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Carlucci PM, Preisinger K, Deonaraine KK, Zaminski D, Dall'Era M, Gold HT, Kalunian K, Fava A, Belmont HM, Wu M, Putterman C, Anolik J, Barnas JL, Furie R, Diamond B, Davidson A, Wofsy D, Kamen D, James JA, Guthridge JM, Apruzzese W, Rao D, Weisman MH, Izmirly PM, Buyon J, Petri M. Extrarenal symptoms associate with worse quality of life in patients enrolled in the AMP RA/SLE Lupus Nephritis Network. Rheumatology (Oxford) 2024:keae189. [PMID: 38530774 DOI: 10.1093/rheumatology/keae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE Lupus nephritis (LN) can occur as an isolated component of disease activity or be accompanied by diverse extrarenal manifestations. Whether isolated renal disease is sufficient to decrease health related quality of life (HRQOL) remains unknown. This study compared Patient-Reported Outcomes Measurement Information System 29-Item (PROMIS-29) scores in LN patients with isolated renal disease to those with extrarenal symptoms to evaluate the burden of LN on HRQOL and inform future LN clinical trials incorporating HRQOL outcomes. METHODS A total of 181 LN patients consecutively enrolled in the multicentre multi-ethnic/racial Accelerating Medicines Partnership completed PROMIS-29 questionnaires at the time of a clinically indicated renal biopsy. Raw PROMIS-29 scores were converted to standardized T scores. RESULTS Seventy-five (41%) patients had extrarenal disease (mean age 34, 85% female) and 106 (59%) had isolated renal (mean age 36, 82% female). Rash (45%), arthritis (40%) and alopecia (40%) were the most common extrarenal manifestations. Compared with isolated renal, patients with extrarenal disease reported significantly worse pain interference, ability to participate in social roles, physical function, and fatigue. Patients with extrarenal disease had PROMIS-29 scores that significantly differed from the general population by > 0.5 SD of the reference mean in pain interference, physical function, and fatigue. Arthritis was most strongly associated with worse scores in these three domains. CONCLUSION Most patients had isolated renal disease and extrarenal manifestations associated with worse HRQOL. These data highlight the importance of comprehensive disease management strategies that address both renal and extrarenal manifestations to improve overall patient outcomes.
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Affiliation(s)
- Philip M Carlucci
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Katherine Preisinger
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Devyn Zaminski
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Maria Dall'Era
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Heather T Gold
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Kenneth Kalunian
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Andrea Fava
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - H Michael Belmont
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Ming Wu
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Jennifer Anolik
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer L Barnas
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard Furie
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Betty Diamond
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Anne Davidson
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - David Wofsy
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Diane Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Judith A James
- Department of Medicine, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Joel M Guthridge
- Department of Medicine, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | - Deepak Rao
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Peter M Izmirly
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Jill Buyon
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Denvir B, Carlucci PM, Corbitt K, Buyon JP, Belmont HM, Gold HT, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Barbour KE, Helmick CG, Parton H, Izmirly PM. Prevalence of concomitant rheumatologic diseases and autoantibody specificities among racial and ethnic groups in SLE patients. Front Epidemiol 2024; 4:1334859. [PMID: 38516120 PMCID: PMC10956350 DOI: 10.3389/fepid.2024.1334859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
Objective Leveraging the Manhattan Lupus Surveillance Program (MLSP), a population-based registry of cases of systemic lupus erythematosus (SLE) and related diseases, we investigated the proportion of SLE with concomitant rheumatic diseases, including Sjögren's disease (SjD), antiphospholipid syndrome (APLS), and fibromyalgia (FM), as well as the prevalence of autoantibodies in SLE by sex and race/ethnicity. Methods Prevalent SLE cases fulfilled one of three sets of classification criteria. Additional rheumatic diseases were defined using modified criteria based on data available in the MLSP: SjD (anti-SSA/Ro positive and evidence of keratoconjunctivitis sicca and/or xerostomia), APLS (antiphospholipid antibody positive and evidence of a blood clot), and FM (diagnosis in the chart). Results 1,342 patients fulfilled SLE classification criteria. Of these, SjD was identified in 147 (11.0%, 95% CI 9.2-12.7%) patients with women and non-Latino Asian patients being the most highly represented. APLS was diagnosed in 119 (8.9%, 95% CI 7.3-10.5%) patients with the highest frequency in Latino patients. FM was present in 120 (8.9%, 95% CI 7.3-10.5) patients with non-Latino White and Latino patients having the highest frequency. Anti-dsDNA antibodies were most prevalent in non-Latino Asian, Black, and Latino patients while anti-Sm antibodies showed the highest proportion in non-Latino Black and Asian patients. Anti-SSA/Ro and anti-SSB/La antibodies were most prevalent in non-Latino Asian patients and least prevalent in non-Latino White patients. Men were more likely to be anti-Sm positive. Conclusion Data from the MLSP revealed differences among patients classified as SLE in the prevalence of concomitant rheumatic diseases and autoantibody profiles by sex and race/ethnicity underscoring comorbidities associated with SLE.
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Affiliation(s)
- Brendan Denvir
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Philip M. Carlucci
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Kelly Corbitt
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - H. Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Heather T. Gold
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Jane E. Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, United States
| | - Anca Askanase
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Joan M. Bathon
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Laura Geraldino-Pardilla
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Yousaf Ali
- Division of Rheumatology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ellen M. Ginzler
- Division of Rheumatology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, United States
| | | | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Kamil E. Barbour
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Charles G. Helmick
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Hilary Parton
- Division of Disease Control, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, NY, United States
| | - Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
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3
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Izmirly PM, Kim MY, Carlucci PM, Preisinger K, Cohen BZ, Deonaraine K, Zaminski D, Dall'Era M, Kalunian K, Fava A, Belmont HM, Wu M, Putterman C, Anolik J, Barnas JL, Diamond B, Davidson A, Wofsy D, Kamen D, James JA, Guthridge JM, Apruzzese W, Rao DA, Weisman MH, Petri M, Buyon J, Furie R. Longitudinal patterns and predictors of response to standard-of-care therapy in lupus nephritis: data from the Accelerating Medicines Partnership Lupus Network. Arthritis Res Ther 2024; 26:54. [PMID: 38378664 PMCID: PMC10877793 DOI: 10.1186/s13075-024-03275-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/23/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Leveraging the Accelerating Medicines Partnership (AMP) Lupus Nephritis (LN) dataset, we evaluated longitudinal patterns, rates, and predictors of response to standard-of-care therapy in patients with lupus nephritis. METHODS Patients from US academic medical centers with class III, IV, and/or V LN and a baseline urine protein/creatinine (UPCR) ratio ≥ 1.0 (n = 180) were eligible for this analysis. Complete response (CR) required the following: (1) UPCR < 0.5; (2) normal serum creatinine (≤ 1.3 mg/dL) or, if abnormal, ≤ 125% of baseline; and (3) prednisone ≤ 10 mg/day. Partial response (PR) required the following: (1) > 50% reduction in UPCR; (2) normal serum creatinine or, if abnormal, ≤ 125% of baseline; and (3) prednisone dose ≤ 15 mg/day. RESULTS Response rates to the standard of care at week 52 were CR = 22.2%; PR = 21.7%; non-responder (NR) = 41.7%, and not determined (ND) = 14.4%. Only 8/180 (4.4%) patients had a week 12 CR sustained through week 52. Eighteen (10%) patients attained a week 12 PR or CR and sustained their responses through week 52 and 47 (26.1%) patients achieved sustained PR or CR at weeks 26 and 52. Week 52 CR or PR attainment was associated with baseline UPCR > 3 (ORadj = 3.71 [95%CI = 1.34-10.24]; p = 0.012), > 25% decrease in UPCR from baseline to week 12 (ORadj = 2.61 [95%CI = 1.07-6.41]; p = 0.036), lower chronicity index (ORadj = 1.33 per unit decrease [95%CI = 1.10-1.62]; p = 0.003), and positive anti-dsDNA antibody (ORadj = 2.61 [95%CI = 0.93-7.33]; p = 0.069). CONCLUSIONS CR and PR rates at week 52 were consistent with the standard-of-care response rates observed in prospective registrational LN trials. Low sustained response rates underscore the need for more efficacious therapies and highlight how critically important it is to understand the molecular pathways associated with response and non-response.
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Affiliation(s)
- Peter M Izmirly
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA.
| | - Mimi Y Kim
- Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Philip M Carlucci
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Katherine Preisinger
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Brooke Z Cohen
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Kristina Deonaraine
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Devyn Zaminski
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Maria Dall'Era
- University of California San Francisco, San Francisco, CA, USA
| | | | - Andrea Fava
- Johns Hopkins University, Baltimore, MD, USA
| | - H Michael Belmont
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Ming Wu
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | | | | | | | - Betty Diamond
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Anne Davidson
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - David Wofsy
- University of California San Francisco, San Francisco, CA, USA
| | - Diane Kamen
- Medical University of South Carolina, Charleston, SC, USA
| | - Judith A James
- Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | | | | | | | | | - Jill Buyon
- New York University Grossman School of Medicine, 550 First Avenue, MSB 593D, New York, NY, 10016, USA
| | - Richard Furie
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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4
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Azzouz DF, Chen Z, Izmirly PM, Chen LA, Li Z, Zhang C, Mieles D, Trujillo K, Heguy A, Pironti A, Putzel GG, Schwudke D, Fenyo D, Buyon JP, Alekseyenko AV, Gisch N, Silverman GJ. Longitudinal gut microbiome analyses and blooms of pathogenic strains during lupus disease flares. Ann Rheum Dis 2023; 82:1315-1327. [PMID: 37365013 PMCID: PMC10511964 DOI: 10.1136/ard-2023-223929] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Whereas genetic susceptibility for systemic lupus erythematosus (SLE) has been well explored, the triggers for clinical disease flares remain elusive. To investigate relationships between microbiota community resilience and disease activity, we performed the first longitudinal analyses of lupus gut-microbiota communities. METHODS In an observational study, taxononomic analyses, including multivariate analysis of ß-diversity, assessed time-dependent alterations in faecal communities from patients and healthy controls. From gut blooms, strains were isolated, with genomes and associated glycans analysed. RESULTS Multivariate analyses documented that, unlike healthy controls, significant temporal community-wide ecological microbiota instability was common in SLE patients, and transient intestinal growth spikes of several pathogenic species were documented. Expansions of only the anaerobic commensal, Ruminococcus (blautia) gnavus (RG) occurred at times of high-disease activity, and were detected in almost half of patients during lupus nephritis (LN) disease flares. Whole genome sequence analysis of RG strains isolated during these flares documented 34 genes postulated to aid adaptation and expansion within a host with an inflammatory condition. Yet, the most specific feature of strains found during lupus flares was the common expression of a novel type of cell membrane-associated lipoglycan. These lipoglycans share conserved structural features documented by mass spectroscopy, and highly immunogenic repetitive antigenic-determinants, recognised by high-level serum IgG2 antibodies, that spontaneously arose, concurrent with RG blooms and lupus flares. CONCLUSIONS Our findings rationalise how blooms of the RG pathobiont may be common drivers of clinical flares of often remitting-relapsing lupus disease, and highlight the potential pathogenic properties of specific strains isolated from active LN patients.
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Affiliation(s)
- Doua F Azzouz
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Ze Chen
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, New York, New York, USA
| | - Peter M Izmirly
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Lea Ann Chen
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Zhi Li
- Institute of Systems Genetics, NYU Grossman School of Medicine, New York, New York, USA
| | - Chongda Zhang
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, New York, New York, USA
| | - David Mieles
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Kate Trujillo
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Adriana Heguy
- Pathology, NYU Grossman School of Medicine, New York, New York, USA
| | - Alejandro Pironti
- Microbiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Greg G Putzel
- Microbiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Dominik Schwudke
- Division of Bioanalytical Chemsitry, Forschungszentrum Borstel Leibniz Lungenzentrum, Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site: Hamburg-Lübeck, Borstel, Germany
- Airway Research Center North, Member of the German Center for Lung Research (DZL), Partner Site: Research Center Borstel, Borstel, Germany
| | - David Fenyo
- Institute of Systems Genetics, NYU Grossman School of Medicine, New York, New York, USA
| | - Jill P Buyon
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Alexander V Alekseyenko
- Department of Public Health Sciences, Biomedical Informatics Center, Program for Microbiome Research, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nicolas Gisch
- Division of Bioanalytical Chemistry, Priority Area Infections, Forschungszentrum Borstel Leibniz Lungenzentrum, Borstel, Germany
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5
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Hasan G, Ferucci ED, Buyon JP, Belmont HM, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Helmick CG, Parton H, Izmirly PM. Population-based prevalence and incidence estimates of mixed connective tissue disease from the Manhattan Lupus Surveillance Program. Rheumatology (Oxford) 2023; 62:2845-2849. [PMID: 36538873 PMCID: PMC11068036 DOI: 10.1093/rheumatology/keac703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/07/2022] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE Epidemiological data for MCTD are limited. Leveraging data from the Manhattan Lupus Surveillance Program (MLSP), a racially/ethnically diverse population-based registry of cases with SLE and related diseases including MCTD, we provide estimates of the prevalence and incidence of MCTD. METHODS MLSP cases were identified from rheumatologists, hospitals and population databases using a variety of International Classification of Diseases, Ninth Revision codes. MCTD was defined as one of the following: fulfilment of our modified Alarcon-Segovia and Kahn criteria, which required a positive RNP antibody and the presence of synovitis, myositis and RP; a diagnosis of MCTD and no other diagnosis of another CTD; and a diagnosis of MCTD regardless of another CTD diagnosis. RESULTS Overall, 258 (7.7%) cases met a definition of MCTD. Using our modified Alarcon-Segovia and Kahn criteria for MCTD, the age-adjusted prevalence was 1.28 (95% CI 0.72, 2.09) per 100 000. Using our definition of a diagnosis of MCTD and no other diagnosis of another CTD yielded an age-adjusted prevalence and incidence of MCTD of 2.98 (95% CI 2.10, 4.11) per 100 000 and 0.39 (95% CI 0.22, 0.64) per 100 000, respectively. The age-adjusted prevalence and incidence were highest using a diagnosis of MCTD regardless of other CTD diagnoses and were 16.22 (95% CI 14.00, 18.43) per 100 000 and 1.90 (95% CI 1.49, 2.39) per 100 000, respectively. CONCLUSIONS The MLSP provided estimates for the prevalence and incidence of MCTD in a diverse population. The variation in estimates using different case definitions is reflective of the challenge of defining MCTD in epidemiologic studies.
