Association of serum high mobility group box 1 levels with disease activity and renal involvement in patients with systemic vasculitis

High mobility group box 1 (HMGB1) is a kind of proinflammatory mediator that acts as an alarmin when released by dying, injured or activated cells. Previous studies have reported that HMGB1 are closely linked to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The present study aimed to evaluate whether serum HMGB1 levels were associated with systemic vasculitis (VAs).The study population consisted of 51 patients with VAs, 46 patients with essential hypertension (EH) and 46 healthy controls (HC). Thirty-five patients with VAs had in active stage and 16 patients with VAs in an inactive stage. Furthermore, 31 patients with VAs had renal involvement, the other 20 patients were selected for without renal involvement. Serum HMGB1 levels were measured by enzyme-linked immunosorbent assay. Associations between serum HMGB1 levels with clinical and laboratory parameters were analyzed.Serum HMGB1 levels in patients with VAs were significantly higher than in EH and HC (all P < .05), and no difference regarding serum HMGB1 levels could be found between EH and HC (P = .208). Serum HMGB1 levels in VAs patients with active stage were significantly higher than those in HC and VAs patients with inactive stage (all P < .05). Patients with renal involvement and non-renal involvement had increased HMGB1 levels compared with HC (all P < .05). In addition, serum HMGB1 levels were significantly higher in patients with renal involvement compared with non-renal involvement patients (P = .001). Correlation analysis showed that serum HMGB1 levels were positive significant correlated with the Birmingham Vasculitis Activity Score, hypersensitive C reactive protein (Hs-CRP), serum creatinine (Scr) and 24-hour proteinuria (all P < .05). Among the subsets of VAs, serum HMGB1 levels were significantly higher in AAV, polyarteritis nodosa (PAN) and takayasu arteritis (TA) than in HC (all P < .05). More interestingly, serum HMGB1 were significantly higher in patients with PAN compared with AAV and TA patients (all P < .05). Furthermore, there was positive correlation between serum HMGB1 levels and Hs-CRP, Scr, and 24-hour proteinuria in patients with PAN (all P < .05).Serum HMGB1 levels are increased in patients with VAs compared with HC and EH and can reflect the disease activity and renal involvement.

Impact of vasculitis on employment and income

OBJECTIVES

Work disability associated with rheumatic diseases accounts for a substantial financial burden. However, few studies have investigated disability among patients with vasculitis. The purpose of this study was to examine the impact of vasculitis on patient employment and income.

METHODS

Patients enrolled in the Vasculitis Clinical Research Consortium (VCRC) Patient Contact Registry, living in the USA or Canada, and followed for >1 year post-diagnosis, participated in an online survey-based study.

RESULTS

421 patients with different systemic vasculitides completed the survey between June and December 2015. The majority of patients were female (70%) and Caucasian (90%); granulomatosis with polyangiitis (GPA) was the most common type of vasculitis (49%), and the mean age at the time of diagnosis was 53 years. At the time of their diagnosis of vasculitis 76% of patients were working a paid job, 6% were retired, and 2% were on disability. Over the course of their disease, and with a mean follow-up of 8±6.4 years post-diagnosis, 26% of participants became permanently work disabled or had to retire early due to vasculitis. Variables that were independently associated with permanent work disability included work physicality, less supportive work environment, and symptoms such as respiratory disease, pain, and cognitive impairment. Overall, patients reported a mean productivity loss of 6.9% and income was reduced by a median of 45%.

CONCLUSIONS

Due to their vasculitis, patients frequently suffer substantial limitations in work and productivity, and personal income loss.

Assessment of work limitations and disability in systemic vasculitis

OBJECTIVES

Despite advances in the management of systemic vasculitis (SV), direct consequences of the disease, leading to impairments in physical and mental function can cause disability. The objective of this study was to assess work limitations in SV.

METHODS

SV patients were recruited from a tertiary care clinic. Work disabled (WD) was defined as not working, early retirement, or reduced hours at work. Participants who were working at the time of enrolment completed the Work Limitations Questionnaire (WLQ). Other work-related measures were self-reported by questionnaire. Disease outcome measures (Vasculitis Damage Index (VDI), Health Assessment Questionnaire-Disability Index (HAQ) and pain visual analogue score (VAS)) were obtained at time of WLQ.

