Use of a Belatacept-based Immunosuppression for Kidney Transplantation From Donors After Circulatory Death: A Paired Kidney Analysis

Background

Efficacy and safety of belatacept have not been specifically reported for kidney transplantations from donors after circulatory death.

Methods

In this retrospective multicenter paired kidney study, we compared the outcome of kidney transplantations with a belatacept-based to a calcineurin inhibitor (CNI)-based immunosuppression. We included all kidney transplant recipients from donors after uncontrolled or controlled circulatory death performed in our center between February 2015 and October 2020 and treated with belatacept (n = 31). The control group included the recipients of the contralateral kidney that were treated with CNI in 8 other centers (tacrolimus n = 29, cyclosporine n = 2).

Results

There was no difference in the rate of delayed graft function. A higher incidence of biopsy-proven rejections was noted in the belatacept group (24 versus 6 episodes). Estimated glomerular filtration rate (eGFR) was significantly higher in the belatacept group at 3-, 12-, and 36-mo posttransplant, but the slope of eGFR was similar in the 2 groups. During a mean follow-up of 4.1 y, 12 patients discontinued belatacept and 2 patients were switched from CNI to belatacept. For patients who remained on belatacept, eGFR mean value and slope were significantly higher during the whole follow-up. At 5 y, eGFR was 80.7 ± 18.5 with belatacept versus 56.3 ± 22.0 mL/min/1.73 m2 with CNI (P = 0.003). No significant difference in graft and patient survival was observed.

Conclusions

The use of belatacept for kidney transplants from either uncontrolled or controlled donors after circulatory death resulted in a better medium-term renal function for patients remaining on belatacept despite similar rates of delayed graft function and higher rates of cellular rejection.

Eculizumab dose tapering should take into account the nonlinearity of its pharmacokinetics

AIMS

Eculizumab is a monoclonal antibody targeting complement protein C5 used in renal diseases. As recommended dosing regimen leads to unnecessarily high concentrations in some patients, tailored dosing therapeutic drug monitoring was proposed to reduce treatment cost. The objectives of the present work were (i) to investigate the target-mediated elimination of eculizumab and (ii) whether a pharmacokinetic model integrating a nonlinear elimination allows a better prediction of eculizumab concentrations than a linear model.

METHODS

We analysed 377 eculizumab serum concentrations from 44 patients treated for atypical haemolytic uraemic syndrome and C3 glomerulopathy with a population pharmacokinetic approach. Critical concentrations (below which a non-log-linear decline of concentration over time is evidenced) were computed to estimate the relevance of the target-mediated elimination. Simulations of dosing regimens were then performed to predict probabilities of target attainment (i.e. trough >100 mg/L).

RESULTS

Pharmacokinetics of eculizumab was nonlinear and followed a mixture of first-order (CL = 1.318 mL/day/kg) and Michaelis-Menten elimination (Vmax = 26.07 mg/day, Km = 24.06 mg/L). Volume of distribution (72.39 mL/kg) and clearance were weight-dependent. Critical concentrations (Vmax/CL) ranged from 144.7 to 759.7 mg/L and were inversely related to body weight (P = .013). Nonlinearity was thus noticeable at therapeutic concentrations. Simulations predicted that 1200 mg of eculizumab every 21 days would allow 85% and 76% of patients to maintain a therapeutic exposure, for 50 or 90 kg body weight, respectively.

CONCLUSIONS

Our study investigates the nonlinear elimination of eculizumab and discusses the importance of accounting for eculizumab target-mediated elimination in therapeutic drug monitoring.

Evaluation of T Cell Response to SARS-CoV-2 in Kidney Transplant Recipients Receiving Monoclonal Antibody Prophylaxis and the Utility of a Bivalent mRNA Vaccine Booster Dose

Monoclonal antibodies have been administered to kidney transplant recipients (KTRs) with a poor or non-responder status to SARS-CoV-2 vaccination. The cellular response to SARS-CoV-2 has been poorly studied in this context. We assessed the T cell response to SARS-CoV-2 in 97 patients on the day of the injection of tixagevimab/cilgavimab using an IFNγ enzyme-linked immunospot assay (ELISPOT). Among the 97 patients, 34 (35%) developed COVID-19 before the injection. Twenty-nine (85.3%) had an ELISPOT compatible with a SARS-CoV-2 infection. There was no difference between KTRs under belatacept or tacrolimus treatment. Sixty-three patients (64.9%) had no known COVID-19 prior to the ELISPOT, but nine (14.3%) had a positive ELISPOT. In 21 KTRs with a positive ELISPOT who received a booster dose of a bivalent mRNA vaccine, median antibody titers and spike-reactive T cells increased significantly in patients under tacrolimus but not belatacept. Our study emphasizes the potential usefulness of the exploration of immune cellular response to SARS-CoV-2 by ELISPOT. In KTRs with a positive ELISPOT and under CNI therapy, a booster dose of mRNA vaccine seems effective in inducing an immune response to SARS-CoV-2.

Serum infrared spectral profile is predictive of the degree of hepatic fibrosis in chronic hepatitis C patients

Assessment of liver fibrosis is crucial to guide the therapeutic strategy in patients with chronic liver disease. We investigated the potential of serum Fourier transform infrared (FTIR) spectroscopy for assessing the degree of hepatic fibrosis in patients with chronic hepatitis C (CHC). The study was conducted on dried serum samples from 94 CHC patients at different histological stages of hepatic fibrosis: METAVIR F0 (n = 20), F1 (n = 17), F2 (n = 20), F3 (n = 20) and F4 (n = 17). Transmission FTIR spectra were acquired in the 4000-400 cm-1 range. Wavenumbers were selected by genetic algorithm (GA) according to their diagnostic performance as assessed by a partial least squares discriminant analysis (PLS-DA) model using a training and a validation set to differentiate severe stages of fibrosis from mild or moderate ones. The GA procedure was applied 50 times on randomly selected sets. Furthermore, the best set of wavenumbers was re-tested in 1000 randomly selected validation sets. Wavenumbers selected by GA corresponded to functional groups present in lipids, proteins, and carbohydrates. This model allowed to identify patients with cirrhosis (METAVIR F4), patients with advanced fibrosis (METAVIR F3 and F4), and patients with significant fibrosis (METAVIR F2, F3 and F4), with AUROC (Area Under the Receiver Operating Characteristic) of 0.88, 0.85 and 0.85, respectively. Thus, serum FTIR spectroscopy appears to have a strong potential as a new diagnostic tool for assessing the degree of fibrosis in patients with chronic liver disease.

Daratumumab for antibody-mediated rejection: Is it time to target the real culprit?

We report the case of a sensitized woman who underwent successful transplantation after a desensitization protocol, with an optically normal 8-day biopsy. At 3 months, she developed active antibody-mediated rejection (AMR) due to preformed donor-specific antibodies. It was decided to treat the patient with daratumumab, an anti-CD38 monoclonal antibody. The mean fluorescence intensity of donor-specific antibodies decreased, pathologic signs of AMR regressed, and kidney function returned to normal. A molecular assessment of biopsies was retrospectively performed. By doing so, regression of the molecular signature of AMR was evidenced between the second and third biopsies. Interestingly, the first biopsy revealed a gene expression profile of AMR, which helped retrospectively classify this biopsy as AMR, illustrating the relevance of molecular phenotyping of biopsy in high-risk situations such as desensitization.

Rare Variants in Complement Gene in C3 Glomerulopathy and Immunoglobulin-Mediated Membranoproliferative GN

BACKGROUND

C3 glomerulopathy and idiopathic immunoglobulin-mediated membranoproliferative GN (Ig-MPGN) are rare complement-mediated kidney diseases. Inherited forms of C3 glomerulopathy/Ig-MPGN are rarely described.

METHODS

Three hundred ninety-eight patients with C3 glomerulopathy ( n =296) or Ig-MPGN ( n =102) from a national registry were screened for three complement genes: factor H ( CFH ), factor I ( CFI ), and C3 . Patients with rare variant (minor allele frequency <0.1%) were included. Epidemiologic, clinical, and immunologic data at diagnosis and kidney outcomes of patients were retrospectively collected.

RESULTS

Fifty-three different rare variants, including 30 (57%), 13 (24%), and ten (19%) in CFH , CFI , and C3 variants, were identified in 66/398 (17%) patients. Thirty-eight (72%) variants were classified as pathogenic, including 20/30 (66%) and 11/13 (84%) variants in CFH and CFI , respectively, impairing synthesis of factor H or factor I regulators. Fifteen of 53 (27%) variants were of unknown significance. At diagnosis, 69% of patients were adult (median age of 31 years). With the exception of biologic stigma of thrombotic microangiopathy, which was more frequent in patients with CFI variants (5/14 [36%] versus 1/37 [3%] and 0% in the CFH group and C3 group, respectively, P < 0.001), the clinical and histologic features were similar among the three variants groups. The kidney outcome was poor regardless of the age at onset and treatment received. Sixty-five percent (43/66) of patients with rare variant reach kidney failure after a median delay of 41 (19-104) months, compared with 28% (55/195) after a median delay of 34 (12-143) months in the nonvariant group. Among 36 patients who received a kidney transplant, 2-year recurrence was frequent, occurring in 39% (12/31), without difference between variant groups, and led to graft failure in three cases.

CONCLUSIONS

In our cohort, 17% of C3 glomerulopathy/Ig-MPGN cases were associated with rare variants in the CFH , CFI , or C3 genes. In most cases, a quantitative deficiency in factor H or factor I was identified. The presence of a rare variant was associated with poor kidney survival.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_08_CJN0000000000000252.mp3.

