Antiphospholipid antibodies and non-thrombotic manifestations of systemic lupus erythematosus

Changes in Clinical Manifestations and Course of Systemic Lupus Erythematosus and Secondary Antiphospholipid Syndrome over Three Decades

Systemic lupus erythematosus (SLE) is often associated with antiphospholipid syndrome (APS), which potentially results in a more severe disease course and reduced life expectancy. Since the therapeutic guidelines have been refined in the last 15 years, we assumed that the diseases course has become more favorable. In order to shed light on these achievements, we compared the data of SLE patients diagnosed before and since 2004. In our retrospective study, we assessed a wide spectrum of clinical and laboratory data of 554 SLE patients who received regular follow-up care and therapy at our autoimmune center. Among these patients, 247 had antiphospholipid antibodies (APAs) without clinical signs of APS, and 113 had definitive APS. In the APS group, among patients diagnosed since 2004, deep vein thrombosis (p = 0.049) and lupus anticoagulant positivity (p = 0.045) were more frequent, while acute myocardial infarction was less frequent (p = 0.021) compared with patients diagnosed before 2004. Among the APA positive patients without definitive APS, anti-cardiolipin antibody positivity (p = 0.024) and development of chronic renal failure (p = 0.005) decreased in patients diagnosed since 2004. Our study demonstrates that the disease course has changed in recent years; however, in the presence of APS, we have to expect repeated thrombotic events despite adequate anticoagulant therapy.

Autoantibody-based subgroups and longitudinal seroconversion in juvenile-onset systemic lupus erythematosus

OBJECTIVE

To explore the clinical value of autoantibody-based subgroup framework and the trend of autoantibody fluctuation in juvenile-onset SLE (JSLE).

METHODS

Eighty-seven patients with JSLE were retrospectively collected and divided into subgroups via a two-step cluster based on the status of nine autoantibodies (double-stranded-DNA (dsDNA), nucleosome, histone, ribosomal P protein, Smith (Sm), u1-ribonucleoprotein (RNP), Sjögren's syndrome antigen A (SSA)/Ro52, SSA/Ro60, Sjögren's syndrome antigen B (SSB)/La). The final model selected in this study was based on adequate goodness of fit of the Silhouette coefficient and clinical interpretability. Clinical manifestations, organ involvements and disease activity were compared among the subgroups. Fluctuation in autoantibody status was also collected and analysed. Flare-free survival rates of the patients with positive/negative seroconversion and patients without seroconversion were studied by the Kaplan-Meier method and compared using a log-rank test.

RESULTS

Two clusters were identified: subgroup 1 (positive anti-Sm/RNP group) and subgroup 2 (negative anti-Sm/RNP group). There were more lupus nephritis (LN) and neuropsychiatric SLE (NPSLE) cases in subgroup 1 than in subgroup 2. Patients in subgroup 1 exhibited higher SLE Disease Activity Index scores compared with those in subgroup 2. Furthermore, anti-ribosomal P protein (61.1%), anti-nucleosome (58.3%) and anti-dsDNA (54%) were most commonly positive autoantibodies. A progressive decrease in the frequency of patients with positive results was demonstrated during the follow-up years. The decrease was notable for anti-dsDNA, anti-nucleosome and anti-ribosomal P protein (remaining 27.27%, 38.89% and 45.00% positive in the fifth year, respectively). While for those negative at baseline diagnosis, the decrease in the frequency of negative results was progressive but modest. Kaplan-Meier curve showed that the flare-free survival of patients with positive seroconversion was significantly lower than those without seroconversion and those with negative seroconversion (p<0.001).

CONCLUSIONS

In children with SLE, subgroups based on autoantibody profile can be applied to differentiate phenotypes and disease activity. Two important organ involvements, LN and NPSLE, are more common in patients with positive anti-Sm/RNP autoantibodies. Positive seroconversion may provide a valuable perspective for assessing flare, and it is worthwhile to retest the array of autoantibodies during follow-up.