RESULTS

103 participants were enrolled with mean age 58 (SD17), 60% females, 48% with anti-neutrophilic cytoplasmic antibody-associated vasculitis (AAV), 26% with large vessel vasculitis (LVV) and 26% with other types of SV. 22 (21%) were WD secondary to SV, 29 (28%) were working and 52 (51%) subjects were not working for reasons other than SV. SV-related WD subjects were more likely to have a lower level of education (p=0.003) than non-WD subjects. The VDI was higher in SV-related WD vs. non-WD subjects: 1.9 (SD 2.7) vs. 2.9 (SD 1.4); p=0.015. 38 subjects were working in some capacity and completed the WLQ; their productivity loss was 8.2% and this was highly correlated with HAQ and pain VAS (rho=0.585 and rho=0.458, respectively).

CONCLUSIONS

SV-related work disability occurred in 21% and was associated with lower levels of education, higher disease severity and worse functional outcomes.

Impaired function of endothelial progenitor cells in children with primary systemic vasculitis

INTRODUCTION

Previously, we demonstrated that children with active systemic vasculitis (SV) have higher circulating CD34 + CD133 + KDR+ endothelial progenitor cells (EPC); the function of these EPCs, and their relationship with disease activity in vasculitis remains largely unexplored. We hypothesized that although EPC numbers are higher, EPC function is impaired in active SV of the young. The aims of this study were therefore to: 1. investigate the relationship between disease activity and EPC function in children with SV; and 2. study the influence of systemic inflammation on EPC function by investigating the effects of hyperthermia and TNF-α on EPC function.

METHODS

We performed a cross-sectional study of unselected children with SV with different levels of disease activity attending a single center (Great Ormond Street Hospital, London) between October 2008 and December 2014. EPCs were isolated from peripheral blood of children with SV, and healthy child controls. EPC function was assessed by their potential to form colonies (EPC-CFU), and ability to form clusters and incorporate into human umbilical vein endothelial cell (HUVEC) vascular structures in matrigel. The effects of hyperthermia and TNF-α on EPC function were also studied.

RESULTS

Twenty children, median age 12-years (5-16.5; nine males) were studied. EPC-CFU and the number of EPC clusters formed on matrigel were significantly reduced in children with active vasculitis compared with healthy controls (p = 0.02 for EPC-CFU; p = 0.01 for EPC cluster formation). Those with active vasculitis had lower EPC-CFU and EPC cluster formation than those with inactive disease, although non-significantly so. In addition, EPC incorporation into matrigel HUVEC networks was lower in children with SV compared with healthy children, irrespective of disease activity. Ex-vivo pre-treatment of EPC with hyperthermia impaired EPC function; TNF-α down-regulated EPC expression of CD18/CD11b and resulted in decreased incorporation into HUVEC networks.

CONCLUSIONS

Whilst our previous work showed that circulating CD34 + EPC numbers are well preserved, this study revealed that EPC function is significantly impaired in children with vasculitis. It is possible that the chronic inflammatory milieu associated with vasculitis may impair EPC function, and thus contribute to an unfavourable balance between endothelial injury and repair. The mechanism of this remains to be established, however.

Crosstalk between intestinal microbiota, adipose tissue and skeletal muscle as an early event in systemic low-grade inflammation and the development of obesity and diabetes

Obesity is associated with a systemic chronic low-grade inflammation that contributes to the development of metabolic disorders such as cardiovascular diseases and type 2 diabetes. However, the etiology of this obesity-related pro-inflammatory process remains unclear. Most studies have focused on adipose tissue dysfunctions and/or insulin resistance in skeletal muscle cells as well as changes in adipokine profile and macrophage recruitment as potential sources of inflammation. However, low-grade systemic inflammation probably involves a complex network of signals interconnecting several organs. Recent evidences have suggested that disturbances in the composition of the gut microbial flora and alterations in levels of gut peptides following the ingestion of a high-fat diet may be a cause of low-grade systemic inflammation that may even precede and predispose to obesity, metabolic disorders or type 2 diabetes. This hypothesis is appealing because the gastrointestinal system is first exposed to nutrients and may thereby represent the first link in the chain of events leading to the development of obesity-associated systemic inflammation. Therefore, the present review will summarize the latest advances interconnecting intestinal mucosal bacteria-mediated inflammation, adipose tissue and skeletal muscle in a coordinated circuitry favouring the onset of a high-fat diet-related systemic low-grade inflammation preceding obesity and predisposing to metabolic disorders and/or type 2 diabetes. A particular emphasis will be given to high-fat diet-induced alterations of gut homeostasis as an early initiator event of mucosal inflammation and adverse consequences contributing to the promotion of extended systemic inflammation, especially in adipose and muscular tissues.

