Searching for a prognostic index in lupus nephritis

BACKGROUND

Currently we do not have an ideal biomarker in lupus nephritis (LN) that should help us to identify those patients with SLE at risk of developing LN or to determine those patients at risk of renal progression. We aimed to evaluate the development of a prognostic index for LN, through the evaluation of clinical, analytical and histological factors used in a cohort of lupus. We have proposed to determine which factors, 6 months after the diagnosis of LN, could help us to define which patients will have a worse evolution of the disease and may be, more aggressive treatment and closer follow-up.

METHODS

A retrospective study to identify prognostic factors was carried out. We have included patients over 18 years of age with a clinical diagnosis of systemic lupus erythematosus (SLE) and kidney involvement confirmed by biopsy, who are followed up in our centre during the last 20 years. A multi-step statistical approach will be used in order to obtain a limited set of parameters, optimally selected and weighted, that show a satisfactory ability to discriminate between patients with different levels of prognosis.

RESULTS

We analysed 92 patients with LN, although only 73 have been able to be classified according to whether or not they have presented poor renal evolution. The age of onset (44 vs. 32; p = 0.024), the value of serum creatinine (1.41 vs. 1.04; p = 0.041), greater frequency of thrombocytopenia (30 vs. 7%; p = 0.038), higher score in the renal chronicity index (2.47 vs. 1.04; p = 0.015), proliferative histological type (100%) and higher frequency of interstitial fibrosis (67 vs. 32%; p = 0.017) and tubular atrophy (67 vs. 32%; p = 0.018) was observed between two groups. The multivariate analysis allowed us to select the best predictive model for poor outcome at 6 months based on different adjustment and discrimination parameters.

CONCLUSION

We have developed a prognostic index of poor renal evolution in patients with LN that combines demographic, clinical, analytical and histopathological factors, easy to use in routine clinical practice and that could be an effective tool in the early detection and management.

Complications of uveitis in a Spanish population, UveCAM study

OBJECTIVE

To estimate the population frequency of uveitis complications and to evaluate their main risk factors in the patients with uveitis from the UVECAM study.

PATIENTS AND METHODS

Development of complications in 386 patients with uveitis in the whole health area of the province of Toledo (UVECAM study) during a period of 1 year. Description of complications and study of their possible determinants by means of multivariate regression models.

RESULTS

Information on the development of complications was available in 371 of the 386 patients of the UVECAM study. The most frequent complications were posterior synechiae (19.0%), ocular hypertension (14.0%), macular edema (7.5%), epirretinal membrane (6.9%), glaucoma (6.6%), iridian atrophy (5.6%) and cataract (5.5%). The risk of complications increases with age, intermediate and panuveitis locations, and those of chronic or recurrent evolution.

CONCLUSION

Uveitis is associated with a high frequency of complications, especially in older patients, with intermediate or posterior localization of the inflammatory process and chronic or recurrent evolution.

AB0120 IDENTIFYING CORE VARIABLES TO DEVELOP A SEVERITY INDEX IN RHEUMATOID ARTHRITIS: A NATIONWIDE DELPHI CONSENSUS

Background:

Early interventions during the “window of opportunity” have been shown to improve clinical outcomes in rheumatoid arthritis (RA). However, intensive treatment can induce toxicity so identifying patients most likely to benefit from it is of great importance. Hence, tools for guiding therapeutic decisions in early disease stages are needed.

Objectives:

To identify core variables to develop a RA severity index according to an expert panel.

Methods:

An expert panel was prompted to analyze relevant variables to define a “severity” construct, specified as “early severe disease”, able to classify patients with data collected on the first 2 years of the disease. They were also asked to identify potential modifying factors and external criteria to evaluate criterion validity.

An anonymous nationwide 2-round Delphi survey was applied to look for consensus about: (1) the priority of inclusion of each variable, (2) the feasibility to obtain them from usual sources (e.g., medical records) and (3) their definition. Each item was rated on a 10-point (priority) or 5-point (feasibility and definition) Likert scales were 0=complete disagreement and 5-10=complete agreement.

After the 1st round, any item rated from 5 to 10 in priority and 3 to 5 for feasibility by at least 70% of responders was included in the final variable list. Items not reaching at least 20% consensus were discarded. The remaining ones would be voted again in the 2nd round and adopted if they reached at least 50% consensus or else discarded.

Results:

The task force identified 17 variables to define the “severity” construct (Table 1). Socio-economic status, knowledge of their own disease, type or work adherence to treatment, among others were proposed modifying factors. Rheumatoid factor or anti-citrullinated peptide antibody seropositivity as predictive factors The physician global assessment and the “burden of treatment” (lines of treatment, number and dose of DMARDs and cumulative steroid dose received) were proposed for evaluating criterion validity.

A total of 61 stakeholders from across Spain took the survey, 56% were female and had 19.8 years of average experience after training. All variables were included after 1st round. Nonetheless, definitions were submitted for a 2nd round after rephrasing, including comments received on the survey. The final list was reduced to 15 items after merging 3 of the initial variables into a new one called “refractoriness”(Table 1).

