Systemic Lupus Erythematosus Classification and Diagnosis

SLE criteria are by necessity still based on clinical (and immunological) criteria items

INTRODUCTION

The 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for systemic lupus erythematosus (SLE) rely on clinical and routine immunological items. The criteria have anti-nuclear antibodies (ANA) as an obligatory entry criterion; items are weighted and ordered in domains. While demonstrating good sensitivity and specificity, the lack of a more molecular approach to some came as a disappointment.

AREAS COVERED

Based on a non-systematic literature search, this review covers items investigated in the EULAR/ACR classification criteria project, but not included in the set of criteria. It demonstrates data on the importance of the criteria and analyses implications of multiomics studies started around the same time as the criteria project. We also discuss data on the type-I interferon signature and on other cytokines, as well as on complement proteins and their split products. The final part deals with the variability in disease and the apparently random pattern of autoantibodies and organ manifestations in individual patients.

EXPERT OPINION

We believe that the EULAR/ACR criteria are a relevant step toward the right direction. A more uniform molecular approach will not be feasible as long as the molecular mechanisms underlying the tendency toward producing multiple autoantibodies are not better understood.

Early Diagnosis of Fibromyalgia Using Surface-Enhanced Raman Spectroscopy Combined with Chemometrics

Fibromyalgia (FM) is a chronic muscle pain disorder that shares several clinical features with other related rheumatologic disorders. This study investigates the feasibility of using surface-enhanced Raman spectroscopy (SERS) with gold nanoparticles (AuNPs) as a fingerprinting approach to diagnose FM and other rheumatic diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), and chronic low back pain (CLBP). Blood samples were obtained on protein saver cards from FM (n = 83), non-FM (n = 54), and healthy (NC, n = 9) subjects. A semi-permeable membrane filtration method was used to obtain low-molecular-weight fraction (LMF) serum of the blood samples. SERS measurement conditions were standardized to enhance the LMF signal. An OPLS-DA algorithm created using the spectral region 750 to 1720 cm-1 enabled the classification of the spectra into their corresponding FM and non-FM classes (Rcv > 0.99) with 100% accuracy, sensitivity, and specificity. The OPLS-DA regression plot indicated that spectral regions associated with amino acids were responsible for discrimination patterns and can be potentially used as spectral biomarkers to differentiate FM and other rheumatic diseases. This exploratory work suggests that the AuNP SERS method in combination with OPLS-DA analysis has great potential for the label-free diagnosis of FM.

SLE classification criteria: Is "The causality principle" integrated and operative - and do the molecular and genetical network, on which criteria depend on, support the definition of SLE as "a one disease entity" - A theoretical discussion

Molecular and cellular aspects of the autoimmune pathophysiology in SLE is linked to the "The causality principle". SLE Classification Criteria identify per definition disease measures (here: synonymous with classification criteria), but not diagnostic criteria within a classical framework. These two mostly theoretical criteria collections represent a salient conflict between phenomenology and the causality principle - between disease measures and molecular interactions that promote such measures, in other words their cause(s). Essentially, each criterion evolves from immunogenic and inflammatory signals - some are interconnected, some are not. Disparate signals instigated by disparate causes. These may promote clinically heterogenous SLE cohorts with respect to organ affection, autoimmunity, and disease course. There is today no concise measures or arguments that settle whether SLE cohorts evolve from one decisive etiological factor (homogenous cohorts), or if disparate patho-biological factors promote SLE (heterogenous cohorts). Current SLE cohorts are not ideal substrates to serve as study objects if the research aims are to describe etiology, and molecular interactions that cause - and link - primary and secondary pathophysiological events together - events that account for early and progressive SLE. We have to develop SLE criteria allowing us to identify definable categories of SLE in order to describe etiology, pathophysiology and diagnostic criteria of delimitated SLE versions. In this regard, the causality principle is central to define dominant etiologies of individual SLE categories, and subsequent and consequent down-stream diagnostic disease measures. In this sense, we may whether we like it or not identify different SLE categories like "genuine SLE" and "SLE-like non-SLE" syndromes. Many aspects of this problem are thoroughly discussed in this study.

