Non-late-onset neutropaenia following treatment of multiple sclerosis with ocrelizumab

Late-onset neutropaenia is defined as an absolute neutrophil count of <1.5×103cells/μL starting>4 weeks after the last dose of rituximab, in the absence of other identifiable causes. Late-onset neutropaenia is a rare adverse reaction to rituximab (observed in approximately 5% of patients). Rheumatic diseases constitute the main indication for rituximab; in these patients, neutropaenia appears after a mean of>28 days. Ocrelizumab is another monoclonal antibody that binds to CD20 (a glycosylated phosphoprotein mainly expressed on the membranes of B-lymphocytes); in January 2018, it was approved for the treatment of relapsing-remitting and primary progressive multiple sclerosis. We present a case of neutropaenia following intravenous infusion of ocrelizumab in a patient with primary progressive multiple sclerosis who presented with neutropaenic fever, herpetic stomatitis, and ecthyma gangrenosum only 20 days after infusion.

AB0503 CLINICAL AND SEROLOGICAL DIFFERENCES BETWEEN CAUCASIAN AND LATIN AMERICAN SLE PATIENTS IN A MULTIETHNIC SPANISH SINGLE-CENTRE COHORT

Background

Systemic lupus erythematosus (SLE) is a highly heterogeneous systemic autoimmune disease with multiorgan manifestations. There are disparities in its manifestations conditioned by sex, age of onset, and serological characteristics. The ethnic origin of the patients may be a conditioning factor for different organic manifestations, immunological markers, and outcomes.

Objectives

Our objective was to evaluate the clinical and serological differences in Caucasian vs. Latin American patients in a multiethnic Spanish single-center SLE cohort.

Methods

Single-centre retrospective observational study from a Spanish Lupus Cohort of adult SLE patients fulfilling the 2019 EULAR/ACR Classification Criteria. Only patients of Caucasian or Latin American origin were included.

Results

The study included 205 patients: 186 (90.7%) Caucasian and 19 (9.3%) Latin American. The mean age at diagnosis was 35.5 years. The female/male ratio was 9:1 in the Caucasian group and 19:1 in the Latin American group (ns). Serous and cutaneous involvement was similar between groups. The presence of arthralgia was also similar (ns) but there were statistically significant differences with the presence of arthritis (p=0.008). Severe hematologic manifestations were also more frequent in Latin American patients but only statistically significant for autoimmune hemolytic anemia (AIHA). Lupus nephritis and end-stage renal disease (ESRD) were two-fold and four-fold more common in Latin American patients. Among the immunological findings: hypocomplementemia, Anti-Sm, and anti-histones were differential markers between the two groups. Anti-RNP was also more frequent in the Latin American group (ns). Regarding treatments, there were no relevant differences between steroids and antimalarials. There were also no disparities in outcomes measured by activity (SLEDAI), cumulative damage (SDI), low activity (LLDAS), remission (DORIS), or death in our cohort.

Table 1.

Caucasian vs. Latin American SLE patients

CaucasianLatin Americanp-valueOdds ratio (IC95%)Serositis (%)22.58 %26.32 %p=0.712Skin involvement (%)65.59 %52.63 %p=0.261Arthritis (%)24.32 %52.63 %p=0.0082.39 (1.06-5.38)AIHA (%)0.00 %5.26 %p=0.00228.69 (1.13-728.60)Lymphopenia (%)34.95 %52.63 %p=0.084Immune thrombocytopenia (%)4.30 %10.53 %p=0.230Neurolupus (%)20.97 %10.53 %p=0.278Glomerulonephritis (%)18.82 %42.11 %p=0.0182.51 (1.05-6.02)ESRD (%)3.76 %15.79 %p=0.0204.20 (1.01-17.58)Low C3 (%)54.30 %89.47 %p=0.0031.65 (0.82-3.31)Low C4 (%)49.46 %84.21 %p=0.0041.70 (0.84-3.46)Low vitamin D (%)11.29 %26.32 %p=0.0612.33 (0.79-6.89)High DNAds (%)61.29 %63.16 %p=0.404Anti-Sm (%)12.37 %36.84 %p=0.0042.98 (1.13-7.85)Anti-Ro (%)26.34 %31.58 %p=0.624Anti-RNP (%)8.06 %21.05 %p=0.0632.61 (0.79-8.66)Anti-histones (%)4.30 %21.05 %p=0.0034.89 (1.35-17.77)Antiphospholipid antibodies (%)45.16 %42.11 %p=0.799Steroids (%)88.71 %94.74 %p=0.419Antimalarials (%)94.05 %89.47 %p=0.436SLEDAI≥6 (%)34.41%26.32%p=0.477SDI ≥1 (%)70.43 %68.42 %p=0.855LLDAS (%)60.99 %66.67 %p=0.637DORIS (%)48.09 %38.89 %p=0.456Death (%)1.61 %0.00 %p=0.577

Conclusion

In our multiethnic Spanish single-center cohort, SLE patients of Latin American origin had a higher frequency of arthritis, glomerulonephritis, and AIHA. They also presented a higher frequency of hypocomplementemia, anti-Sm, and anti-histones at the immunological level. However, these clinical and serological differences did not correlate with outcomes of activity, damage, remission, or mortality. Future studies are needed to assess the definitive effect of ethnicity on SLE.

References

[1]Gómez-Puerta JA, Pons-Estel GJ, Quintana R, et al. A longitudinal multiethnic study of biomarkers in systemic lupus erythematosus: Launching the GLADEL 2.0 Study Group. Lupus. 2021;961203320988586.

[2]Pons-Estel GJ, Catoggio LJ, Cardiel MH, et al. Lupus in Latin-American patients: lessons from the GLADEL cohort. Lupus. 2015;24(6):536-545.

Disclosure of Interests

None declared

AB0489 ORGANIC DAMAGE MEASURED BY SDI IN A LONG-FOLLOW-UP SLE COHORT

Background

SLICC Damage Index (SDI) index was designed to reflect accrual damage in patients with systemic lupus erythematosus (SLE). It reflects an irreversible change, unrelated to inflammatory activity, that has occurred since the diagnosis of SLE, verified by clinical assessment, and has been present for at least 6 months.