Risk of livedo with antiphospholipid antibodies in patients with systemic lupus erythematosus: A systematic review and meta-analysis

Background

Livedo is a well-known skin condition in patients with systemic lupus erythematosus (SLE) which correspond to small vessels involvement. The influence of antiphospholipid antibodies (aPL) on the occurrence of livedo is controversial. The aim of our study was to estimate the risk of livedo associated with aPL in patients with SLE.

Methods

We conducted a systematic review and meta-analysis of the literature from 1977 to 2021 to estimate the risk of livedo in SLE patients according to different aPL profiles. Data sources were PubMed, Embase, Cochrane Library, hand search, and reference lists of studies. Studies were selected if they included SLE patients with descriptions of the exposure to aPL and the outcome ( livedo). Two independent investigators assessed study eligibility, quality, and extracted patient characteristics from each study as well as exposure (aPL) and outcome ( livedo). Risk estimates were pooled using random effects models and sensitivity analyses. For all stages of the meta-analysis, we followed the PRISMA guidelines. PROSPERO registration number: CRD42015027377.

Results

Of the 2,355 articles identified, 27 were included with a total of 4,810 SLE patients. The frequency of livedo was 25.5% in aPL-positive patients and 13.3% in aPL-negative patients. The overall Odds Ratio (OR) for livedo in aPL-positive patients compared to aPL-negative patients was 2.91 (95% CI; 2.17–3.90). The risk of livedo was significantly increased for most of aPL subtypes, including lupus anticoagulant (LA) (OR = 4.45 [95% CI; 2.21–8.94]), IgG anticardiolipin (OR = 3.95 [95% CI; 2.34–6.65]), and IgG anti-β2-glycoprotein 1 (OR = 3.49 [95% CI; 1.68–7.27]).

Conclusions

We demonstrated in this meta-analysis an excess risk of livedo in aPL-positive SLE patients compared to aPL-negative patients. For daily practice, in patients with SLE, livedo associated with aPL could correspond to a peculiar group of patients with small vessel disease. Livedo could be a good candidate for inclusion in future classification criteria for antiphospholipid syndrome.

Predictors of hospitalization in patients with systemic lupus erythematosus: a 10-year cohort study

INTRODUCTION/OBJECTIVES

Recognising systemic lupus erythematosus (SLE) patients at higher risk for hospitalization, aiming at developing tailored management strategies, may help minimize admissions and improve long-term health outcomes. Our study aimed to identify predictors for hospitalization in patients with SLE.

METHOD

Cohort study of SLE patients followed in a referral centre. All hospitalizations from study baseline up to 120 months were identified, and the primary indication for admission was categorized as follows: (1) SLE disease activity; (2); infection; and (3) other conditions. Demographic, clinical, and laboratory parameters at baseline were sought as predictors of hospitalization for (i) any cause, (ii) disease activity, and (iii) infection using survival analysis with Kaplan-Meier curves and log-rank tests. Potential predictors were further tested using multivariate Cox proportional hazards regression models.

RESULTS

We included 398 patients (median follow-up: 120 months). The incidence rate of hospitalization was 17.7 per 100 patient-years. The most frequent indications for hospitalization were SLE disease activity (29.4%) and infection (23.4%). In multivariate analysis, male gender, age > 50 years, antiphospholipid antibodies positivity (aPL), SLEDAI-2 K > 5, organ damage, and prednisone daily dose (PDN) predicted hospitalization for any cause. SLEDAI-2 K > 5, aPL, PDN, and IS medication predicted hospitalization for active SLE. Male gender, prior biopsy-proven lupus nephritis, aPL, organ damage, and ongoing treatment with high-risk IS predicted hospitalization for infection. Treatment with antimalarials was associated with a lower risk of hospitalization for any cause and for infection.

CONCLUSIONS

Positive aPL identifies SLE patients presenting a higher risk of hospitalization, while medication with antimalarials was associated with a lower risk. Key Points • Positive aPL is predictive of hospitalization for any medical condition, disease activity, and infection • Organ damage is predictive of hospitalization for any condition and infection • Antimalarials are predictive of a lower risk of hospitalization for any condition and infection.