Conclusion:

The consensus process resulted in a list of variables and modifying factors deemed of relevance for the severity construct as we defined it. These items will be used to develop a severity index to guide treatment decisions in early disease stages.

Table 1.

Variables proposed for the severity construct.

NInitially proposed variablesNFinal variables after Delphi1Polyarthritis1Polyarthritis2Big joint involvement2Big joint involvement3High disease activity at 2 years of follow-up3High disease activity at 2 years of follow-up4Maintained disease activity in the first 2 years4Maintained disease activity in the first 2 years5Acute phase reactants persistently elevated5Acute phase reactants persistently elevated6Extra-articular manifestations6Extra-articular manifestations7Failure to reach remission7Failure to reach remission8Need for aggressive therapy in the first 2 years8Need for aggressive therapy in the first 2 years9Presence of erosions at diagnosis9Presence of erosions by at diagnosis10Number of erosions at 2 years of follow-up10Number of erosions at 2 years of follow-up11Lack of improvement in the HAQ-DI11Lack of improvement in the HAQ-DI12Need for prosthetic surgery12Need for prosthetic surgery13Hospital Admissions13Hospital Admissions14Cortico-dependence14Cortico-dependence15MTX withdrawal due to loss of efficacy15Refractoriness16Completely absent response to MTX17Number of drugs with lack of efficacy

Underlined variables on the left were merged into a new variable called “Refractoriness”. HAQ-DI: Health Assessment Questionnaire-Disability Index

Disclosure of Interests:

Sebastián C Rodriguez-García Speakers bureau: Roche, Sanofi, MSD, UCB-Pharma, Bristol-Myers-Squibb, Novartis, janssen, Consultant of: Bristol-Myers-Squibb, Galapagos, ESTHER TOLEDANO MARTINEZ: None declared, María Jesús García de Yébenes: None declared, Loreto Carmona Grant/research support from: Novartis Farmacéutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA, Isidoro González-Álvaro Speakers bureau: Abbvie, MSD, Roche, Lilly, Paid instructor for: Lilly, Consultant of: Lilly, Sanofi, Grant/research support from: Roche

AB0579 ANTI-JO1 ANTIBODIES IN A REAL-WORLD POPULATION

Background:

The presence of anti-aminoacyl transfer RNA synthetase (ARS) autoantibodies is essential for the antisynthetase syndromes (ASSD) diagnosis; as well, Anti-Jo1 ARS positivity is the highest weighted criterion in the 2017 EULAR/ACR criteria for idiopathic inflammatory myopathies (IIM).

Previous studies have shown differences in ARS specificity between different blot assays. Nevertheless, an adequate clinical correlation and its detection by another monospecific-assays or indirect immunofluorescence assay (IIFA), can safeguard it.

Objectives:

To evaluate the prevalence of Anti-Jo1 ARS and their performance in the ASSD and IIM diagnosis criteria fulfillment in a real-world population.

Methods:

We performed an observational retrospective study in one center in which IIFA and a blot assay (EUROLINE ANA Profile 3-IgG that include Anti-Jo1 but not other ARS) were performed in all cases with autoimmune disease suspicion (03/2007-07/2019).

We assessed: 1) Anti-Jo1 ARS prevalence, 2) The rate of Anti-Jo1 positivity in the performed blot assays, 3) The rate of patients with Anti-Jo1 ARS meeting ASSD or IIM criteria, and 4) The rate of true and false positive Anti-Jo1 ARS considering the IIFA and clinical correlation.

Results:

A total of 419.361 inhabitants are under the center coverage area at the date, a total of 12.711 blot assays were performed during the observation period, and 61 cases presented Anti-Jo1 ARS positivity. The Anti-Jo1 ARS prevalence in the whole studied population was 0.00014, representing 0.04% positivity of the performed blot assays.

Of those with Anti-Jo1 positivity:

– Only 4 patients (6.6%) met Solomon´s ASSD criteria and 26 (42.6%) met Connors ASSD criteria (less strict), representing the 0.0009% and 0.006% of the whole population respectively.

– Five cases (8.2%) presented a possible or probable IIM by Bohan and Peter criteria and 55 cases (90.16%) presented a probable or definitive IIM by EULAR/ACR criteria, representing 0.001% and the 0.013% of the whole population respectively.

– The Anti-Jo1 positivity was not confirmed by a monospecific-assay. Nevertheless, 52 cases (85.25%) presented positive IIFA (>1/80): 27 (51.92%) nuclear, 12 (23.08%) cytoplasmic and 12 (25%) with both patterns. A total of 23 cases presented a fine speckled AC-19/AC-20 pattern; representing the 40.98% of all Anti-Jo1 ARS cases.

– Only 4 cases (6.56%) did not meet any of the ASSD or IIM classification criteria. And only 4 cases (6.56%) fulfilled Solomon ASSD criteria or presented a probable IIM by Bohan and Peter criteria, or a definite IIM by EULAR/ACR criteria. Thus, we can estimate that 6.56% of the cases were clinically false positives and other 6.56% were clinically true positive; leading a gap of 86.88% of cases with Anti-Jo1 ARS that only fulfill Connors ASSD criteria (less strict) or a not complete score to confirm the IIM diagnosis by Bohan and Peter or EULAR/ACR criteria.