Advances in the management of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a severe multisystem autoimmune disease that can cause injury in almost every body system. While considered a classic example of autoimmunity, it is still relatively poorly understood. Treatment with immunosuppressive agents is challenging, as many agents are relatively non-specific, and the underlying disease is characterized by unpredictable flares and remissions. This State of The Art Review provides a comprehensive current summary of systemic lupus erythematosus based on recent literature. In basic and translational science, this summary includes the current state of genetics, epigenetics, differences by ancestry, and updates about the molecular and immunological pathogenesis of systemic lupus erythematosus. In clinical science, the summary includes updates in diagnosis and classification, clinical features and subphenotypes, and current guidelines and strategies for treatment. The paper also provides a comprehensive review of the large number of recent clinical trials in systemic lupus erythematosus. Current knowns and unknowns are presented, and potential directions for the future are suggested. Improved knowledge of immunological pathogenesis and the molecular differences that exist between patients should help to personalize treatment, minimize side effects, and achieve better outcomes in this difficult disease.

Clinical value of chemiluminescence method for detection of antinuclear antibody profiles

BACKGROUND

Antinuclear antibodies (ANAs) are crucial in diagnosing autoimmune diseases, mainly systemic lupus erythematosus (SLE). This study aimed to compare the performance of chemiluminescence assay (CLIA) and line immunoassay (LIA) in detecting ANAs in patients with autoimmune diseases, evaluate their diagnostic accuracy for SLE, and develop a novel diagnostic model using CLIA-detected antibodies for SLE. Specimens from patients with autoimmune diseases and physical examination specimens were collected to parallel detect specific antibodies. Individual antibodies' diagnostic performance and a model combining multiple antibodies were assessed. The findings provide valuable insights into improving the diagnosis of SLE through innovative approaches.

AIM

To compare the performance of CLIA and LIA in detecting ANAs in patients with autoimmune diseases, assess their accuracy for SLE, and develop a novel diagnostic model using CLIA-detected antibodies for SLE.

METHODS

Specimens have been obtained from 270 patients with clinically diagnosed autoimmune disorders, as well as 130 physical examination specimens. After that, parallel detection of anti-double-stranded DNA (dsDNA) antibody, anti-histone (Histone) antibody, anti-nucleosome (Nuc) antibody, anti-Smith (Sm) antibody, anti-ribosomal P protein (Rib-P) antibody, anti-sicca syndrome A (Ro60) antibody, anti-sicca syndrome A (Ro52) antibody, anti-sicca syndrome (SSB) antibody, anti-centromere protein B (Cenp-B) antibody, anti-DNA topoisomerase 1 (Scl-70) antibody, anti-histidyl tRNA synthetase (Jo-1) antibody, and anti-mitochondrial M2 (AMA-M2) antibody was performed using CLIA and LIA. The detection rates, compliance rates, and diagnostic performance for SLE were compared between the two methodologies, followed by developing a novel diagnostic model for SLE.

RESULTS

CLIA and LIA exhibited essentially comparable detection rates for anti-dsDNA antibody, anti-Histone antibody, anti-Nuc antibody, anti-Sm antibody, anti-Rib-P antibody, anti-Ro60 antibody, anti-Ro52 antibody, anti-SSB antibody, anti-Cenp-B antibody, anti-DNAScl-70 antibody, anti-Jo-1 antibody and anti-AMA-M2 antibody (P > 0.05). The two methods displayed identical results for the detection of anti-dsDNA antibody, anti-Histone antibody, anti-Nuc antibody, anti-Sm antibody, anti-Ro60 antibody, anti-Ro52 antibody, anti-SSB antibody, anti-Cenp-B antibody, anti-Scl-70 antibody, and anti-AMA-M2 antibody (Kappa > 0.7, P < 0.05), but showed a moderate agreement for the detection of anti-Rib-P antibody and anti-Jo-1 antibody (Kappa = 0.671 and 0.665; P < 0.05). In addition, the diagnostic performance of these antibodies detected by both methods was similar for SLE. The diagnostic model's area under the curve values, sensitivity, and specificity, including an anti-dsDNA antibody and an anti-Ro60 antibody detected by CLIA, were 0.997, 0.962, and 0.978, respectively. These values were higher than the diagnostic performance of individual antibodies.