Impact of Calcineurin Inhibitor-Based Immunosuppression Maintenance During the Dialysis Period After Kidney Transplant Failure on the Next Kidney Graft Outcome: A Retrospective Multicenter Study With Propensity Score Analysis

The impact of immunosuppressive therapy (IS) strategies after kidney transplant failure (KTF) on potential future new grafts is poorly established. We assessed the potential benefit of calcineurin inhibitor (CNI)-based IS maintenance throughout the dialysis period on the outcome of the second kidney transplant (KT). We identified 407 patients who underwent a second KT between January 2008 and December 2018 at four French KT centers. Inverse probability of treatment weighting was used to control for potential confounding. We included 205 patients with similar baseline characteristics at KTF: a total of 53 received at least CNIs on the retransplant day (G-CNI), and 152 did not receive any IS (G-STOP). On the retransplant date, G-STOP patients experienced a longer pretransplant dialysis time, were more often hyperimmunized, and underwent more expanded-criteria donor KTs than G-CNI patients. During the second KT follow-up period, rejection episodes were similar in both groups. The 10-year survival rates without death and dialysis were 98.7% and 59.5% in G-CNI and G-STOP patients, respectively. In the multivariable analysis, CNI-based IS maintenance was associated with better survival (hazard ratio: 0.08; 95% confidence interval: 0.01-0.58, p = 0.01). CNI-based IS maintenance throughout the dialysis period after KTF may improve retransplantation outcomes.

The Clinical Utility of Post-Transplant Monitoring of Donor-Specific Antibodies in Stable Renal Transplant Recipients: A Consensus Report With Guideline Statements for Clinical Practice

Solid phase immunoassays improved the detection and determination of the antigen-specificity of donor-specific antibodies (DSA) to human leukocyte antigens (HLA). The widespread use of SPI in kidney transplantation also introduced new clinical dilemmas, such as whether patients should be monitored for DSA pre- or post-transplantation. Pretransplant screening through SPI has become standard practice and DSA are readily determined in case of suspected rejection. However, DSA monitoring in recipients with stable graft function has not been universally established as standard of care. This may be related to uncertainty regarding the clinical utility of DSA monitoring as a screening tool. This consensus report aims to appraise the clinical utility of DSA monitoring in recipients without overt signs of graft dysfunction, using the Wilson & Junger criteria for assessing the validity of a screening practice. To assess the evidence on DSA monitoring, the European Society for Organ Transplantation (ESOT) convened a dedicated workgroup, comprised of experts in transplantation nephrology and immunology, to review relevant literature. Guidelines and statements were developed during a consensus conference by Delphi methodology that took place in person in November 2022 in Prague. The findings and recommendations of the workgroup on subclinical DSA monitoring are presented in this article.

Conversion From Intravenous In-Hospital Belatacept Injection to Subcutaneous Abatacept Injection in Kidney Transplant Recipients During the First COVID-19 Stay-at-Home Order in France

The first COVID-19 stay-at-home order came into effect in France on 17 March 2020. Immunocompromised patients were asked to isolate themselves, and outpatient clinic visits were dramatically reduced. In order to avoid visits to the hospital by belatacept-treated kidney transplant recipients (KTRs) during the initial period of the pandemic, we promptly converted 176 KTRs at two French transplant centers from once-monthly 5 mg/kg in-hospital belatacept infusion to once-weekly 125 mg subcutaneous abatacept injection. At the end of follow-up (3 months), 171 (97.16%) KTRs survived with a functioning graft, 2 (1.14%) had died, and 3 (1.70%) had experienced graft loss. Two patients (1.1%) experienced acute T cell-mediated rejection. Nineteen patients (10.80%) discontinued abatacept; 47% of the KTRs found the use of abatacept less restrictive than belatacept, and 38% would have preferred to continue abatacept. Mean eGFR remained stable compared to baseline. Seven patients (3.9%) had COVID-19; among these, two developed severe symptoms but survived. Only one patient had a de novo DSA. Side effects of abatacept injection were uncommon and non-severe. Our study reports for the first time in a large cohort that once-weekly injection of abatacept appears to be feasible and safe in KTRs previously treated with belatacept.

Imlifidase for Kidney Transplantation of Highly Sensitized Patients With a Positive Crossmatch: The French Consensus Guidelines

Imlifidase recently received early access authorization for highly sensitized adult kidney transplant candidates with a positive crossmatch against an ABO-compatible deceased donor. These French consensus guidelines have been generated by an expert working group, in order to homogenize patient selection, associated treatments and follow-up. This initiative is part of an international effort to analyze properly the benefits and tolerance of this new costly treatment in real-life. Eligible patients must meet the following screening criteria: cPRA ≥ 98%, ≤ 65-year of age, ≥ 3 years on the waiting list, and a low risk of biopsy-related complications. The final decision to use Imlifidase will be based on the two following criteria. First, the results of a virtual crossmatch on recent serum, which shall show a MFI for the immunodominant donor-specific antibodies (DSA) > 6,000 but the value of which does not exceed 5,000 after 1:10 dilution. Second, the post-Imlifidase complement-dependent cytotoxicity crossmatch must be negative. Patients treated with Imlifidase will receive an immunosuppressive regimen based on steroids, rATG, high dose IVIg, rituximab, tacrolimus and mycophenolic acid. Frequent post-transplant testing for DSA and systematic surveillance kidney biopsies are highly recommended to monitor post-transplant DSA rebound and subclinical rejection.

The importance of ligand gated ion channels in sleep and sleep disorders

On average, humans spend about 26 years of their life sleeping. Increased sleep duration and quality has been linked to reduced disease risk; however, the cellular and molecular underpinnings of sleep remain open questions. It has been known for some time that pharmacological modulation of neurotransmission in the brain can promote either sleep or wakefulness thereby providing some clues about the molecular mechanisms at play. However, the field of sleep research has developed an increasingly detailed understanding of the requisite neuronal circuitry and key neurotransmitter receptor subtypes, suggesting that it may be possible to identify next generation pharmacological interventions to treat sleep disorders within this same space. The aim of this work is to examine the latest physiological and pharmacological findings highlighting the contribution of ligand gated ion channels including the inhibitory GABA_A and glycine receptors and excitatory nicotinic acetylcholine receptors and glutamate receptors in the sleep-wake cycle regulation. Overall, a better understanding of ligand gated ion channels in sleep will help determine if these highly druggable targets could facilitate a better night's sleep.

A Simple Molecular Tool for the Assessment of Kidney Transplant Biopsies

BACKGROUND

The Banff Classification for Allograft Pathology recommendations for the diagnosis of kidney transplant rejection includes molecular assessment of the transplant biopsy. However, implementation of molecular tools in clinical practice is still limited, partly due to the required expertise and financial investment. The reverse transcriptase multiplex ligation-dependent probe amplification (RT-MLPA) assay is a simple, rapid, and inexpensive assay that permits simultaneous evaluation of a restricted gene panel using paraffin-embedded tissue blocks. The aim of this study was to develop and validate a RT-MLPA assay for diagnosis and classification of rejection.

METHODS

A retrospective cohort of 220 kidney transplant biopsies from two centers, which included 52 antibody-mediated rejection, 51 T-cell-mediated rejection, and 117 no-rejection controls, was assessed. A 17-gene panel was identified on the basis of relevant pathophysiological pathways. A support vector machine classifier was developed. A subset of 109 biopsies was also assessed using the Nanostring Banff Human Organ Transplant panel to compare the two assays.

RESULTS

The support vector machine classifier train and test accuracy scores were 0.84 and 0.83, respectively. In the test cohort, the F1 score for antibody-mediated rejection, T-cell-mediated rejection, and control were 0.88, 0.86, and 0.69, respectively. Using receiver-operating characteristic curves, the area under the curve for class predictions was 0.96, 0.89, and 0.91, respectively, with a weighted average at 0.94. Classifiers' performances were highest for antibody-mediated rejection diagnosis with 94% correct predictions, compared with 88% correct predictions for control biopsies and 60% for T-cell-mediated rejection biopsies. Gene expression levels assessed by RT-MLPA and Nanostring were correlated: r = 0.68, P < 0.001. Equivalent gene expression profiles were obtained with both assays in 81% of the samples.

CONCLUSIONS

The 17-gene panel RT-MLPA assay, developed here for formalin-fixed paraffin-embedded kidney transplant biopsies, classified kidney transplant rejection with an overall accurate prediction ratio of 0.83.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_04_10_CJN10100822.mp3.

Nonskeletal and skeletal effects of high doses versus low doses of vitamin D3 in renal transplant recipients: Results of the VITALE (VITamin D supplementation in renAL transplant recipients) study, a randomized clinical trial

Vitamin D sufficiency is associated with a reduced risk of fractures, diabetes mellitus, cardiovascular events, and cancers, which are frequent complications after renal transplantation. The VITALE (VITamin D supplementation in renAL transplant recipients) study is a multicenter double-blind randomized trial, including nondiabetic adult renal transplant recipients with serum 25-hydroxy vitamin D (25(OH) vitamin D) levels of <30 ng/mL, which is randomized 12 to 48 months after transplantation to receive high (100 000 IU) or low doses (12 000 IU) of cholecalciferol every 2 weeks for 2 months and then monthly for 22 months. The primary outcome was a composite endpoint, including diabetes mellitus, major cardiovascular events, cancer, and death. Of 536 inclusions (50.8 [13.7] years, 335 men), 269 and 267 inclusions were in the high-dose and low-dose groups, respectively. The serum 25(OH) vitamin D levels increased by 23 versus 6 ng/mL in the high-dose and low-dose groups, respectively (P < .0001). In the intent-to-treat analysis, 15% versus 16% of the patients in the high-dose and low-dose groups, respectively, experienced a first event of the composite endpoint (hazard ratio, 0.94 [0.60-1.48]; P = .78), whereas 1% and 4% of patients in the high-dose and low-dose groups, respectively, experienced an incident symptomatic fracture (odds ratio, 0.24 [0.07-0.86], P = .03). The incidence of adverse events was similar between the groups. After renal transplantation, high doses of cholecalciferol are safe but do not reduce extraskeletal complications (trial registration: ClinicalTrials.gov; identifier: NCT01431430).

Belatacept rescue conversion in kidney transplant recipients with vascular lesions (Banff cv score >2): a retrospective cohort study

BACKGROUND

Immunosuppression in kidney transplant recipients with decreased graft function and histological vascular changes can be particularly challenging. The impact of a late rescue conversion to belatacept on kidney graft survival in this context has never been studied.