Conclusion:

The low prevalence of Anti-Jo1 ARS positivity observed and the low number of cases with confirmed ASSD or IIM in the Anti-Jo1 positive detected cases, suggest that:

– It is not efficient to test it by screening.

– It should be tested only under adequate clinical suspicion.

– Probably it is not convenient to include it in not myositis specific blot assays. Despite it is desirable to incorporate the evaluation of myositis specific antibodies in the IIM classification criteria; the differences observed between Bohan and Peter and 2017 EULAR/ACR criteria fulfillment in our series, suggest that the latter could be overweighting the Anti-Jo1 ARS positivity.

Disclosure of Interests:

Martín Greco: None declared, María Jesús García de Yébenes: None declared, Francisco Javier Nóvoa Medina Speakers bureau: I have been paid as a speaker for a few medical talks, José A Hernandez Beriain: None declared, Marta María Riaño Ruiz: None declared, María Jesús Montesa: None declared, Iñigo Rua-Figueroa: None declared, Estíbaliz Loza Grant/research support from: Roche, Pfizer, Abbvie, MSD, Novartis, Gebro, Adacap, Astellas, BMS, Lylly, Sanofi, Eisai, Leo, Sobi, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

[Spanish version of the 7 Minute screening neurocognitive battery. Normative data of an elderly population sample over 70]

INTRODUCTION

To standardize the Spanish version of the 7 Minute screening neurocognitive battery (7MS) in a population sample of elderly over 70 years.

METHODS

We examined 416 persons, living at home, participating in elderly the longitudinal study "Aging in Leganes", aged 71 to 99 years old (mean age: 79 +- 9.2 years; 51.7 % women; 10.6 illiterate, 25 % without formal education). In order to do so, we used an extensive clinical survey, general and neurological exam and extensive neuropsychological battery with several cognitive scales, attention, language, memory, visuomotor skill and reasoning tests, Jorm's IQCODE questionnaire, CES-D depression questionnaire and the 7MS including the Benton Orientation Test, Clock Drawing Test, Free and Cued Learning Test and Categorial Verbal Fluency. Dementia was diagnosed according to DSM-IV criteria but independently of the 7MS scores. Several methods to obtain the total score of the 7MS were analyzed and the normative parameters of the test were obtained in the subgroup of non-demented subjects.

RESULTS

The easiest and most efficient method to obtain the total score of the 7MS was the sum of the z-scores of the four subtests. We present the mean values, -1 and -1.5 standard deviations, range and percentiles of the partial and total scores of the 7MS stratified by age (71-75, 76-80, 81-85 and > or = 86 years) and education (less than primary education and primary education or greater) in the subgroup of non-demented subjects.

CONCLUSIONS

The normative data of the 7MS obtained in a representative sample of the general elderly population support its rigorous use in the Spanish clinical setting.

[Prevalence of urinary incontinence and linked factors in men and women over 65]

OBJECTIVES

To calculate the prevalence of urinary incontinence and to identify linked factors in a population of elderly people living in their homes.

DESIGN

Population survey.

SETTING

Leganés (Madrid).

PARTICIPANTS

Representative sample of people over 65 registered in Leganés (n=1560). Two interviews at home were conducted. The second interview included a medical examination. The reply rate was 75% (n=1150).

MAIN MEASUREMENTS

Frequency of involuntary losses of urine and use of medication and absorbents, health status, use of diuretics and oxybutinin, and demographic and social variables.

RESULTS

The prevalence of urinary incontinence was 14% (95% CI, 11%-17%) in men and 30% (95% CI, 26%-34%) in women. Advanced age was associated with greater prevalence in men but not in women. In the multivariate analysis, factors associated with urinary incontinence were comorbidity and cognitive deficit. In addition, in women, high Body Mass Index and seriously limited movement were added factors. 20% of women and 5% of men over 65 used absorbents. The use of diuretics and the low number of patients receiving specific treatment for urinary incontinence suggested that there was low detection of this problem.

CONCLUSIONS

Urinary incontinence is common and could be better detected and treated in primary care. Prevention of urinary incontinence in women should begin before old age.

Acute effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in a model of rat designated a poor metabolizer of debrisoquine

The relationship between oxidative polymorphisms and the cause of Parkinson's disease is controversial. The drug 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), which induces parkinsonism in humans and in some animal models, is metabolized by cytochrome P450 db1 isozyme (the same enzymatic system implicated in 4-hydroxylation of debrisoquine). In this study, we treated females of three rat species, which differ in their ability to hydroxylate debrisoquine, with MPTP (three doses of 30 mg/kg s.c. at 12-h intervals), and we measured their motor activity and brain monoamine levels. Female dark-adapted rats (poor metabolizers of debrisoquine) showed a more pronounced and more maintained reduction of their motor activity after treatment with MPTP. MPTP-treated, dark-adapted rats also had a depletion of noradrenaline in the diencephalon and a depletion of dopamine and serotonine and their respective metabolites in the limbic system when compared with the other two species. These results suggest that oxidative polymorphism of debrisoquine plays a role in the acute effects of MPTP.