CONCLUSION

CLIA and LIA demonstrated excellent overall consistency in detecting ANA profiles. A diagnostic model based on CLIA-detected antibodies can successfully contribute to developing a novel technique for detecting SLE.

The role of first-trimester NLR (neutrophil to lymphocyte ratio), systemic immune-inflammation index (SII), and, systemic immune-response index (SIRI) in the prediction of composite adverse outcomes in pregnant women with systemic lupus erythematosus

To evaluate the utility of neutrophil to lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) in the prediction of adverse pregnancy outcomes in pregnant women with systemic lupus erythematosus (SLE). This retrospective case-control study was conducted in Ankara City Hospital perinatology clinic between 2019 and 2023. First-trimester NLR, SII (NLR X platelet count), and SIRI (NLR X monocyte count) values were compared between pregnant women with SLE (n = 29) and low-risk controls (n = 110). Afterward, pregnant women with SLE were divided into two groups: 1) SLE with perinatal complications (n = 15) and 2) SLE without perinatal complications (n = 14). NLR, SII, and SIRI values were compared between the two subgroups. Finally, a ROC analysis was performed to determine optimal cut-off values for NLR, SII, and SIRI in the prediction of composite adverse pregnancy outcomes. The study group had significantly higher first-trimester NLR, SII, and SIRI values compared to the controls. The SLE with perinatal complications group had significantly higher NLR, SII, and SIRI values than the SLE group without perinatal complications (p < 0.05). Optimal cut-off values were 6.5 (66.7% sensitivity,71.4% specificity), 1612.6 (73.3% sensitivity, 71.4% specificity), and, 4.7 (73.3% sensitivity, 77.6% specificity) for NLR, SII, and SIRI, respectively. SII, SIRI, and NLR may be used to predict adverse pregnancy outcomes in pregnant women with SLE.

Anti-ribosomal P protein antibodies and insomnia correlate with depression and anxiety in patients suffering from systemic lupus erythematosus

Objective

Anxiety and depression in patients with systemic lupus erythematosus (SLE) complicate clinical treatment and can seriously affect prognosis. The present study aims to investigate the effects of the anti-ribosomal P protein antibody (anti-RibP) in the peripheral blood and insomnia on the severity of anxiety and depression in case of SLE. The study compared both the results of the investigation on the objective perceptions of physicians concerning mood changes in patients with SLE and the results of self-rating scales that were completed by the enrolled patients. The conclusion of the comparation is used to determine the probability of the accurate detection of anxiety and depression by physicians. The study aims to assist in the early detection in clinical practice of abnormal emotions in patients with SLE and to summarize common clinical interventions for anxiety and depression.

Method

The relationship between anxiety and depression was evaluated by the Zung self-rating anxiety/depression scale (SAS/SDS). Basic information (e.g., blood type, smoking history, drinking history, educational background, duration of illness), the insomnia severity index (ISI) results, and anti-RibP in the peripheral blood, were investigated in 107 patients with SLE in northeastern China to further analyze the correlation between the severity of depression and anti-RibP, together with the consistency between results of the questionnaire for physicians and the self-rating scale for patients.

Results

Gender, smoking history, drinking history, educational background, and duration of illness were correlated with the SAS/SDS scores (P < 0.05). Family history had a significant effect on the SAS score (P = 0.031), while the SDS score was significantly correlated with blood type (P = 0.021). The ISI score was significantly and positively correlated with the SAS/SDS score (P < 0.001). The titer of anti-RibP showed a correlation with the SDS score (P < 0.05) but not with the SAS score (P = 0.198). The titer of anti-RibP was significantly higher in patients with major depression compared with those with no depression, patients with mild depression, and those with moderate depression (P < 0.001).

Conclusion

Anxiety and depression in patients with SLE were correlated with sleeping, educational background, blood type, smoking history, and alcohol consumption. Although anti-RibP was not significantly correlated with anxiety, it indicated a significant correlation with major depression. Clinicians were more accurate in assessing anxiety compared with depression.