Objectives

Our objective is to determine the factors associated with higher mean SDI and SDI≥1 in patients with SLE in a long-follow-up cohort.

Methods

Single-centre retrospective observational study of SDI in SLE in a Spanish Lupus Cohort (HAPLES cohort: single-center cohort designed for the prospective evaluation of cardiac involvement in SLE). We included 219 SLE patients but 9 were excluded from the study because they did not fulfill the EULAR/ACR 2019 classification criteria.

Results

Two hundred and ten patients with a mean age at diagnosis of 35.3 years (89.1% women) were analyzed. The mean follow-up time was 15.4 years. Mean SDI was 2.21 (range 0-26). The majority (70,9%) of patients presented an SDI≥1. However, an SDI≥1 was more frequent with longer follow-up (p=0.034): 23.8% in ≤5 years vs 74% in ≥10 years. The mean SDI increases over time (follow-up) (p<0.001): in patients with <5 years since diagnosis is 1.16, between 5-10 years 2.14 and in >10 years of follow-up 2.47. A positive correlation was also found between mean SDI and age (p<0.001), hypertension (p<0.001), diabetes (p=0.004), dyslipidemia (p<0.001), obesity (p=0.045), thrombosis (p<0.001), serositis (p=0.005), renal involvement (p=0.012), neurolupus (p<0.001), cardiac involvement (p<0.001) and antiphospholipid antibodies (aPLs) (p=0.002). A negative (protective) correlation was only found with antimalarials (p=0.002). Patients with SDI=0 (no damage) vs. SDI≥1 (any damage) were compared (Table 1) to evaluate the risk factors of presenting some irreversible accrual damage in the follow-up.

Table 1.

Damage accrual measured by SDI (SDI=0 vs SDI≥1)

SDI=0SDI≥1p valueOR (IC95%)Female sex (%)88.71 %88.51 %p=0.967Late onset SLE (≥50 years) (%)6.45 %23.65 %p=0.0033.43 (1.41-8.32)Obesity (%)6.45 %16.89 %p=0.0452.83 (1.07-7.48)Hypertension (%)24,19 %53.38 %p<0.0012.21 (1.27-3.86)Diabetes (%)1.61 %7.43 %p=0.097Dyslipidemia (%)22.58 %45.27 %p=0.0021.96 (1.10-3.47)Thrombosis (%)3.23 %18.24 %p=0.0046.00 (1.71-21.01)Serositis (%)12.90 %27.03 %p=0.0262.08 (1.01-4.26)Neurolupus (%)8.06 %25.00 %p=0.0053.12 (1.35-7.26)Glomerulonephritis (%)14.52 %24.32 %p=0.114Cardiac involvement (%)15.52 %54.86 %p<0.0013.67 (1.95-6.92)DNAds+ (%)56.45 %63.51 %p=0.338Anti-Sm (%)12.90 %14.86 %p=0.711Anti-Ro (%)29.03 %25.68 %p=0.616Anti-RNP (%)11.29%8.11%p=0.463Antiphospholipid antibodies (%)25.81 %54.05 %p<0.0012.16 (1.25-3.75)LLDAS (%)56.14 %63.51 %p=0.331DORIS (%)41.38%48.65%p=0.347Prednisone (or equivalent) >7.52.94 %12.93 %p=0.0194.33 (1.20-15.67)Antimalarials90.16 %79.73 %p=0.0220.43 (0.17-1.09)Conventional DMARDs (%)37.70%47.97%p=0.175Belimumab (%)1.64%5.41%p=0.223Death (%)0.00 %2.03 %p=0.259

Conclusion

SDI in our SLE-cohort was correlated with age, vascular risk factors, severe organ involvement, aPLs and steroid use. Only antimalarials were associated with a lower mean SDI. SDI increases significantly with longer follow-up time, especially after the fifth year of follow-up. Prevention and early treatment of the aforementioned risk factors could avoid irreversible organ accrual damage in lupus.

References

[1]Bruce IN, O’Keeffe AG, Farewell V, et al. Factors associated with damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort. Ann Rheum Dis. 2015;74(9):1706-1713.

[2]Raman L, Yahya F, Ng CM, et al. Early damage as measured by SLICC/ACR damage index is a predictor of hospitalization in systemic lupus erythematosus (SLE). Lupus. 2020;29(14):1885-1891.

[3]Johnson SR, Gladman DD, Brunner HI, et al. Evaluating the construct of damage in systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2021;10.1002/acr.24849.

Disclosure of Interests

None declared

AB0376 DIFFERENCES IN IMMUNOGLOBULIN LEVELS IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS AND RHEUMATOID ARTHRITIS TREATED WITH RITUXIMAB

Background

Hypogammaglobulinemia (HGGS) is one of the adverse effects of Rituximab (RTX), a chimeric monoclonal antibody directed against the CD20 receptor, frequently observed in ANCA-associated vasculitis (AAV) patients.

Objectives

To study the characteristics of patients with AAV on RTX treatment and to analyze the factors associated with HGGS, as well as to compare them with patients with rheumatoid arthritis (RA) on the same treatment.

Methods

Retrospective descriptive study of patients with a diagnosis of AAV or RA treated with RTX who had immunoglobulin levels prior to treatment and after each cycle were included. Demographic, clinical and analytical variables were analyzed. Patients who developed HGGS versus those who did not were compared using Student’s t and Mann-Whitney U for continuous variables and chi-square for categorical variables.

Results

Ninety-five patients were included, 19 (20%) with AAV and 76 (80%) with RA. Of the 34 (35.8%) who developed HGGS, 19 had RA (25%) and 15 AAV (79%) (p<0.001). The 6 patients who presented with severe HGGS (IgG<500) belonged to the AAV group.

The overall sample was divided into patients with HGGS and patients without (Table 1). Significant differences were obtained in relation to diagnosis (p<0.001), age at diagnosis and at the start of treatment, being higher in patients with HGGS (p 0.005 and p 0.001) and years of disease evolution (p 0.036). Patients with HGGS had a lower mean baseline IgG (p<0.001). The HGGS group had more severe infections (infections requiring admission) (p 0.005) and the time from RTX administration to the development of infection was shorter in this group (p 0.017). The frequency of abdominal infection was higher in the HGGS group (p 0.050), and there were no significant differences with the other types of infection.

