AB0114 IMPROVEMENT OF GUT MICROBIOTA DYSBIOSIS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AFTER ONE YEAR OF BIOLOGICAL TREATMENT

Background

Emerging evidence suggests that dysbiosis of the gut microbiota is involved in the initiation and perpetuation of spondyloarthritis (SpA). Biological disease-modifying antirheumatic drugs (bDMARDs) are a successful treatment to improve symptoms and reduce structural damage occurring in SpA; however, non-responders are frequent and few predictive factors for clinical response have been identified. Whether or not a patient responds to treatment could be related to gut microbiota composition.

Objectives

To investigate the gut microbiota changes in patients with radiographic axial SpA (r-axSpA) after receiving one year of treatment with bDMARDs and identify potential microbial biomarkers predictive of treatment response.

Methods

Patients with r-axSpA were recruited between 2015 and 2019 in an extension of the prospective GErman SPondyloarthritis Inception Cohort (GESPIC) before beginning bDMARD therapy. All patients had high disease activity (BASDAI >=4 and/or ASDAS >=2.1) despite previous treatment with nonsteroidal anti-inflammatory drugs, and had not received treatment with bDMARDs for at least three months before enrollment in the study. The choice of bDMARD was left to the discretion of the clinical rheumatologists in accordance with standard practice. Disease activity measures (BASDAI, CRP and ASDAS) and fecal samples were assessed at baseline prior to treatment and after one year of treatment. Patients with back pain negative for inflammatory disease served as a control group. Microbiota composition was determined by 16S rRNA gene sequencing, followed by taxonomic profiling with the SILVA138 database. Response to bDMARD therapy was defined as a clinically important improvement of ASDAS (>=1.1).

Results

A total of 99 patients with r-axSpA and 63 control individuals were included based on the availability of clinical and microbiome samples. Average age (mean±SD) was 36.4±10.4 years and 64 patients were males. The prevalence of HLA-B27 was 89.9% among r-axSpA patients compared to 7.9% among control individuals. Simpson indices showed an increase in alpha diversity between baseline and year 1 in r-axSpA patients which was statistically insignificant (paired Wilcoxon p=0.154) but brought the r-axSpA cohort nearer to controls. Likewise, Bray-Curtis dissimilarities to measure beta diversity showed a qualitative normalization to healthy individuals after treatment when visualized in principal coordinate space.

At the genus level, patients were mainly depleted in Lachnospiraceae taxa such as Blautia, Roseburia, and Fusicatenibacter, and enriched in Collinsella compared to the control group at baseline. After one year of treatment, most SpA patients exhibited increased abundances of these taxa, most notably Blautia. Patients also exhibited depletions in Bacteroides and Faecalibacterium, which was strongly enriched in HLA-B27+ individuals at baseline (adjusted Wilcoxon p<0.001). Collinsella showed a very slight median increase after one year of treatment, with no significant difference between responders and non-responders (adjusted Wilcoxon p=0.33). Shifts in highly abundant Prevotella and Bacteroides were strongly correlated with the change in ASDAS after one year when controlling for intra-individual variance and overall changes in alpha diversity.

Conclusion

The gut microbiota composition of r-axSpA patients who underwent treatment with bDMARDs for one year more closely resembled the controls. The unique enrichment of Collinsella in r-axSpA patients remained stable across time and treatment, suggesting it may be a disease biomarker.

Figure 1.

a) Flowchart of axSpA patients summarizing the main clinical and disease activity parameters of the cohort. b) Taxa with the most pronounced shifts in median relative abundance in patients with axSpA after receiving biological treatment for one year. c-d) Alpha and beta diversity analyses, respectively, of axSpA patients before and after treatment compared to control individuals. Labeled points in d represent group means.

Disclosure of Interests

None declared

Anakinra for colchicine refractory familial Mediterranean fever: a cohort of 44 patients

OBJECTIVE

FMF is an autoinflammatory disease of genetic origin. Colchicine is the mainstay of treatment for the prevention of attacks and long-term complications but 5-10% of FMF patients are resistant to colchicine therapy. The aim of our study was to investigate the real-life safety and efficacy of anakinra in a cohort of patients with colchicine-resistant FMF.

METHODS

In this retrospective study, patients treated with anakinra for colchicine-resistant FMF between 2010 and 2018 were identified using the computerized database of Sheba Medical Center and enrolled in the study. Data from structured clinical files were analysed to evaluate the efficacy and safety outcomes. To assess efficacy, we used the Global Assessment Score (GAS), a measure comprised of three different domains: number of attacks per month, duration of attacks and number of sites involved in the attacks. Reported adverse events were compiled.