Cutaneous and systemic vasculitis: cellular players and pathogenetic aspects

Vascular wall damage, inflammatory cell recruitment and subsequent structural remodelling define a vasculitic process. Histopathological classification of vasculitis is based on the caliber of the vessel involved and on the prevalent type of inflammatory cells (neutrophils in acute forms, lymphocytic for chronic, histiocytic for granulomatous). A large amount of information is emerging from the literature on the complex pathophysiology of the cellular components of vessel wall. For instance, endothelial cells not only have the task to cover the inner surface of the vascular system but they also play an active role in tuning the immunological response in a very sophisticated way. Neutrophils are not only terminally differentiated cells sacrificed for a valuable cause. Cellular types of the perivascular microenvironment play roles one time not expected. The spread of the inflammatory process into the vascular wall is not necessarily inside-out. These and other selected concepts will be discussed in this paper.

Cytomegalovirus-related necrotising vasculitis mimicking Henoch-Schönlein syndrome

Viral vasculitides have been previously reported in the literature, the role of infections in their pathogenesis ranging from direct cause to trigger event. Here we report the case of a 3-year-old immunocompetent girl who developed a systemic vasculitis leading to ileal perforation, mimicking a full blown picture of Henoch-Schönlein purpura. High dosage steroid treatment was started, with good response. The anatomopathological examination of the resected gastrointestinal tract showed features of necrotising vasculitis and cytomegalovirus (CMV)-related inclusion bodies in the endothelial cells, with direct correlation to vascular damage. The causative role of viral infection was revealed by the presence of CMV DNA in patient's blood and positive IgG titer against the virus. Steroid therapy was then tapered: the patient achieved clinical remission, which still persists after a six-months follow-up. Our report suggests that CMV vasculitis is probably more frequent than previously thought, even in immunocompetent patients, with a protean clinical presentation, mimicking other types of vasculitides.

Acute dilated cardiomyopathy in a patient with beriberi and cryoglobulinaemic vasculitis: an unusual potential complication of two rare disorders

We report the case of a 45-year-old patient who presented with acute dilated cardiomyopathy. During admission the patient was consecutively diagnosed with cryoglobulinaemic vasculitis and beriberi. In both diseases, cardiac involvement may occur as dilated cardiomyopathy. Thiamin deficiency was the final cause for the severe cardiac manifestations (cardiac acute beriberi or Shoshin syndrome), which returned to normal after thiamin supplementation.

[Systemic vasculitides: novel nomenclature and novel therapeutic approaches]

A novel nomenclature of systemic vasculitides is proposed by the 2012 Chapel Hill Consensus Conference. It aims at substituting established eponyms and introducing new terms and groups closer to our current understanding of vasculitis pathophysiology. In parallel, a therapeutic revolution is taking place partially based on the concept of re-induction of immune tolerance for ANCA-associated vasculitis (AAV). Two major multicentric randomized studies have shown that rituximab (RTX), monoclonal antibody capable of selectively killing B lymphocytes, is not inferior when compared to cyclophosphamide (CYC) to induce remission in AAV, and superior in the case of disease relapse. Thus, a hot debate is taking place whether or not to maintain CYC or use RTX in AAV. An individual-based choice may be wise for the moment being.

A case of primary systemic necrotizing vasculitis presenting primarily with neurologic involvement

Systemic necrotizing vasculitis (SNV) is a type of vasculitis that presents with necrosis, predominantly involving large, medium-sized and small arteries. Peripheral neuropathy is a major clinical feature of the primary and secondary systemic vasculitides, and is often observed during the early phases of the disease, causing axonal neuropathy. The prevalence of central nervous system (CNS) involvement ranges from 4% to 45%. Encephalopathy, focal neurological deficits, and seizures are the most common manifestations and usually occur late during the course of SNV. In this report, we describe a 61-year-old woman with SNV who had both CNS and peripheral nervous system vasculitic involvement. We also discuss the pathophysiology of nervous system involvement in patients with SNV.