Table 1.Total sample (n= 95)HGGS IgG (n= 34)No HGGS IgG (n= 61)PWomen n/N(%)70/95(73.7)23/34(67.6)47/61(77)0.318Age (m±SD)64±1268±1062±120.005Age at start of treatment (m±SD)57±1262±1054±120.001Years of evolution (m±SD)11±98±912±100.036RA n/N(%)76/95(80)19/34(55.9)57/61(93.4)<0.001AAV n/N(%)19/95(20)15/34(44.1)4/61(6.6)<0.001Glomerular filtration rate <60 n/N(%)7/91(7.7)4/34(11.8)3/61(4.9)0.164GCS AD in the previous year (m±SD)2918±31023265±30502690±31550.238GC AD during treatment (m±SD)4656±177132889±27785576±217750.271Total GC AD (m±SD)56411±326716117050±4841865879±60890.159CFM AD (m±SD)0.51±2.251.1±3.10.2±1.50.032Baseline IgG (m±SD)1107±340933±3461203±297<0.001Infection n/N(%)58/95(61.1)23/34(67.6)35/61(57.3)0.325Severe infection n/N(%)19/95(20)12/34(35.3)7/61(11.5)0.005Time to infection (months)(m±SD)43±4330±3657±450.017Exitus n/N(%)8/95(8.4)2/34(5.9)6/61(9.9)0.270

Conclusion

A significantly higher percentage of HGGS is observed in patients with AAV treated with RTX compared to patients with RA. The development of HGGS seems to be influenced by age at diagnosis and at the start of treatment, years of disease evolution and low levels of IgGs prior to the start of treatment. In addition, there is a higher frequency of severe infections in the HGGS group. Studies with larger sample sizes are needed to confirm these results.

References

[1]Roberts DM, Jones RB, Smith RM, Alberici F, Kumaratne DS, Burns S, Jayne DR. Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun. 2015 Feb;57:60-5. doi: 10.1016/j.jaut.2014.11.009.

Disclosure of Interests

None declared

OP0292 SURVEY ON THE PERCEPTIONS AND EXPERIENCES OF SPANISH LUPUS PATIENTS. RESULTS ABOUT KNOWLEDGE OF THE DISEASE AND RELATIONSHIP TO DISEASE-FELUPUS SURVEY

Background:

Despite great advances in the diagnosis and treatment of lupus, the scientific community does not know the perception of our patients regarding the knowledge of the disease and the relationship between patients and disease. Fatigue had the greatest impact on activities of daily living, yet the majority reported receiving no support or poor support in managing it1.

Objectives:

Through this initiative, it is intended to investigate about the knowledge of the disease and impact of the disease on quality of life of Lupus patients. Another objective is to give visibility to the current needs of people living with lupus.

Methods:

It was performed a national survey with 1,263 interviews with Lupus patients who reside in Spanish territory and belonging to lupus patient associations in Spain. The survey was carried out by the Spanish Lupus Federation (FELUPUS) in collaboration with GSK company.

Online interview lasting approximately 25 minutes. The collection of information was anonymously carried out from May 21 to June 30, 2020.

Results:

1.263 lupus patients were interviewed, 92% diagnosed with SLE and 8% with CLE. Survey sample is representative of the Lupus patient population in Spain [associated sampling error: 2.76%]. Questions about knowledge of the disease showed that 73% of patients considered that there is very little knowledge of the disease by society. Patient awareness of lupus increases as the disease progresses, so at the time of diagnosis, level of knowledge of the patient about Lupus is low in 92% of patients and at the moment of survey, 68% of patient had high knowledge. In terms of the perception of his illness, the affectation of the kidneys and heart (97%), fatigue and skin rashes (97%), are the statements that generate the greatest consensus. The survey about the relationship to disease demonstrated that 3 out of 4 patients have symptoms related to the disease, muscle and joint pain (75%) and fatigue (74%) are the symptoms that cause the greatest discomfort (Graph 1). Remarkable degree of agreement with the fact of not being able to sunbathe (78%), as well as the lack of energy (61%) and weakness in the body (60%). Flare-ups (86%), followed by fatigue (78%) and pain (77%) cause great concern. At diagnosis, 92% of patients have some organic involvement and regarding the diagnosis, at present, a greater number of patients present damage to the CNS (17%) and bones (21%). Many patients do not understand the concept of organ damage, wrongly relating it to fatigue (38%) or joint pain (47%).

Graph 1.

Conclusion:

Among the conclusions of the survey, it stands out that society and the general population are unaware of what lupus is, while in the case of lupus patients, knowledge increases as the disease progresses. Citizen awareness campaigns about this disease are necessary, where patient associations together with health authorities have a crucial job. On the other hand, 92% of patients present organ damage at diagnosis. This means that we are arriving late to the diagnosis of many patients, which makes it necessary to promote a close collaboration between Primary Care and Hospitals, to refer patients as soon as they suspect SLE.

References:

[1]Sloan M, Harwood R, Sutton S, D’Cruz D, Howard P, Wincup C, Brimicombe J, Gordon C. Medically explained symptoms: a mixed methods study of diagnostic, symptom and support experiences of patients with lupus and related systemic autoimmune diseases. Rheumatol Adv Pract. 2020 Feb 26;4(1):rkaa006.

What worries the most to Lupus patients?

Question P12. Please indicate your level of concern with the following aspects of Lupus. Percentage of patients who have scored a 4 or 5 for each item (% T2B).

Acknowledgements:

GSK funded the study presented in the abstract.

Disclosure of Interests:

Patricia Fanlo Grant/research support from: GSK funded the study presented in the abstract.

POS0888 EPIDEMIOLOGICAL AND CLINICAL DIFFERENCES BETWEEN ANTI-MDA5 PHENOTYPES: DATA FROM A LARGE COHORT (MEDRA5) STUDY

Background:

Idiopathic inflammatory myopathies are a heterogenous group of systemic autoimmune diseases. Several phenotypes have been linked to specific autoantibodies. Clinically amyopathic dermatomyositis with rapidly progressive interstitial lung disease, the most severe form of ILD, is associated with the anti-MDA5 antibodies. However not all the patients with dermatomyositis and anti-MDA5 positive antibodies develop this severe condition.

