Activity Index good responses, EULAR good response, remission rate and low disease activity rate. Significant improvement in the Health Assessment Questionnaire and 36-item Short-Form Health Survey questionnaire scores from baseline to week 24 was seen in each treatment arm (p<0.05), though no significant difference was found among the treatment arms (p>0.05). The result of per-protocol analysis agreed with that seen in the intention-to-treat analysis. Seven, three and five women in the TwHF, MTX and combination groups, respectively, developed irregular menstruation (TwHF vs MTX monotherapy, p=0.216). Conclusions TwHF monotherapy was not inferior to, and MTX+TwHF was better than, MTX monotherapy in controlling disease activity in patients with active RA. Trial registration number NCT01613079.

Reduction of forkhead box P3 levels in CD4+CD25high T cells in patients with new‐onset systemic lupus erythematosus

The aim of this study was to quantify and evaluate the forkhead box P3 (FoxP3) expression regulatory T cells in new‐onset systemic lupus erythematosus (SLE) patients before and after treatment. Forty‐four newly diagnosed and untreated SLE patients, including 24 with active disease (SLEDAI ≥ 10) and 20 with inactive disease (SLEDAI < 5), were enrolled in this study. Twenty‐one age‐ and sex‐matched healthy volunteers were also included as controls. Peripheral blood samples were collected and mononuclear cells isolated. The expression of CD25 and FoxP3 in CD4+ T cells were analysed with flow cytometry. CD4+CD25+ (3·95–13·04%) and CD4+CD25high (0·04–1·34%) T cells in peripheral blood in untreated patients with new‐onset active lupus were significantly lower than that in the patients with inactive lupus (7·27–24·48%, P < 0·05 and 0·14–3·07% P < 0·01 respectively) and that in healthy controls (5·84–14·84%, P < 0·05). Interestingly, the decrease in CD4+CD25high T cells was restored significantly in patients with active lupus after corticosteroid treatment. There was, however, a significantly higher percentage of CD4+FoxP3+ T cells in patients with active (5·30–23·00%) and inactive (7·46–17·38%) new‐onset lupus patients compared with healthy control subjects (2·51–12·94%) (P < 0·01). Intriguingly, CD25 expression in CD4+FoxP3+ T cells in patients with active lupus (25·24–62·47%) was significantly lower than that in those patients with inactive lupus (30·35–75·25%, P < 0·05) and healthy controls (54·83–86·38%, P < 0·01). Most strikingly, the levels of FoxP3 expression determined by mean fluorescence intensity in CD4+CD25high cells in patients with active SLE were significantly down‐regulated compared with healthy subjects (130 ± 22 versus 162 ± 21, P = 0·012). CD4+CD25high T cells are low in new‐onset patients with active SLE and restored after treatment. Despite that the percentage of CD4+FoxP3+ T cells appear high, the levels of FoxP3 expression in CD4+CD25high T cells are down‐regulated in untreated lupus patients. There is a disproportional expression between CD25high and FoxP3+ in new‐onset patients with active SLE.

Are CD4+CD25-Foxp3+ cells in untreated new-onset lupus patients regulatory T cells?

IntroductionOur previous study has reported that, in patients with untreated new-onset lupus (UNOL), there was an abnormal increase in the number of CD4+CD25-Foxp3+ T cells that correlated with disease activity and significantly decreased after treatment. However, little is known about the nature of this cell entity. The aim of this study was to explore the nature of abnormally increased CD4+CD25-Foxp3+ T cells in UNOL patients.MethodsThe expressions of surface (CD4, CD25, CD127, chemokine receptor 4 [CCR4], glucocorticoid-induced tumor necrosis factor receptor [GITR], and cytotoxic T lymphocyte-associated antigen 4 [CTLA-4]) and intracellular (Foxp3) molecules as well as cytokine synthesis of peripheral blood mononuclear cells from 22 UNOL patients were analyzed by flow cytometry. The proliferative and suppressive capacities of different T-cell subgroups from UNOL patients were also assessed.ResultsIn UNOL patients, the percentages of CD127low/- in CD25high, CD25low, and CD25- subpopulations of CD4+Foxp3+ T cells were 93.79% ± 3.48%, 93.66% ± 2.31%, and 91.98% ± 2.14%, respectively (P > 0.05), whereas the expressions of Foxp3 showed significant differences in CD25high (91.38% ± 2.57%), CD25low (71.89% ± 3.31%), and CD25- (9.02% ± 2.21%) subpopulations of CD4+CD127low/- T cells (P < 0.01). The expressions of surface CCR4, GITR, and CTLA-4 on CD4+CD25-Foxp3+ T cells were significantly less than CD4+CD25+Foxp3+ T cells (P < 0.05). Moreover, unlike CD4+CD25+Foxp3+ T cells, CD4+CD25-Foxp3+ T cells also synthesized interferon-gamma, interleukin (IL)-4, IL-2, and IL-17 (P < 0.05), though less than CD4+CD25+Foxp3- T cells. The suppressive capacity was most prominent in CD4+CD25highCD127low/-, followed by CD4+CD25lowCD127low/-. CD4+CD25-CD127- T cells showed the least suppressive capacity, which was similar to the effector T cells.ConclusionsCD4+CD25-Foxp3+ T cells in UNOL patients are different from regulatory T cells, both phenotypically and functionally. CD127 is not an appropriate surface marker for intracellular Foxp3 in CD4+CD25- T cells.