METHODS

We report a bicentric retrospective cohort study comparing a calcineurin inhibitor (CNI) to belatacept switch versus CNI continuation in 139 kidney transplant recipients with histological kidney vascular damage (cv ≥2, g + cpt ≤1, i + t ≤1) and low estimated glomerular filtration rate (≤40 mL/min/1.73 m²). Primary outcome was death-censored graft survival.

RESULTS

During the study follow-up, 10 graft losses (14.5%) occurred in the belatacept group (n = 69) versus 26 (37.1%) in the matched CNI group (n = 70) (P = .005). Death-censored graft survival was significantly higher in the belatacept group (P = .001). At 3 years, graft survival was 84.0% in the belatacept group compared with 65.1% in the control group. Continuing CNI was an independent risk factor for graft loss [hazard ratio (HR) 3.46; P < .005]. The incidence of cellular rejection after the conversion was low (4.3% in both groups) and not significantly different between groups (P = .84). Patients switched to belatacept developed significantly less donor-specific antibodies de novo. Belatacept was an independent risk factor for the occurrence of opportunistic infections (HR 4.84; P < .005).

CONCLUSION

The replacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in graft survival and represents a valuable option in a context of organ shortage. Caution should be exercised regarding the increased risk of opportunistic infection.

Specificities of Meningitis and Meningo-Encephalitis After Kidney Transplantation: A French Retrospective Cohort Study

Kidney transplant recipients develop atypical infections in their epidemiology, presentation and outcome. Among these, meningitis and meningoencephalitis require urgent and adapted anti-infectious therapy, but published data is scarce in KTRs. The aim of this study was to describe their epidemiology, presentation and outcome, in order to improve their diagnostic and management. We performed a retrospective, multicentric cohort study in 15 French hospitals that included all 199 cases of M/ME in KTRs between 2007 and 2018 (0.9 case per 1,000 KTRs annually). Epidemiology was different from that in the general population: 20% were due to Cryptococcus neoformans, 13.5% to varicella-zoster virus, 5.5% to Mycobacterium tuberculosis, and 4.5% to Enterobacteria (half of which produced extended spectrum beta-lactamases), and 5% were Post Transplant Lymphoproliferative Disorders. Microorganisms causing M/ME in the general population were infrequent (2%, for Streptococcus pneumoniae) or absent (Neisseria meningitidis). M/ME caused by Enterobacteria, Staphylococci or filamentous fungi were associated with high and early mortality (50%-70% at 1 year). Graft survival was not associated with the etiology of M/ME, nor was impacted by immunosuppression reduction. Based on these results, we suggest international studies to adapt guidelines in order to improve the diagnosis and the probabilistic treatment of M/ME in SOTRs.

Absence of Mortality Differences Between the First and Second COVID-19 Waves in Kidney Transplant Recipients

Introduction

SARS-CoV-2 pandemic evolved in 2 consecutive waves during 2020. Improvements in the management of COVID-19 led to a reduction in mortality rates among hospitalized patients during the second wave. Whether this progress benefited kidney transplant recipients (KTRs), a population particularly vulnerable to severe COVID-19, remained unclear.

Methods

In France, 957 KTRs were hospitalized for COVID-19 in 2020 and their data were prospectively collected into the French Solid Organ Transplant (SOT) COVID registry. The presentation, management, and outcomes of the 359 KTRs diagnosed during the first wave were compared to those of the 598 of the second wave.

Results

Baseline comorbidities were similar between KTRs of the 2 waves. Maintenance immunosuppression was reduced in most patients but withdrawal of antimetabolite (73.7% vs. 58.4%, P < 0.001) or calcineurin inhibitor (32.1% vs. 16.6%, P < 0.001) was less frequent during the second wave. Hydroxychloroquine and azithromycin that were commonly used during the first wave (21.7% and 30.9%, respectively) but were almost abandoned during the second wave. In contrast, the use of high dose corticosteroids doubled (19.5% vs. 41.6%, P < 0.001). Despite these changing trends in COVID-19 management, 60-day mortality was not statistically different between the 2 waves (25.3% vs. 23.9%; Log Rank, P = 0.48) and COVID-19 hospitalization period was not associated with death due to COVID-19 in multivariate analysis (Hazard ratio 0.89, 95% confidence interval 0.67–1.17, P = 0.4).

Conclusion

We conclude that changing of therapeutic trends during 2020 did not reduce COVID-19 related mortality among KTRs. Our data indirectly support the importance of vaccination and neutralizing monoclonal anti-SARS-CoV-2 antibodies to protect KTRS from severe COVID-19.

POS0207 UNRAVELING THE COMPLEX INTERACTION BETWEEN DISEASE ACTIVITY AND FATIGUE IN EARLY RA: A MEDIATION ANALYSIS WITH DATA FROM THE CareRA TRIAL

Background

Fatigue is recognized as one of the most important symptoms of rheumatoid arthritis (RA). Although inflammation is often proposed as the predominant pathophysiological mechanism, many patients with RA continue to experience fatigue despite inflammatory disease control. The relationship between RA disease activity and fatigue appears to be complex and is likely confounded by cognitive, emotional and social aspects.

Objectives

To unravel the complex interaction between disease activity and fatigue in early RA.

Methods

Data were analyzed from the 2-year treat-to-target trial Care in early RA (CareRA), which compared different remission-induction DMARD regimens, either with or without bridging glucocorticoids, in treatment-naïve patients with early RA. Fatigue was measured on a visual analog scale (VAS) at every study visit. The association between inflammatory disease activity (DAS28-CRP) and fatigue (VAS) over time was studied with a multilevel mediation analysis, including as mediators the individual components of the DAS28-CRP, pain (VAS), disability (HAQ), psychosocial aspects (Short-Form 36 [SF-36]), illness perceptions (Revised Illness Perception Questionnaire [IPQ-R]), and sleep quality (Pittsburgh Sleep Quality Index [PSQI]).

Results

A total of 356 patients were included in these analyses, with a mean (SD) fatigue (VAS) of 48/100 (24) at study initiation. Although there was a consistently positive association between DAS28-CRP and fatigue over time, this association was fully mediated by patient global assessment (PGA) and pain, and to a lesser extent by SF-36 Mental Health and the PSQI global score (Figure 1). Full mediation implies the absence of a significant direct association between DAS28-CRP and fatigue after adjusting for these mediators. In addition, no mediating effect was found for tender/swollen joint counts or CRP.

Figure 1.

Mediation analysis of the association between DAS28-CRP and fatigue (VAS) over time.

Reported are the standardized regression coefficients with indicators of significance (* p < 0.05; ** p < 0.01; *** p < 0.001). DAS28-CRP = Disease Activity Score in 28 joints with C-reactive protein, SJC28/TJC28 = swollen/tender joint count in 28 joints, HAQ = Health Assessment Questionnaire, SF-36 = Short-Form 36, MH = mental health, RE = emotional role functioning, SF = social functioning, IPQ-R = Revised Illness Perception Questionnaire, PSQI = Pittsburgh Sleep Quality Index

Conclusion

Our mediation analysis suggests that the relationship between disease activity and fatigue in early RA is complex and fully mediated by aspects of wellbeing like pain, mental health, sleep quality, and the patient’s overall assessment of disease. These results imply a mainly indirect relation between fatigue and inflammation. Clinicians should reserve specific attention for the psychosocial determinants of fatigue, particularly when no improvement is seen with DMARDs.

Disclosure of Interests

Michaël Doumen: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Diederik De Cock: None declared, Johan Joly: None declared, Rene Westhovens Speakers bureau: Honoraria for lectures:

- Celltrion

- Gilead

- Galapagos, Consultant of: - Celltrion

- Gilead

- Galapagos, Patrick Verschueren Speakers bureau: MSD

Galapagos

Eli Lilly, Consultant of: Sanofi

Galapagos

Pfizer

Gilead, Grant/research support from: Pfizer Chair Management of Early Rheumatoid Arthritis at KU Leuven Belgium

CD86 occupancy in belatacept-treated kidney transplant patients is not associated with clinical and infectious outcomes

The CD86 occupancy assay has been developed to measure the number of CD86 molecules unbound to belatacept, but its association with clinical outcomes has not been assessed yet. All kidney transplant patients switched to belatacept in our center between 2016 and 2018 were included. Blood samples were collected before each infusion for 1 year to assess CD86 occupancy by CD86 antibody cytometry staining on the surface of CD14⁺ monocytes. Results were expressed as the median fluorescence intensity (MFI) value of CD86 staining. At each infusion, the MFI_{Day of infusion} /MFI_{Day 0} ratio was calculated. Forty-one patients were consecutively included. After every 2-week infusion period, CD86 MFI ratio dropped from 1.00 to 0.73 [0.57-0.98], p = .07. However, this ratio progressively increased to 0.78 [0.53-1.13] at 1 year, which was not statistically different from pre-switch ratio, p = .4. Over the first year, the MFI ratio coefficient of variation was 31.58% [23.75-38.31]. MFI ratio was not different between patients with or without opportunistic infections: 0.73 [0.60-0.88] versus 0.80 [0.71-1.00], p = .2, or between patients with or without EBV DNAemia, p = .2. Despite previous in vitro results, the CD86 occupancy assay suffers from a high intra-individual variability and does not appear to be relevant to clinical outcomes.

AB1395 PATIENTS’ AND RHEUMATOLOGISTS’ PERCEPTIONS REGARDING TAPERING OF RITUXIMAB

Background

Rituximab is an efficacious drug for the treatment of Rheumatoid Arthritis (RA). The commonly used dose consists of two infusions of 1000 mg with a 2-week interval, but evidence is growing that a lower dose could be as effective. Before implementing a tapering strategy, understanding the perceptions of patients and rheumatologists in this regard is important.

Objectives

The aim was to investigate patients’ and rheumatologists’ perceptions on rituximab tapering.