Objectives:

We aim to define different phenotypes from a large cohort of patients diagnosed with dermatomyositis who were positive to anti-MDA5 antibodies.

Methods:

We retrospective analyzed the clinical and immunological data of 90 anti-MDA5 patients [50 female, 55.6%, mean (SD) age at diagnosis 47 (15.4) yrs.] with dermatomyositis recruited from a multicenter register in Spain (MEDRA5) including 30 hospitals. All the patients fulfill de International Myositis Classification Criteria (EULAR/ACR) for dermatomyositis (score >90%). Anti-MDA5 were detected by means of commercial immunoblot (EUROIMMUN©). The chi-square test was used to assess the relationships between qualitative variables. The Kruskal-Wallis test was used to compared medians between groups.

Results:

Sixty-six patients (73.3%) were diagnosed with clinically amyopathic dermatomyositis. Three different phenotypes linked with the anti-MDA5 antibody were identified. Group 1: patients with rapidly-ILD phenotype (28 patients, 31.1%), group 2: antisynthetase-like phenotype (23 patients, 25.5%), and group 3: non-ILD phenotype (39 patients, 43.3%). Clinical and immunological comparison between the groups disclosed that age at disease onset was higher (median, IQR) in patients from group 1 [53 (43-60)] vs. group 2 [46 (40-56)] or group 3 [42(41-51)] (p=0.01); disease onset was more frequent in spring in patients from group 1 (46.5%) than in the rest of the groups (21.7% and 28.9%) (p<0.01). Cancer was detected in 7 patients, only associated with myositis in 3 cases (3 years interval between cancer and dermatomyositis) without significant differences between phenotypes. Vasculitis (one case ANCA positive) was detected in 9 cases (6 limited to skin, 1 renal and 1 intestinal), 6 of them in the group 3 (statistical significance, in comparison with group 1 and 2, p<0.01). Mortality rate was higher in group 1 (51.9%, 16 out of 17 due to refractory respiratory failure) vs group 2 (12.5%) or 3 (0%) (p<0.001). Anti Ro52 positivity was more frequent in group 1 (65.4%) vs. group 2 (25%) or 3 (35.5%) (p<0.017), although it did not reach statistical significance in terms of mortality (p=0.173) or patients admitted in the intensive care unit (p=0.173). Mechanic hands were more frequent in group 2 (40.6%) than in groups 1 (25%) and 3 (34.4%) (p=0.05). Fever was significantly most frequent in group 1(52.6%) than in group 2 (21.1%) and 3 (26.3%) (p=0.001). Other clinical or immunological features such as arthritis, myositis, or the number of characteristic skin lesions among others were not more frequent in one group or another.

Conclusion:

Three different phenotypes of patients positive to anti-MDA5 were identified. The presence or not of ILD, or the different type (rapidly progressive or not) of ILD were the main feature that allow to differentiate these phenotypes, which are relevant in clinical practice.

References:

[1]Allenbach Y, Uzunhan Y, Toquet S, et al; French Myositis Network. Different phenotypes in dermatomyositis associated with anti-MDA5 antibody: Study of 121 cases. Neurology. 2020;95: e70-e78.

Acknowledgements:

List of contributors of MEDRA5 group: Aguilar-García J (Internal Medicine, Hospital Costa del Sol, Marbella), Carrión-Barberá I (Rheumatology, Hospital del Mar, Barcelona), Cobo-Ibañez T (Rheumatology, Hospital Infanta Sofía, San Sebastián de los Reyes), de Escalante-Yangüela B (Internal Medicine, Hospital Clínico Lozano Blesa, Zaragoza), Fonseca-Aizpuru EM (Internal Medicine, Hospital de Cabueñes, Gijón), González-Cubillo L (Intensive Medicine, Hospital Universitario de Cruces, Barakaldo), González-Gay MA (Rheumatology, Hospital Marqués de Valdecilla, Santander), Prieto-González S (Internal Medicine, Hospital Clinic, Barcelona), Ruiz-Román A (Rheumatology, Hospital Universitario Virgen del Rocío, Sevilla), Calero-Paniagua I (Internal Medicine, Hospital Virgen de la Luz, Cuenca), Callejas-Rubio JL (Internal Medicine, Hospital Clínico San Cecilio, Granada), Gil-Vila A (Internal Medicine, Hospital Vall d’Hebron, Barcelona), de Miguel-Campo B (Internal Medicine, Hospital Doce de Octubre, Madrid), García-Sevilla R (Pneumology, Hospital General Universitario de Alicante, Alicante), Iriarte-Fuster A (Internal Medicine, Hospital de Bellvitge, Hospitalet de Llobregat), Jovani-Casano V (Rheumatology, Hospital General Universitario de Alicante, Alicante), Lozano-Rivas N (Rheumatology, Hospital Virgen de la Arritxaca, Murcia), Martín-Gascón M (Internal Medicine, Hospital Morales Meseguer, Murcia), Martinez-González O (Rheumatology, Hospital Universitario de Salamanca, Salamanca), Monteagudo-Jiménez M (Internal Medicine, Hospital Parc Taulí, Sabadell), Mora-Ortega GM (Pneumology, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes), Moral-Moral Pedro (Internal Medicine, Hospital Universitari i Politecnic La Fe, Valencia), Pérez-De Pedro I (Interna Medicine, Hospital Regional Universitario de Málaga, Málaga), Picazo-Talavera MR (Rheumatology, Hospital del Sureste, Madrid), Rubio-Rivas M (Internal Medicine, Hospital de Bellvitge, Hospitalet de Llobregat)

Disclosure of Interests:

None declared

POS0119 RENAL INVOLVEMENT AND NEED OF RENAL REPLACEMENT THERAPY IN ANCA ASSOCIATED VASCULITIS IN A SPANISH SINGLE-CENTER STUDY

Background:

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EPGA). Renal involvement is frequent in AAV and is an important factor for morbidity and mortality.