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Affiliation(s)
- Ghadeer Hasan
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Elizabeth D Ferucci
- Division of Community Health Services, Department of Research Services, Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - H Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Jane E Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Anca Askanase
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Joan M Bathon
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Laura Geraldino-Pardilla
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Yousaf Ali
- Division of Rheumatology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ellen M Ginzler
- Division of Rheumatology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Chaim Putterman
- Division of Rheumatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Charles G Helmick
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hilary Parton
- Division of Disease Control, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, New York, USA
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
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6
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Kleitsch J, Mazori DR, Masson M, Izmirly PM, Saxena A, Buyon JP, Glick SA. Cutaneous Neonatal Lupus in Patients with Skin of Color: A Retrospective Cohort Study from a National Registry. J Am Acad Dermatol 2023:S0190-9622(23)00513-3. [PMID: 36997071 DOI: 10.1016/j.jaad.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/03/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023]
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7
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Clancy RM, Guthridge CJ, Marion MC, Guthridge J, Howard TD, Izmirly PM, Masson M, Buyon JP, James J, Langefeld CD. The modifying influence of HLA class II DQB1*06:02 on the Streptococcus and clinical phenotype correlation among anti-Ro+ mothers of children with neonatal lupus. Genes Dis 2022. [DOI: 10.1016/j.gendis.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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8
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Carlucci PM, Li J, Fava A, Deonaraine KK, Wofsy D, James JA, Putterman C, Diamond B, Davidson A, Fine DM, Monroy-Trujillo J, Atta MG, DeJager W, Guthridge JM, Haag K, Rao DA, Brenner MB, Lederer JA, Apruzzese W, Belmont HM, Izmirly PM, Zaminski D, Wu M, Connery S, Payan-Schober F, Furie R, Dall'Era M, Cho K, Kamen D, Kalunian K, Anolik J, Barnas J, Ishimori M, Weisman MH, Buyon JP, Petri M. High incidence of proliferative and membranous nephritis in SLE patients with low proteinuria in the Accelerating Medicines Partnership. Rheumatology (Oxford) 2022; 61:4335-4343. [PMID: 35212719 PMCID: PMC9629353 DOI: 10.1093/rheumatology/keac067] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/17/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Delayed detection of LN associates with worse outcomes. There are conflicting recommendations regarding a threshold level of proteinuria at which biopsy will likely yield actionable management. This study addressed the association of urine protein:creatinine ratios (UPCR) with clinical characteristics and investigated the incidence of proliferative and membranous histology in patients with a UPCR between 0.5 and 1. METHODS A total of 275 SLE patients (113 first biopsy, 162 repeat) were enrolled in the multicentre multi-ethnic/racial Accelerating Medicines Partnership across 15 US sites at the time of a clinically indicated renal biopsy. Patients were followed for 1 year. RESULTS At biopsy, 54 patients had UPCR <1 and 221 had UPCR ≥1. Independent of UPCR or biopsy number, a majority (92%) of patients had class III, IV, V or mixed histology. Moreover, patients with UPCR <1 and class III, IV, V, or mixed had a median activity index of 4.5 and chronicity index of 3, yet 39% of these patients had an inactive sediment. Neither anti-dsDNA nor low complement distinguished class I or II from III, IV, V or mixed in patients with UPCR <1. Of 29 patients with baseline UPCR <1 and class III, IV, V or mixed, 23 (79%) had a UPCR <0.5 at 1 year. CONCLUSION In this prospective study, three-quarters of patients with UPCR <1 had histology showing class III, IV, V or mixed with accompanying activity and chronicity despite an inactive sediment or normal serologies. These data support renal biopsy at thresholds lower than a UPCR of 1.
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Affiliation(s)
- Philip M Carlucci
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Jessica Li
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Andrea Fava
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - David Wofsy
- Rheumatology Division, Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA
| | - Judith A James
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Chaim Putterman
- Division of Rheumatology, Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
- Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel
| | - Betty Diamond
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Anne Davidson
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Derek M Fine
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose Monroy-Trujillo
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mohamed G Atta
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Wade DeJager
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Joel M Guthridge
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Kristin Haag
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael B Brenner
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James A Lederer
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William Apruzzese
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - H Michael Belmont
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Peter M Izmirly
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Devyn Zaminski
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Ming Wu
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Sean Connery
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Fernanda Payan-Schober
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Richard Furie
- Division of Rheumatology, Department of Medicine, Northwell Health, Great Neck, NY
| | - Maria Dall'Era
- Rheumatology Division, Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA
| | - Kerry Cho
- Nephrology Division, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Diane Kamen
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kenneth Kalunian
- Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA
| | - Jennifer Anolik
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY
| | - Jennifer Barnas
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY
| | - Mariko Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael H Weisman
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jill P Buyon
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
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Clancy RM, Marion MC, Ainsworth HC, Chang M, Howard TD, Izmirly PM, Masson M, Buyon JP, Langefeld CD. Gut dysbiosis and the clinical spectrum in anti-Ro positive mothers of children with neonatal lupus. Gut Microbes 2022; 14:2081474. [PMID: 35704681 PMCID: PMC9225419 DOI: 10.1080/19490976.2022.2081474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Anti-SSA/Ro antibodies, while strongly linked to fetal cardiac injury and neonatal rash, can associate with a spectrum of disease in the mother, ranging from completely asymptomatic to overt Systemic Lupus Erythematosus (SLE) or Sjögren's Syndrome (SS). This study was initiated to test the hypothesis that the microbiome, influenced in part by genetics, contributes to disease state. The stool microbiome of healthy controls (HC) was compared to that of anti-SSA/Ro positive women whose children had neonatal lupus. At the time of sampling, these women were either asymptomatic (Asym), had minor rheumatic symptoms or signs considered as an undifferentiated autoimmune syndrome (UAS), or were diagnosed with SLE or SS. Differences in microbial relative abundances among these three groups were tested assuming an ordering in clinical severity (HC<Asym/UAS<SS/SLE) and then again without the ordinal assumption. Those taxa that showed differential relative abundances were then tested for whether the effect size differed depending on the women's HLA SLE-risk allele genotype (DRB1*03:01, DRB1*15:01, DQB1*02:01 and DQB1*06:02) or anti-SSA/Ro autoantibody levels. Multiple genera within the families Ruminococcaceae and Lachnospiraceae showed evidence of an HLA-by-genus interaction (P < .05). Four genera exhibited evidence of an interaction with anti-Ro52 IgA: Lachnoclostridium, Romboutsia, Bacteroides and Actinomyces (P < .01). In addition to documenting differences in microbial relative abundances across clinical severity of disease, these data provide a first-time demonstration that microbial differences are correlated with HLA SLE-risk alleles. Taken together, these data suggest that the clinical spectrum from benign to overt clinical autoimmunity may partially result from or trigger a complex interplay among specific microbial profiles, anti-Ro autoantibodies, and genetics.
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Affiliation(s)
- Robert M. Clancy
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA,CONTACT Robert M. Clancy Division of Rheumatology, NYU Grossman School of Medicine, New York, NY10016, USA
| | - Miranda C. Marion
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA,Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hannah C. Ainsworth
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA,Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Miao Chang
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Timothy D. Howard
- Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA,Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Peter M. Izmirly
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Mala Masson
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jill P. Buyon
- Department of Medicine, Division of Rheumatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA,Center for Precision Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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10
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Guttmann A, Denvir B, Aringer M, Buyon JP, Belmont HM, Sahl S, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Helmick CG, Parton H, Izmirly PM. Evaluation of the EULAR/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus in a Population-Based Registry. Arthritis Care Res (Hoboken) 2022; 75:1007-1016. [PMID: 35638708 DOI: 10.1002/acr.24960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Using the Manhattan Lupus Surveillance Program, a multiracial/ethnic population-based registry, we aimed to compare 3 commonly used classification criteria for systemic lupus erythematosus (SLE) to identify unique cases and determine the incidence and prevalence of SLE using the EULAR/American College of Rheumatology (ACR) criteria. METHODS SLE cases were defined as fulfilling the 1997 ACR, the Systemic Lupus International Collaborating Clinics (SLICC), or the EULAR/ACR classification criteria. We quantified the number of cases uniquely associated with each and the number fulfilling all 3 criteria. Prevalence and incidence using the EULAR/ACR classification criteria and associated 95% confidence intervals (95% CIs) were calculated. RESULTS A total of 1,497 cases fulfilled at least 1 of the 3 classification criteria, with 1,008 (67.3%) meeting all 3 classifications, 138 (9.2%) fulfilling only the SLICC criteria, 35 (2.3%) fulfilling only the 1997 ACR criteria, and 34 (2.3%) uniquely fulfilling the EULAR/ACR criteria. Patients solely satisfying the EULAR/ACR criteria had <4 manifestations. The majority classified only by the 1997 ACR criteria did not meet any of the defined immunologic criteria. Patients fulfilling only the SLICC criteria did so based on the presence of features unique to this system. Using the EULAR/ACR classification criteria, age-adjusted overall prevalence and incidence rates of SLE in Manhattan were 59.6 (95% CI 55.9-63.4) and 4.9 (95% CI 4.3-5.5) per 100,000 population, with age-adjusted prevalence and incidence rates highest among non-Hispanic Black female patients. CONCLUSION Applying the 3 commonly used classification criteria to a population-based registry identified patients with SLE fulfilling only 1 validated definition. The most recently developed EULAR/ACR classification criteria revealed prevalence and incidence estimates similar to those previously established for the ACR and SLICC classification schemes.
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Affiliation(s)
| | - Brendan Denvir
- New York University School of Medicine, New York, New York
| | - Martin Aringer
- University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jill P Buyon
- New York University School of Medicine, New York, New York
| | | | - Sara Sahl
- Harbor-University of California Medical Center, Los Angeles
| | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Anca Askanase
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Joan M Bathon
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Yousaf Ali
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen M Ginzler
- State University of New York Downstate Health Sciences University, Brooklyn
| | | | | | | | - Hilary Parton
- New York City Department of Health and Mental Hygiene, Long Island City, New York
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11
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Izmirly PM, Ferucci ED, Somers EC, Wang L, Lim SS, Drenkard C, Dall'Era M, McCune WJ, Gordon C, Helmick C, Parton H. Incidence rates of systemic lupus erythematosus in the USA: estimates from a meta-analysis of the Centers for Disease Control and Prevention national lupus registries. Lupus Sci Med 2021; 8:8/1/e000614. [PMID: 34921094 PMCID: PMC8685969 DOI: 10.1136/lupus-2021-000614] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/25/2021] [Indexed: 11/12/2022]
Abstract
Objective To estimate the annual incidence rate of SLE in the USA. Methods A meta-analysis used sex/race/ethnicity-specific data spanning 2002–2009 from the Centers for Disease Control and Prevention network of four population-based state registries to estimate the incidence rates. SLE was defined as fulfilling the 1997 revised American College of Rheumatology classification criteria. Given heterogeneity across sites, a random effects model was employed. Applying sex/race/ethnicity-stratified rates, including data from the Indian Health Service registry, to the 2018 US Census population generated estimates of newly diagnosed SLE cases. Results The pooled incidence rate per 100 000 person-years was 5.1 (95% CI 4.6 to 5.6), higher in females than in males (8.7 vs 1.2), and highest among black females (15.9), followed by Asian/Pacific Islander (7.6), Hispanic (6.8) and white (5.7) females. Male incidence was highest in black males (2.4), followed by Hispanic (0.9), white (0.8) and Asian/Pacific Islander (0.4) males. The American Indian/Alaska Native population had the second highest race-specific SLE estimates for females (10.4 per 100 000) and highest for males (3.8 per 100 000). In 2018, an estimated 14 263 persons (95% CI 11 563 to 17 735) were newly diagnosed with SLE in the USA. Conclusions A network of population-based SLE registries provided estimates of SLE incidence rates and numbers diagnosed in the USA.
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Affiliation(s)
- Peter M Izmirly
- Department of Medicine, Division of Rheumatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Elizabeth D Ferucci
- Department of Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska, USA
| | - Emily C Somers
- University of Michigan Schools of Medicine & Public Health, Ann Arbor, Michigan, USA
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - S Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA, USA
| | - Cristina Drenkard
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA, USA
| | - Maria Dall'Era
- University of California, San Francisco, California, USA
| | - W Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Charles Helmick
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hilary Parton
- New York City Department of Health and Mental Hygiene, New York, New York, USA
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12
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Geisler BP, Kingsley TC, Izmirly PM, Costedoat-Chalumeau N, Roswell RO. Hydroxychloroquine Toxicity: Concurrent Complete Heart Block and Severe Left Ventricular Systolic Dysfunction. A Clinical Image. J Clin Rheumatol 2021; 27:S657-S658. [PMID: 33252397 DOI: 10.1097/rhu.0000000000001647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Deonaraine KK, Carlucci PM, Fava A, Li J, Wofsy D, James JA, Putterman C, Diamond B, Davidson A, Fine DM, Monroy-Trujillo J, Atta MG, Haag K, Rao DA, Apruzzese W, Belmont HM, Izmirly PM, Wu M, Connery S, Payan-Schober F, Furie RA, Berthier CC, Dall'Era M, Cho K, Kamen DL, Kalunian K, Anolik J, Ishimori M, Weisman MH, Petri MA, Buyon JP. Safety of procuring research tissue during a clinically indicated kidney biopsy from patients with lupus: data from the Accelerating Medicines Partnership RA/SLE Network. Lupus Sci Med 2021; 8:8/1/e000522. [PMID: 34389634 PMCID: PMC8354250 DOI: 10.1136/lupus-2021-000522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/28/2021] [Indexed: 12/19/2022]
Abstract
Objectives In lupus nephritis the pathological diagnosis from tissue retrieved during kidney biopsy drives treatment and management. Despite recent approval of new drugs, complete remission rates remain well under aspirational levels, necessitating identification of new therapeutic targets by greater dissection of the pathways to tissue inflammation and injury. This study assessed the safety of kidney biopsies in patients with SLE enrolled in the Accelerating Medicines Partnership, a consortium formed to molecularly deconstruct nephritis. Methods 475 patients with SLE across 15 clinical sites in the USA consented to obtain tissue for research purposes during a clinically indicated kidney biopsy. Adverse events (AEs) were documented for 30 days following the procedure and were determined to be related or unrelated by all site investigators. Serious AEs were defined according to the National Institutes of Health reporting guidelines. Results 34 patients (7.2%) experienced a procedure-related AE: 30 with haematoma, 2 with jets, 1 with pain and 1 with an arteriovenous fistula. Eighteen (3.8%) experienced a serious AE requiring hospitalisation; four patients (0.8%) required a blood transfusion related to the kidney biopsy. At one site where the number of cores retrieved during the biopsy was recorded, the mean was 3.4 for those who experienced a related AE (n=9) and 3.07 for those who did not experience any AE (n=140). All related AEs resolved. Conclusions Procurement of research tissue should be considered feasible, accompanied by a complication risk likely no greater than that incurred for standard clinical purposes. In the quest for targeted treatments personalised based on molecular findings, enhanced diagnostics beyond histology will likely be required.