Cognitive Impairment in Anti-Phospholipid Syndrome and Anti-Phospholipid Antibody Carriers

Cognitive impairment is frequently reported among anti-phospholipid syndrome (APS) patients as well as anti-phospholipid antibody (aPL) carriers, but it is less studied than other manifestations of this condition. Moreover, the exact prevalence of cognitive impairment in these patients has not been accurately determined, mainly due to inconsistency in the tools used to identify impairment, small sample sizes, and variability in the anti-phospholipid antibodies measured and positivity cutoffs. The notion of a direct pathogenic effect is supported by the observation that the higher the number of aPLs present and the higher the load of the specific antibody, the greater the risk of cognitive impairment. There is some evidence to suggest that besides the thrombotic process, inflammation-related pathways play a role in the pathogenesis of cognitive impairment in APS. The cornerstone treatments of APS are anti-coagulant and anti-thrombotic medications. These treatments have shown some favorable effects in reversing cognitive impairment, but solid evidence for the efficacy and safety of these treatments in the context of cognitive impairment is still lacking. In this article, we review the current knowledge regarding the epidemiology, pathophysiology, clinical associations, and treatment of cognitive impairment associated with APS and aPL positivity.

Clinical and laboratory characteristics of Brazilian versus non-Brazilian primary antiphospholipid syndrome patients in AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) clinical database and repository

BACKGROUND

Antiphospholipid syndrome (APS) is characterized by episodes of thrombosis, obstetric morbidity or both, associated with persistently positive antiphospholipid antibodies (aPL). Studying the profile of a rare disease in an admixed population is important as it can provide new insights for understanding an autoimmune disease. In this sense of miscegenation, Brazil is characterized by one of the most heterogeneous populations in the world, which is the result of five centuries of interethnic crosses of people from three continents. The objective of this study was to compare the clinical and laboratory characteristics of Brazilian vs. non-Brazilian primary antiphospholipid syndrome (PAPS) patients.

METHODS

We classified PAPS patients into 2 groups: Brazilian PAPS patients (BPAPS) and PAPS patients from other countries (non-BPAPS). They were compared regarding demographic characteristics, criteria and non-criteria APS manifestations, antiphospholipid antibody (aPL) profile, and the adjusted Global Antiphospholipid Syndrome Score (aGAPSS).

RESULTS

We included 415 PAPS patients (88 [21%] BPAPS and 327 [79%] non-BPAPS). Brazilian patients were significantly younger, more frequently female, sedentary, obese, non-white, and had a higher frequency of livedo (25% vs. 10%, p < 0.001), cognitive dysfunction (21% vs. 8%, p = 0.001) and seizures (16% vs. 7%, p = 0.007), and a lower frequency of thrombocytopenia (9% vs. 18%, p = 0.037). Additionally, they were more frequently positive for lupus anticoagulant (87.5% vs. 74.6%, p = 0.01), and less frequently positive to anticardiolipin (46.6% vs. 73.7%, p < 0.001) and anti-ß2-glycoprotein-I (13.6% vs. 62.7%, p < 0.001) antibodies. Triple aPL positivity was also less frequent (8% vs. 41.6%, p < 0.001) in Brazilian patients. Median aGAPSS was lower in the Brazilian group (8 vs. 10, p < 0.0001). In the multivariate analysis, BPAPS patients still presented more frequently with livedo, cognitive dysfunction and sedentary lifestyle, and less frequently with thrombocytopenia and triple positivity to aPL. They were also less often white.

CONCLUSIONS

Our study suggests a specific profile of PAPS in Brazil with higher frequency of selected non-criteria manifestations and lupus anticoagulant positivity. Lupus anticoagulant (not triple positivity) was the major aPL predictor of a classification criteria event.

Comparison of Role of Hand and Wrist Ultrasound in Diagnosis of Subclinical Synovitis in Patients with Systemic Lupus Erythematosus and Rheumatoid Arthritis: A Retrospective, Single-Center Study

Background

This retrospective study aimed to compare the roles of hand and wrist ultrasound in diagnosing subclinical synovitis in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) at a single center in Sichuan, China.