Methods

Patients with RA, who were currently or previously treated with rituximab, and rheumatologists were invited to participate in a qualitative study consisting of individual, in depth, face-to-face, semi-structured interviews. Participants were recruited based on purposive sampling to ensure diversity. Interviews were conducted via video or telephone call. Additional participants were interviewed until data saturation was achieved, meaning no new information emerged from the last 3 interviews. Interviews were audiotaped and transcribed verbatim, followed by analysis according to the Qualitative analysis guide of Leuven, which generated themes. Patient experts were involved in this research.

Results

In total, 16 patients with RA and 13 rheumatologists were interviewed. Four themes were found: In favour/reluctant of tapering, shared decision making, implementation and evidence gap (Figure 1). Patients and rheumatologists were IN FAVOUR of rituximab tapering, for reasons of safety and economic benefit. Patients and rheumatologists mentioned that a lower dose could allow shorter retreatment intervals, which might avoid flares. Furthermore, rheumatologists referred to available evidence of the effectiveness of a lower rituximab dose. Additionally, patients and rheumatologists indicated that the dose could be tailored based on the patient’s clinical manifestations, e.g. usual cycle interval and disease activity measures. However, some patients and rheumatologists felt RELUCTANT towards rituximab tapering. Patients and rheumatologists were concerned about potential loss of effectiveness and quality of life, next to more practical concerns. Rheumatologists mentioned that they had insufficient experience with rituximab in general to feel comfortable with tapering. Moreover, when applying an on-flare retreatment strategy, patients present with an active disease at the time of retreatment and therefore the option of tapering is less appealing. The next theme was SHARED DECISION MAKING. Patients and rheumatologists mentioned that patients have trust in their physician and thus leave the tapering decision in the hands of the rheumatologists. However, rheumatologists added that this should be combined with explanation of the tapering rationale. Another theme was IMPLEMENTATION. When asking participants about 2 possible dose reduction regimens, a cycle consisting of 2 infusions with a lower dose or a cycle of only 1 infusion with a higher dose, advantages were raised for both regimens (e.g. safety reasons and time savings, respectively). On the other hand, the on-flare retreatment regimen itself was already perceived as a kind of tapering, as the interval is prolonged as much as possible between the cycles. EVIDENCE GAP was the last theme, meaning that patients and rheumatologists felt there was a need of more research regarding rituximab tapering. For instance, predictive tools for flares, as well as the possibility of subcutaneous administration of rituximab, were mentioned as unmet needs by rheumatologists.

Figure 1.

Conceptual framework of the patients’ and rheumatologists’ perceptions regarding tapering of rituximab. (Icons: Iconfinder)

Conclusion

It seems that rituximab tapering is not yet incorporated in daily practice as much as tapering of other antirheumatic drugs and this could potentially be related to a lack of experience with rituximab. However, with appropriate education and communication, rheumatologists and patients are willing to taper rituximab. Although, many questions remain, indicating an evidence gap and a need of more research.

Disclosure of Interests

None declared

OP0301-HPR Patient Adherence to e-Health Interventions for Remote Disease Monitoring in Chronic Arthritis

Background

Chronic inflammatory arthritides require lifelong follow-up and treatment. Electronic health (eHealth) could be used to remotely monitor disease, possibly improving patient self-management and lowering the burden of in-person consultations. For clinical use, it is important to understand adherence rates of patients with chronic arthritis to eHealth tools.

Objectives

To systematically review the literature on adherence to eHealth tools for remote monitoring of symptoms or disease activity in chronic arthritis.

Methods

We systematically searched the following databases: Embase, PubMed, Cochrane Central, CINAHL, Web of Science, Clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). Eligible articles reported adherence rates to an eHealth tool in patients with rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), spondyloarthritis (SpA), osteoarthritis (OA), or gout. Included texts were screened individually. Finally, quality assessment was done with the Newcastle-Ottawa scale (NOS) and the PEDro scale.

Results

The literature search resulted in 7027 articles. After deduplication, 4219 articles were screened for eligibility, and 47 articles were included. We found highest adherence rates in studies applying electronic diaries (81.8%), followed by text messages (79.9%), web-based platforms (74.6%), activity trackers (73%), and smartphone applications (65.5%). Highest adherence was reported in studies on patients with OA (79.7%), followed by patients with gout (73.7%), RA (71.3%), ankylosing SpA (67%), and JIA (59%). Demographic characteristics did not seem to affect patient adherence. Based on frequency of data entering, a time interval of once-daily showed highest adherence rates (72.6%), followed by entering data more than once a day (72.3%) and once a week (67.7%), or longer (59.2%). Adherence declined with longer study duration.

Conclusion

Our literature review identified declining adherence levels with longer study duration, and highest adherence rates for patients with OA, making use of electronic diaries, and requesting once-a-day completion. OA studies had an overall shorter duration than RA studies, which could be an explanation as to why OA patients showed higher adherence. Lower adherence rates were reported in studies in juvenile populations, while older age did not seem to affect reported adherence.

Figure 1.

Linear regression model of adherence based on study duration per disease. X = study duration (days), Y = adherence (%). Y = -0.0332X + 71.84. Light blue = RA, yellow = OA, dark blue = JIA, red = Gout, green = SpA, white = >1 disease

Table 1.

Included studies. Adh = adherence SA = smartphone app, ED = electronic diary, AT = activity tracker, OP = online platform, TM= text message. JIA= Juvenile Idiopathic Arthritis, PsA = Psoriatic Arthritis, SpA = Spondyloarthritis, OA = osteoarthritis, RA = Rheumatoid arthritis

StudyDiseaseEHealthAdh (%)StudyDiseaseEHealthAdh (%)StudyDiseaseEHealthAdh (%)Skrepnik, ‘17OAAT/SA91 AT 36 SABeukenhorst, ‘20OAAT/SA75 AT 62 SAMcKenna, ‘18RAAT43Lee, ‘20JIASA51Nowell, ‘20RAAT/SA82 AT 72 SAYu, ‘20OAAT99Serlachius, ‘19GoutSA67Heiberg, ‘07RAED95Zaslavsky, ‘19OAAT/SA85Pers, ‘21RASA67Connelly, ‘11JIAED71Gossec, ‘18RAOP63Heale, ‘18JIAAT/SA19 ATConnelly, ‘10JIAED88Walter, ‘14RAOP61Reade, ‘17RASA77Bromberg, ‘16JIAED66Christodoulou, ‘14OAOP98Bellamy, ‘10OASA100Bromberg, ‘14JIAED66Renskers, ‘20RA/SpAOP68Seppen, ‘20RASA69Franceschelli, ‘19OAED/Tyrell, ‘16SpAOP67Harbottle, ‘18JIAAT/SA17 SABingham, ‘19RAED94Martin, ‘21RAOP69Pouls, ‘20GoutSA94Connelly, ‘17JIAED87Kai, ‘19OAOP52Colls, ‘21RASA79Stinson, ‘08JIAED72Richter, ‘21RAOP98Brayne, ‘21RASA41Wilson, ‘13OAED83Broderick, ‘13OAOP>95Austin, ‘20RASA91Jacquemin, ‘18RA/SpAAT88Zuidema, ‘19RAOP71Crouthamel, ‘18RASA20Elmagboul, ‘20GoutAT61Barber, ‘18RAOP69Nowell, ‘21AS, OA, SpA, RASA55Östlind, ‘21OAAT/SA88 ATChristie, ‘14RA/SpATM98Lee, ‘12RATM73

Disclosure of Interests

None declared

POS0523 FATIGUE TRAJECTORIES IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: A LONGITUDINAL ANALYSIS OF DATA FROM THE CareRA TRIAL

Background

Fatigue is a common and impactful symptom of rheumatoid arthritis (RA). Given its heterogeneity and unpredictable nature, studies on contributing factors of RA-related fatigue should include multidimensional measures of fatigue and assess these longitudinally with multivariate methods, starting early in the disease.

Objectives

We aimed to explore the longitudinal course of fatigue and its predictors among patients with early RA starting DMARD therapy.

Methods

Data came from the 2-year treat-to-target trial Care in early RA (CareRA) and its 3-year extension. Fatigue was measured based on visual analog scale (VAS), Multidimensional Fatigue Inventory (MFI), and Short-Form 36 (SF-36). Longitudinal fatigue trajectories were identified with multivariable growth mixture modeling. Baseline and early predictors of trajectory membership, including treatment response, were studied with multinomial logistic regression adjusted for age, gender, and treatment type. Patient global assessment (PGA), pain (VAS), and disability (HAQ) were studied in separate models because of collinearity (Spearman r > 0.60). For all models, posterior probabilities of trajectory assignment were included in the regression as weights to account for classification uncertainty. Treatment response was defined, based on whether remission (DAS28-CRP < 2.6) was achieved by week 16 and sustained until year 2, as either early persistent response, secondary failure, or delayed response.

Results

In total, 356 and 244 patients were included in the 2-year and 5-year analyses, respectively. Mean (SD) fatigue (VAS) at inclusion was 48/100 (24). Four fatigue trajectories were identified: Rapid, Gradual, and Transient Improvement, and Early Deterioration, consisting of 10%, 14%, 56%, and 20% of patients, respectively (Figure 1). Higher PGA, pain and HAQ at baseline were associated with increased probability of Rapid Improvement compared to Transient Improvement or Early Deterioration (Table 2). Secondary treatment failure and delayed treatment response strongly increased the probability of less positive fatigue trajectories when compared to early persistent response.

Figure 1.

Latent trajectories of fatigue evolution over the first 2 years in CareRA (n = 356).

Conclusion

The longitudinal course of fatigue in early RA is dynamic but highly refractory, with less than 25% of patients making lasting improvements and 20% even experiencing worsening fatigue despite intensive DMARD therapy. Remarkably, a higher perceived disease impact at baseline was associated with an increased probability of fatigue improvement, possibly reflecting the fluctuating nature of this complex symptom. However, early inflammatory disease control appears to be the most important contributor to improved long-term fatigue outcomes, illustrating the far-reaching impact of the therapeutic window of opportunity in early RA.

References

/

Table 1.