RESULTS

A total of 44 patients (24 female) were treated with anakinra. Of these patients, 75% were homozygous for the M649V mutation. The mean duration of treatment was 18 months. The GAS decreased significantly from 6.6 (IQR 5.3-7.8) before treatment to 2 (IQR 0-4.2) while on treatment (P < 0.001). During anakinra treatment, six hospitalizations were reported (three due to related adverse effects). In addition, 11 patients suffered from injection site reactions (5 ceased treatment). Twelve patients reported mild side effects.

CONCLUSION

Treatment with anakinra is beneficial for the majority of colchicine-resistant FMF patients and is relatively safe.

OP0031 SHARED AND DISTINCT GUT MICROBIOME SIGNATURES IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND ITS RELATED IMMUNE-MEDIATED DISEASES

Background:

Immune-mediated diseases such as spondyloarthritis (SpA) consistently coincide with dysbiosis of the gut microbiota and frequently present with additional inflammatory pathologies such as Crohn’s disease (CD) and acute anterior uveitis (AAU). Deep profiling of gut microbiota may reveal new pathways of how SpA and its related diseases are initiated and perpetuated.

Objectives:

To identify the presence of shared and specific gut microbiota signatures for SpA and its related diseases as a whole, as well as for the individual diseases, relative to healthy controls.

Methods:

Patients were recruited with a definite diagnosis of axial SpA, AAU or CD and were compared to controls (patients with back pain and previously ruled out SpA/CD/AAU diagnosis). All patients were naïve to or did not receive treatment with biological disease-modifying antirheumatic drugs for at least 3 months before enrollment of the study. Fecal samples were collected and microbiota composition was determined by 16S rRNA gene sequencing, followed by computational analysis referencing the SILVA138 database. Nonparametric Wilcoxon tests were used to calculate differential abundances between binary groups, and the Spearman correlation was used with continuous covariates. Nested linear models and likelihood ratio tests were used to assess confounding with respect to patient characteristics, HLA-B27 expression, inflammatory markers, and the presence of other immune-mediated diseases.

Results:

A total of 300 patients were recruited for the study: 111 axial SpA, 110 AAU, and 79 CD patients and were compared to 63 control individuals. Fifty-three of patients were males with an age (mean±SD) of 39.1±12.3 years. The prevalence of HLA-B27 was 63.0% by patients compared to 7.9% by control individuals. A multivariate PERMANOVA test between the groups was significant (p<0.001), revealing a difference in overall composition between the groups.

At the phylum level, patients with axial SpA, AAU and CD contained higher abundances of Proteobacteria, Bacteroidetes and Fusobacteria, and lower abundances of Firmicutes and Actinobacteria compared to the control group. At the genus level, patients (with axial SpA, AAU and CD) displayed a shared gut microbiome signature differing from that of control individuals. Patients samples were strongly depleted in Blautia compared to the control group. Many of the differentially abundant taxa also correlated with increased inflammation as measured by C-reactive protein (CRP), including a depletion of Fusicatenibacter, Lachnospiraceae FCS020 and Roseburia, as well as an enrichment of Lactobacillus and Veillonella. By looking at each separate disease phenotype, CD patients differed significantly from the control individuals with respect to many genera. These primarily consisted of depletions in Clostridiales (Roseburia, Coprococcus, Ruminococcaceae), and enrichments of pathogen-harboring genera such as Escherichia-Shigella and Fusobacterium. Axial SpA patients were uniquely enriched in Collinsella and Holdemanella and depleted in Cupriavidus; the enrichment of Lactobacillus and depletion of Blautia observed in all patient groups was also associated to the presence of axial SpA, though confounded by CRP. There were strong taxa associations to the presence of HLA-B27, including enrichment of Asteroleplasma, Coprococcus, Faecalibacterium, Rominococcaceae, Lachnospiraceae NK4A136 and Rikenellaceae.

Conclusion:

There is a robust shared taxonomic signature among related immune-mediated diseases, in addition to individual disease phenotype signatures. Patients frequently exhibited a strong depletion in Blautia and an enrichment in Lactobacillus as well as pathogen-harboring genera such as Escherichia-Shigella and Fusobacterium.

Figure 1.