Objectives:

The main objective of this study was to analyze the demographic, clinical, histological and therapeutic characteristics of renal involvement in patients with AAV and the risk of renal replacement therapy (RRT) or death.

Methods:

Retrospective observational study of 56 patients with AAV fulfilling classificatory criteria and renal involvement diagnosed between 1995 and 2020 from a Spanish tertiary centre. We studied the histological involvement (according to the 2010 classification in focal, crescentic, mixed or sclerotic), immunofluorescence (IF) and the treatment received with the risk of RRT or death.

Results:

We included 56 patients diagnosed with AAV and renal involvement. The mean age was 61.08±4.05 years; 58.9% were women. The mean follow-up time of these patients was 16.14± 8.80 years. Only 57.1% of patients presented systemic involvement.

Most frequent non-renal AAV manifestations were lung involvement (39.3%), central nervous system (30.4%), otorhinolaryngology (ORL) (14.3%), skin (8.9%) and cardiac involvement (8.9%). Main immunological findings were ANCA-MPO+ (69.6%), ANCA-PR3+ (23.2%), ANCA-negative (5.4%). Low C3 was found in 19.6% patients. Histologic classification (HC) and need of RRT is described in table 1. Main HC in renal AAV was crescentic, mixed, focal and sclerotic respectively. Eight patients had not biopsy performed. IF was positive for C3 deposits in 20 patients (35.7%). Half of the patients presented <50% normal glomeruli.

The treatment of renal involvement in AAV in our cohort was as follows: 83.9% (47) corticosteroids (CS) and cyclophosphamide (of which 40 received intravenous and 7 oral cyclophosphamide; and 12 patients associated plasma exchange (PE) with this treatment), 5.36% CS alone, 2 patients received CS and mycophenolate; 1 CS and rituximab, 1 CS and PE, and 2 patients received no treatment. A total of 13 patients received PE and 18 RRT. The mean time to RRT was 65.44±32.72 months. Relapses were not uncommon, 33.93% of the patients presented ≥1 relapse and 10.71% presented ≥2.

Infections were very frequent since they were present in 91.07% of the patients. Other frequent non-immunological complications observed in the follow-up of these patients were thrombosis in 31.14%, cardiovascular events in 28.57% and cancer in 19.64%.

Patients with ANCA-PR3+ were younger at diagnosis (p<0.001), were more likely to present cardiac (p=0.045) and ORL involvement (p<0.001). However, neither ANCA-PR3+ nor ANCA-MPO+ were specifically associated with the need of RRT or higher risk of death in our cohort. Use of CS alone for the treatment of renal AAV was associated with higher mortality (p=0.006) but CS and cyclophosphamide with lower mortality (p=0.044). ANCA-negative patients were more likely to receive no treatment. Having <50% normal glomeruli and C3 deposits on IF were associated with an increased need for RRT. Presenting focal disease on HC was protective for the need of RRT. Older age at diagnosis, systemic involvement of AAV and need of RRT was associated with higher mortality.

Conclusion:

AAVs are complex vasculitides with frequent renal involvement. Increased C3 deposition, non-focal histological forms, and <50% normal glomeruli were related to the need for RRT. In turn, the need for RRT, a later age at diagnosis, and systemic involvement were associated with higher mortality. Holistic and multidisciplinary early management of AAVs in experience centers can help improve renal prognosis and decrease mortality.

References:

[1]Binda et al. ANCA-associated vasculitis with renal involvement. J Nephrol. 2018 Apr;31(2):197-208.

[2]Kronbichler et al. Clinical associations of renal involvement in ANCA-associated vasculitis. Autoimmun Rev. 2020 Apr;19(4):102495.

Disclosure of Interests:

None declared

AB0333 USEFULNESS OF MULTI-PARAMETRIC EVALUATION INCLUDING MINOR SALIVARY GLAND BIOPSY FOR THE DIFFERENTIAL DIAGNOSIS OF SICCA SYNDROME IN A SPANISH SINGLE-CENTER EXPERIENCE

Background:

Sjögren’s syndrome (SS) is a systemic autoimmune disease characterized by mononuclear cell infiltration of the exocrine glands, which leads to sicca syndrome and systemic manifestations. The minor salivary gland biopsy (MSGB) is undoubtedly important for the classification, diagnosis and prognosis of SS. However, differentiating SS and non-Sjögren’s sicca syndrome (NSS) can be challenging.

Objectives:

The aim was to evaluate the histological characteristics of MSGB besides focus score (FS) in patients with sicca syndrome and the usefulness of the different clinical, serological and histological parameters to diagnose, classify and describe the prognosis of patients with Sjögren’s syndrome.

Methods:

Prospective observational single-center study of patients referred for study of sicca syndrome with multi-parametric evaluation from January 2019 to December 2020. A diagnostic protocol based on Schirmer’s test, unstimulated whole salivary flow (UWSF) and minimally invasive MSGB was applied. Patients fulfilling 2016 ACR-EULAR classification criteria were classified as SS.

Results:

In a cohort of 115 patients with sicca syndrome, 55 (47.8%) were diagnosed with SS. The mean age was 56.9±14.5 years and most of the patients were women (81,7%) with no significant differences between SS and NSS. SS were more likely to present positive Schirmer’s test, positive UWSF, anti-Ro+, FS≥1, antinuclear antibodies (ANA+), rheumatoid factor (RF+) and anti-La+ among others.

MSGB was a safe procedure and very effective (only 7% insufficient biopsies) in our cohort. The mean gland size of the MSGB was 5.7±0.37 mm2. Furthermore, it was the individual parameter that most correlated with SS, even more than anti-Ro+, Schirmer’s and UWSF. Seronegative SS (Anti-Ro-) was 47.3%. These patients could not have been diagnosed except by MSGB. Scintigraphy did not help to differentiate SS from NSS, neither patient-referred xerostomia nor xerophthalmia. The most frequent histological diagnosis was focal lymphocytic sialadenitis (FLS) (81.8%) followed by nonspecific chronic sialadenitis (9.1%). However, only FLS had a correlation with SS. There were no MSGBs labeled normal among the SS patients. Mean FS was 2.22±0.2 (16.7% had FS≥3).