Predictors of fatigue trajectory membership

Gradual improvementTransient improvementEarly deteriorationOR (95% CI)pOR (95% CI)pOR (95% CI)pFatigue (0-100)1.01 (0.99; 1.04)0.320.99 (0.97; 1.01)0.160.98 (0.96; 1.00)0.07PGA (0-100)0.98 (0.95; 1.01)0.110.96 (0.94; 0.99)0.0030.95 (0.92; 0.98)<0.001Tender joints (0-28)1.00 (0.91; 1.13)0.821.00 (0.91; 1.09)0.970.99 (0.88; 1.11)0.80Swollen joints (0-28)1.01 (0.90; 1.15)0.820.99 (0.89; 1.10)0.830.93 (0.81; 1.06)0.30CRP (mg/dL)1.00 (0.98; 1.01)0.670.99 (0.98; 1.01)0.361.00 (0.97; 1.02)0.66Pain (0-100)0.99 (0.96; 1.02)0.360.96 (0.94; 0.98)0.0020.95 (0.92; 0.98)<0.001HAQ (0-3)1.07 (0.52; 2.20)0.850.55 (0.30; 1.01)0.050.24 (0.11; 0.51)<0.001SF-36 Mental Component Score (0-100)1.00 (0.96; 1.04)0.971.02 (0.99; 1.06)0.231.02 (0.98; 1.06)0.34Treatment responseSecondary failure2.22 (0.78; 6.32)0.133.87 (1.57; 9.55)0.0037.88 (2.68; 23.13)<0.001Delayed response2.93 (0.70; 12.15)0.146.82 (1.91; 24.44)0.00311.14 (2.33; 53.19)0.003

Disclosure of Interests

Michaël Doumen: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Diederik De Cock: None declared, Johan Joly: None declared, Rene Westhovens Speakers bureau: - Celltrion

- Galapagos

- Gilead, Consultant of: - Celltrion

- Galapagos

- Gilead, Patrick Verschueren Speakers bureau: - MSD

- Eli Lilly

- Galapagos, Consultant of: - Sanofi

- Galapagos

- Gilead

- Pfizer, Grant/research support from: Pfizer Chair Management of Early Rheumatoid Arthritis at KU Leuven Belgium

AB1394 ON-FLARE RETREATMENT WITH RITUXIMAB IN RHEUMATOID ARTHRITIS: PATIENTS’ AND RHEUMATOLOGISTS’ PERCEPTIONS

Background

Rituximab is an efficacious drug for the treatment of Rheumatoid Arthritis (RA). According to literature, administration of rituximab can be based on a fixed interval or on relapse of disease activity. In some countries, like Belgium, after the first rituximab cycle a flare is required for reimbursement of a subsequent cycle. A better understanding of the perceptions of patients and rheumatologists regarding this retreatment strategy would be informative in view of potential adjustments.

Objectives

The aim was to investigate patients’ and rheumatologists’ perceptions on the on-flare retreatment strategy of rituximab.

Methods

Patients with RA, who were currently or previously treated with rituximab, and rheumatologists were invited to participate in a qualitative study consisting of individual, in depth, face-to-face, semi-structured interviews. Participants were recruited based on purposive sampling to ensure diversity. Interviews were conducted via video or telephone call. Additional participants were interviewed until data saturation was achieved, meaning no new information emerged from the last 3 interviews. Interviews were audiotaped and transcribed verbatim, followed by analysis according to the Qualitative analysis guide of Leuven, which generated themes and subthemes. Patient experts were involved in this research.

Results

In total, 16 patients with RA and 13 rheumatologists were interviewed. Five overarching themes were generated from the interviews: flare definition, recognition, reaction, balance between benefits and barriers and suggestions (Figure 1). Patients and rheumatologists described how they perceive the on-flare retreatment strategy in daily practice, starting with the FLARE DEFINITION itself. Namely, what patients perceived as a flare and the impact of this flare. The second step was RECOGNITION of the flare. Both rheumatologists and patients indicated that patients are able to recognise a flare. However, the patient’s ability to discriminate between inflammatory and other types of pain was perceived as a difficulty. Moreover, patients indicated that depending on the flare’s intensity, they can cope with it themselves, delaying the need for a rituximab cycle. The next step after correctly recognising a flare, was the REACTION, from both the patient’s and rheumatologist’s side. It was stressed that patients must contact their treating rheumatologists in time. Furthermore, a swift response of the rheumatologists was perceived as important. After confirming eligibility, the shared decision to plan a new rituximab cycle can be made while keeping an eye on the organisation. Remarkably, it seemed that rheumatologists approached the retreatment strategy in different ways, meaning that not everyone adhered to the on-flare principle. Several perceived BENEFITS (e.g. lower safety risk, societal cost savings) and BARRIERS (e.g. disease activity fluctuations, slow working mechanism) were mentioned, making clear that the optimal retreatment strategy should be based on a BALANCE between both. Finally, some SUGGESTIONS (e.g. biomarkers for flare prediction, subcutaneous administration of rituximab) were brought up that could be helpful in applying the optimal retreatment strategy.

Figure 1.

Conceptual framework of the perceptions of patients and rheumatologists regarding the on-flare retreatment strategy with rituximab. SDM = Shared decision making. (Icons: Iconfinder)

Conclusion

Patients play an important role in the recognition of flares and their reaction, in shared decision with the rheumatologist, contributes to the effectiveness of the rituximab on-flare retreatment strategy. Rheumatologists handle the on-flare retreatment strategy as pragmatically as possible, resulting in different approaches. Moreover, both benefits and barriers of on-flare retreatment were perceived, making clear that a balance should be found to determine the optimal retreatment strategy.

Disclosure of Interests

None declared

OP0032 AN ECONOMIC WINDOW OF OPPORTUNITY FOR PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: 5-YEAR COST-EFFECTIVENESS ANALYSIS OF THE CareRA TRIAL

Background

The CareRA trial showed that remission induction with methotrexate (MTX) and glucocorticoid (GC) bridging in a treat-to-target setting is cost-effective up to 2 years in early Rheumatoid Arthritis (eRA) patients.

Objectives

To evaluate the long-term cost-effectiveness of treat-to-target treatments among recently diagnosed (<1 year), DMARD naïve patients with eRA using MTX and a step-down GC scheme (COBRA-Slim) compared to (a) the same combination with either sulphasalazine (COBRA-Classic) or leflunomide (COBRA-Avant-Garde) in high-risk patients and (b) MTX without GCs (Tight-Step-Up: TSU) in low-risk patients up to 5 years.

Methods

We used data from the 2-year RCT CareRA trial and its 3-year observational follow-up, CareRA plus. Patients completing the 2-year visit of CareRA were eligible for participation in CareRA plus, in which patients were evaluated every 6 months till year 5. Healthcare costs considered in this piggyback economic analysis were rheumatology visits, RA-related medication (synthetic and biological DMARDs, GCs, and all recorded analgesics including paracetamol, non-steroidals, tramadol and opioids), hospital admissions, laboratory tests and radiographs occurring during the 5-year trial. All pricing is based on December 2021 rates. Total costs per resource were calculated by multiplying the number of resources by the cost unit price extracted from Belgian national websites. Total costs per patient were obtained by summing costs of all resources. Effectiveness was measured with DAS28-CRP and compared between the originally allocated treatment arms. An incremental cost-effectiveness ratio (ICER) was calculated by dividing the cost difference by the DAS28-CRP<2.6 remission difference per pair of treatment schemes. Multiple imputation was used to handle missing data and non-parametric bootstrapping with 25000 iterations of random sampling with replacement to calculate confidence intervals (95% CIs).

Results

Of 322 eligible patients, 252 were included in CareRA plus, of which 203 completed the trial. Rates of disease control (DAS28-CRP<2.6) at year 5 in high-risk patients were 68%, 72% and 64% in the Classic, Slim and Avant-Garde group respectively (p=0.63) and related total costs were €11 358.39 (CI 7 776.84-14 939.93), €8 463.12 (CI 6 789.44-10 136.80), €11 752.47 (CI 7 705.11-15 799.82) respectively. In the low-risk population, 80% of patients in Slim and the TSU arm reached remission (DAS28-CRP<2.6) at year 5. While the costs were €6 332.55 (CI 3 607.63-9 057.48) for Slim, and €10 398.19 (CI 4165.95-16630.43) for TSU. In the high-risk group, Classic (ICER -€723.82) and Avant-Garde (ICER -€411.17) were more expensive and less effective compared to Slim. In the low-risk group, Slim was less expensive (Δ -€4 065.64) and equally effective as TSU. Figure 1 depicts how the different medication costs evolved during the 5-year follow-up. 22% of all patients were ever on bDMARDs. More specifically in 23% (16/69) of Classic, 21% (16/75) of Slim high-risk, 25% (15/59) of Avant-Garde, 17% (4/23) of Slim low-risk, and in 15% (4/26) of TSU patients. On average a first bDMARD was started later in the Slim arms, more specifically at week 69 for Classic, week 106 for Slim high-risk, week 97 for Avant-Garde, week 102 for Slim low-risk and week 76 for TSU.

Conclusion

The combination of MTX with a GC bridging scheme (COBRA Slim) was more cost-effective (less expensive with comparable disease control) than more intensive step-down combination strategies or a conventional step-up approach 5 years after initial treatment. Over 5 years, around one-fifth of all patients, were in need of starting biological treatment and the transition to a bDMARD was later in COBRA Slim. These results point out the possibility of an early “economic” window of opportunity for diminishing costs long-term while still maintaining optimal disease control.

Disclosure of Interests

None declared

Impact of targeted hypothermia in expanded-criteria organ donors on recipient kidney-graft function: study protocol for a multicentre randomised controlled trial (HYPOREME)

INTRODUCTION

Expanded-criteria donors (ECDs) are used to reduce the shortage of kidneys for transplantation. However, kidneys from ECDs are associated with an increased risk of delayed graft function (DGF), a risk factor for allograft loss and mortality. HYPOREME will be a multicentre randomised controlled trial (RCT) comparing targeted hypothermia to normothermia in ECDs, in a country where the use of machine perfusion for organ storage is the standard of care. We hypothesise that hypothermia will decrease the incidence of DGF.