Taxa associations within and between the groups resulting from comparing each with the control group and accounting for disease concomitance and patient characteristics (FDR ≤ 0.05). AAU, anterior acute uveitis; CD, Crohn’s disease; SpA, spondyloarthritis.

Disclosure of Interests:

None declared

Predictors of responses to clinic-based childhood obesity care

BACKGROUND/OBJECTIVE

Lifestyle modification is the therapy of choice for childhood obesity, yet the response rate is variable and may be affected by genetic factors. We aimed to investigate predictors of poor response to lifestyle modification obesity treatment in children.

METHODS

A prospective cohort study of 434 youths (64.5% females) between 4 and 20 years of age undergoing a standard care of lifestyle modification obesity management for 35.9 ± 20.8 months at Yale Childhood Obesity Clinic, USA. The primary outcome was a "poor response," defined as the quintile with the largest increase in BMI Z-score over time. The secondary outcome was the endpoint BMI Z-score. Covariates investigated were sex, baseline pubertal status and degree of obesity, race, biochemical profile, and family history of overweight. A subsample (n = 214) had FTO genotyping (SNP rs8050136) tested.

RESULTS

Males (hazard ratio [HR] = 5.35, 95% confidence interval [CI] [3.32-8.61], P < 0.0001) and pubertal adolescents (HR = 2.78, [1.40-5.50], P = 0.003) compared to prepubertal children were more prone to respond poorly. Baseline degree of obesity was associated with relative protection from responding poorly (HR per BMI Z-score unit = 0.32, [0.17-0.61], P = 0.0006). Carriers of the FTO obesity-predisposing allele (AA genotype) were protected from responding poorly compared to non-carriers (CC genotype) (HR = 0.33, [0.12-0.88], P = 0.028).

CONCLUSIONS

Boys and pubertal adolescents are more prone to respond poorly to standard obesity care while those with greater baseline degree of obesity and carriers of the FTO obesity-predisposing allele are not.

Is It Me or My Hormones? Neuroendocrine Activation Profiles to Visual Food Stimuli Across the Menstrual Cycle

CONTEXT

Homeostatic energy balance is controlled via the hypothalamus, whereas regions controlling reward and cognitive decision-making are critical for hedonic eating. Eating varies across the menstrual cycle peaking at the midluteal phase.

OBJECTIVE

To test responses of females with regular cycles during midfollicular and midluteal phase and of users of monophasic oral contraception pills (OCPs) to visual food cues.

DESIGN

Participants performed a functional magnetic resonance imaging while exposed to visual food cues in four time points: fasting and fed conditions in midfollicular and midluteal phases.

PATIENTS

Twenty females with regular cycles and 12 on monophasic OCP, aged 18 to 35 years.

MAIN OUTCOME MEASURES

Activity in homeostatic (hypothalamus), reward (amygdala, putamen and insula), frontal (anterior cingulate cortex, dorsolateral prefrontal cortex), and visual regions (calcarine and lateral occipital cortex).

SETTING

Tertiary hospital.

RESULTS

In females with regular cycles, brain regions associated with homeostasis but also the reward system, executive frontal areas, and afferent visual areas were activated to a greater degree during the luteal compared with the follicular phase. Within the visual areas, a dual effect of hormonal and prandial state was seen. In females on monophasic OCPs, characterized by a permanently elevated progesterone concentration, activity reminiscent of the luteal phase was found. Androgen, cortisol, testosterone, and insulin levels were significantly correlated with reward and visual region activation.

CONCLUSIONS

Hormonal mechanisms affect the responses of women's homeostatic, emotional, and attentional brain regions to food cues. The relation of these findings to eating behavior throughout the cycle needs further investigation.

Decreased peroxisome proliferator-activated receptor γ level and signalling in sebaceous glands of patients with acne vulgaris

Little is known about the altered lipid metabolism-related transcriptional events occuring in sebaceous glands of patients with acne vulgaris. Peroxisome proliferator-activated receptor (PPAR)γ, a lipid-activated transcription factor, is implicated in differentiation and lipid metabolism of sebocytes. We have observed that PPARγ and its target genes, ADRP (adipose differentiation related protein) and PGAR (PPARγ angioprotein related protein) are expressed at lower levels in sebocytes from patients with acne than in those from healthy controls (HCs) Furthermore, endogenous PPARγ activator lipids such as arachidonic acid-derived keto-metabolites (e.g. 5KETE, 12KETE) are increased in acne-involved and nonacne-involved skin of patients with acne, compared with skin from healthy individuals. Our findings highlight the possible anti-inflammatory role of endogenous ligand-activated PPARγ signaling in human sebocyte biology, and suggest that modulating PPARγ- expression and thereby signaling might be a promising strategy for the clinical management of acne vulgaris.