Defective PTEN regulation contributes to B cell hyperresponsiveness in systemic lupus erythematosus

Decreased expression of PTEN regulated by miR-7 contributes to B cell hyperresponsiveness and disturbed B cell homeostasis in SLE. “miR”roring Lupus Control Decreased expression of the B cell signaling inhibitor PTEN may contribute to lupus pathology. Wu et al. found that microRNA (miR)–mediated regulation of PTEN is altered in patients with the autoimmune disease systemic lupus erythematosus (SLE). Patients with SLE have hyperactivated B cells, which results in the production of autoantibodies. The authors found that decreased expression of PTEN in B cells from SLE patients contributes to this B cell hyperactivation. What’s more, they found that PTEN expression in these cells was regulated by miRs, and that blocking miR-7 could restore PTEN expression and function to that of healthy controls. These data support exploring miR-7 and PTEN as therapeutic targets for SLE. PTEN regulates normal signaling through the B cell receptor (BCR). In systemic lupus erythematosus (SLE), enhanced BCR signaling contributes to increased B cell activity, but the role of PTEN in human SLE has remained unclear. We performed fluorescence-activated cell sorting analysis in B cells from SLE patients and found that all SLE B cell subsets, except for memory B cells, showed decreased expression of PTEN compared with B cells from healthy controls. Moreover, the level of PTEN expression was inversely correlated with disease activity. We then explored the mechanisms governing PTEN regulation in SLE B cells. Notably, in normal but not SLE B cells, interleukin-21 (IL-21) induced PTEN expression and suppressed Akt phosphorylation induced by anti–immunoglobulin M and CD40L stimulation. However, this deficit was not primarily at the signaling or the transcriptional level, because IL-21–induced STAT3 (signal transducer and activator of transcription 3) phosphorylation was intact and IL-21 up-regulated PTEN mRNA in SLE B cells. Therefore, we examined the expression of candidate microRNAs (miRs) that could regulate PTEN: SLE B cells were found to express increased levels of miR-7, miR-21, and miR-22. These miRs down-regulated the expression of PTEN, and IL-21 stimulation increased the expression of miR-7 and miR-22 in both normal and SLE B cells. Indeed, a miR-7 antagomir corrected PTEN-related abnormalities in SLE B cells in a manner dependent on PTEN. Therefore, defective miR-7 regulation of PTEN contributes to B cell hyperresponsiveness in SLE and could be a new target of therapeutic intervention.

Expressions of BAFF/BAFF receptors and their correlation with disease activity in Chinese SLE patients.