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Affiliation(s)
- Kristina K Deonaraine
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Philip M Carlucci
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Andrea Fava
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica Li
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - David Wofsy
- Rheumatology Division and Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Judith A James
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Chaim Putterman
- Division of Rheumatology and Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Betty Diamond
- Center for Autoimmune and Musculoskeletal Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Anne Davidson
- Center for Autoimmune and Musculoskeletal Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Derek M Fine
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Mohamed G Atta
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Kristin Haag
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William Apruzzese
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - H Michael Belmont
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Peter M Izmirly
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Ming Wu
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sean Connery
- Department of Internal Medicine, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Fernanda Payan-Schober
- Department of Internal Medicine, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, NY, USA
| | - Celine C Berthier
- Internal Medicine, Department of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Maria Dall'Era
- Rheumatology Division and Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Kerry Cho
- Nephrology Division, University of California San Francisco, San Francisco, CA, USA
| | - Diane L Kamen
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth Kalunian
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Jennifer Anolik
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Mariko Ishimori
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael H Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Michelle A Petri
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Jill P Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
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14
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Izmirly PM, Kim MY, Samanovic M, Fernandez-Ruiz R, Ohana S, Deonaraine KK, Engel AJ, Masson M, Xie X, Cornelius AR, Herati RS, Haberman RH, Scher JU, Guttmann A, Blank RB, Plotz B, Haj-Ali M, Banbury B, Stream S, Hasan G, Ho G, Rackoff P, Blazer AD, Tseng CE, Belmont HM, Saxena A, Mulligan MJ, Clancy RM, Buyon JP. Evaluation of Immune Response and Disease Status in SLE Patients Following SARS-CoV-2 Vaccination. Arthritis Rheumatol 2021; 74:284-294. [PMID: 34347939 PMCID: PMC8426963 DOI: 10.1002/art.41937] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multi-ethnic/racial cohort of patients with systemic lupus erythematosus (SLE). METHODS 90 SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; IFN-γ production to assess T cell responses was measured by ELISpot. Disease activity was measured by the hybrid SLE disease activity index (SLEDAI) and flares were assigned by the SELENA/SLEDAI flare index. RESULTS Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD than controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-dsDNA level prior to vaccination associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 Spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and antigen-specific IFN-γ production determined by ELISpot. In a subset of patients with poor antibody responses, IFN-γ production was likewise diminished. Pre-/post-vaccination SLEDAI scores were similar. Only 11.4% of patients had a post-vaccination flare; 1.3% were severe. CONCLUSION In a multi-ethnic/racial study of SLE patients 29% had a low response to the COVID-19 vaccine which was associated with being on immunosuppression. Reassuringly, disease flares were rare. While minimal protective levels remain unknown, these data suggest protocol development is needed to assess efficacy of booster vaccination.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mimi Y Kim
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, New York, NY, 10461, USA
| | - Marie Samanovic
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Sharon Ohana
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Kristina K Deonaraine
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Alexis J Engel
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Xianhong Xie
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, New York, NY, 10461, USA
| | - Amber R Cornelius
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ramin S Herati
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Rebecca H Haberman
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Jose U Scher
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Allison Guttmann
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Rebecca B Blank
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Benjamin Plotz
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mayce Haj-Ali
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Brittany Banbury
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Sara Stream
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ghadeer Hasan
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Gary Ho
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Paula Rackoff
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Ashira D Blazer
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Chung-E Tseng
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - H Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Mark J Mulligan
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Vaccine Center, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY, 10016, USA
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15
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Izmirly PM, Parton H, Wang L, McCune WJ, Lim SS, Drenkard C, Ferucci ED, Dall'Era M, Gordon C, Helmick CG, Somers EC. Prevalence of Systemic Lupus Erythematosus in the United States: Estimates From a Meta-Analysis of the Centers for Disease Control and Prevention National Lupus Registries. Arthritis Rheumatol 2021; 73:991-996. [PMID: 33474834 PMCID: PMC8169527 DOI: 10.1002/art.41632] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/23/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Epidemiologic data on systemic lupus erythematosus (SLE) are limited, particularly for racial/ethnic subpopulations in the US. This meta-analysis leveraged data from the Centers for Disease Control and Prevention (CDC) National Lupus Registry network of population-based SLE registries to estimate the overall prevalence of SLE in the US. METHODS The CDC National Lupus Registry network includes 4 registries from unique states and a fifth registry from the Indian Health Service. All registries defined cases of SLE according to the American College of Rheumatology (ACR) 1997 revised classification criteria for SLE. Case findings spanned either 2002-2004 or 2007-2009. Given the heterogeneity across sites, a random-effects model was used to calculate the pooled prevalence of SLE. An estimate of the number of SLE cases in the US was generated by applying sex/race-stratified estimates to the 2018 US Census population. RESULTS In total, 5,417 cases were identified as fulfilling the ACR SLE classification criteria. The pooled prevalence of SLE from the 4 state-specific registries was 72.8 per 100,000 person-years (95% confidence interval [95% CI] 65.3-81.0). The prevalence estimate was 9 times higher among females than among males (128.7 versus 14.6 per 100,000), and highest among Black females (230.9 per 100,000), followed by Hispanic females (120.7 per 100,000), White females (84.7 per 100,000), and Asian/Pacific Islander females (84.4 per 100,000). Among males, the prevalence of SLE was highest in Black males (26.7 per 100,000), followed by Hispanic males (18.0 per 100,000), Asian/Pacific Islander males (11.2 per 100,000), and White males (8.9 per 100,000). The American Indian/Alaska Native population had the highest race-specific SLE estimates, both among females (270.6 per 100,000) and among males (53.8 per 100,000). In 2018, an estimated 204,295 individuals (95% CI 160,902-261,725) in the US fulfilled the ACR classification criteria for SLE. CONCLUSION A coordinated network of population-based SLE registries provides more accurate estimates of the prevalence of SLE and the numbers of individuals affected with SLE in the US in 2018.
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Affiliation(s)
- Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Hilary Parton
- New York City Department of Health and Mental Hygiene, Long Island City, New York, NY
| | - Lu Wang
- Department of Biostatistics, University of Michigan Schools of Medicine & Public Health, Ann Arbor, MI
| | - W. Joseph McCune
- Division of Rheumatology, Department of Medicine, University of Michigan Schools of Medicine, Ann Arbor, MI
| | - S. Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA
| | - Cristina Drenkard
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA
| | - Elizabeth D. Ferucci
- Division of Community Health Services, Department of Clinical and Research Services, Alaska Native Tribal Health Consortium, Anchorage, AK
| | - Maria Dall'Era
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Charles G. Helmick
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Emily C. Somers
- Division of Rheumatology, Department of Internal Medicine, Department of Environmental Health Sciences, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor MI
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16
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Saxena A, Guttmann A, Masson M, Kim MY, Haberman RH, Castillo R, Scher JU, Deonaraine KK, Engel AJ, Belmont HM, Blazer AD, Buyon JP, Fernandez-Ruiz R, Izmirly PM. Evaluation of SARS-CoV-2 IgG antibody reactivity in patients with systemic lupus erythematosus: analysis of a multi-racial and multi-ethnic cohort. Lancet Rheumatol 2021; 3:e585-e594. [PMID: 34075358 PMCID: PMC8159192 DOI: 10.1016/s2665-9913(21)00114-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Patients with systemic lupus erythematosus (SLE) are at risk of developing COVID-19 due to underlying immune abnormalities and regular use of immunosuppressant medications. We aimed to evaluate the presence of SARS-CoV-2 IgG antibodies in patients with SLE with or without previous COVID-19-related symptoms or RT-PCR-confirmed SARS-CoV-2 infection. Methods For this analysis, we included patients with SLE from two cohorts based in New York City: the Web-based Assessment of Autoimmune, Immune-Mediated and Rheumatic Patients during the COVID-19 pandemic (WARCOV) study; and the NYU Lupus Cohort (a prospective registry of patients at NYU Langone Health and NYC Health + Hospitals/Bellevue). Patients in both cohorts were tested for SARS-CoV-2 IgG antibodies via commercially available immunoassays, processed through hospital or outpatient laboratories. Patients recruited from the NYU Lupus Cohort, referred from affiliated providers, or admitted to hospital with COVID-19 were tested for SARS-CoV-2 IgG antibodies as part of routine surveillance during follow-up clinical visits. Findings 329 patients with SLE were included in this analysis, 146 from the WARCOV study and 183 from the NYU Lupus Cohort, and were tested for SARS-CoV-2 antibodies between April 29, 2020, and Feb 9, 2021. 309 (94%) were women and 91 (28%) were of Hispanic ethnicity. 51 (16%) of 329 patients had a positive SARS-CoV-2 IgG antibody test. Seropositive patients were more likely than seronegative patients to be Hispanic (24 [47%] of 51 vsz 67 [24%] of 278). Other demographic variables, SLE-specific factors, and immunosuppressant use were not associated with SARS-CoV-2 positivity. Of the 29 patients with COVID-19 previously confirmed by RT-PCR, 18 (62%) were on immunosuppressants; 24 (83%) of 29 patients tested positive for SARS-CoV-2 IgG antibodies. Of 17 patients who had symptoms of COVID-19 but negative concurrent RT-PCR testing, one (6%) developed an antibody response. Of 26 patients who had COVID-19-related symptoms but did not undergo RT-PCR testing, six (23%) developed an antibody response. Of 83 patients who had no symptoms of COVID-19 and no RT-PCR testing, four (5%) developed an antibody response. Among 36 patients who were initially SARS-CoV-2 IgG positive, the majority maintained reactivity serially (88% up to 10 weeks, 83% up to 20 weeks, and 80% up to 30 weeks). Seven (70%) of ten patients with confirmed COVID-19 had antibody positivity beyond 30 weeks from disease onset. Interpretation Most patients with SLE and confirmed COVID-19 were able to produce and maintain a serological response despite the use of a variety of immunosuppressants, providing reassurance about the efficacy and durability of humoral immunity and possible protection against re-infection with SARS-CoV-2. Funding National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, and Bloomberg Philanthropies COVID-19 Response Initiative Grant.
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Affiliation(s)
- Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Allison Guttmann
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Mimi Y Kim
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, The Bronx, New York, NY, USA
| | - Rebecca H Haberman
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Rochelle Castillo
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Jose U Scher
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Kristina K Deonaraine
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Alexis J Engel
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - H Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Ashira D Blazer
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
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17
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Hartl J, Serpas L, Wang Y, Rashidfarrokhi A, Perez OA, Sally B, Sisirak V, Soni C, Khodadadi-Jamayran A, Tsirigos A, Caiello I, Bracaglia C, Volpi S, Ghiggeri GM, Chida AS, Sanz I, Kim MY, Belmont HM, Silverman GJ, Clancy RM, Izmirly PM, Buyon JP, Reizis B. Autoantibody-mediated impairment of DNASE1L3 activity in sporadic systemic lupus erythematosus. J Exp Med 2021; 218:e20201138. [PMID: 33783474 PMCID: PMC8020718 DOI: 10.1084/jem.20201138] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/18/2020] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
Antibodies to double-stranded DNA (dsDNA) are prevalent in systemic lupus erythematosus (SLE), particularly in patients with lupus nephritis, yet the nature and regulation of antigenic cell-free DNA (cfDNA) are poorly understood. Null mutations in the secreted DNase DNASE1L3 cause human monogenic SLE with anti-dsDNA autoreactivity. We report that >50% of sporadic SLE patients with nephritis manifested reduced DNASE1L3 activity in circulation, which was associated with neutralizing autoantibodies to DNASE1L3. These patients had normal total plasma cfDNA levels but showed accumulation of cfDNA in circulating microparticles. Microparticle-associated cfDNA contained a higher fraction of longer polynucleosomal cfDNA fragments, which bound autoantibodies with higher affinity than mononucleosomal fragments. Autoantibodies to DNASE1L3-sensitive antigens on microparticles were prevalent in SLE nephritis patients and correlated with the accumulation of cfDNA in microparticles and with disease severity. DNASE1L3-sensitive antigens included DNA-associated proteins such as HMGB1. Our results reveal autoantibody-mediated impairment of DNASE1L3 activity as a common nongenetic mechanism facilitating anti-dsDNA autoreactivity in patients with severe sporadic SLE.
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Affiliation(s)
- Johannes Hartl
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Lee Serpas
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Yueyang Wang
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Ali Rashidfarrokhi
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Oriana A. Perez
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Benjamin Sally
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Vanja Sisirak
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
- Le Centre national de la recherche scientifique - unité mixte de recherche 5164, ImmunoConcEpt, Universite ´de Bordeaux, Bordeaux, France
| | - Chetna Soni
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
| | - Alireza Khodadadi-Jamayran
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
- Applied Bioinformatics Laboratories, New York University School of Medicine, New York, NY
| | - Aristotelis Tsirigos
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
- Applied Bioinformatics Laboratories, New York University School of Medicine, New York, NY
| | - Ivan Caiello
- Division of Rheumatology, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Claudia Bracaglia
- Division of Rheumatology, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Stefano Volpi
- Centro per le Malattie Autoinfiammatorie e Immunodeficienze, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università degli Studi di Genova, Genoa, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis and Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Asiya Seema Chida
- Division of Rheumatology, Department of Medicine, Lowance Center for Human Immunology, Emory University, Atlanta, GA
| | - Ignacio Sanz
- Division of Rheumatology, Department of Medicine, Lowance Center for Human Immunology, Emory University, Atlanta, GA
| | - Mimi Y. Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - H. Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Gregg J. Silverman
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Robert M. Clancy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Boris Reizis
- Department of Pathology, New York University Grossman School of Medicine, New York, NY
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
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18
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Aringer M, Brinks R, Dörner T, Daikh D, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Schmajuk G, Tani C, Tedeschi SK, Touma Z, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Costenbader K, Johnson SR. European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance. Ann Rheum Dis 2021; 80:775-781. [PMID: 33568386 DOI: 10.1136/annrheumdis-2020-219373] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 classification criteria for systemic lupus erythematosus system showed high specificity, while attaining also high sensitivity. We hereby analysed the performance of the individual criteria items and their contribution to the overall performance of the criteria. METHODS We combined the EULAR/ACR derivation and validation cohorts for a total of 1197 systemic lupus erythematosus (SLE) and n=1074 non-SLE patients with a variety of conditions mimicking SLE, such as other autoimmune diseases, and calculated the sensitivity and specificity for antinuclear antibodies (ANA) and the 23 specific criteria items. We also tested performance omitting the EULAR/ACR criteria attribution rule, which defines that items are only counted if not more likely explained by a cause other than SLE. RESULTS Positive ANA, the new entry criterion, was 99.5% sensitive, but only 19.4% specific, against a non-SLE population that included other inflammatory rheumatic, infectious, malignant and metabolic diseases. The specific criteria items were highly variable in sensitivity (from 0.42% for delirium and 1.84% for psychosis to 75.6% for antibodies to double-stranded DNA), but their specificity was uniformly high, with low C3 or C4 (83.0%) and leucopenia <4.000/mm³ (83.8%) at the lowest end. Unexplained fever was 95.3% specific in this cohort. Applying the attribution rule improved specificity, particularly for joint involvement. CONCLUSIONS Changing the position of the highly sensitive, non-specific ANA to an entry criterion and the attribution rule resulted in a specificity of >80% for all items, explaining the higher overall specificity of the criteria set.