The rest of the histological parameters that showed a positive correlation with SS were glandular atrophy (GA), germinal centers (GC), lymphoepithelial lesions (LEL) and lymphoid follicles (LF). FS≥1 is the current histological classification criteria for ACR/EULAR. However, the presence of lymphocytic infiltrates (LI) (although not FS≥1) and FLS were suggestive markers of SS with greater sensitivity (SE) and specificity (SP). FS≥3, GC, LEL and LF were only found in SS and were associated in previous studies with higher risk of lymphoma and systemic disease.

PrevalenceTestSSNSSp valueSensitivitySpecificityClassification criteriaSchirmer’s test78.6%57.6%p=0.0190.780.42UWSF65.5%38.3%p=0.0040.650.62Anti-Ro+52.7%6.7%p<0.0010.530.93FS≥166.7%25%p=0,0270.670.75Non classification criteriaAnti-La+18.5%1.8%p=0.0030.430.87ANA+74.5%28.3%p<0.0010.750.72RF+38.2%10.0%p=0.0010.430.87Scintigraphy49.1%38.3%p=0.2450.490.62Xerostomia76.1%77.9%p=0.6630.760.2Xerophthalmia74.5%83.8%p=0.3020.740.16Histological characteristicsLI92.2%27.5%p<0.0010.90.78FLS81.8%6.7%p<0.0010.820.93GA75.5%50.9%p=0.0100.760.49GC2.0%-p=0.3100.021.00LEL12.2%-p=0.0110.111.00LF4.1%-p=0.1530.041.00

Conclusion:

SS is a heterogeneous disease that requires a comprehensive clinical, serological, functional and histological evaluation. MSGB is a simple, safe, repeatable procedure that provides enormous information. It was the single parameter that best correlated with SS and allowed the diagnosis of seronegative SS. In summary, the use of MSGB is essential not only for the differential diagnosis of sicca syndrome but also as a prognostic marker for SS.

References: :

[1]Bautista-Vargas et al. Autoimmun Rev. 2020 Dec;19(12):102690.

Disclosure of Interests:

None declared

POS0875 MYOSITIS-SPECIFIC ANTIBODIES IN A RETROSPECTIVE SINGLE-CENTER OBSERVATIONAL STUDY

Background:

Myositis-specific antibodies (MSA) are highly specific and useful to classify patients as having syndromes with distinct clinical features and prognosis. MSA are almost always mutually exclusive and quite specific, adding value as a useful biomarker for diagnosis. Although individual autoantibodies aren’t sensitive enough to detect the full spectrum of idiopathic inflammatory myopathies (IIM), the sensitivity of a myositis panel is increasing as more autoantibodies are discovered, and as better assays become available.

Objectives:

We aimed to analyze the usefulness of a myositis-specific immunoblot for the diagnosis of IIM in a hospital cohort from January 2019 to December 2020. We also seek to correlate immunological findings with the risk of associated interstitial lung disease (ILD), cancer, or death.

Methods:

Retrospective single-center observational study conducted in a Spanish tertiary hospital. In patients with high clinical suspicion of IIM, a myositis immunoblot was performed including Jo1, PL-7, PL-12, EJ, SRP, Mi2, Ku, MDA-5, TIF1-γ, HMGCR, PM-Scl and Ro52 antibodies. The demographic characteristics, the risk of ILD, cancer and death were analyzed.

Results:

In a cohort of 313 patients with high suspicion of IIM, 87 patients (27.8%) presented a positive MSA (MSA+ve). The mean age at diagnosis was 56.7±16.9 years, with no significant differences between MSA+ve and MSA-ve (p=0.597). Most of the patients were women with significant differences between both groups (80.5% MSA+ve vs 68.1% MSA-ve, p=0.030).

IIM were classified as antisynthetase syndrome (ARS) (38%), dermatomyositis (DM) (31%), overlap myopathy (OM) (16.9%) and necrotizing myopathy (NM) (14.1%) according to the manifestations and MSA found (Jo1, PL-12, PL-7, EJ in ARS; Mi-2, MDA-5 and TIF1-γ in DM; Ku and PM-Scl in OM; HMGCR and SRP in NM). The most frequent MSA were anti-Jo1 (16.9%), TIF1-γ (15.5%), Ku (12.7%), Mi-2 (9.9%), PL-7 (9.9%), HMCGR (8.5%), PL-12 (7%), MDA-5 (5.6%), SRP (5.6%) and EJ (4.2%). The presence of Ro52 associated with other MSA was found in 20 patients (22.9%).

ILD was the most frequent manifestation (45.2% of the MSA+ve). Non-specific interstitial pneumonia (NSIP) was the most frequent ILD (39.5%), followed by usual interstitial pneumonia (34.2%). The main risk factors associated with IIM-ILD were some subtypes of the MSAs (p<0.001), the association of Ro52 (p<0.001), and older age (p=0.027). Among the IIM, ARS and OM (p<0.001) were more frequently associated with IIM-ILD. The MSAs most associated with IIM-ILD were Jo1, PL-7, PM-Scl, Ku and SRP (p<0.001).

Cancer was found in 9.6% of MSA+ve patients. The most frequent tumors were gynecological (37.5%), followed by gastrointestinal (25%) and breast cancer (12.5%). Factors associated with cancer were age (p=0.010), TIF1-γ (p<0.001), SRP (p=0.004), PL-12 (p=0.013), PL-7 (p=0.047) and HMGCR (p=0.027).

The mortality of these patients was 3.5%. There were no differences regarding MSA+ve/-ve (p = 0.911). However, MDA-5 (p=0.033) and older age (p=0.001) were associated with higher mortality. There were no significant differences between the IIM classifications, the associated SAD, the presence of cancer or ILD. However, longer follow-up periods and future studies are necessary to confirm these results.

Conclusion:

The use of a myositis blot allowed classifying, stratifying the risk of ILD, the risk of cancer and the risk of mortality in IIM. IIM-ILD was the most frequent complication, usually manifested as NSIP. The associated risk factors were ARS, OM, some MSAs, Ro52+ and older age. Cancer was a serious and frequent manifestation in these patients, especially in patients with TIF1-γ and other MSAs, so it is essential to know the risk factors and perform an early screening, especially in older patients.