METHODS AND ANALYSIS

HYPOREME is a multicentre RCT comparing the effect on kidney function in recipients of targeted hypothermia (34°C-35°C) and normothermia (36.5°C-37.5°C) in the ECDs. The temperature intervention starts from randomisation and is maintained until aortic clamping in the operating room. We aim to enrol 289 ECDs in order to analyse the kidney function of 516 recipients in the 53 participating centres. The primary outcome is the occurrence of DGF in kidney recipients, defined as a requirement for renal replacement therapy within 7 days after transplantation (not counting a single session for hyperkalemia during the first 24 hours). Secondary outcomes include the proportion of patients with individual organs transplanted in each group; the number of organs transplanted from each ECD and the vital status and kidney function of the recipients 7 days, 28 days, 3 months and 1 year after transplantation. An interim analysis is planned after the enrolment of 258 kidney recipients.

ETHICS AND DISSEMINATION

The trial was approved by the ethics committee of the French Intensive Care Society (CE-SRLF-16-07) on 26 April 2016 and by the competent French authorities on 20 April 2016 (Comité de Protection des Personnes-TOURS-Région Centre-Ouest 1, registration #2016-S3). Findings will be published in peer-reviewed journals and presented during national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03098706.

Campylobacter fetus bacteremia complicated by multiple splenic abscesses and multivisceral signs in a renal transplant recipient: a case report and review of the literature

We report a rare case of Campylobacter fetus bacteremia in a 50-year-old woman following kidney transplantation. Bacteremia was complicated by multivisceral signs such as multiple splenic abscesses, bacterial hepatitis, erythema nodosum and reactive arthritis. Despite a prolonged diagnostic delay, the diagnosis was made on blood culture identification and the global outcome was favorable with adequate antibiotherapy. Reports in the literature describe a high rate of mortality for Campylobacter spp. septicemia, with most patients being immunocompromised. However, Campylobacter spp. has been rarely described in renal transplant patients. Moreover, a splenic septic localization due to Campylobacter spp. has been reported only once to our knowledge. Clinicians should be aware of the diagnostic difficulties related to the frequent negativity of stool samples in C. fetus septicemia, in order to implement a tailored medical strategy. Some data suggest that rapid introduction of adapted antibiotic therapy is associated with a reduction in mortality.

Prognostic Value of C4d Immunolabelling in Adult Patients With IgA Vasculitis

Background and Objectives: Glomerular C4d deposits are associated the severity and outcomes of IgA nephropathy. Whether this holds true in immunoglobulin A vasculitis (IgAV) is not known. The main objective of the study was to analyze the prognostic value of glomerular C4d immunolabelling on kidney impairment in adults with IgAV.

Design, Setting, Participants, Measurements: This retrospective cohort study included 120 adults with IgAV and a kidney biopsy performed between 1995 and 2018 in two French university hospital centers. All paraffin-embedded biopsies were reassessed according to Oxford classification. Immunofluorescence for C4d was performed in all cases. For analysis, patients were grouped according to positivity for C4d in the glomerular area. The main outcome was a composite endpoint of 50% increase in 24 h-proteinuria, or eGFR decrease by 50%, or kidney replacement therapy.

Results: The median follow-up was 28.3 months. Twenty-three patients met the composite endpoint, 12 for kidney replacement therapy, 6 for an eGFR decrease >50% and 5 for a >50% increase in proteinuria. At time of biopsy, the median proteinuria was 1.9 g/24 h and the median eGFR 73.5 mL/min/1.73 m². Among the 102 patients evaluable for C4d, 24 were positive on >30% glomeruli, mainly with a parieto-mesangial pattern. In this group, the initial proteinuria was more frequently nephrotic than in the C4d– group (60% vs. 33%, P = 0.039). Mesangial hypercellularity was more frequent in the C4d+ group (42% vs. 13%; P = 0.006) whereas macroscopic hematuria was more frequent in the C4d– group (18% vs. 0%; P = 0.03). After a median follow-up of 28 months, kidney survival did not differ according to C4d status.

Conclusion: In a population of adult IgAV patients, glomerular positivity for C4d was associated with the severity of the kidney disease at presentation, but not with subsequent renal function deterioration.

SARS-CoV-2-specific Humoral and Cellular Immunities in Kidney Transplant Recipients and Dialyzed Patients Recovered From Severe and Nonsevere COVID-19

Kidney transplantation and dialysis are two major risk factors for severe forms of coronavirus disease 2019 (COVID-19). The dynamics of the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this population remain largely unknown.

Methods

We report here the analysis of anti-SARS-CoV-2 antibody- and T cell-mediated immune responses in 26 kidney transplant recipients (KTRs) and 11 dialyzed patients (DPs) who recovered from COVID-19.

Results

After a mean time of 83 ± 26 d post-symptom onset for KTRs and 97 ± 31 d for DPs, 20 KTRs (76.9%) and 10 DPs (90.9%) displayed anti-S1 immunoglobulin G SARS-CoV-2 antibodies (P = 0.34), at similar titers in both groups. SARS-CoV-2-specific interferon-γ-producing T cells were evidenced in 26 KTRs (100%) and 10 DPs (90.9%). Total numbers of SARS-CoV-2-reactive T cells were high and not statistically different between the 2 groups. No correlation between the severity of the disease and the number of reactive T cells was found in KTRs. In 5 KTRs, also evaluated 10 mo after COVID-19, weak or absent antibody response was observed, whereas specific memory T-cell response was detected in all cases.

Conclusion

T-cell response persisted up to 3 mo post-symptom onset, even in KTRs in whom full immunosuppressive regimen was reinstated at recovery, and seems to be present up to 10 mo after infection. Our findings have implications in the understanding of the natural course of the disease in transplant patients and DPs.

Belgian rheumatologists' preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study

The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician's global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient's global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34-2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial

Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

Rituximab for recurrence of primary focal segmental glomerulosclerosis after kidney transplantation: Results of a nationwide study

Rituximab (RTX) therapy for primary focal segmental glomerulosclerosis recurrence after kidney transplantation (KT) has been extensively debated. We aimed to assess the benefit of adding RTX to plasmapheresis (PP), corticosteroids, and calcineurin inhibitors (standard of care, SOC). We identified 148 adult patients who received KT in 12/2004-12/2018 at 21 French centers: 109 received SOC (Group 1, G1), and 39 received immediate RTX along with SOC (Group 2, G2). In G1, RTX was introduced after 28 days of SOC in the event of failure (G1a, n = 19) or PP withdrawal (G1b, n = 12). Complete remission (CR) was achieved in 46.6% of patients, and partial remission (PR) was achieved in 33.1%. The 10-year graft survival rates were 64.7% and 17.9% in responders and nonresponders, respectively. Propensity score analysis showed no difference in CR+PR rates between G1 (82.6%) and G2 (71.8%) (p = .08). Following the addition of RTX (G1a), 26.3% of patients had CR, and 31.6% had PR. The incidence of severe infections was similar between patients treated with and without RTX. In multivariable analysis, infection episodes were associated with hypogammaglobulinemia <5 g/L. RTX could be used in cases of SOC failure or remission for early discontinuation of PP without increasing the risk of infection.

Antibody and T Cell Response to SARS-CoV-2 Messenger RNA BNT162b2 Vaccine in Kidney Transplant Recipients and Hemodialysis Patients

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with a high rate of mortality in patients with ESKD, and vaccination is hoped to prevent infection.

METHODS

Between January 18 and February 24, 2021, 225 kidney transplant recipients (KTRs) and 45 patients on hemodialysis (HDPs) received two injections of mRNA BNT162b2 vaccine. The postvaccinal humoral and cellular response was explored in the first 45 KTRs and ten HDPs.

RESULTS

After the second dose, eight HDPs (88.9%) and eight KTRs (17.8%) developed antispike SARS-CoV-2 antibodies (P<0.001). Median titers of antibodies in responders were 1052 AU/ml (IQR, 515-2689) in HDPs and 671 AU/ml (IQR, 172-1523) in KTRs (P=0.40). Nine HDPs (100%) and 26 KTRs (57.8%) showed a specific T cell response (P=0.06) after the second injection. In responders, median numbers of spike-reactive T cells were 305 SFCs per 10⁶ CD3+ T cells (IQR, 95-947) in HDPs and 212 SFCs per 10⁶ CD3+ T cells (IQR, 61-330) in KTRs (P=0.40). In KTRs, the immune response to BNT162b2 seemed influenced by the immunosuppressive regimen, particularly tacrolimus or belatacept.

CONCLUSION

Immunization with BNT162b2 seems more efficient in HDPs, indicating that vaccination should be highly recommended in these patients awaiting a transplant. However, the current vaccinal strategy for KTRs may not provide effective protection against COVID-19 and will likely need to be improved.

Kidney Transplant T Cell-Mediated Rejection Occurring After Anti-CD19 CAR T-Cell Therapy for Refractory Aggressive Burkitt-like Lymphoma With 11q Aberration: A Case Report

Post-transplant lymphoproliferative disorder is a growing complication of kidney transplantation and is associated with a poor prognosis. Anti-CD19 chimeric antigen receptor (CAR) T-cell therapy is an important new treatment option modifying the outcome of refractory hematological cancers. Here, we report the case of a 40-year-old kidney transplant recipient who developed a Burkitt-like lymphoma with 11q aberration 5 years after transplantation. After 3 unsuccessful lines of chemotherapy, it was decided to treat the patient with anti-CD19 CAR T cells as a salvage therapy. Three months after CAR T-cell infusion, she experienced a grade IIB T cell-mediated rejection with severe tubulitis (T3), slight interstitial inflammation (I1), and severe intimal arteritis (V2) with blood suffusion. Among T cells infiltrating the graft, some of them expressed the anti-CD19 CAR. CAR T cells within the graft and in blood samples were also detected by droplet digital polymerase chain reaction. Function of the kidney transplant improved after corticosteroid treatment and remained stable. However, lymphoma progressed, with a massive pulmonary mass leading to the patient's death 10 months after CAR T-cell infusion.