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Affiliation(s)
- Martin Aringer
- University Medical Center and Faculty of Medicine, Department of Medicine III, Division of Rheumatology, TU Dresden, Dresden, Germany
| | - Ralph Brinks
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - David Daikh
- Oregon Health and Sciences University and Portland VA Health Care System, Portland, Oregon, USA
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Medicine/ Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - David Wofsy
- Russell/ Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, California, USA
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Division of Nephrology, Department of Medicine, University of Cambridge, Cambridge, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine, Centre de référence maladies auto-immunes et systémiques rares d'île de France, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bevra Hahn
- Rheumatology, UCLA School of Medicine, Los Angeles, California, USA
| | - Falk Hiepe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Bizkaia, The Basque Country, Spain
| | - Jorge Sanchez-Guerrero
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico.,Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Murray Urowitz
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Heraklion, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Bimba F Hoyer
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- University Medical Center and Faculty of Medicine, Department of Medicine III, Division of Rheumatology, TU Dresden, Dresden, Germany
| | - Gabriela Schmajuk
- Department of Medicine, Division of Rheumatology, University of California at San Francisco and the VA Medical Center, San Francisco, California, USA
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Ann Elaine Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Lupus Clinical Research Program, Office of the Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Department of Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico
| | - Íñigo Rúa-Figueroa
- Rheumatology, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Raphaèle Seror
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Vasconcelos
- Centro Hospitalar do Porto, ICBAS, UMIB, University of Porto, Porto, Portugal
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Rheumatology, Istanbul Bilim Universitesi, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Fcaulty of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Karen Costenbader
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sindhu R Johnson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada .,Department of Medicine, Division of Rheumatology, Toronto Western Hospital, Toronto, Ontario, Canada
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19
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Fernandez-Ruiz R, Masson M, Kim MY, Myers B, Haberman RH, Castillo R, Scher JU, Guttmann A, Carlucci PM, Deonaraine KK, Golpanian M, Robins K, Chang M, Belmont HM, Buyon JP, Blazer AD, Saxena A, Izmirly PM. Leveraging the United States Epicenter to Provide Insights on COVID-19 in Patients With Systemic Lupus Erythematosus. Arthritis Rheumatol 2020; 72:1971-1980. [PMID: 32715660 PMCID: PMC7941257 DOI: 10.1002/art.41450] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/06/2020] [Accepted: 07/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To characterize patients with systemic lupus erythematosus (SLE) affected by coronavirus disease 2019 (COVID-19) and to analyze associations of comorbidities and medications on infection outcomes. METHODS Patients with SLE and reverse transcriptase-polymerase chain reaction-confirmed COVID-19 were identified through an established New York University lupus cohort, query of 2 hospital systems, and referrals from rheumatologists. Data were prospectively collected via a web-based questionnaire and review of medical records. Data on baseline characteristics were obtained for all patients with COVID-19 to analyze risk factors for hospitalization. Data were also collected on asymptomatic patients and those with COVID-19-like symptoms who tested negative or were not tested. Statistical analyses were limited to confirmed COVID-19-positive patients. RESULTS A total of 226 SLE patients were included: 41 with confirmed COVID-19, 19 who tested negative for COVID-19, 42 with COVID-19-like symptoms who did not get tested, and 124 who remained asymptomatic without testing. Of the SLE patients with confirmed COVID-19, hospitalization was required in 24 (59%) and intensive care unit-level of care in 4, and 4 died. Hospitalized patients tended to be older, nonwhite, Hispanic, have higher body mas index (BMI), history of nephritis, and at least 1 comorbidity. An exploratory (due to limited sample size) logistic regression analysis identified race, presence of at least 1 comorbidity, and BMI as independent predictors of hospitalization. CONCLUSION In general, the variables predictive of hospitalization in our SLE patients were similar to those identified in the general population. Further studies are needed to understand additional risk factors for poor COVID-19 outcomes in patients with SLE.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Mimi Y. Kim
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, New York, NY
| | | | - Rebecca H. Haberman
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Rochelle Castillo
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Jose U. Scher
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Allison Guttmann
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Philip M. Carlucci
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Kristina K. Deonaraine
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Michael Golpanian
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Kimberly Robins
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Miao Chang
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - H. Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Ashira D. Blazer
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
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20
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Johnson SR, Brinks R, Costenbader KH, Daikh D, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger WB, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Aringer M. Performance of the 2019 EULAR/ACR classification criteria for systemic lupus erythematosus in early disease, across sexes and ethnicities. Ann Rheum Dis 2020; 79:1333-1339. [PMID: 32816709 DOI: 10.1136/annrheumdis-2020-217162] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 Classification Criteria for systemic lupus erythematosus (SLE) have been validated with high sensitivity and specificity. We evaluated the performance of the new criteria with regard to disease duration, sex and race/ethnicity, and compared its performance against the Systemic Lupus International Collaborating Clinics (SLICC) 2012 and ACR 1982/1997 criteria. METHODS Twenty-one SLE centres from 16 countries submitted SLE cases and mimicking controls to form the validation cohort. The sensitivity and specificity of the EULAR/ACR 2019, SLICC 2012 and ACR 1982/1997 criteria were evaluated. RESULTS The cohort consisted of female (n=1098), male (n=172), Asian (n=118), black (n=68), Hispanic (n=124) and white (n=941) patients; with an SLE duration of 1 to <3 years (n=196) and ≥5 years (n=879). Among patients with 1 to <3 years disease duration, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 81%). The EULAR/ACR criteria performed well in men (sensitivity 93%, specificity 96%) and women (sensitivity 97%, specificity 94%). Among women, the EULAR/ACR criteria had better sensitivity than the ACR criteria (97% vs 83%) and better specificity than the SLICC criteria (94% vs 82%). Among white patients, the EULAR/ACR criteria had better sensitivity than the ACR criteria (95% vs 83%) and better specificity than the SLICC criteria (94% vs 83%). The EULAR/ACR criteria performed well among black patients (sensitivity of 98%, specificity 100%), and had better sensitivity than the ACR criteria among Hispanic patients (100% vs 86%) and Asian patients (97% vs 77%). CONCLUSIONS The EULAR/ACR 2019 criteria perform well among patients with early disease, men, women, white, black, Hispanic and Asian patients. These criteria have superior sensitivity than the ACR criteria and/or superior specificity than the SLICC criteria across many subgroups.
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Affiliation(s)
- Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaulation, University of Toronto, Toronto, Ontario, Canada
| | - Ralph Brinks
- Policlinic and Hiller Research Unit of Rheumatology, Heinrich-Heine-University Duesseldorf, Düsseldorf, Germany
| | - Karen H Costenbader
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Rheumatology, Harvard Medical School, Boston, Massachusetts, USA
| | - David Daikh
- Medicine/Rheumatology, UCSF Medical Center, San Francisco, California, USA
| | - Marta Mosca
- Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Medicine/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Vienna, Austria
| | - David Wofsy
- Division of Rheumatology, , Russell/Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, California, USA
| | - Dimitrios T Boumpas
- Medicine, National and Kapodestrian University of Athens, and Biomedical Research Foundation of the Athens Academy, Athens, Greece.,Rheumatology, University of Cyprus Medical School, Nicosia, Nicosia, Cyprus
| | - Diane L Kamen
- Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Medicine, University of Cambridge, Cambridge, UK
| | - R Cervera
- Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine, Hospital Cochin, Paris, Île-de-France, France.,INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Betty Diamond
- Autoimmune and Musculoskeletal, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Medicine, University of Toronto, Toronto, Ontario, Canada.,Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Bevra Hahn
- Rheumatology, UCLA School of Medicine, Los Angeles, California, USA
| | - Falk Hiepe
- Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Department of Rheumatology, Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Rheumatology, Harvard Medical School, Boston, Massachusetts, USA.,Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | - Jorge Sanchez-Guerrero
- Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada.,Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty,Heinrich-Heine-University, Düsseldorf, Germany
| | - Murray Urowitz
- Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Crete, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Rheumatology and Clinical Immunology, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Rheumatology, Azienda Ospedaliero Universitaria Pisana, Pisa, Toscana, Italy.,Rheumatology, University of Pisa, Pisa, Toscana, Italy
| | - Sara K Tedeschi
- Rheumatology, Harvard Medical School, Boston, Massachusetts, USA.,Medicine, Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gabriela Schmajuk
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, San Francisco, California, USA
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Ann Elaine Clarke
- Rheumatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Rheumatology, NIAMS, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Rheumatology, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR, Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Íñigo Rúa-Figueroa
- Rheumatology, Dr Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Raphaèle Seror
- INSERM UMR 1163, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Paris, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athinon, Greece
| | | | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D J Wallace
- Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Rheumatology, Istanbul Bilim Universitesi, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ray Naden
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Aringer
- Rheumatology, University Medical Center and Faculty of Medicine Carl Gustav Carus, Dresden, Germany
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21
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Friedman DM, Kim M, Costedoat-Chalumeau N, Clancy R, Copel J, Phoon CK, Cuneo BF, Cohen R, Masson M, Wainwright BJ, Zahr N, Saxena A, Izmirly PM, Buyon JP. Electrocardiographic QT Intervals in Infants Exposed to Hydroxychloroquine Throughout Gestation. Circ Arrhythm Electrophysiol 2020; 13:e008686. [PMID: 32907357 DOI: 10.1161/circep.120.008686] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Based on inhibition of viral replication and limited reports on clinical efficacy, hydroxychloroquine is being considered as prophylaxis and treatment of coronavirus disease-19 (COVID-19). Although hydroxychloroquine is generally considered safe during pregnancy based on studies in patients with systemic lupus erythematosus and other rheumatic conditions, there may still be reluctance to institute this antimalarial during pregnancy for the sole purpose of antiviral therapy. METHODS To provide data regarding any potential fetal/neonatal cardiotoxicity, we leveraged a unique opportunity in which neonatal ECGs and hydroxychloroquine blood levels were available in a recently completed study evaluating the efficacy of hydroxychloroquine 400 mg daily to prevent the recurrence of congenital heart block associated with anti-SSA/Ro (anti-Sjögren's Syndrome A/Ro) antibodies. RESULTS Forty-five ECGs were available for corrected QT interval (QTc) measurement, and levels of hydroxychloroquine were assessed during each trimester of pregnancy and in the cord blood, providing unambiguous assurance of drug exposure. Overall, there was no correlation between cord blood levels of hydroxychloroquine and the neonatal QTc (R=0.02, P=0.86) or the mean of hydroxychloroquine values obtained throughout each individual pregnancy and the QTc (R=0.04, P=0.80). In total 5 (11% [95% CI, 4%-24%]) neonates had prolongation of the QTc >2 SD above historical healthy controls (2 markedly and 3 marginally) but ECGs were otherwise normal. CONCLUSIONS In aggregate, these data provide reassurances that the maternal use of hydroxychloroquine is associated with a low incidence of infant QTc prolongation. However, if included in clinical COVID-19 studies, early postnatal ECGs should be considered. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01379573.
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Affiliation(s)
| | - Mimi Kim
- Albert Einstein College of Medicine, Bronx, NY (M.K.)
| | | | - Robert Clancy
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | | | - Colin K Phoon
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Bettina F Cuneo
- University of Colorado School of Medicine, Aurora, CO (B.F.C.)
| | - Rebecca Cohen
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Mala Masson
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Benjamin J Wainwright
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Noel Zahr
- Pitié-Salpêtrière University Hospital, Paris, France (N.Z.)
| | - Amit Saxena
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Peter M Izmirly
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
| | - Jill P Buyon
- New York University School of Medicine, New York, NY (R. Clancy, C.K.P., R. Cohen, M.M., B.J.W., A.S., P.M.I., J.P.B.)
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22
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Fernandez-Ruiz R, Bornkamp N, Kim MY, Askanase A, Zezon A, Tseng CE, Belmont HM, Saxena A, Salmon JE, Lockshin M, Buyon JP, Izmirly PM. Discontinuation of hydroxychloroquine in older patients with systemic lupus erythematosus: a multicenter retrospective study. Arthritis Res Ther 2020; 22:191. [PMID: 32807233 PMCID: PMC7430013 DOI: 10.1186/s13075-020-02282-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/31/2020] [Indexed: 02/07/2023] Open
Abstract
Background Although hydroxychloroquine (HCQ) is a mainstay of treatment for patients with systemic lupus erythematosus (SLE), ocular toxicity can result from accumulated exposure. As the longevity of patients with SLE improves, data are needed to balance the risk of ocular toxicity and the risk of disease flare, especially in older patients with quiescent disease. Accordingly, this study was initiated to examine the safety of HCQ withdrawal in older SLE patients. Methods Data were obtained by retrospective chart review at three major lupus centers in New York City. Twenty-six patients who discontinued HCQ and thirty-two patients on HCQ matched for gender, race/ethnicity, and age were included in this study. The primary outcome was the occurrence of a lupus flare classified by the revised version of the Safety of Estrogens in Lupus Erythematosus: National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) Flare composite index, within 1 year of HCQ withdrawal or matched time of continuation. Results Five patients (19.2%) in the HCQ withdrawal group compared to five (15.6%) in the HCQ continuation group experienced a flare of any severity (odds ratio [OR] = 1.28; 95% CI 0.31, 5.30; p = 0.73). There were no severe flares in either group. The results were similar after adjusting for length of SLE, number of American College of Rheumatology criteria, low complement levels, and SELENA-SLEDAI score, and in a propensity score analysis (OR = 1.18; 95% CI 0.23, 6.16; p = 0.84). The analysis of time to any flare revealed a non-significant earlier time to flare in the HCQ withdrawal group (log-rank p = 0.67). Most flares were in the cutaneous and musculoskeletal systems, but one patient in the continuation group developed pericarditis. The most common reason for HCQ withdrawal was retinal toxicity (42.3%), followed by patient’s preference (34.6%), other confirmed or suspected adverse effects (15.4%), ophthalmologist recommendation for macular degeneration (3.8%), and rheumatologist recommendation for quiescent SLE (3.8%). Conclusions In this retrospective study of older stable patients with SLE on long-term HCQ, withdrawal did not significantly increase the risk of flares.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA.
| | - Nicole Bornkamp
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Mimi Y Kim
- Division of Biostatistics, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, New York, NY, USA
| | - Anca Askanase
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Anna Zezon
- Division of Rheumatology, Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - Chung-E Tseng
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - H Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Jane E Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Michael Lockshin
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY, USA.
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23
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Miller-Archie SA, Izmirly PM, Berman JR, Brite J, Walker DJ, Dasilva RC, Petrsoric LJ, Cone JE. Systemic Autoimmune Disease Among Adults Exposed to the September 11, 2001 Terrorist Attack. Arthritis Rheumatol 2020; 72:849-859. [PMID: 31762219 PMCID: PMC7216890 DOI: 10.1002/art.41175] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 11/19/2019] [Indexed: 12/18/2022]
Abstract
Objective Autoimmune disease is an emerging condition among persons exposed to the September 11, 2001 attack on the World Trade Center (WTC). Components of the dust cloud resulting from the collapse of the WTC have been associated with development of a systemic autoimmune disease, as has posttraumatic stress disorder (PTSD). We undertook this study to determine whether dust exposure and PTSD were associated with an increased risk of systemic autoimmune disease in a 9/11‐exposed cohort. Methods Among 43,133 WTC Health Registry enrollees, 2,786 self‐reported having a post‐9/11 systemic autoimmune disease. We obtained informed consent to review medical records to validate systemic autoimmune disease diagnoses for 1,041 enrollees. Diagnoses of systemic autoimmune diseases were confirmed by classification criteria, rheumatologist diagnosis, or having been prescribed systemic autoimmune disease medication. Controls were enrollees who denied having an autoimmune disease diagnosis (n = 37,017). We used multivariable log‐binomial regression to examine the association between multiple 9/11 exposures and risk of post‐9/11 systemic autoimmune disease, stratifying by responders (rescue, recovery, and clean‐up workers) and community members (e.g., residents, area workers). Results We identified 118 persons with systemic autoimmune disease. Rheumatoid arthritis was most frequent (n = 71), followed by Sjӧgren's syndrome (n = 22), systemic lupus erythematosus (n = 20), myositis (n = 9), mixed connective tissue disease (n = 7), and scleroderma (n = 4). Among 9/11 responders, those with intense dust cloud exposure had almost twice the risk of systemic autoimmune disease (adjusted risk ratio 1.86 [95% confidence interval 1.02–3.40]). Community members with PTSD had a nearly 3‐fold increased risk of systemic autoimmune disease. Conclusion Intense dust cloud exposure among responders and PTSD among community members were associated with a statistically significant increased risk of new‐onset systemic autoimmune disease. Clinicians treating 9/11 survivors should be aware of the potential increased risk of systemic autoimmune disease in this population.