B-cell activating factor belonging to tumour necrosis factor family (BAFF) is essential for B-cell survival and function through interaction with its receptors BAFF receptor 3 (BR3), B-cell maturation antigen (BCMA) and/or transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI), though BCMA and/or TACI can also bind to a proliferation-inducing ligand (APRIL). We evaluate the correlation of the expressions of these ligands/receptors with different clinical manifestations of systemic lupus erythematosus (SLE). Levels of BAFF and APRIL in plasma from 73 SLE patients were determined by enzyme-linked immunosorbent assay. Expressions of BR3, TACI and BCMA on CD19+ B cells were detected by flow cytometry. Clinical data were collected and disease activity was evaluated using SLEDAI-2000. SLE patients had elevated BAFF and APRIL levels in their plasma. BAFF levels correlated positively with SLEDAI while negatively with the BR3 protein expression on CD19+ B cells (p < .05). The detected BR3 protein expression in SLE patients was reduced on CD19+IgD+CD27—, CD19+IgD+CD27+ as well as CD19+IgD—CD27+ B cells compared to the counterparts of healthy controls (p < .001), whereas SLE patients did not differ from healthy controls in BR3 mRNA levels. In untreated new-onset patients, the expression rate of BR3 on CD19+ B cells correlated negatively with SLEDAI (p < .05). Elevation of BAFF and reduction of BR3 on CD19+ B cells were more obvious in those with lupus nephritis (LN, p < .05). TACI expression on CD19+ B cells was up-regulated only in those subjects with LN (p < .05). Elevated plasma BAFF and reduced BR3 protein expression on peripheral B cells could act as biomarkers for active disease in SLE patients. High expression of TACI may indicate the occurrence of LN.

Clinical features and outcome of neuropsychiatric lupus in Chinese: analysis of 240 hospitalized patients

Neuropsychiatric (NP) events are severe manifestations of systemic lupus erythematosus (SLE) and relate to poor outcome. The aims of this study are to investigate the NP manifestations of SLE and to identify the predictive factors for clinical outcome. There was a retrospective review of 240 hospital patients with primary NP events of SLE (NPSLE) from 1990 to 2004. Neuropsychiatric manifestations, SLE disease activity index (SLEDAI) score, System lupus International Collaborating Clinic/American College of Rheumatology Damage Index (SLICC/ACR-DI) score, magnetic resonance imaging (MRI) findings, treatment and mortality rate were included for analysis. From this group of patients, 15 NP syndromes were identified. The most frequent manifestation was headache, followed by seizure. The mean SLEDAI and SLICC/ACR-DI scores were 19.9 ± 6.9 and 3.5 ± 1.6, respectively. Abnormal MRI features were found in 67% (61/91) patients. At least one intrathecal (IT) injection of methotrexate (MTX) plus dexamethasone (DXM) was administered to 109 (45.4%) patients. High dose (1 g) intravenous methylprednisolone pulse therapy (IVMP) was administered to 167 (69.5%) patients. Multifactor analysis revealed that high SLICC/ACR-DI scores and sets of concurrent NP symptoms were independently associated with poor outcome, whereas pulse IVMP and IT injection of MTX plus DXM were protective factors against poor outcome. From our data, NPSLE is heterogeneous and is usually associated with high disease activity and organ damage scores. High SLICC/ACR-DI score and having more than two sets of NP symptoms are the predictors for poor outcome, whereas pulse IVMP and IT injection of MTX plus DXM can improve the prognosis. Lupus (2008) 17, 93—99.

Protein-losing enteropathy in systemic lupus erythematosus: analysis of the clinical features of fifteen patients.

Objective:Protein-losing enteropathy (PLE) is an unusual manifestation of systemic lupus erythematosus (SLE), so its clinical manifestations and management are not well understood. In this study, we try to characterize the basic clinical features and the management of PLE by retrospectively analyzing the clinical data of 15 PLE patients and hope this study can improve the awareness of PLE in lupus patients with severe hypoalbuminemia that could not be explained by other causes. Methods:The clinical data of 15 SLE patients with PLE hospitalized during November 2001 and April 2006 in Peking Union Medical College Hospital were retrospectively reviewed. The PLE was diagnosed by Tc-99m albumin scintigraphy (99mTc-HAS). The clinical characteristics, laboratory tests, response to treatment, and the outcome were studied. Results:The mean age of PLE onset was 40.1 ± 15.4 years (19–71 years). Twelve were female and 3 were male. 53.3% (8 of 15) patients had PLE as the initial presentation of SLE. All patients had different degree of peripheral pitting edema. Eleven had ascites, 9 had pleural effusion, and 7 had pericardial effusion. Only 6 patients presented with abdominal pain and diarrhea. Positive antinuclear antibodies (HEP-2) with a speckled pattern were found in all patients, but the antidsDNA antibody was negative in most cases. All patients had marked hypoalbuminemia, 80% had hypocomplementemia, 66.7% had hyperlipoproteinemia, and 40% had hypocalcemia. The liver function tests and the prothrombin time were in normal ranges. The 24-hours urine protein was less than 0.5 g in 60% (9 of 15) and more than 1.0 g in 20% (3 of 15) patients who were renal biopsied but only found to have very mild pathologic changes. Gastrointestinal endoscopy examination discovered generalized edema in the intestinal wall whereas the biopsy showed chronic inflammation only. Most cases had good response to corticosteroid and immunosuppressive therapies. The serum albumin level improved evidently in all patients after treatment and normal scintigraphic finding was found in 9 patients. Conclusion:PLE can be the initial presentation of SLE or can develop a very long time after the diagnosis of SLE. The prominent clinical presentations are caused by hypoalbuminemia. 99mTc-HAS is useful not only for the diagnosis of PLE but is also helpful for monitoring the efficacy of treatment. When a SLE patient presents with evident hypoalbuminemia without evidence of other causes, PLE should be considered. Early diagnosis and treatment may improve the prognosis.