Material/Methods

Forty-one patients with SLE and 20 patients with RA were included. SLE was diagnosed using the American rheumatology Society (ACR) classification standard. Severity of SLE was evaluated using the SLE disease activity index (SLEDAI). General and clinical manifestations and laboratory indicators were measured. Spearman correlation analysis was used for analyzing correlations between musculoskeletal ultrasound results and indexes.

Results

Among 41 patients with SLE, 26 (63.4%) had joint pain, and 39 (95.1%) had at least 1 joint abnormality. Thirteen patients with SLE (31.7%) had wrist joint involvement, 7 (17.1%) had metacarpal phalangeal-1 (MCP1) involvement, 8 (19.5%) had MCP2 involvement, 17 (41.5%) had MCP3 involvement, 14 (34.1%) had MCP4 involvement, and 5 (12.2%) had MCP5 involvement. Meanwhile, 2 (4.8%) had proximal interphalangeal-1 (PIP1) involvement, 10 (24.4%) had PIP2 involvement, 17 (41.5%) had PIP3 involvement, 12 (29.3%) had PIP4 involvement, and 3 (7.3%) had PIP4 involvement. Twelve patients demonstrated knee joint involvement. MCP joints had the highest involvement frequency (P=0.003). The most frequently detected disease was synovitis, followed by tenosynovitis, joint effusion, and bone erosion. ESR (P=0.002), CRP (P=0.020), and SLEDAI (P=0.011) of patients with SLE with arthralgia were significantly higher compared to patients without arthralgia. In patients with RA, musculoskeletal ultrasound scores were correlated with erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), disease activity score-28 (DAS28), and interleukin-6 (IL-6). In patients with SLE, musculoskeletal ultrasound scores were correlated with double-stranded DNA (dsDNA), ribonucleoprotein (RNP), DAS28, and IL-6.

Conclusions

Musculoskeletal ultrasound is highly sensitive in evaluating subclinical synovitis in patients with SLE, and its score is positively correlated with dsDNA, RNP IL-6, and DAS28 in patients with SLE.

Antiphospholipid syndrome (APS) in patients with systemic lupus erythematosus (SLE) implies a more severe disease with more damage accrual and higher mortality

INTRODUCTION

Antiphospholipid antibodies (aPL) have been associated with organ damage and certain features in systemic lupus erythematosus(SLE) patients. Our aim was to investigate the differences between SLE patients according to the presence of aPL and/or clinical antiphospholipid syndrome (APS).

MATERIALS AND METHODS

Patients from the RELESSER-T registry were included. RELESSER-T is a Spanish multicenter, hospital-based, retrospective, SLE registry.

RESULTS

We included 2398 SLE patients, 1372 of whom were positive for aPL. Overall 1026 patients were classified as SLE, 555 as SLE-APS and817 as SLE-aPL. Regarding cardiovascular risk factors, SLE-APS patients had higher rates of hypertension, dyslipidemia and diabetes than those with SLE-aPL and SLE (p < 0.001). SLE-APS patients showed higher rates of neuropsychiatric, cardiac, pulmonary, renal and ophthalmological manifestations than the other groups (p < 0.001). SLE-APS patients presented greater damage accrual with higher SLICC values (1.9 ± 2.2 in SLE-APS, 0.9 ± 1.4 in SLE-aPL and 1.1 ± 1.6 in SLE, p < 0.001) and more severe disease as defined by the Katz index (3 ± 1.8 in SLE-APS, 2.7 ± 1.7 in SLE-aPL and 2.6 ± 1.6 in SLE, p  < 0.001). SLE-APS patients showed higher mortality rates (p < 0.001).

CONCLUSIONS

SLE-APS patients exhibited more severe clinical profiles with higher frequencies of major organ involvement, greater damage accrual and higher mortality than SLE-aPL and SLE patients.