[Autoimmune diagnostics in nephrology and rheumatology]

Autoimmune diagnostics plays a central role in the detection of various acute and/or chronic diseases in both nephrology and rheumatology, which are associated with high morbidity and mortality if left untreated or not detected in time. Patients are threatened with significant limitations in everyday skills and quality of life due to loss of kidney function and dialysis, immobilizing and destructive joint processes or also significant damage of organ systems. In all of these autoimmune diseases, early diagnosis and treatment is of central importance for the further course and prognosis of disease.Antibodies play an essential role in the pathogenesis of autoimmune diseases. Antibodies are either directed against organ or tissue-specific antigens, such as in primary membranous glomerulonephritis or Goodpasture's syndrome, or they lead to a systemic disease such as systemic lupus erythematosus (SLE) or rheumatoid arthritis.Knowledge of the sensitivity and specificity of antibodies is crucial for the interpretation of antibody diagnostics results. Antibody detection can precede the clinical onset of the disease, and antibody titers often reflect disease activity. However, there are also false positive results. Detection of antibodies in the absence of disease symptoms often leads to uncertainty and unnecessary further diagnostics. Therefore, an unfounded "antibody screening" is not recommended.A rational antibody diagnostics is an integral part of the diagnostics and during treatment of nephrological and rheumatological diseases like glomerulonephrititis, pulmorenal syndrome, SLE and other collagenosis, thrombotic microangiopathy (HUS/TTP) and rheumatoid arthritis.

Lupus spectrum ambiguity has long-term negative implications for patients

Lupus is a complex disease that is often difficult to diagnose. Risks of diagnostic delays include non-specific signs and symptoms that mimic other diseases and a lack of diagnostic criteria and referral pathways for non-specialists. To address these issues, we convened a series of virtual meetings with members of our Addressing Lupus Pillars for Health Advancement clinical care team. Meeting participants included lupus physicians, treatment developers from biotechnology, patient advocacy group representatives from the Lupus Foundation of America and advocacy/government consultants. Causes and consequences of ambiguity in diagnosis and diagnostic delays were evaluated through historical, experiential and evidence-based accounts (survey data, literature reviews and patient testimonials). Discussions highlighted the need for a clearer understanding of the definition of lupus, the natural history of the disease and the need for advancements in biotechnology to support an accurate and timely diagnosis with the potential development of a lupus spectrum.

Belimumab in childhood systemic lupus erythematosus: A review of available data

Introduction

Childhood systemic lupus erythematosus (cSLE) is a complex multisystem autoimmune disease. In 2019, belimumab was approved for the clinical treatment for cSLE, making it the only biological agent approved for cSLE children aged 5 and older in 60 years.

Objective

To review emerging evidence on belimumab in cSLE published up to April 2022, so as to provide information for clinical decision-making.

Method

A comprehensive search of relevant publications up to the date of April 2022 in PUBMED, EMBASE, WOS, COCHRANE, ClinicalTrials.gov, CBM, CNKI and WANFANG was performed using the following criteria: (a) English and Chinese language studies; (b) RCT studies, cohort studies, or case-control studies; (c) patients with age &lt;18; (d) Observational studies or case series studies contain more than 5 patients. All relevant literature was independently screened and reviewed by at least two reviewers and the obtained literature data were extracted and reviewed by two authors.

Results

Five publications met the inclusion/exclusion criteria for cSLE: one randomized controlled trial, one retrospective cohort study, and three case series. There was a high degree of heterogeneity among several studies, and the availability of baseline and outcome data provided was uneven.

Conclusion

At present, there is a lack of high-quality clinical trials of belimumab in the treatment of cSLE. Based on the current research, it is believed that the use of belimumab can inhibit cSLE activity, reduce the dose of corticosteroids and immunosuppressants, and delay kidney damage. Also it shows clinical benefit in alleviating symptoms of monogenic cSLE refractory to standard therapy. More studies are urgently needed to validate the clinical efficacy of belimumab in cSLE and to evaluate its long-term safety in pediatric populations to promote evidence-based practice.