Ligand gated receptor interactions: A key to the power of neuronal networks

The discovery of the chemical synapse was a seminal finding in Neurobiology but the large body of microscopic interactions involved in synaptic transmission could hardly have been foreseen at the time of these first discoveries. Characterization of the molecular players at work at synapses and the increased granularity at which we can now analyze electrical and chemical signal processing that occur in even the simplest neuronal system are shining a new light on receptor interactions. The aim of this review is to discuss the complexity of some representative interactions between excitatory and inhibitory ligand-gated ion channels and/or G protein coupled receptors, as well as other key machinery that can impact neurotransmission and to explain how such mechanisms can be an important determinant of nervous system function.

POS0616 LONG-TERM EFFECTIVENESS AFTER MULTIPLE CYCLES WITH RITUXIMAB FOLLOWING AN ON-FLARE RETREATMENT STRATEGY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rituximab is known as an efficacious drug for the treatment of Rheumatoid Arthritis (RA). The recommended administration schedule consist of 2 infusions of 1000 mg with a 2-week interval. In Belgium an on-flare retreatment strategy is followed, making evaluation of effectiveness over time challenging. Moreover the patient’s view on this strategy is unclear.

Objectives:

To explore long-term effectiveness and safety of rituximab in daily clinical practice in patients with RA.

Methods:

Data of patients diagnosed with RA and treated with rituximab in a tertiary university hospital were retrospectively collected. For every cycle, clinical data were recorded at the time of the first and second infusion, the 16-week visit and the visit on which the treating rheumatologist decided to prescribe a new cycle. Data on demographics, previous RA treatment, disease activity, patient-reported outcomes, adverse events related to rituximab, dose and number of cycles were collected from 01/01/2006 until 01/12/2019 or until discontinuation of rituximab. The visit on which rituximab was prescribed for the first time was considered as the baseline visit. The data were analysed descriptively.

Results:

Data of 66 patients with RA were collected. The median (IQR) age was 57.0 (47.0-65.0) years at baseline and 56% (37/66) were female. Most patients were seropositive (RF 91% and ACPA 92%), and had erosive (71%) or nodular disease (53%). The median (IQR) disease duration was 12.5 (4.0-18.3) years. In total, 94% of the patients had failed at least one other biological Disease-modifying Antirheumatic Drug (bDMARD) before starting rituximab. Overall, patients received a median (IQR) of 3 (2-7) cycles of rituximab. Seven of the 66 patients (11%) discontinued rituximab and changed to another bDMARD after a median (IQR) of 1 (1-6) cycles and 11% were treated with a lower dose than 2x1000mg. The median (IQR) interval between the first 2 cycles was 7.0 (6.0-10.0) months, after which this increased to up to one year (interval between cycle 2-3: 10.0 (7.0-13.0) months, cycle 3-4: 12.0 (7.3-15.5) months). The overall median (IQR) follow-up time was 45.5 (14.8-82.3) months. The efficacy of rituximab remained after repeated cycles: after every treatment with rituximab, a reduction in disease activity based on the disease activity score in 28 joints (DAS28) could be noticed (figure 1A). The evolution in patients’ (PaGH) and physicians’ global health (PhGH) assessment followed the same pattern as the DAS28-score (Figure 1B). High PaGH-scores could be noticed at every start of a new rituximab cycle. The proportion of patients with a PaGH-score above 20 ranged from 84% - 100%, 74% - 100% and 66% - 86% at the first infusion, second infusion and week 16 visits, respectively. Rituximab was considered to be well-tolerated. In total, 23 adverse events in 12 patients were recorded and none of them were serious.

Conclusion:

Rituximab can be considered a highly efficacious drug for RA treatment in daily practice. There were no major side effects and there was an increasing treatment interval over time. However, a healthy survivor effect should be kept in mind when interpreting the results. It should be noted that with the on-flare retreatment strategy, every new rituximab cycle was preceded by a rise in PaGH-scores, which reflects a state of impaired wellbeing reported by patients. This should be further studied with qualitative methods and in a randomized trial setting comparing on-flare with fixed-interval retreatment to evaluate optimal effectiveness.

Figure 1.

Evolution in median - interquartile range disease activity (DAS28CRP) (A) and patients’ (PaGH) and physicians’ global health (PhGH) (B) over the different rituximab cycles. The disease activity, PaGH and PhGH were measured at baseline, the time of the first and second infusion, W16 and the visit on which a new rituximab cycle was prescribed. The dotted lines represent a DAS28CRP-score of 2.6 (remission cut-off) and 3.2 (low disease activity cut-off). C: cycle; W: week; VAS: visual analogue scale.

Disclosure of Interests:

None declared

AB0109 VALIDATION OF SEPARATE PATIENT-REPORTED, CLINICAL AND LABORATORY FACTOR SCORES AS REPRESENTATION OF DISEASE BURDEN IN A POPULATION WITH ESTABLISHED RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) can cause important bio-psychosocial burden. When exploring disease burden evolution in the 2-year Care in early RA (CareRA) trial, 3 factor scores were extracted via exploratory factor analysis (EFA).1 EFA uncovers the fact that multiple observed variables have similar patterns of responses because they are all associated with a latent, not directly observable, variable.

Objectives:

To validate in a population with established RA, the 3 factors scores and their individual components originally extracted in CareRA.

Methods:

Patients with established RA in sustained remission under treatment with etanercept (≥1 year) were enrolled in the TapERA (Tapering Etanercept in RA) trial between 2012 and 2014. Patients completed the Flare Assessment in RA (FLARE-RA) questionnaire.2

Components of disease activity scores (swollen/tender joint count, physician and patient global health assessment, CRP and ESR), as well as pain (question 2) and fatigue evaluation (question 8), from the FLARE-RA questionnaire, and HAQ were recorded at every visit (v=5).

Missingness on previously mentioned variables was handled with multiple imputation (100 imputations). Pain and fatigue were re-scaled from their original Likert scale of 1-6 to 0-100 to match CareRA data. Next, timepoint clustering was removed with multiple outputation (1000x) and each of the 100 000 datasets was analyzed by EFA with principal component extraction and oblimin rotation. The analyses were combined after re-ordering the factors by maximizing factor congruence.

Results:

Sixty-six patients with a mean disease duration of 14.8 years (SD 9.03), mean age of 55.21 years (SD12.87), 96% (63/66) positive to RF or ACPA, 77% (51/66) with erosions and 68% (45/66) female were included in this analysis.

Table 1 provides the results of the EFAs from CareRA and TapERA. The factor structure and factor components remained the same in both datasets. The factor loadings, indicating how strongly a variable relates to its factor (correlation between observed and latent score), were also comparable. The HAQ, however; did have a stronger factor loading in TapERA (0.57 vs 0.92).

Table 1.

Results from the exploratory factor analyses in CareRA and TapERA

VariableCareRATapERAPRFCFLFPRFCFLFFatigue0.900.80PaGH0.870.81Pain0.860.75HAQ0.570.92SJC280.920.82TJC280.890.84PhGH0.760.60CRP0.870.85ESR0.780.82

Factor loadings presented (correlation between the observed score and the latent factor). Cross-loadings were negligible (<0.3) -not presented. The factor order is by % of variance explained.

PRF: patient-reported factor, CF: clinical factor, LF: laboratory factor, PaGH: patient’s global health assessment, HAQ: health assessment questionnaire, SJC28: 28 swollen joint count, TJC28: 28 tender joint count, PhGH: physician’s global health assessment, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate

Conclusion:

The latent factor structure for disease burden originally found in CareRA was successfully validated in the TapERA dataset, underlining the robustness of the PRF, CF and LF scores. HAQ seems to take “greater importance” on established RA. However, deviations in factor loadings (e.g., HAQ) could be attributed to differences between study populations (e.g., early vs. established RA, sample size). Apart from traditional clinical and laboratory factors, patient-reported pain, fatigue, functionality and overall well-being determine disease burden, both in early and established RA. Using these factor scores could facilitate detection and management of patient’s unmet needs.

References:

[1]Pazmino, et al. Does Including Pain, Fatigue, and Physical Function When Assessing Patients with Early Rheumatoid Arthritis Provide a Comprehensive Picture of Disease Burden? J Rheumatology 2020 Nov.

[2]Berthelot JM, et al. A tool to identify recent or present rheumatoid arthritis flare from both patient and physician perspectives: the ‘FLARE’ instrument. Annals Rheumatic Diseases. 2012.

Disclosure of Interests:

None declared

POS1434 WHICH PROGNOSTIC FACTORS MIGHT PREDICT THE NEED FOR TREATMENT ADAPTATION IN EARLY RHEUMATOID ARTHRITIS? A COMPARISON OF MACHINE LEARNING, SURVIVAL ANALYSIS AND REGRESSION METHODS

Background:

Current EULAR guidelines recommend treating RA early, intensively and to-target. A data-driven tool for planning the optimal moment for subsequent visits might adapt visit schedules more to the patient’s needs, without losing treatment quality.

Objectives:

To determine the optimal statistical model and clinical factors to predict the time to a treatment adaptation in early RA patients.

Methods:

This study included 379 patients from the treat-to-target Care in Rheumatoid Arthritis (CareRA) trial. The CareRA protocol included 2 predefined treatment adaptation steps for patients not reaching low disease activity (DAS28CRP<3.2). The 1st adaptation was an MTX dose increase and the second one was adding/increasing the dose of a 2nd csDMARD. Three predictive models (Cox Proportional Hazards, Linear Multi-Task Regression and Random Survival Forest) were trained and validated to predicting time until these 2 adaptations. Factor selection for these models was performed by applying Cox Proportional Hazards with LASSO penalty to each set of demographic and clinical variables recorded at baseline, w4 and w8. Models used these factors at these 3 time points to predict future treatment adaptations. Model performance was estimated by the Uno Concordance Index with five-fold cross-validation. Missing data were imputed by interpolation or mean score.

Results:

Factors selected to predict the first per protocol change included TJC, SJC, HAQ, CRP, pain and morning stiffness>15min. Factors selected to predict the second per protocol change included TJC, SJC, PGA, PhGA. Uno Concordance indices showed similar scores per different statistical model but higher scores at w4 and w8 compared to baseline indicating a better predictive performance (Table 1. next page).