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Affiliation(s)
| | | | - Jessica R Berman
- Hospital for Special Surgery and Weill Cornell Medical College, New York, New York
| | - Jennifer Brite
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Deborah J Walker
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Renato C Dasilva
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Lysa J Petrsoric
- New York City Department of Health and Mental Hygiene, New York, New York
| | - James E Cone
- New York City Department of Health and Mental Hygiene, New York, New York
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24
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Nusbaum JS, Mirza I, Shum J, Freilich RW, Cohen RE, Pillinger MH, Izmirly PM, Buyon JP. Sex Differences in Systemic Lupus Erythematosus: Epidemiology, Clinical Considerations, and Disease Pathogenesis. Mayo Clin Proc 2020; 95:384-394. [PMID: 32029091 DOI: 10.1016/j.mayocp.2019.09.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/17/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multiorgan, systemic autoimmune disease that is more common in women than men and is typically diagnosed during reproductive age, necessitating sex-specific considerations in care. In women there is no substantive evidence to suggest that SLE reduces fertility, but subfertility may occur as a result of active disease, immunosuppressive drugs, and age-related declines in fertility related to delays in childbearing. Although pregnancy outcomes have improved, SLE still poses risks in pregnancy that contribute to poorer maternal and fetal outcomes. Cyclophosphamide, an important agent for the treatment of severe or life-threatening lupus, may adversely affect fertility, particularly with increases in dose and patient age. Fertility preservation techniques are therefore an important consideration for women and men before cytotoxic treatment. There is mixed evidence as to whether exogenous estrogen in the form of oral contraceptive pills or hormone replacement therapy may increase the risk for the development of SLE, but among women with SLE already diagnosed, combined oral contraceptive pills and hormone replacement therapy do not confer risk for severe flare and remain important in reproductive care. The higher incidence of SLE in women may nonetheless be attributable to effects of endogenous estrogen, as well as failures in X chromosome inactivation, increased Toll-like receptor gene products, and changes in microRNA function. A greater appreciation of the biological underpinnings and consequences of sex differences in SLE may lead to more targeted treatments and improved outcomes for patients with SLE.
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Affiliation(s)
- Julie S Nusbaum
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York.
| | - Ibraheem Mirza
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Justine Shum
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Robert W Freilich
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Rebecca E Cohen
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Michael H Pillinger
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
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25
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Clancy RM, Marion MC, Ainsworth HC, Blaser MJ, Chang M, Howard TD, Izmirly PM, Lacher C, Masson M, Robins K, Buyon JP, Langefeld CD. Salivary dysbiosis and the clinical spectrum in anti-Ro positive mothers of children with neonatal lupus. J Autoimmun 2019; 107:102354. [PMID: 31677965 DOI: 10.1016/j.jaut.2019.102354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/15/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
Abstract
Mothers giving birth to children with manifestations of neonatal lupus (NL) represent a unique population at risk for the development of clinically evident pathologic autoimmunity since many are asymptomatic and only become aware of anti-SSA/Ro positivity (anti-Ro+) based on heart block in their fetus. Accordingly, we hypothesized that the microbiome in saliva is associated with the development of autoreactivity and in some cases the progression in health status from benign to overt clinical disease including Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE). The study comprised a clinical spectrum of anti-Ro+ mothers, all of whom gave birth to a child with NL: 9 were asymptomatic or had an undifferentiated autoimmune disease (Asym/UAS) and 16 fulfilled criteria for SS and/or SLE. Microbial diversity was reduced across all levels from kingdom to species for the anti-Ro+ mothers vs healthy controls; however, there were no significant differences between Asym/UAS and SS/SLE mothers. Relative abundance of Proteobacteria and more specifically class Betaproteobacteria decreased with clinical severity (healthy controls < Asym/UAS < SS/SLE). These ordered differences were maintained through the taxonomic hierarchy to three genera (Lautropia, Comamonas, and Neisseria) and species within these genera (L. mirabilis, N. flavescens and N. oralis). Biometric analysis comparing von Willebrand Factor domains present in human Ro60 with L. mirabilis proteins support the hypothesis of molecular mimicry. These data position the microbiome in the development of anti-Ro reactivity and subsequent clinical spectrum of disease.
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Affiliation(s)
- R M Clancy
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA.
| | - M C Marion
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - H C Ainsworth
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M J Blaser
- Rutgers University, Center for Advanced Biotechnology and Medicine, Piscataway, NJ, USA
| | - M Chang
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - T D Howard
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - P M Izmirly
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - C Lacher
- Rutgers University, Center for Advanced Biotechnology and Medicine, Piscataway, NJ, USA
| | - M Masson
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - K Robins
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - J P Buyon
- NYU Langone Health, Department of Medicine, Division of Rheumatology, New York, NY, USA
| | - C D Langefeld
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
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26
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Saxena A, Izmirly PM, Bomar RP, Golpanian RS, Friedman DM, Eisenberg R, Kim MY, Buyon JP. Factors associated with long-term cardiac dysfunction in neonatal lupus. Ann Rheum Dis 2019; 79:217-224. [PMID: 31672776 DOI: 10.1136/annrheumdis-2019-215900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Cardiac manifestations of neonatal lupus (NL) have been associated with significant morbidity and mortality; however, there is minimal information on long-term outcomes of affected individuals. This study was initiated to evaluate the presence of and the risk factors associated with cardiac dysfunction in NL after birth in multiple age groups to improve counselling, to further understand pathogenesis and to provide potential preventative strategies. METHODS Echocardiogram reports were evaluated in 239 individuals with cardiac NL: 143 from age 0-1 year, 176 from age >1-17 years and 64 from age >17 years. Logistic regression analyses evaluated associations of cardiac dysfunction at each age group with demographic, fetal and postnatal factors, using imputation to address missing data. RESULTS Cardiac dysfunction was identified in 22.4% at age 0-1 year, 14.8% at age >1-17 years and 28.1% at age >17 years. Dysfunction in various age groups was significantly associated with male sex, black race, lower fetal heart rates, fetal extranodal cardiac disease and length of time paced. In 106 children with echocardiograms at ages 0-1 year and >1-17 years, 43.8% with dysfunction at age 0-1 year were also affected at age >1-17 years, while the others reverted to normal. Of children without dysfunction at age 0-1 year, 8.9% developed new dysfunction between ages >1 and 17 years. Among 34 with echocardiograms at ages >1-17 years and >17 years, 6.5% with normal function at age >1-17 years developed dysfunction in adulthood. CONCLUSIONS Risk factors in fetal life can influence cardiac morbidity into adulthood.Although limited by a small number of cases, cardiac dysfunction in the first year often normalises by later childhood. New-onset dysfunction, although rare, can occur de novo after the first year.
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Affiliation(s)
- Amit Saxena
- Medicine, NYU School of Medicine, New York, New York, United States
| | - Peter M Izmirly
- Medicine, NYU School of Medicine, New York, New York, United States
| | - Rebecca P Bomar
- Medicine, NYU School of Medicine, New York, New York, United States
| | | | | | - Ruth Eisenberg
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mimi Y Kim
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jill P Buyon
- Medicine, NYU School of Medicine, New York, New York, United States
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27
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Shipman WD, Chyou S, Ramanathan A, Izmirly PM, Sharma S, Pannellini T, Dasoveanu DC, Qing X, Magro CM, Granstein RD, Lowes MA, Pamer EG, Kaplan DH, Salmon JE, Mehrara BJ, Young JW, Clancy RM, Blobel CP, Lu TT. A protective Langerhans cell-keratinocyte axis that is dysfunctional in photosensitivity. Sci Transl Med 2019; 10:10/454/eaap9527. [PMID: 30111646 DOI: 10.1126/scitranslmed.aap9527] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 07/13/2018] [Indexed: 12/14/2022]
Abstract
Photosensitivity, or skin sensitivity to ultraviolet radiation (UVR), is a feature of lupus erythematosus and other autoimmune and dermatologic conditions, but the mechanistic underpinnings are poorly understood. We identify a Langerhans cell (LC)-keratinocyte axis that limits UVR-induced keratinocyte apoptosis and skin injury via keratinocyte epidermal growth factor receptor (EGFR) stimulation. We show that the absence of LCs in Langerin-diphtheria toxin subunit A (DTA) mice leads to photosensitivity and that, in vitro, mouse and human LCs can directly protect keratinocytes from UVR-induced apoptosis. LCs express EGFR ligands and a disintegrin and metalloprotease 17 (ADAM17), the metalloprotease that activates EGFR ligands. Deletion of ADAM17 from LCs leads to photosensitivity, and UVR induces LC ADAM17 activation and generation of soluble active EGFR ligands, suggesting that LCs protect by providing activated EGFR ligands to keratinocytes. Photosensitive systemic lupus erythematosus (SLE) models and human SLE skin show reduced epidermal EGFR phosphorylation and LC defects, and a topical EGFR ligand reduces photosensitivity. Together, our data establish a direct tissue-protective function for LCs, reveal a mechanistic basis for photosensitivity, and suggest EGFR stimulation as a treatment for photosensitivity in lupus erythematosus and potentially other autoimmune and dermatologic conditions.
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Affiliation(s)
- William D Shipman
- Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program, New York, NY 10065, USA.,Immunology and Microbial Pathogenesis Program, Weill Cornell Graduate School of Medical Sciences, New York, NY 10065, USA.,Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA
| | - Susan Chyou
- Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA
| | - Anusha Ramanathan
- Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA
| | - Peter M Izmirly
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
| | - Sneh Sharma
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Tania Pannellini
- Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA
| | - Dragos C Dasoveanu
- Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA.,Department of Physiology, Biophysics and Systems Biology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Xiaoping Qing
- Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA
| | - Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | | | | | - Eric G Pamer
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniel H Kaplan
- Department of Dermatology, University of Pittsburgh, PA 15260, USA.,Department of Immunology, University of Pittsburgh, PA 15260, USA
| | - Jane E Salmon
- Immunology and Microbial Pathogenesis Program, Weill Cornell Graduate School of Medical Sciences, New York, NY 10065, USA.,Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA.,Division of Rheumatology and Pediatric Rheumatology, Hospital for Special Surgery, New York, NY 10021, USA
| | - Babak J Mehrara
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - James W Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Rockefeller University, New York, NY 10065, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA.,Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Robert M Clancy
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
| | - Carl P Blobel
- Department of Physiology, Biophysics and Systems Biology, Weill Cornell Medicine, New York, NY 10065, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA.,Arthritis and Tissue Degeneration Program, Hospital for Special Surgery, New York, NY 10021, USA.,Institute for Advanced Studies, Technical University Munich, Munich, Germany
| | - Theresa T Lu
- Immunology and Microbial Pathogenesis Program, Weill Cornell Graduate School of Medical Sciences, New York, NY 10065, USA. .,Autoimmunity and Inflammation Program, Hospital for Special Surgery, New York, NY 10021, USA.,Division of Rheumatology and Pediatric Rheumatology, Hospital for Special Surgery, New York, NY 10021, USA.,Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY 10065, USA
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28
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Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Fernández Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Johnson SR. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol 2019; 71:1400-1412. [PMID: 31385462 DOI: 10.1002/art.40930] [Citation(s) in RCA: 913] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 05/01/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop new classification criteria for systemic lupus erythematosus (SLE) jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS This international initiative had four phases. 1) Evaluation of antinuclear antibody (ANA) as an entry criterion through systematic review and meta-regression of the literature and criteria generation through an international Delphi exercise, an early patient cohort, and a patient survey. 2) Criteria reduction by Delphi and nominal group technique exercises. 3) Criteria definition and weighting based on criterion performance and on results of a multi-criteria decision analysis. 4) Refinement of weights and threshold scores in a new derivation cohort of 1,001 subjects and validation compared with previous criteria in a new validation cohort of 1,270 subjects. RESULTS The 2019 EULAR/ACR classification criteria for SLE include positive ANA at least once as obligatory entry criterion; followed by additive weighted criteria grouped in 7 clinical (constitutional, hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and 3 immunologic (antiphospholipid antibodies, complement proteins, SLE-specific antibodies) domains, and weighted from 2 to 10. Patients accumulating ≥10 points are classified. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%, compared with 82.8% sensitivity and 93.4% specificity of the ACR 1997 and 96.7% sensitivity and 83.7% specificity of the Systemic Lupus International Collaborating Clinics 2012 criteria. CONCLUSION These new classification criteria were developed using rigorous methodology with multidisciplinary and international input, and have excellent sensitivity and specificity. Use of ANA entry criterion, hierarchically clustered, and weighted criteria reflects current thinking about SLE and provides an improved foundation for SLE research.