A better knowledge of the serological profiles of IIM will provide more individualized approaches and better risk stratification, helping in the management and treatment of these patients.

References:

[1]Satoh et al. Clin Rev Allergy Immunol. 2017 Feb;52(1):1-19.

[2]Betteridge et al. J Intern Med. 2016 Jul;280(1):8-23.

Disclosure of Interests:

None declared

Non-late-onset neutropaenia following treatment of multiple sclerosis with ocrelizumab

Late-onset neutropaenia is defined as an absolute neutrophil count of <1.5×103cells/μL starting>4 weeks after the last dose of rituximab, in the absence of other identifiable causes. Late-onset neutropaenia is a rare adverse reaction to rituximab (observed in approximately 5% of patients). Rheumatic diseases constitute the main indication for rituximab; in these patients, neutropaenia appears after a mean of>28 days. Ocrelizumab is another monoclonal antibody that binds to CD20 (a glycosylated phosphoprotein mainly expressed on the membranes of B-lymphocytes); in January 2018, it was approved for the treatment of relapsing-remitting and primary progressive multiple sclerosis. We present a case of neutropaenia following intravenous infusion of ocrelizumab in a patient with primary progressive multiple sclerosis who presented with neutropaenic fever, herpetic stomatitis, and ecthyma gangrenosum only 20 days after infusion.

THU0256 CARDIAC INVOLVEMENT IN NEWLY DIAGNOSED SPANISH PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: DATA FROM THE RELES COHORT

Background:

Cardiac involvement is one of the most important causes of disability and mortality in patients with systemic lupus erythematosus (SLE). Transthoracic echocardiography (TTE) is a sensitive and specific technique in detecting cardiac abnormalities, particularly mild pericarditis, valvular lesions and myocardial dysfunction in SLE.

Objectives:

Using data of patients from the inception cohort Registro Español de Lupus Eritematoso Sistémico (RELES), we aimed to analyse the echocardiographic features of cardiac involvement of systemic lupus erythematosus (SLE).

Methods:

Prospective observational study on a multicenter Spanish inception cohort. Patients with SLE, diagnosed by the American College of Rheumatology (ACR) criteria, since January 2009, who had at least one TTE performed were selected. Demographic data, diagnostic criteria, follow-ups, treatments and SLEDAI were analyzed.

Results:

We included 289 patients diagnosed with SLE with TTE performed. The mean age was 40.5 ± 1.9 years, of which 86.9% (251) were women and 82.4% (238) Caucasian. The ACR score at diagnosis was 4.98 ± 0.1. Most frequent SLE manifestations were arthritis (59.2%), photosensitivity (49.5%), malar rash (39.1%) and serositis (31.1%). The main immunological findings were: ANA (97.6%), anti-DNA (66.4%), hypocomplementemia (58.7%), antiphospholipid antibodies (31.5%). One third (31.5%) of the TTE performed were pathological. Of these, 13.8% had pericardial effusion, 13.3% valvulopathy, 6.5% myocardial dysfunction, 5.2% pulmonary hypertension and 3.2% myocardiopathy. Regarding valvulopathies, 9,5% presented valvular dysfunction, 3.2% valvular thickening and 0.6% vegetation. The most frequently injured valve was the mitral (9.1%), followed by the aortic (2.8%). The majority of patients (88.26%) were asymptomatic at the time of TTE. However, patients with pathological TTE had more dyspnea than those in the normal TTE group (24.7% vs. 5.8%, p<0.001). Presenting a pathological TTE was associated with higher SLICC score (p<0.001), greater number of admissions (p<0.001) and mortality (p=0.002). A higher SLEDAI was also associated with higher mortality (p<0.001).

Conclusion:

Cardiac involvement in SLE is not only related to damage accrual but can also be an early manifestation (beyond pericarditis), especially in active SLE. TTE assessment should be considered as a part of routine examination for SLE due to the high prevalence of heart disease even in asymptomatic patients.

References:

[1]Doria A, Iaccarino L, Sarzi-Puttini P, Atzeni F, Turriel M, Petri M. Cardiac involvement in systemic lupus erythematosus.Lupus. 2005;14(9):683–686.

[2]Chen J, Tang Y, Zhu M, Xu A. Heart involvement in systemic lupus erythematosus: a systemic review and meta-analysis.Clin Rheumatol. 2016;35(10):2437–2448.

Disclosure of Interests:

Jorge Álvarez Troncoso: None declared, Ángel Robles Marhuenda: None declared, Francesca Mitjavila Villero: None declared, Francisco José García Hernández: None declared, Adela Marín Ballvé: None declared, Antoni Castro Consultant of: Actelion pharmaceuticals, GSK, MSD., Gonzalo Salvador Cervelló: None declared, Eva Fonseca: None declared, Isabel Perales Fraile: None declared, Guillermo Ruiz-Irastorza: None declared

FRI0152 PULMONARY HYPERTENSION IN NEWLY DIAGNOSED SPANISH PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: DATA FROM THE RELES COHORT

Background:

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by multiorgan involvement. Pulmonary hypertension (PH) is an uncommon manifestation with high morbidity and mortality whose characteristics, prevalence and evolution in SLE are not completely defined.

Objectives:

Using data of patients from the inception cohort Registro Español de Lupus Eritematoso Sistémico (RELES), we aimed to to identify the factors associated with pulmonary hypertension (PH) in systemic lupus erythematosus (SLE).

Methods:

Prospective observational study on a multicenter Spanish inception cohort. Patients with SLE, diagnosed by the American College of Rheumatology (ACR) criteria, since January 2009, who had at least one transthoracic echocardiogram (TTE) performed were selected. Demographic data, diagnostic criteria, follow-ups, treatments and SLEDAI were analyzed.