Functional transient receptor potential vanilloid 1 and transient receptor potential vanilloid 4 channels along different segments of the renal vasculature

AIM

Transient receptor potential vanilloid 1 (TRPV1) and vanilloid 4 (TRPV4) cation channels have been recently identified to promote endothelium-dependent relaxation of mouse mesenteric arteries. However, the role of TRPV1 and TRPV4 in the renal vasculature is largely unknown. We hypothesized that TRPV1/4 plays a role in endothelium-dependent vasodilation of renal blood vessels.

METHODS

We studied the distribution of functional TRPV1/4 along different segments of the renal vasculature. Mesenteric arteries were studied as control vessels.

RESULTS

The TRPV1 agonist capsaicin relaxed mouse mesenteric arteries with an EC50 of 25 nm, but large mouse renal arteries or rat descending vasa recta only at >100-fold higher concentrations. The vasodilatory effect of capsaicin in the low-nanomolar concentration range was endothelium-dependent and absent in vessels of Trpv1 -/- mice. The TRPV4 agonist GSK1016790A relaxed large conducting renal arteries, mesenteric arteries and vasa recta with EC50 of 18, 63 nm and ~10 nm respectively. These effects were endothelium-dependent and inhibited by a TRPV4 antagonist, AB159908 (10 μm). Capsaicin and GSK1016790A produced vascular dilation in isolated mouse perfused kidneys with EC50 of 23 and 3 nm respectively. The capsaicin effects were largely reduced in Trpv1 -/- kidneys, and the effects of GSK1016790A were inhibited in Trpv4 -/- kidneys.

CONCLUSION

Our results demonstrate that two TRPV channels have unique sites of vasoregulatory function in the kidney with functional TRPV1 having a narrow, discrete distribution in the resistance vasculature and TRPV4 having more universal, widespread distribution along different vascular segments. We suggest that TRPV1/4 channels are potent therapeutic targets for site-specific vasodilation in the kidney.

Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial

AIMS/HYPOTHESIS

Bariatric surgery is gaining acceptance as a 'metabolic surgical intervention' for patients with type 2 diabetes. The optimal form of surgery and the mechanism of action of these procedures are much debated. We compared two bariatric procedures for obese patients with type 2 diabetes and evaluated their effects on HbA1c and glucose tolerance.

METHODS

We performed a parallel un-blinded randomised trial of Roux-en-Y gastric bypass (RYGB) vs sleeve gastrectomy (SG) in 41 obese patients with type 2 diabetes, who were bariatric surgery candidates attending the obesity clinic. HbA1c, body composition and glucose tolerance were evaluated at baseline, and at 3 and 12 months.

RESULTS

Of the 41 patients, 37 completed the follow-up (19 RYGB, 18 SG). Both groups had similar baseline anthropometric and biochemical measures, and showed comparable weight loss and fat:fat-free mass ratio changes at 12 months. A similar normalisation of HbA1c levels was observed as early as 3 months post-surgery (6.37 ± 0.71% vs 6.23 ± 0.69% for RYGB vs SG respectively, p < 0.001 in both groups for baseline vs follow-up).

CONCLUSIONS/INTERPRETATION

In this study, RYGB did not have a superior effect in comparison to SG with regard to HbA1c levels or weight loss during 12 months of follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00667706.

FUNDING

This work was supported by grant no. 3-000-8480 from the Israel Ministry of Health Chief Scientist, the Stephen Morse Diabetes Research Foundation and by Johnson & Johnson.

Novel signalling mechanisms and targets in renal ischaemia and reperfusion injury

Acute kidney injury (AKI) induced by ischaemia and reperfusion (I/R) injury is a common and severe clinical problem. Vascular dysfunction, immune system activation and tubular epithelial cell injury contribute to functional and structural deterioration. The search for novel therapeutic interventions for I/R-induced AKI is a dynamic area of experimental research. Pharmacological targeting of injury mediators and corresponding intracellular signalling in endothelial cells, inflammatory cells and the injured tubular epithelium could provide new opportunities yet may also pose great translational challenge. Here, we focus on signalling mediators, their receptors and intracellular signalling pathways which bear potential to abrogate cellular processes involved in the pathogenesis of I/R-induced AKI. Sphingosine 1 phosphate (S1P) and its respective receptors, cytochrome P450 (CYP450)-dependent vasoactive eicosanoids, NF-κB- and protein kinase-C (PKC)-related pathways are representatives of such 'druggable' pleiotropic targets. For example, pharmacological agents targeting S1P and PKC isoforms are already in clinical use for treatment for autoimmune diseases and were previously subject of clinical trials in kidney transplantation where I/R-induced AKI occurs as a common complication. We summarize recent in vitro and in vivo experimental studies using pharmacological and genomic targeting and highlight some of the challenges to clinical application of these advances.