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Affiliation(s)
- Martin Aringer
- University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Karen Costenbader
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Daikh
- VA Medical Center and University of California, San Francisco
| | - Ralph Brinks
- Heinrich Heine University Dusseldorf, Dusseldorf, Germany
| | | | | | | | | | - Dimitrios T Boumpas
- National and Kapodestrian University of Athens Medical School and Biomedical Research Foundation of the Academy of Athens, Athens, Greece, and University of Cyprus Medical School, Nicosia, Cyprus
| | | | | | - Ricard Cervera
- Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, New York
| | - Dafna D Gladman
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Falk Hiepe
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Elena Massarotti
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jorge Sanchez-Guerrero
- Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada, and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Murray Urowitz
- Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | - George Bertsias
- University of Crete Medical School, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany, and University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zahi Touma
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Branimir Anic
- University of Zagreb School of Medicine and University Hospital Center Zagreb, Zagreb, Croatia
| | - Florence Assan
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM 1184, Le Kremlin-Bicêtre, France
| | | | - Ann Elaine Clarke
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Sarfaraz Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | - Michelle Jung
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Xavier Mariette
- AP-HP, Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, and Université Paris-Sud, INSERM UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- University of Zagreb School of Medicine and University Hospital Center Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Raphaèle Seror
- Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Edward M Vital
- University of Leeds, NIHR Leeds Biomedical Research Center, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Sule Yavuz
- Istanbul Bilim University, Istanbul, Turkey
| | | | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- McMaster University, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sindhu R Johnson
- Toronto Western Hospital, University Health Network, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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29
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Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, Smolen JS, Wofsy D, Boumpas DT, Kamen DL, Jayne D, Cervera R, Costedoat-Chalumeau N, Diamond B, Gladman DD, Hahn B, Hiepe F, Jacobsen S, Khanna D, Lerstrøm K, Massarotti E, McCune J, Ruiz-Irastorza G, Sanchez-Guerrero J, Schneider M, Urowitz M, Bertsias G, Hoyer BF, Leuchten N, Tani C, Tedeschi SK, Touma Z, Schmajuk G, Anic B, Assan F, Chan TM, Clarke AE, Crow MK, Czirják L, Doria A, Graninger W, Halda-Kiss B, Hasni S, Izmirly PM, Jung M, Kumánovics G, Mariette X, Padjen I, Pego-Reigosa JM, Romero-Diaz J, Rúa-Figueroa Fernández Í, Seror R, Stummvoll GH, Tanaka Y, Tektonidou MG, Vasconcelos C, Vital EM, Wallace DJ, Yavuz S, Meroni PL, Fritzler MJ, Naden R, Dörner T, Johnson SR. 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Ann Rheum Dis 2019; 78:1151-1159. [PMID: 31383717 DOI: 10.1136/annrheumdis-2018-214819] [Citation(s) in RCA: 619] [Impact Index Per Article: 123.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 04/27/2019] [Accepted: 05/01/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To develop new classification criteria for systemic lupus erythematosus (SLE) jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). METHODS This international initiative had four phases. (1) Evaluation of antinuclear antibody (ANA) as an entry criterion through systematic review and meta-regression of the literature and criteria generation through an international Delphi exercise, an early patient cohort and a patient survey. (2) Criteria reduction by Delphi and nominal group technique exercises. (3) Criteria definition and weighting based on criterion performance and on results of a multi-criteria decision analysis. (4) Refinement of weights and threshold scores in a new derivation cohort of 1001 subjects and validation compared with previous criteria in a new validation cohort of 1270 subjects. RESULTS The 2019 EULAR/ACR classification criteria for SLE include positive ANA at least once as obligatory entry criterion; followed by additive weighted criteria grouped in seven clinical (constitutional, haematological, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and three immunological (antiphospholipid antibodies, complement proteins, SLE-specific antibodies) domains, and weighted from 2 to 10. Patients accumulating ≥10 points are classified. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%, compared with 82.8% sensitivity and 93.4% specificity of the ACR 1997 and 96.7% sensitivity and 83.7% specificity of the Systemic Lupus International Collaborating Clinics 2012 criteria. CONCLUSION These new classification criteria were developed using rigorous methodology with multidisciplinary and international input, and have excellent sensitivity and specificity. Use of ANA entry criterion, hierarchically clustered and weighted criteria reflect current thinking about SLE and provide an improved foundation for SLE research.
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Affiliation(s)
- Martin Aringer
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Karen Costenbader
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Daikh
- University of California at San Francisco and VA Medical Center, San Francisco, California, USA
| | - Ralph Brinks
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rosalind Ramsey-Goldman
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef S Smolen
- Department of Rheumatology, Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Wofsy
- Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California at San Francisco, San Francisco, California, USA
| | - Dimitrios T Boumpas
- Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, and Biomedical Research Foundation of the Athens Academy, Athens, Greece.,Departments of Internal Medicine and Rheumatology, Clinical Immunology and Allergy, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Diane L Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nathalie Costedoat-Chalumeau
- Medicine, Toronto Western Hospital, University Health Network, Mount Sinai Hospital, University of Toronto, Toronto Scleroderma Research Program, Toronto, Ontario, Canada
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Dafna D Gladman
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bevra Hahn
- Division of Rheumatology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Falk Hiepe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Elena Massarotti
- Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Bizkaia, The Basque Country, Spain
| | - Jorge Sanchez-Guerrero
- Division of Rheumatology, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Matthias Schneider
- Policlinic and Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Lupus Clinic, Toronto, Ontario, Canada
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Crete, Greece
| | - Bimba F Hoyer
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Medicine III, University of Schleswig-Holstein at Kiel, Kiel, Germany
| | - Nicolai Leuchten
- Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Chiara Tani
- Department of Clinical and Experimental Medicine, Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara K Tedeschi
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gabriela Schmajuk
- University of California at San Francisco and VA Medical Center, San Francisco, California, USA
| | - Branimir Anic
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Florence Assan
- Department of Rheumatology, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Ann Elaine Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary K Crow
- Hospital for Special Surgery, Ney York, New York, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | | | | | - Sarfaraz Hasni
- Lupus Clinical Research Program, Office of the Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter M Izmirly
- Rheumatology, New York University School of Medicine, New York, New York, USA
| | - Michelle Jung
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux universitaires Paris-Sud - Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Department of Rheumatology, Université Paris-Sud, Center for Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - José M Pego-Reigosa
- Department of Rheumatology, University Hospital of Vigo, IRIDIS Group, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Juanita Romero-Diaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Raphaèle Seror
- Department of Rheumatology, Université Paris Sud, Hôpitaux Universitaires Paris-Sud, AP-HP, INSERM UMR 1184, Le Kremlin-Bicêtre, France
| | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Maria G Tektonidou
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto, ICBAS, University of Porto, Porto, Portugal
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sule Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul, Turkey
| | - Pier Luigi Meroni
- Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marvin J Fritzler
- Faculty of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ray Naden
- Maternal-Fetal Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sindhu R Johnson
- Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares d'île deFrance, Cochin Hospital, Université Paris Descartes-Sorbonne Paris Cité, INSERM U1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, France .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Izmirly PM, Buyon JP, Wan I, Belmont HM, Sahl S, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Helmick CG, Parton H. The Incidence and Prevalence of Adult Primary Sjögren's Syndrome in New York County. Arthritis Care Res (Hoboken) 2019; 71:949-960. [PMID: 30044541 DOI: 10.1002/acr.23707] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/17/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Extant epidemiologic data of primary Sjögren's syndrome (SS) remains limited, particularly for racial/ethnic populations in the US. The Manhattan Lupus Surveillance Program (MLSP) is a population-based retrospective registry of cases of systemic lupus erythematosus and related diseases, including primary SS in Manhattan, New York. The MLSP was used to provide estimates of the incidence and prevalence of primary SS across major racial/ethnic populations. METHODS MLSP cases were identified from hospitals, rheumatologists, and population databases. Three case definitions were used for primary SS, including physician diagnosis, rheumatologist diagnosis, and modified primary SS criteria. Rates among Manhattan residents were age-adjusted, and capture-recapture analyses were conducted to assess underascertainment of cases. RESULTS By physician diagnosis, age-adjusted overall incidence and prevalence rates of primary SS among adult Manhattan residents were 3.5 and 13.1 per 100,000 person-years, respectively. Capture-recapture adjustment increased incidence and prevalence rates (4.1 and 14.2 per 100,000 person-years, respectively). Based on physician diagnosis, incidence and prevalence rates were approximately 6 times higher among women than men (P < 0.001). Incidence of primary SS was statistically higher among non-Latina Asian women (10.5) and non-Latina white women (6.2) compared with Latina women (3.2). Incidence was also higher among non-Latina Asian women compared with non-Latina black women (3.3). Prevalence of primary SS did not differ by race/ethnicity. Similar trends were observed when more restrictive case definitions were applied. CONCLUSION Data from the MLSP revealed disparities among Manhattan residents in primary SS incidence and prevalence by sex and differences in primary SS incidence by race/ethnicity among women. These data also provided epidemiologic estimates for the major racial/ethnic populations in the US.
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Affiliation(s)
| | - Jill P Buyon
- New York University School of Medicine, New York, New York
| | - Isabella Wan
- New York University School of Medicine, New York, New York
| | | | - Sara Sahl
- Harbor-University of California Medical Center, Los Angeles
| | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Anca Askanase
- Columbia University College of Physicians & Surgeons, New York, New York
| | - Joan M Bathon
- Columbia University College of Physicians & Surgeons, New York, New York
| | | | - Yousaf Ali
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen M Ginzler
- State University of New York Downstate College of Medicine, Brooklyn
| | | | | | | | - Hilary Parton
- New York City Department of Health and Mental Hygiene, Long Island City, New York
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31
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Barsalou J, Costedoat-Chalumeau N, Berhanu A, Fors-Nieves C, Shah U, Brown P, Laskin CA, Morel N, Levesque K, Buyon JP, Silverman ED, Izmirly PM. Effect of in utero hydroxychloroquine exposure on the development of cutaneous neonatal lupus erythematosus. Ann Rheum Dis 2018; 77:1742-1749. [PMID: 30297329 DOI: 10.1136/annrheumdis-2018-213718] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Cutaneous neonatal lupus (cNL) occurs in possibly 5%-16% of anti-Ro±anti-La antibody-exposed infants. Data suggest in utero exposure to hydroxychloroquine (HCQ) may prevent cardiac NL. The aim was to assess whether in utero exposure to HCQ decreases the risk of cNL and/or delays onset. METHODS A multicentre case-control study was performed with 122 cNL cases and 434 controls born to women with a rheumatological disease who had documentation of maternal anti-Ro±anti-La antibodies at pregnancy and confirmation of medication use and the child's outcome. A secondary analysis was performed on 262 cNL cases, irrespective of maternal diagnosis, to determine if HCQ delayed time to cNL onset. RESULTS Twenty (16%) cNL cases were exposed to HCQ compared with 146 (34%) controls (OR 0.4 (95% CI 0.2 to 0.6); p<0.01). Exposure to HCQ was associated with a reduced risk of cNL; exposure to anti-La antibody and female gender were associated with an increased risk of cNL. Exposure to HCQ remained significantly associated with a reduced cNL risk in the analyses limited to mothers with systemic lupus erythematosus and those who developed rash ≤1 month. When analysing all 262 cNL cases, HCQ-exposed infants were older (6.0 (95% CI 5.7 to 6.3) weeks) at cNL onset versus HCQ-non-exposed infants (4.4 (95% CI 3.9 to 5.0) weeks), but the difference was not statistically significant (p=0.21). CONCLUSION Exposure to HCQ was associated with a reduced risk of cNL. Among cNL cases, those exposed to HCQ tend to have later onset of rash. Both findings suggest a protective effect of HCQ on cNL.
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Affiliation(s)
- Julie Barsalou
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Cochin Hospital, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, AP-HP, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Adey Berhanu
- Arthritis & Rheumatism Associates, PS Wheaton, Maryland, USA
| | - Cesar Fors-Nieves
- Division of Rheumatology, New York University School of Medicine, New York City, New York, USA
| | - Ummara Shah
- Division of Allergy, Immunology and Rheumatology, University of Rochester, School of Medicine and Dentistry, Rochester, USA
| | - Patrick Brown
- Department of Statistical Science, University of Toronto, Centre for Global Health Research, St Michael's Hospital, Toronto, Ontario, Canada
| | - Carl A Laskin
- Department of Medicine, Obstetrics and Gynaecology, University of Toronto, TRIO Fertility, Toronto, Ontario, Canada
| | - Nathalie Morel
- Department of Internal Medicine, Cochin Hospital, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, AP-HP, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Kateri Levesque
- Department of Internal Medicine, Cochin Hospital, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, AP-HP, Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Jill P Buyon
- Division of Rheumatology, New York University School of Medicine, New York City, New York, USA
| | - Earl D Silverman
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter M Izmirly
- Division of Rheumatology, New York University School of Medicine, New York City, New York, USA
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Yuriditsky E, Torres J, Izmirly PM, Belmont HM. Resolution of large aortic valve vegetations in antiphospholipid syndrome treated with therapeutic anticoagulation: a report of two cases and literature review. Lupus 2018; 27:2269-2273. [DOI: 10.1177/0961203318804876] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Non-bacterial thrombotic endocarditis in antiphospholipid syndrome presents a management dilemma. Large mobile valvular lesions pose an increased risk of stroke and arterial embolization. However, surgical excision or valve replacement in such patients carries high morbidity and mortality, while anticoagulation alone has limited data. We describe two patients with antiphospholipid syndrome presenting with neurologic events and large non-bacterial aortic valve vegetations. Both patients were successfully managed with anticoagulation and demonstrated rapid dissolution of lesions without evidence of recurrent embolic events. We provide a literature review describing additional cases managed with anticoagulation with dissolution of valvular lesions over time. Our cases further support the efficacy and safety of anticoagulation in patients with antiphospholipid syndrome and non-bacterial thrombotic endocarditis in the context of arterial embolization.
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Affiliation(s)
- E Yuriditsky
- New York University School of Medicine, New York, USA
| | - J Torres
- New York University School of Medicine, New York, USA
| | - P M Izmirly
- New York University School of Medicine, New York, USA
| | - H M Belmont
- New York University School of Medicine, New York, USA
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33
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Kim M, Merrill JT, Kalunian KC, Hanrahan L, Izmirly PM. CT-06 Missing outcomes in SLE clinical trials: impact on estimating treatment effects. Clin Trials 2018. [DOI: 10.1136/lupus-2018-lsm.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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34
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Izmirly PM, Wan I, Sahl S, Buyon JP, Belmont HM, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Helmick CG, Parton H. The Incidence and Prevalence of Systemic Lupus Erythematosus in New York County (Manhattan), New York: The Manhattan Lupus Surveillance Program. Arthritis Rheumatol 2017; 69:2006-2017. [PMID: 28891252 DOI: 10.1002/art.40192] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/22/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The Manhattan Lupus Surveillance Program (MLSP) is a population-based registry designed to determine the prevalence of systemic lupus erythematosus (SLE) in 2007 and the incidence from 2007 to 2009 among residents of New York County (Manhattan), New York, and to characterize cases by race/ethnicity, including Asians and Hispanics, for whom data are lacking. METHODS We identified possible SLE cases from hospital records, rheumatologist records, and administrative databases. Cases were defined according to the American College of Rheumatology (ACR) classification criteria, the Systemic Lupus International Collaborating Clinics (SLICC) classification criteria, or the treating rheumatologist's diagnosis. Rates among Manhattan residents were age-standardized, and capture-recapture analyses were conducted to assess case underascertainment. RESULTS By the ACR definition, the age-standardized prevalence and incidence rates of SLE were 62.2 and 4.6 per 100,000 person-years, respectively. Rates were ∼9 times higher in women than in men for prevalence (107.4 versus 12.5) and incidence (7.9 versus 1.0). Compared with non-Hispanic white women (64.3), prevalence was higher among non-Hispanic black (210.9), Hispanic (138.3), and non-Hispanic Asian (91.2) women. Incidence rates were higher among non-Hispanic black women (15.7) compared with non-Hispanic Asian (6.6), Hispanic (6.5), and non-Hispanic white (6.5) women. Capture-recapture adjustment increased the prevalence and incidence rates (75.9 and 6.0, respectively). Alternate SLE definitions without capture-recapture adjustment revealed higher age-standardized prevalence and incidence rates (73.8 and 6.2, respectively, by the SLICC definition and 72.6 and 5.0 by the rheumatologist definition) than the ACR definition, with similar patterns by sex and race/ethnicity. CONCLUSION The MLSP confirms findings from other registries on disparities by sex and race/ethnicity, provides new estimates among Asians and Hispanics, and provides estimates using the SLICC criteria.