Progranulin Mediates Proinflammatory Responses in Systemic Lupus Erythematosus: Implications for the Pathogenesis of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease caused by the disorders of immune regulation but its pathogenesis is poorly understood. Progranulin (PGRN) is an immunomodulatory protein that is upregulated in SLE patients. However, the factors involved in regulating the pathogenesis of SLE by PGRN are largely unknown. We sought to investigate the role and molecular mechanisms of PGRN in SLE to develop a novel therapeutic target. We used an animal model of SLE that was induced in PGRN-deficient and normal wild type (WT) mice using pristane. PGRN concentrations were measured in SLE and the impact of PGRN deficiency was examined by measuring tissue injury and immune responses of T cells (Th1, Th2, Th17, and Treg) and B cells. SLE patients and mice showed elevated PGRN levels. Compared with WT SLE mice, inflammatory cell infiltration, tissue edema, and necrosis were alleviated in PGRN^-/- SLE mice and the levels of serum chemistry markers of tissue damage and the presence of anti-double-stranded DNA and anti-ribosomal protein P0 antibodies were all significantly decreased. We further discovered that PGRN deficiency could disturb the immune responses of T cell (Th1, Th2, Th17, and Treg) and B cell responses, leading to the decrease of inflammatory cytokines including interferon-γ and interleukin-17A and increased levels of regulatory B cells. PGRN plays a proinflammatory role in the development of SLE partially through promoting the production of autoantibodies and enhancing Th1 and Th17 cell responses. This may provide new therapeutic options for patients with SLE.

Clinical characteristics of patients with systemic lupus erythematosus showing a false-positive result of syphilis screening

A false-positive result of syphilis screening test (FPST) is a characteristic finding in patients with systemic lupus erythematosus (SLE). We evaluated the clinical characteristics of SLE patients with FPST at SLE diagnosis. We reviewed the medical records of patients with SLE who underwent the Venereal Disease Research Laboratory or Rapid Plasma Reagin tests at SLE diagnosis at Severance Hospital between 2006 and 2016. The baseline characteristics and clinical outcomes were compared between patients with FPST and those with a negative result of syphilis screening test. Of 145 patients with SLE, 20 patients showed FPST and 125 patients showed a negative syphilis screening result. At SLE diagnosis, patients with a negative result had higher SLE disease activity index (5.0 vs. 8.0, P < 0.001) and were more commonly complicated with nephritis (15.0% vs. 41.6%, P = 0.026). High level of serum total protein (> 8 g/dL) and the presence of anti-cardiolipin antibodies were independently associated with FPST (P = 0.010 and 0.037, respectively). During the follow-up (median 61 months), 5 patients with FPST (20.0%) and 12 patients without FPST (9.6%) were finally diagnosed with APS. The long-term risk of de novo thrombosis was higher in the FPST group (n = 4/20, 20% vs n = 6/125, 4.8%, P = 0.041). However, all-cause mortality showed no difference between the FPST group and the negative group. Patients with SLE showing FPST showed lower disease activity at SLE diagnosis but higher thrombotic risk and similar overall survival compared to those without FPST.

Posterior Reversible Encephalopathy Syndrome with Stroke in Puerperal Woman with High Titer of Anti-Phospholipid IgM Antibody

Posterior reversible encephalopathy syndrome with stroke is very rare in puerperal women. A 36-year-old nulliparous woman with both rheumatoid arthritis and recurrent pregnancy loss, probably due to a high titer of anti-phospholipid IgM antibody, was referred at 10 weeks of gestation. Low-dose aspirin at 100 mg/day and heparin calcium subcutaneous injection at 10,000 units/day were started before pregnancy and stopped at 35⁺⁶ and 40⁺² weeks, respectively. She transabdominally delivered a male infant weighing 3,344 g at 40⁺⁵ weeks. A tonic-clonic seizure abruptly occurred without either hypertension or proteinuria 5 days after delivery. Intracerebral hemorrhage involving an area of 2 cm in diameter in the right frontal lobe and subarachnoid hemorrhage with PRES were confirmed. Seizure recurred 2 days after the initial episode. She showed severe headache and mild disturbance of consciousness but no neurological findings. We suggested that a high titer of anti-phospholipid IgM antibody might be associated with stroke.