Low-dose rituximab therapy for refractory thrombocytopenia in patients with systemic lupus erythematosus—a prospective pilot study

OBJECTIVES To evaluate the safety and efficacy of low-dose rituximab therapy for refractory thrombocytopenia in patients with SLE. METHODS Ten adult SLE patients with severe refractory thrombocytopenia (mean platelet count 10.4 × 10(9)/l) were enrolled in this prospective pilot study. All patients had failed traditional high-dose CSs and immunosuppressants including methylprednisolone pulse therapy. Patients were scheduled to receive i.v. rituximab at a dose of 100 mg once weekly for 4 weeks. Previous dose of CSs were gradually tapered, and immunosuppressants were withdrawn. Patients were followed at Weeks 4, 12, 24 and 36. RESULTS All patients completed four courses of low-dose rituximab infusion. At Week 4, two (20%) patients achieved complete responses (CRs, platelet count >100 × 10(9)/l). The CR rate increased to 60% (six patients) at Week 12, was maintained at Week 24 and began to drop at Week 36 (four patients, 40%). Overall response (OR, platelet count >50 × 10(9)/l) was achieved in 5/10, 6/10, 7/10 and 5/10 patients at Weeks 4, 12, 24 and 36, respectively. Peripheral CD19(+) B cells were depleted (<5 × 10(6)/l) in all patients at Week 4, and gradually increased at Weeks 24 and 36. Serum C3, IgG, IgA and IgM levels did not change significantly (P < 0.05). Infusion reaction was observed in two patients. One patient developed pulmonary thrombosis at Week 14 and active tuberculosis at Week 25. CONCLUSIONS Low-dose rituximab therapy is effective in treating severe thrombocytopenia in SLE patients who do not respond to vigorous glucocorticoid plus immunosuppressants, and in most cases is safe.

Anti-cyclic citrullinated Peptide antibody is associated with interstitial lung disease in patients with rheumatoid arthritis.

Objective Patients with rheumatoid arthritis (RA) are at risk to develop RA-associated interstitial lung disease (RA-ILD). This retrospective study aimed to investigate the potential association of the positivity of serum anti-cyclic citrullinated peptide antibody (anti-CCP2) and rheumatoid factor (RF) with RA-ILD in RA patients. Methods A total of 285 RA patients were recruited at the inpatient service of Peking Union Medical College Hospital in China between 2004 and 2013. Individual patients were evaluated for the evidence of ILD. The concentrations of serum anti-CCP2 and RF in individual patients were measured. The potential risk factors for ILD in RA patients were assessed by univariate and multivariate models. Results There were 71 RA patients with RA-ILD, accounting for 24.9% in this population. The positive rates of anti-CCP2 and RF in the patients with RA-ILD were significantly higher than that in the patients with RA-only (88.7% vs. 67.3%, p<0.001; 84.5% vs. 70.6%, p = 0.02, respectively). Univariate and multivariate logistic regression analysis revealed that RA patients with positive serum anti-CCP2, but not RF, were associated with an increased risk of ILD (crude odds ratio [cOR] 3.83, 95% confidence interval [CI] 1.74–8.43, p<0.001; adjusted odds ratio [aOR] 3.50, 95% CI 1.52–8.04, p<0.001). Conclusion Our findings suggest that positive serum anti-CCP2, but not RF, may be associated with RA-ILD in RA patients.