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Affiliation(s)
| | - Isabella Wan
- New York University School of Medicine, New York, New York
| | - Sara Sahl
- New York University School of Medicine, New York, New York
| | - Jill P Buyon
- New York University School of Medicine, New York, New York
| | | | - Jane E Salmon
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Anca Askanase
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Joan M Bathon
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Yousaf Ali
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen M Ginzler
- State University of New York Downstate College of Medicine, Brooklyn
| | | | | | | | - Hilary Parton
- New York City Department of Health and Mental Hygiene, Long Island City, New York
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35
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Friedman D, Lovig L, Halushka M, Clancy RM, Izmirly PM, Buyon JP. No histologic evidence of foetal cardiotoxicity following exposure to maternal hydroxychloroquine. Clin Exp Rheumatol 2017; 35:857-859. [PMID: 28598777 PMCID: PMC5657477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Abstract
It is currently recommended that hydroxychloroquine (HCQ) be maintained during pregnancy in patients with systemic lupus erythematosus. Recent data suggest that this Toll-like receptor inhibitor may also reduce the recurrence rate of anti-SSA/Ro associated congenital heart block (CHB). This case report describes a unique situation in which a CHB-afflicted, HCQ-exposed pregnancy was electively terminated. The heart did not reveal any characteristic features of cardiotoxicity, providing further evidence supporting the safety of foetal exposure to HCQ.
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Affiliation(s)
| | - Leif Lovig
- Paediatric Cardiology, Children's and Women's Physicians of Westchester LLP, Norwalk, CT, USA
| | - Marc Halushka
- Pathology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Robert M Clancy
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Peter M Izmirly
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Jill P Buyon
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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Abstract
Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.
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Affiliation(s)
- P Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M A Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, Kings College London St Thomas Hospital, United Kingdom
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Izmirly PM, Saxena A. In search of an antibody specificity highly predictive of congenital heart block. Lupus Sci Med 2016; 3:e000154. [PMID: 27158527 PMCID: PMC4854070 DOI: 10.1136/lupus-2016-000154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine , New York University School of Medicine , New York, New York , USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine , New York University School of Medicine , New York, New York , USA
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38
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Izmirly PM, Saxena A, Sahl SK, Shah U, Friedman DM, Kim MY, Buyon JP. Assessment of fluorinated steroids to avert progression and mortality in anti-SSA/Ro-associated cardiac injury limited to the fetal conduction system. Ann Rheum Dis 2015; 75:1161-5. [PMID: 26835701 DOI: 10.1136/annrheumdis-2015-208311] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/07/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Extension of disease beyond the atrioventricular (AV) node is associated with increased mortality in cardiac neonatal lupus (NL). Treatment of isolated heart block with fluorinated steroids to prevent disease progression has been considered but published data are limited and discordant regarding efficacy. This study evaluated whether fluorinated steroids given to manage isolated advanced block prevented development of disease beyond the AV node and conferred a survival benefit. METHODS In this retrospective study of cases enrolled in the Research Registry for NL, inclusion was restricted to anti-SSA/Ro-exposed cases presenting with isolated advanced heart block in utero who either received fluorinated steroids within 1 week of detection (N=71) or no treatment (N=85). Outcomes evaluated were: development of endocardial fibroelastosis, dilated cardiomyopathy and/or hydrops fetalis; mortality and pacemaker implantation. RESULTS In Cox proportional hazards regression analyses, fluorinated steroids did not significantly prevent development of disease beyond the AV node (adjusted HR=0.90; 95% CI 0.43 to 1.85; p=0.77), reduce mortality (HR=1.63; 95% CI 0.43 to 6.14; p=0.47) or forestall/prevent pacemaker implantation (HR=0.87; 95% CI 0.57 to 1.33; p=0.53). No risk factors for development of disease beyond the AV node were identified. CONCLUSIONS These data do not provide evidence to support the use of fluorinated steroids to prevent disease progression or death in cases presenting with isolated heart block.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Sara K Sahl
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Ummara Shah
- Division of Rheumatology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, New York, USA
| | - Deborah M Friedman
- Division of Pediatric Cardiology, Department of Pediatrics, New York Medical College, Valhalla, New York, USA
| | - Mimi Y Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA
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39
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Saxena A, Izmirly PM, Han SW, Briassouli P, Rivera TL, Zhong H, Friedman DM, Clancy RM, Buyon JP. Serum Biomarkers of Inflammation, Fibrosis, and Cardiac Function in Facilitating Diagnosis, Prognosis, and Treatment of Anti-SSA/Ro-Associated Cardiac Neonatal Lupus. J Am Coll Cardiol 2015; 66:930-9. [PMID: 26293764 DOI: 10.1016/j.jacc.2015.06.1088] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 06/11/2015] [Accepted: 06/15/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cardiac manifestations of neonatal lupus (cardiac NL) include congenital heart block and cardiomyopathy. Several candidate biomarkers were evaluated in cases at risk for cardiac NL on the basis of potential roles in inflammation, fibrosis, and cardiac dysfunction: C-reactive protein (CRP); NT-pro-B-type natriuretic peptide (NT-proBNP); troponin I; matrix metalloproteinase (MMP)-2; urokinase plasminogen activator (uPA); urokinase plasminogen activator receptor (uPAR); plasminogen; and vitamin D. OBJECTIVES Identification of maternal and fetal biomarkers associated with development and morbidity of cardiac NL should provide clues to pathogenesis with translational implications for management. METHODS Cord (139) and maternal (135) blood samples collected during pregnancies at risk for cardiac NL were available for study. Levels of cord and maternal CRP, cord NT-proBNP, and cord troponin I were evaluated using multiplex assays. Cord and maternal vitamin D were assessed by liquid chromatography-mass spectrometry. MMP-2, uPA, uPAR, and plasminogen were evaluated using ELISA. RESULTS Cord CRP, NT-proBNP, MMP-2, uPA, uPAR, and plasminogen levels were higher in cardiac NL-affected fetuses than in unaffected cases, independent of maternal rheumatic disease, season at highest risk of cardiac NL development, and medications taken during pregnancy. These biomarkers were positively associated with a disease severity score derived from known risk factors for mortality in cardiac NL. Maternal CRP and cord troponin I levels did not differ between the groups. Cord and maternal vitamin D levels were not significantly associated with cardiac NL, but average maternal vitamin D level during pregnancy was positively associated with longer time to postnatal pacemaker placement. CONCLUSIONS These data support the association of fetal reactive inflammatory and fibrotic components with development and morbidity of cardiac NL. Following CRP and NT-proBNP levels after birth can potentially monitor severity and progression of cardiac NL. MMP-2 and the uPA/uPAR/plasminogen cascade provide therapeutic targets to decrease fibrosis. Although decreased vitamin D did not confer increased risk, given the positive influence on postnatal outcomes, maternal levels should be optimized.
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Affiliation(s)
- Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York.
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Sung Won Han
- Department of Population Health, New York University School of Medicine, New York, New York
| | - Paraskevi Briassouli
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Tania L Rivera
- Division of Rheumatology, Department of Medicine, Scripps Memorial Hospital, La Jolla, San Diego, California
| | - Hua Zhong
- Department of Population Health, New York University School of Medicine, New York, New York
| | - Deborah M Friedman
- Division of Pediatric Cardiology, New York Medical College, Valhalla, New York
| | - Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
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Graffeo CS, Tanweer O, Nieves CF, Belmont HM, Izmirly PM, Becske T, Huang PP. Rapid aneurysm growth and rupture in systemic lupus erythematosus. Surg Neurol Int 2015; 6:9. [PMID: 25657862 PMCID: PMC4310132 DOI: 10.4103/2152-7806.149617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 11/02/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) due to intracranial aneurysm rupture is a major neurosurgical emergency associated with significant morbidity and mortality. Rapid aneurysm growth is associated with rupture. Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder whose complications can include cerebral vasculitis and vasculopathy. Intracranial aneurysms are not known to occur more frequently in SLE patients than the general population; however, aneurysm growth rates have not been studied in SLE. CASE DESCRIPTION We present a 43-year-old female with SLE on prednisone, hydroxychloroquine, and azathioprine with moderate disease activity who presented with severe, acute-onset headache and was found to have Hunt and Hess grade II SAH due to rupture of an 8 mm saccular anterior communicating artery (ACoA) aneurysm. The patient developed severe vasospasm, re-ruptured, and was taken for angiography and embolization, which was challenging due to a high degree of vasospasm and arterial stenosis. Review of imaging from less than 2 years prior demonstrated a normal ACoA complex without evidence of an aneurysm. CONCLUSION We review the literature and discuss the risk factors and pathophysiology of rapid aneurysm growth and rupture, as well as the pathologic vascular changes associated with SLE. Although SLE patients do not develop intracranial aneurysm at an increased rate, these changes may predispose them to higher incidence of growth and rupture. This possibility-coupled with increased morbidity and mortality of SAH in SLE-suggests that SAH should be considered in SLE patients presenting with headache, and advocates for more aggressive treatment of SLE patients with unruptured aneurysms.
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Affiliation(s)
| | - Omar Tanweer
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Cesar Fors Nieves
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - H Michael Belmont
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Peter M Izmirly
- Department of Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Tibor Becske
- Department of Radiology, New York University School of Medicine, New York, USA ; Department of Neurology, New York University School of Medicine, New York, USA
| | - Paul P Huang
- Department of Neurosurgery, New York University School of Medicine, New York, USA
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Abstract
PURPOSE OF REVIEW Cardiac manifestations of neonatal lupus include anti-SSA/Ro-SSB/La-mediated conduction system disease and endocardial/myocardial damage resulting in cardiomyopathy. This review will focus on recent data regarding updates on the proposed pathogenesis of disease, morbidity and mortality, and preventive and treatment therapies. RECENT FINDINGS Evidence from animal models suggests that reactivity to the p200 region of the Ro52 protein, as well as antibody targeting of L-type calcium channels may be important in the development of cardiac neonatal lupus. In-vitro studies support a protective role of β-2 glycoprotein 1 (prevents anti-Ro binding to apoptotic cells) and pathologic roles of the urokinase-plasminogen activator/receptor system (leads to activation of TGF-β), and endothelin-1 secretion by macrophages in mediating tissue injury. Genetic studies highlight the fetal major histocompatibility complex in the development of disease, and a multigenerational study demonstrates that mothers of neonatal lupus children accumulate genetic risk factors preferentially from the neonatal lupus child's grandparents. Retrospective studies identify demographic and echocardiographic risk factors for morbidity and mortality and address the role of fluorinated steroids, intravenous immunoglobulin and hydroxychloroquine for prevention and treatment of disease. SUMMARY Animal studies, in-vitro experiments, genetic analysis and clinical-translational research in cardiac neonatal lupus reveal novel insights and targets for therapy in this often devastating disease.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, USA.
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Reed JH, Clancy RM, Lee KH, Saxena A, Izmirly PM, Buyon JP. Umbilical cord blood levels of maternal antibodies reactive with p200 and full-length Ro 52 in the assessment of risk for cardiac manifestations of neonatal lupus. Arthritis Care Res (Hoboken) 2012; 64:1373-81. [PMID: 22511615 DOI: 10.1002/acr.21704] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Maternal anti-Ro autoantibodies are associated with cardiac manifestations of neonatal lupus (cardiac NL), yet only 2% of women with this reactivity have an affected child. Identification of a more specific marker would channel intense monitoring to fetuses at greater risk. This study aimed to determine whether autoantibodies against Ro 52 amino acids 200-239 (p200) confer added risk over autoantibodies to full-length Ro 52, Ro 60, or La. METHODS Anti-Ro-exposed pregnancies resulting in cardiac NL or no cardiac manifestations were identified from the Research Registry for Neonatal Lupus and the PR Interval and Dexamethasone Evaluation study. Umbilical cord (n = 123) and maternal (n = 115) samples were evaluated by enzyme-linked immunosorbent assay. RESULTS The frequencies of p200, Ro 52, Ro 60, and La autoantibodies were not significantly different between affected and unaffected children. However, neonatal anti-Ro 52 and Ro 60 titers were highest in cardiac NL and their unaffected siblings compared to unaffected neonates without a cardiac NL sibling. Although both maternal anti-Ro 52 and p200 autoantibodies were less than 50% specific for cardiac NL, anti-p200 was the least likely of the Ro autoantibodies to be false-positive in mothers who have never had an affected child. Titers of anti-Ro 52 and p200 did not differ during a cardiac NL or unaffected pregnancy from the same mother. CONCLUSION Maternal reactivity to p200 does not confer an added risk to fetal conduction defects over full-length Ro 52 or Ro 60 autoantibodies. Mothers who may never be at risk for having an affected child have lower anti-Ro 60 titers and may require less stringent echocardiographic monitoring compared to women with high-titer autoantibodies.
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Affiliation(s)
- Joanne H Reed
- New York University School of Medicine, New York, USA.
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Izmirly PM, Costedoat-Chalumeau N, Pisoni CN, Khamashta MA, Kim MY, Saxena A, Friedman D, Llanos C, Piette JC, Buyon JP. Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus. Circulation 2012; 126:76-82. [PMID: 22626746 DOI: 10.1161/circulationaha.111.089268] [Citation(s) in RCA: 250] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND A recent case-control study suggested a benefit of hydroxychloroquine (HCQ) in lowering the risk of cardiac manifestations of neonatal lupus (cardiac-NL) in pregnancies of anti-SSA/Ro-positive patients with systemic lupus erythematosus. A historical cohort assembled from 3 international databases was used to evaluate whether HCQ reduces the nearly 10-fold increase in risk of recurrence of cardiac-NL independently of maternal health status. METHODS AND RESULTS Two hundred fifty-seven pregnancies of anti-SSA/Ro-positive mothers (40 exposed and 217 unexposed to HCQ) subsequent to the birth of a child with cardiac-NL were identified from 3 databases (United States, England, and France). Exposure was defined as the sustained use of HCQ throughout pregnancy with initiation before 10 weeks of gestation. The recurrence rate of cardiac-NL in fetuses exposed to HCQ was 7.5% (3 of 40) compared with 21.2% (46 of 217) in the unexposed group (P=0.050). Although there were no deaths in the exposed group, the overall case fatality rate of the cardiac-NL fetuses in the unexposed group was 21.7%. In a multivariable analysis that adjusted for database source, maternal race/ethnicity, and anti-SSB/La status, HCQ use remained significantly associated with a decreased risk of cardiac-NL (odds ratio, 0.23; 95% confidence interval, 0.06-0.92; P=0.037). Similar results were obtained with propensity score analysis, an alternative approach to adjust for possible confounding by indication. CONCLUSION Aggregate data from a multinational effort show that in mothers at high risk of having a child with cardiac-NL, the use of HCQ may protect against recurrence of disease in a subsequent pregnancy.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA.