Table 1.

Uno Concordance Scores. Format ‘mean (min-max)’.

BaselineWeek 4Week 8Cox Proportional HazardsChange 10.63 (0.59-0.69)0.72 (0.68-0.80)0.75 (0.69-0.82)Change 20.58 (0.50-0.66)0.75 (0.65-0.87)0.78 (0.65-0.93)Linear Multi-Task RegressionChange 10.65 (0.62-0.68)0.72 (0.68-0.78)0.75 (0.69-0.79)Change 20.58 (0.51-0.68)0.72 (0.67-0.82)0.77 (0.68-0.89)Random Survival ForestChange 10.64 (0.58-0.67)0.71 (0.66-0.78)0.76 (0.68-0.80)Change 20.56 (0.50-0.68)0.72 (0.60-0.82)0.77 (0.64-0.92)

Conclusion:

Our data-driven approach identified predictive clinical factors with a high face validity including joint counts, functionality scores and global health indicators. The different model approaches did not seem to increase the predictive capacity performance. However, our results underline that not so much the baseline disease status but rather the early response to initial treatment reflected in the selected predictive factors can be used for prediction of the need for further treatment adaptation. These models will have to be enriched with patient reported outcomes to further improve predictive performance.

Disclosure of Interests:

None declared

POS0503 THE DISCORDANCE BETWEEN PATIENT-REPORTED AND CLINICAL/BIOLOGICAL OUTCOMES COULD HELP IN PREDICTING FUTURE DISEASE IMPACT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Treatment of Rheumatoid Arthritis (RA) has improved significantly based on early treat-to-target (T2T) strategies. Still, decreased health related quality of life (QoL), restricted ability to work and other unmet needs are reported by RA patients even in the absence of disease activity. We previously identified 3 factors representing the broader impact of RA using exploratory factor analysis: a patient-reported factor (patients global health, pain, fatigue and HAQ), a clinical factor (physician’s global health, tender and swollen joint count), and a laboratory factor (ESR and CRP)1.

Objectives:

To test whether the discordance between patient-reported (PRF) and clinical(CF)/laboratory(LF) measures can predict QoL, or has a mediating effect in predicting future disease burden based on disease activity (DAS28CRP).

Methods:

This is a post-hoc analysis of the 2-year CareRA trial. PRF, CF and LF scores were calculated as weighted (by factor loading) sum of their components at week 16, 52 and 104 after treatment initiation. A discordance score (DS) between PRF and the mean of the other two scores was also computed.

Mediation analyses were fitted to test the hypothesis (Figure 1) that DS could be a mediator for predicting PRF, CF and LF at a future time point (week 16, 52 and 104) using DAS28CRP at a previous time point (baseline and week 16). Confidence intervals were estimated via 10 000 bootstraps. Finally, a linear regression was fitted for DS to predict future QoL (RAQoL questionnaire; range 0-30; higher values indicating worse QoL).

Results:

Patients with early RA (n=379) were included with a mean (SD) age of 53.9 (13.0), 77% seropositive and 69% women.

The DS was shown to be mediating the effect of DAS28CRP on any future PRF (Table1). On the other hand, there was no mediation effect of the DS in the prediction of the CF and an inconsistent mediation effect when predicting the LF.

Moreover, the DS at week 16 significantly predicted (p<0.0001) RAQoL scores at year 1 with an effect of β 19.05 (SE 1.58) and an R2 of 0.30 (CI 0.22-0.38). Similarly, it predicted RAQoL (p<0.0001) at year 2 with a β 19.74 (SE 1.56) and R2 of 0.32 (CI 0.24-0.40).

Table 1.

Results of mediation analyses for prediction of future burden based on previous DAS28CRP and mediated by discordance.

TimepointPredictor variablesDirect Effect95% CIsR2Mediation effect Patient-reported factorW16DAS28CRP at BL-0.0091-0.0240, 0.00580.1450PresentDS at BL0.0246*0.0169, 0.03310.1784W52DAS28CRP at W160.0215*0.0010, 0.04190.3394PartialDS at W160.0580*0.0442, 0.07390.2749W104DAS28CRP at W160.0101-0.0102, 0.03050.2798PresentDS at W160.0528*0.0396, 0.06860.2749Clinical factorW16DAS28CRP at BL0.0153*0.0074, 0.02320.0599AbsentDS at BL0.0019-0.0010, 0.00480.1784W52DAS28CRP at W160.0365*0.0267, 0.04630.1944AbsentDS at W160.0034-0.0031, 0.00950.2749W104DAS28CRP at W160.0115*0.0024, 0.02070.0409AbsentDS at W160.0033-0.0019, 0.00890.2749Laboratory factorW16DAS28CRP at BL0.0063*0.0015, 0.01110.0634PartialDS at BL0.0030*0.0012, 0.00500.1784W52DAS28CRP at W160.0003-0.0063, 0.00680.0305PresentDS at W160.0051*0.0012, 0.00960.2749W104DAS28CRP at W16-0.0007-0.0079, 0.00640.0014AbsentDS at W160.0013-0.0019, 0.00460.2749

W: week BL: baseline DS: discordance score

DAS28CRP: disease activity score in 28 joints with C-reactive protein

*p<0.01

Conclusion:

Early discordance between patient-reported and biological/clinical factors mediates the effect of disease activity on future patient-reported outcomes, but also predicts QoL. Paying attention to this early discordance might provide opportunities to prevent patient’s unmet needs by additional non-pharmacological interventions, hence broadening the scope of T2T.

References:

[1]Pazmino S, et al. Does Including Pain, Fatigue, and Physical Function When Assessing Patients with Early Rheumatoid Arthritis Provide a Comprehensive Picture of Disease Burden? J Rheumatol. 2020 Nov 15:jrheum.200758. doi: 10.3899/jrheum.200758. Ahead of print.

Disclosure of Interests:

None declared

POS0266-HPR PATIENT-PERCEIVED ASPECTS OF RA FLARE EVOLVE OVER TIME, AS REFLECTED BY THE FLARE-RA QUESTIONNAIRE: POST-HOC ANALYSIS OF TAPERA

Background:

Flares are common in rheumatoid arthritis (RA). While flares negatively impact clinical and patient-reported outcomes, different aspects of disease activity may constitute a flare to patients. Flare Assessment in RA (FLARE-RA) is a patient-reported questionnaire aiming to detect active or recent RA flares (1). During its validation, arthritis and general health subscales were identified and the instrument was adapted from 13 questions (1-6 Likert scale) to 11 questions (0-10).

Objectives:

To investigate which patient-perceived aspects of flare are assessed by FLARE-RA in the context of a TNFi-tapering trial, using exploratory factor analysis (EFA).

Methods:

Patients with RA in DAS28CRP/ESR-remission (≥6 months) and treated with etanercept 50 mg weekly (≥1 year) were included in the 12-month TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial between 2012 and 2014. Participants completed 3-monthly FLARE-RA questionnaires.

The first and final follow-up visits (M3 & M12) were analyzed. Missing data were imputed with multiple imputation (n = 10). Sampling adequacy was assessed by Kaiser-Meyer-Olkin (KMO) and correlations between variables were evaluated with Bartlett’s sphericity test. Spearman correlation matrices were constructed in each of the 10 imputed datasets. The pooled matrix was then analyzed by EFA with principal component extraction and promax-rotation. EFA aims to identify clusters of questions that elicit similar responses because of association with the same underlying latent (not observable) constructs/factors.

Results:

Sixty-six patients (68% female) with a mean age of 55 years (SD 13) and a mean disease duration of 14.8 years (SD 9) completed a total of 330 FLARE-RA questionnaires. Sampling adequacy was acceptable (KMO = 0.94) and correlation between items was sufficient for factor analysis (p < 0.001).

Table 1 shows the results of EFA in TapERA compared to the validation study (1). Factor loadings indicate how strongly each item correlates with its underlying factor. EFA of the full 13-item FLARE-RA at M3 revealed 3 factors: Arthritis, General health and a Medication factor relating to management of flare. The Arthritis factor explained the largest proportion of variance (31%). EFA at M12 showed the same underlying factors, but a less robust factor structure (cross-loadings >0.3) and a larger proportion of variance explained by the General health factor (33%).

Conclusion:

FLARE-RA assessed similar patient-perceived aspects of RA flare within the context of a TNFi-tapering trial when compared to the validation study, including a Medication factor reflecting use of both glucocorticoids and analgesics. This underlines the usefulness of FLARE-RA in providing a multi-faceted view of patients’ conceptions of RA flare. However, these aspects and their relative importance do seem to evolve over time. Further research is needed to assess if this is due to the influence of time or specific to the studied population/tapering setting.

References:

[1]Fautrel B, et al. Validation of FLARE-RA, a Self-Administered Tool to Detect Recent or Current Rheumatoid Arthritis Flare. Arthritis Rheumatol. 2017;69(2):309–19

Table 1.

Factor loadings (>0.3) from exploratory factor analysis of the 13-question FLARE-RA collected in TapERA, compared to results from the FLARE-RA validation study (1). Factors presented in descending order of % variance explained. Q5 & Q7 were removed in the final FLARE-RA.

ITEMFLARE-RA ValidationTapERA M3TapERA M12GFAFAFGFMFGFAFMFQ1: stiffness0.330.750.930.73Q2: pain0.470.650.911.00Q3: swelling0.350.800.920.93Q4: nocturnal pain0.390.820.670.76Q5: overall0.390.840.860.86Q6: analgesics0.360.810.680.470.51Q7: glucocorticoids0.910.96Q8: fatigue0.680.510.700.87Q9: limitation0.730.480.300.750.74Q10: irritability0.850.390.770.69Q11: mood0.830.440.970.79Q12: withdrawal0.900.891.06Q13: needing help0.810.380.720.600.30Variance explained (%)6610313112333110

AF = arthritis factor, GF = general health factor, MF = medication factor

Disclosure of Interests:

None declared