Results:

Of 289 patients diagnosed with SLE with TTE performed, 15 (5.2%) patients were identified to have PH. Mean age was 56,9±7,7 years, of which 93,3% (14) were women and 80% (12) Caucasian. The ACR score at diagnosis was 4.66. Mean SLEDAI was 15. Only 5 patients had dyspnea at the time of diagnosis. Mean pulmonary arterial systolic pressure was 49.2±5.6 mmHg. Among the PH, 4 patients had pericarditis (26.6%), 3 (20%) valvulopathies (1 antiphospholipid syndrome), 1 patient pulmonary embolism and 1 shrinking lung. Multivariable analysis indicated that pericarditis (odds ratio (OR)=2.53), and valvulopathies (OR 8.96) were independently associated with the development of PH in SLE. Having PH was associated with older age at diagnosis (p<0.001), more dyspnea (p<0.001), higher ESR (p=0.007), more serositis (p<0.001), higher SLEDAI (p=0.011), higher SLICC (p <0.001), higher number of admissions (p=0.006) and higher mortality (p=0.003).

Conclusion:

PH in SLE is a serious comorbidity with high mortality. In the RELES cohort it was associated with increased disease activity, pericarditis and valvulopathies. Performing TTE in patients with SLE may favor early diagnosis and treatment.

References:

[1]Kim JS, Kim D, Joo YB, et al. Factors associated with development and mortality of pulmonary hypertension in systemic lupus erythematosus patients.Lupus. 2018;27(11):1769–1777.

[2]Bazan IS, Mensah KA, Rudkovskaia AA, et al. Pulmonary arterial hypertension in the setting of scleroderma is different than in the setting of lupus: A review.Respir Med. 2018;134:42–46.

Disclosure of Interests:

Jorge Álvarez Troncoso: None declared, Ángel Robles Marhuenda: None declared, Francesca Mitjavila Villero: None declared, Francisco José García Hernández: None declared, Adela Marín Ballvé: None declared, Antoni Castro Consultant of: Actelion pharmaceuticals, GSK, MSD., Gonzalo Salvador Cervelló: None declared, Eva Fonseca: None declared, Isabel Perales Fraile: None declared, Guillermo Ruiz-Irastorza: None declared

SAT0197 NON MYOCARDIAL CARDIAC INVOLVEMENT IN ANTIPHOSPHOLIPID SYNDROME IN A SPANISH REFERENCE CENTER

Background:

Antiphospholipid syndrome (APS) is a systemic autoimmune disease, associated with a hypercoagulable state and fetal loss and with other clinical manifestations including cardiac involvement. APS occurs as a primary disorder (PAPS) or secondary to another autoimmune disease (SAPS). Due to its vascular nature, various organs and tissues may be affected, including the cardiac system. Cardiac manifestations of APS are valve abnormalities (valve thickening and vegetations), occlusive arterial disease (atherosclerosis and myocardial infarction) and pulmonary hypertension (PH).

Objectives:

To assess the prevalence of non-myocardial involvement (valvulopathy and pulmonary hypertension) in a cohort of patients with antiphospholipid antibodies (aPLs).

Methods:

Retrospective observational study in a Spanish reference center for systemic autoimmune diseases. All patients with aPLs and performed transthoracic echocardiogram (TTE) were included in the study. Patients were divided between PAPS, SAPS and aPLs carriers. A cohort of 50 patients with systemic lupus erythematosus (SLE) without aPLs was used as a control. Anti-cardiolipin, anti-B2GP1 and lupus anticoagulant antibodies were determined by standard techniques.

Results:

A total of 220 patients were reviewed. 145 (65.9%) were female. The mean age was 42 years. Among all patients with aPLs, 102 were PAPS, 73 SAPS, and 45 asymptomatic carriers (silent APS). Patients with aPLs, unlike patients with SLE without aPLs, presented more often pathological TTE (114 patients, 52%) (p = 0.02), with more valvular involvement (87, 39%) (p = 0.005) and pulmonary hypertension (21, 9.5%, p = ns). Valve involvement was identified in 99 patients: 45 in PAPS, 27 in SAPS, 14 in aPLs carriers and 13 in the SLE without aPLs, these differences being statistically significant (p = 0.002). Valvulopathy was asymptomatic in the majority of patients but required valve replacement in two patients. Mitral valve was the most affected, especially in the form of insufficiency (57%), followed by aortic valve, combined mitral and aortic valve, and less frequently the pulmonary valve alone (3 cases).

aPLs globalPAPSSAPSaPLs carriersSLE w/o aPLsTotal220 (100%)102 (46.4%)73 (33.2%)45 (20.4%)50 (100%)Men75 (34.1%)41 (40.2%)23 (31.5%)11 (24.4%)6 (12%)Women145 (65.9%)61 (59.8%)50 (68.5%)34 (75.6%)44 (88%)

Conclusion:

Subclinical valve involvement was very common in patients with APS. There was no correlation with other clinical manifestations of APS nor were other risk factors identified. PH was less frequent than valvular involvement in patients with APS. However, despite not being statistically significant, close to 10% of patients with APS had PH compared to 6% of patients without APS.

aPLs globalPAPSSAPSaPLs carriersSLE w/o aPLsTTE performed220 (100%)102 (46.4%)73 (33.2%)45 (20.4%)50 (100%)Pathological TTE114 (52%)16 (32%)p=0.02Valvular involvement87 (39%)45 (20.4%)27 (12.3%)14 (6.3%)13 (26%)p=0.005Pulmonary hypertension21 (9.5%)3 (6%)p=ns

Every patient with APS should have an echocardiogram in the initial study protocol in order to rule out both valvulopathy and pulmonary hypertension. This could modify the patient’s management both in the short and long term, as well as the prognosis.

References:

[1]Radin M, Ugolini-Lopes MR, Sciascia S, Andrade D. Extra-criteria manifestations of antiphospholipid syndrome: Risk assessment and management.Semin Arthritis Rheum. 2018;48(1):117–120.

[2]Tenedios F, Erkan D, Lockshin MD. Cardiac involvement in the antiphospholipid syndrome.Lupus. 2005;14(9):691–696.

[3]Kolitz T, Shiber S, Sharabi I, Winder A, Zandman-Goddard G. Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form.Front Immunol. 2019;10:941.

Disclosure of Interests:

None declared