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Llanos C, Friedman DM, Saxena A, Izmirly PM, Tseng CE, Dische R, Abellar RG, Halushka M, Clancy RM, Buyon JP. Anatomical and pathological findings in hearts from fetuses and infants with cardiac manifestations of neonatal lupus. Rheumatology (Oxford) 2012; 51:1086-92. [PMID: 22308531 DOI: 10.1093/rheumatology/ker515] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The autopsy and clinical information on children dying with anti-SSA/Ro-associated cardiac manifestations of neonatal lupus (cardiac NL) were examined to identify patterns of disease, gain insight into pathogenesis and enhance the search for biomarkers and preventive therapies. METHODS A retrospective analysis evaluating reports from 18 autopsies of cardiac NL cases and clinical data from the Research Registry for Neonatal Lupus was performed. RESULTS Of the 18 cases with autopsies, 15 had advanced heart block, including 3 who died in the second trimester, 9 in the third trimester and 3 post-natally. Three others died of cardiomyopathy without advanced block, including two dying pre-natally and one after birth. Pathological findings included fibrosis/calcification of the atrioventricular (AV) node, sinoatrial (SA) node and bundle of His, endocardial fibroelastosis (EFE), papillary muscle fibrosis, valvular disease, calcification of the atrial septum and mononuclear pancarditis. There was no association of pathology with the timing of death except that in the third-trimester deaths more valvular disease and/or extensive conduction system abnormalities were observed. Clinical rhythm did not always correlate with pathology of the conduction system, and the pre-mortem echocardiograms did not consistently detect the extent of pathology. CONCLUSION Fibrosis of the AV node/distal conduction system is the most characteristic histopathological finding. Fibrosis of the SA node and bundle of His, EFE and valve damage are also part of the anti-Ro spectrum of injury. Discordance between echocardiograms and pathology findings should prompt the search for more sensitive methods to accurately study the phenotype of antibody damage.
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Affiliation(s)
- Carolina Llanos
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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Izmirly PM, Shvartsbeyn M, Meehan S, Franks A, Braun A, Ginzler E, Xu SX, Yee H, Rivera TL, Rivera T, Esmon C, Barisoni L, Merrill JT, Buyon JP, Clancy RM. Dysregulation of the microvasculature in nonlesional non-sun-exposed skin of patients with lupus nephritis. J Rheumatol 2012; 39:510-5. [PMID: 22298906 DOI: 10.3899/jrheum.110878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Membrane endothelial protein C receptor (mEPCR) is highly expressed in peritubular capillaries of kidneys from patients with active and poorly responsive lupus nephritis (LN). We investigated the hypothesis that changes in the microvasculature are widespread with extension to the dermal vasculature. METHODS Skin biopsies from uninvolved skin (buttocks) were performed in 27 patients with LN and 5 healthy controls. Sections were stained with specific antibodies reactive with mEPCR, adiponectin, intercellular adhesion molecule-1 (ICAM-1), and CD31; then assessed by enumeration of stained blood vessels (percentage positive blood vessels) blinded to knowledge of clinical information. RESULTS There was a significant increase in the prevalence of blood vessels that stained for mEPCR and ICAM-1 in patients compared to controls [94% vs 59% (p = 0.045) and 81% vs 67% (p = 0.037), respectively]. Adiponectin staining and CD31 staining were similar between the groups (45% vs 43% and 98% vs 92%). Dermal staining for mEPCR was greater in patients with proliferative glomerulonephritis than in those with membranous disease (96% vs 60%; p = 0.029). A composite of poor prognostic renal markers and death was significantly associated with greater expression of mEPCR staining. CONCLUSION These data are consistent with the notion that in patients with LN, activation of the microvasculature extends beyond the clinically targeted organ. The insidious expression of this widespread vasculopathy may be a contributor to longterm comorbidities.
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Affiliation(s)
- Peter M Izmirly
- Department of Medicine, NYU School of Medicine, New York, NY 10016, USA
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46
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Izmirly PM, Saxena A, Kim MY, Wang D, Sahl SK, Llanos C, Friedman D, Buyon JP. Maternal and fetal factors associated with mortality and morbidity in a multi-racial/ethnic registry of anti-SSA/Ro-associated cardiac neonatal lupus. Circulation 2011; 124:1927-35. [PMID: 21969015 PMCID: PMC3206147 DOI: 10.1161/circulationaha.111.033894] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac manifestations of neonatal lupus include conduction disease and, rarely, an isolated cardiomyopathy. This study was initiated to determine the mortality and morbidity of cardiac neonatal lupus and associated risk factors in a multi-racial/ethnic US-based registry to provide insights into the pathogenesis of antibody-mediated injury and data for counseling. METHODS AND RESULTS Three hundred twenty-five offspring exposed to maternal anti-SSA/Ro antibodies with cardiac neonatal lupus met entry criteria. Maternal, fetal echocardiographic, and neonatal risk factors were assessed for association with mortality. Fifty-seven (17.5%) died, 30% in utero. The probability of in utero death was 6%. The cumulative probability of survival at 10 years for a child born alive was 86%. Fetal echocardiographic risk factors associated with increased mortality in a multivariable analysis of all cases included hydrops and endocardial fibroelastosis. Significant predictors of in utero death were hydrops and earlier diagnosis, and of postnatal death were hydrops, endocardial fibroelastosis, and lower ventricular rate. Isolated heart block was associated with a 7.8% case fatality rate, whereas the concomitant presence of dilated cardiomyopathy or endocardial fibroelastosis quadrupled the case fatality rate. There was a significantly higher case fatality rate in minorities compared with whites, who were at a lower risk of hydrops and endocardial fibroelastosis. Pacing was required in 70%; cardiac transplantation was required in 4 children. CONCLUSION Nearly one fifth of fetuses who develop cardiac neonatal lupus die of complications predicted by echocardiographic abnormalities consistent with antibody-associated disease beyond the atrioventricular node. The disparity in outcomes observed between minorities and whites warrants further investigation.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, NYU School of Medicine, New York, NY 10016, USA.
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Izmirly PM, Kim MY, Llanos C, Le PU, Guerra MM, Askanase AD, Salmon JE, Buyon JP. Evaluation of the risk of anti-SSA/Ro-SSB/La antibody-associated cardiac manifestations of neonatal lupus in fetuses of mothers with systemic lupus erythematosus exposed to hydroxychloroquine. Ann Rheum Dis 2010; 69:1827-30. [PMID: 20447951 PMCID: PMC3593727 DOI: 10.1136/ard.2009.119263] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Based on the potential involvement of Toll-like receptor (TLR) signalling in the pathogenesis of neonatal lupus (NL), it was hypothesised that fetal exposure to hydroxychloroquine (HCQ), a TLR inhibitor, might reduce the risk of anti-SSA/Ro/SSB/La antibody-associated cardiac manifestations of NL (cardiac-NL). METHODS Cardiac-NL children (N=50) and controls (N=151) were drawn from the following overlapping pregnancy studies: Research Registry for NL; PR Interval and Dexamethasone Evaluation in Cardiac-NL; and Predictors of Pregnancy Outcomes: Biomarkers in Antiphospholipid Syndrome and Systemic Lupus Erythematosus (SLE). Pregnancies met the following inclusion criteria: documentation of maternal anti-SSA/Ro/SSB/La antibodies at pregnancy, confirmation of medication use and child's outcome, a diagnosis of SLE before pregnancy and birth by 31 December 2007. RESULTS Seven (14%) of the cardiac-NL children were exposed to HCQ compared with 56 (37%) of the controls (p=0.002; OR 0.28; 95% CI 0.12 to 0.63). Cases and controls were similar with respect to demographic and antibody status. Multivariable analysis adjusting for birth year, maternal race/ethnicity, antibody status, non-fluorinated steroid use and prior cardiac-NL risk yielded an OR associated with HCQ use of 0.46 (95% CI 0.18 to 1.18; p=0.10). CONCLUSION This case-control study suggests that, in mothers with SLE with anti-SSA/Ro/SSB/La antibodies, exposure to HCQ during pregnancy may decrease the risk of fetal development of cardiac-NL. Prospective studies are needed for confirmation.
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Affiliation(s)
- Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, TH-407, New York, NY 10016, USA.
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Friedman DM, Llanos C, Izmirly PM, Brock B, Byron J, Copel J, Cummiskey K, Dooley MA, Foley J, Graves C, Hendershott C, Kates R, Komissarova EV, Miller M, Paré E, Phoon CKL, Prosen T, Reisner D, Ruderman E, Samuels P, Yu JK, Kim MY, Buyon JP. Evaluation of fetuses in a study of intravenous immunoglobulin as preventive therapy for congenital heart block: Results of a multicenter, prospective, open-label clinical trial. ACTA ACUST UNITED AC 2010; 62:1138-46. [PMID: 20391423 DOI: 10.1002/art.27308] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The recurrence rate of anti-SSA/Ro-associated congenital heart block (CHB) is 17%. Sustained reversal of third-degree block has never been achieved. Based on potential reduction of maternal autoantibody titers as well as fetal inflammatory responses, intravenous immunoglobulin (IVIG) was evaluated as preventive therapy for CHB. METHODS A multicenter, prospective, open-label study based on Simon's 2-stage optimal design was initiated. Enrollment criteria included the presence of anti-SSA/Ro antibodies in the mother, birth of a previous child with CHB/neonatal lupus rash, current treatment with < or = 20 mg/day of prednisone, and <12 weeks pregnant. IVIG (400 mg/kg) was given every 3 weeks from week 12 to week 24 of gestation. The primary outcome was the development of second-degree or third-degree CHB. RESULTS Twenty mothers completed the IVIG protocol before the predetermined stopping rule of 3 cases of advanced CHB in the study was reached. CHB was detected at 19, 20, and 25 weeks; none of the cases occurred following the finding of an abnormal PR interval on fetal Doppler monitoring. One of these mothers had 2 previous children with CHB. One child without CHB developed a transient rash consistent with neonatal lupus. Sixteen children had no manifestations of neonatal lupus at birth. No significant changes in maternal titers of antibody to SSA/Ro, SSB/La, or Ro 52 kd were detected over the course of therapy or at delivery. There were no safety issues. CONCLUSION This study establishes the safety of IVIG and the feasibility of recruiting pregnant women who have previously had a child with CHB. However, IVIG at low doses consistent with replacement does not prevent the recurrence of CHB or reduce maternal antibody titers.
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Izmirly PM, Llanos C, Lee LA, Askanase A, Kim MY, Buyon JP. Cutaneous manifestations of neonatal lupus and risk of subsequent congenital heart block. Arthritis Rheum 2010; 62:1153-7. [PMID: 20131261 PMCID: PMC2919829 DOI: 10.1002/art.27333] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Cutaneous disease associated with placental transport of maternal anti-SSA/Ro or anti-SSB/La antibodies is transient, and children often appear to be otherwise healthy. However, the impact of this manifestation of neonatal lupus (NL) on the risk of cardiac disease occurring in a future pregnancy is critical for family counseling and for powering preventive trials. The purpose of this study was to determine the recurrence rates of NL, with specific focus on cardiac NL following cutaneous NL in a child enrolled in the Research Registry for Neonatal Lupus (RRNL). METHODS Fifty-eight families who were enrolled in the RRNL met the following inclusion criteria for our study: maternal anti-SSA/Ro or anti-SSB/La antibodies, a child with cutaneous NL, and a pregnancy subsequent to the child with cutaneous NL. RESULTS The majority of the 58 mothers (78%) were Caucasian. Of 77 pregnancies that occurred following the birth of a child with cutaneous NL, the overall recurrence rate for any manifestation of NL was 49% (95% confidence interval [95% CI] 37-62%); 14 pregnancies (18.2%) were complicated by cardiac NL, 23 (29.9%) by cutaneous NL, and 1 (1.3%) by hematologic/hepatic NL. A subset analysis was restricted to the 39 children who were born after the initial child with cutaneous NL had been enrolled in the RRNL. The overall recurrence rate for NL was 36% (95% CI 20-52%); 5 pregnancies (12.8%) were complicated by cardiac NL and 9 (23.1%) by cutaneous NL. There were no significant differences in the following maternal risk factors for having a subsequent child with cardiac or cutaneous NL: age, race/ethnicity, anti-SSB/La status, diagnosis, use of nonfluorinated steroids, or breastfeeding. The sex of the subsequent fetus did not influence the development of cardiac or cutaneous NL. CONCLUSION Based on data from this large cohort, the identification of cutaneous NL in an anti-SSA/Ro antibody-exposed infant is particularly important, since it predicts a 6-10-fold risk of a subsequent child developing cardiac NL.
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Affiliation(s)
- Peter M Izmirly
- New York University School of Medicine, New York, New York 10016, USA.
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50
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Askanase AD, Izmirly PM, Katholi M, Mumtaz J, Buyon JP. Frequency of neuro-psychiatric dysfunction in anti-SSA/SSB exposed children with and without neonatal lupus. Lupus 2009; 19:300-6. [DOI: 10.1177/0961203309354542] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neonatal lupus is a model of passively acquired autoimmunity whereby anti-SSA/Ro-SSB/La antibodies target the fetal heart and neonatal skin in a minority of cases. Since neuro-psychiatric impairment has been reported in humans and mice exposed prenatally to a variety of maternal autoantibodies including anti-Ro/La, this study was initiated to evaluate the potential neurotoxic effects of these specific autoantibodies and the overall frequency of autoimmune diseases, general health, and somatic growth of children with neonatal lupus and their unaffected siblings. In addition to the general health questionnaires maintained on family members enrolled in the Research Registry for Neonatal Lupus (RRNL), specific questionnaires related to neuro-psychiatric development were sent to all mothers whose children (both affected and unaffected) were older than 5 years of age. Controls consisted of healthy friends. Of 121 anti-Ro exposed children meeting the inclusion criteria, information was returned on 104 (33 cardiac manifestations of neonatal lupus, 20 rash, and 51 unaffected siblings) and 22 of the friend controls. The mean age of all of the children was 14.5 years (range 5—39). In total, 42 (40%) of the 104 anti-Ro exposed children were reported to have a neuro-psychiatric disorder, compared with 6 (27%) of the friend controls (p = 0.34). For 8 (24%) of the congenital heart block (CHB) children (6 boys, 2 girls) the mothers reported attention problems. Four, all boys, were on stimulants. Of the rash children, 4 (20%) (2 boys, 2 girls) had attention problems with one boy on Ritalin. Of the unaffected siblings, 9 (18%) (8 boys and 1 girl) had attention problems with 3 boys on stimulants. One (5%) of the control children (a girl) had attention problems, not requiring therapy. There was no statistical difference in attention problems between the groups (p = 0.120). Behavioral problems were present in all groups with no statistical differences noted. The prevalence of depression, anxiety, developmental delays, learning, hearing, and speech problems were not significantly different between groups. In the CHB children, one boy has nephrotic syndrome and one girl has psoriasis. In the rash children, one girl has juvenile rheumatoid arthritis. In the unaffected group there are five children with autoimmune diseases, two with inflammatory bowel diseases (one boy and one girl), one boy has a spondyloarthropathy, one girl has alopecia areata and one young woman has Antiphospholipid syndrome. In the control group one boy has Henoch Schonlein purpura. There were four cases of hypothyroidism, possibly secondary to Hashimoto’s thyroiditis, three in boys with CHB and one in a girl with rash. None of the unaffected siblings or controls had hypothyroidism. Parental reporting of neuro-psychiatric abnormalities was high in anti-Ro exposed children regardless of the neonatal lupus manifestation. However, medication use was limited and although the frequency of this reporting was greater than friend controls, it did not reach significance. Lupus (2010) 19, 300—306.
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