Morphology of glomerular hematuria is reproduced in vitro by carbonyl stress

BACKGROUND

In glomerulonephritides, dysmorphic red blood cells (RBCs) with membrane blebs can be found in the urine; this is referred to as glomerular hematuria. Glomerulonephritides are characterized by increased carbonyl stress and elevated methylglyoxal (MGO) levels. MGO causes oxidative stress and intracellular calcium accumulation. In the present study, we investigated whether the effect of MGO-induced calcium accumulation in RBCs develops through increased oxidative stress. Furthermore, we studied whether MGO can lead to RBC membrane blebbing.

METHODS

RBC suspensions from healthy volunteers were incubated with different concentrations of MGO at 37 degrees C. We measured oxidative stress and intracellular calcium level using fluorescent indicators. We determined the frequency of dysmorphic RBCs, and also performed scanning electron microscopy.

RESULTS

MGO increased oxidative stress and caused accumulation of calcium in isolated RBCs. These effects could be prevented using antioxidants. In the presence of MGO, RBC membrane blebbing developed.

CONCLUSION

According to our findings, MGO causes calcium accumulation through oxidative stress. Carbonyl and oxidative stress may play an important role in the formation of dysmorphic RBCs in glomerular hematuria.

[Malignant melanoma of soft parts (clear cell sarcoma)--a rare case of multiorgan localization]

Malignant melanoma of soft parts (MMSP) is a rare tumor originally described by Enzinger in 1965 as clear cell sarcoma of tendons and aponeuroses because of its affinity to tenosynovial structures. Tumors are found predominantly at the extremities. First visceral case was described in 1993 in the duodenum. We describe the case of 64-years old man with malignant melanoma of soft parts in the stomach, in the pancreas, in the mesocolon, in the left thigh and in the left axilla. This patient was successfully treated surgically by the resection of the stomach, resection of the pancreatic head, extirpation of the tumor from mesocolon, from the left thigh and from the left axilla. In all these localisations the tumor was histologically and imunohistochemically proved to be MMSP (positivity: s-100 protein, vimentin, HMB-45 and negativity CK, EMA, desmin, actin). This multivisceral occurrence is extremely rare and according to the review of literature this is probably the first published case of MMSP in the stomach and in the pancreas.

[Initial experience with laparoscopic adrenalectomy]

We present the first experience with laparoscopic adrenalectomy, which was in Slovakia introduced to the surgical practice on March 3, 1996. We analyse first seven patients who underwent completed laparoscopic adrenalectomy (five leftsided, two right-sided). Four patients had cortex adenoma (clinically 2 incidentalomas and 2 Cishing syndroma), three patients had cortex hyperplasia (clinically Conn syndroma). Average duration of operation was 120 minutes, there were no postoperative complications. Average postoperative hospital stay was 5 days. Our initial experiences are comparable with that of surgical departments which has more than two-years experiences. Laparoscopic adrenalectomy is a perfect method for the small adrenal tumors and it is better than traditional transabdominal approach.

[Pancreatic abscesses]

The paper deals with pancreatic abscess as one of three entities of pancreatic infection. In spite of the common origin with infected pancreatic necrosis and infected pancreatic pseudocyst, the treatment of each kind of pancreatic necrosis has its own requirements. By comparing 30 pancreatic abscesses (mortality 18%), 29 infected pancreatic pseudocysts (mortality 6%) and 35 infected pancreatic necroses (mortality 43.5%) we concluded that the best treatment for pancreatic abscess is surgical evacuation with external drainage, for that of infected pancreatic pseudocyst internal drainage operation, and for infected pancreatic necrosis surgical debridement with external drainage, lavage and open-abdomen procedure. Differences in CT scan, treatment and prognosis require different surgical approach to each type of pancreatic necrosis. (Fig. 3, Ref. 24.)