[The current classification of systemic vasculitides]

Systemic vasculitides (SV) are severe multiorgan diseases whose early diagnosis and treatment can significantly improve prognosis. Improving the classification of SV may lead to a significant reduction in the likelihood of diagnostic errors. The presented paper deals with the results of the International Consensus Conference on the Nomenclature of SV (Chappel Hill, USA) in 2012. The nomenclature and definitions of the major forms of SV were revised and additional categories of vasculitis were included into the classification, by relying on the current trends in the practical use of terms, on the current ideas on the specific features of manifestations of diseases, and on achievements in studying the pathogenesis.

[Academician V.A. Nasonova's role in the study of systemic vasculitides]

Article is dedicated to academician V.A.Nasonova contribution to the development of clinic, diagnostics and treatment of systemic vasculitides].

[System of microcirculation, markers of vascular wall damage and systematicity of the process in rheumatic diseases]

The work was aimed at studying the interrelationship of the microcirculation system and the parameters of endothelial activation with markers of inflammatory process activity in rheumatic diseases (RD). We carried out a comprehensive examination of a total of 330 patients presenting with systemic diseases of connective tissue (SDCT), rheumatoid arthritis (RA) and systemic vasculitis (SV). Studying microcirculation included impregnation of filmy preparations according to the V.V. Kupriyanov technique and biomicroscopy of the conjunctiva of the eyeball. We also determined markers of endothelial activation and lesion of vascular wall, indices of activity of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and vasculitis clinical activity index (VCAI), common carotid artery intima-media thickness (CCA-IMT), biopsy materials of the musculocutaneous flap, of the operational and autopsy materials. Determining the indices of microcirculation showed that first of all the process involves postcapillaries and venules which are dilated, becoming tortuous, with the formation of microaneurysms and stellate venules. Capillaries, postcapillaries and venules were found to contain parietally located small-grained conglomerates of blood platelets and thrombocytic masses plugging up the lumens of microvessels. Intravascular alterations were characterized by the presence of erythrocyte aggregates, stases, microthrombovasculitis, «sludge» phenomenon, and a decrease in capillary blood flow. Extravascular changes included perivascular haemorrhages. In arterioles and precapillaries the inflammatory process manifested itself by swelling, dystrophy and desquamation of endothelial cells, plasmatic impregnation of the walls, luminal thrombosis followed by the development of severe sclerosis and glialinosis. The morphological study showed the presence of destructive alterations in the vascular wall, fibrinoid necrosis, and infiltration-proliferative cellular reaction. The most pronounced changes in the autoimmune inflammation markers had place in RA and systemic lupus erythematosus (SLE). We revealed increased indices of inflammatory process activity such as interleukin-8, C-reactive protein (CRP). We also revealed the signs of endothelial dysfunction, manifesting itself as a statistically significant (p<0.01) increase in concentrations of the soluble vascular cell adhesion molecule (sVCAM-1), von Willebrand factor antigen (VWFA), the number of desquamated endotheliocytes (DE). Also observed was a clear-cut dependence of the level of endothelial activation markers from the degree of the processes activity. We revealed a positive correlation between the level of CRP, IgG RF, the level of sVCAM-1 and the number of DE. The levels of interleukin-8, sVCAM-1 and VWFA were elevated in patients with RD. Increased activity of the disease was accompanied by impairments at the level of the microcirculatory bed, an increase in the concentration of inflammation markers and indices of endothelial dysfunction.

Treat-to-target in vasculitis: is this a sensible approach?

It is possible to achieve substantial initial control of systemic vasculitis in the majority of patients. However, the 'target' has shifted considerably over the last 20-30 years from keeping patients alive to maintaining good quality disease control, avoiding the development of comorbidities - either as a result of disease or treatment, and also preventing relapses. This expansion of potential targets that can be achieved in systemic vasculitis has arisen because we have more effective therapies, but more importantly we have developed a framework within which targets can be created reproducibly. In other words we have much clearer definitions of what constitutes clinical disease activity, relapse, remission and morbidity. These targets are based on simple clinical evaluation, limited laboratory assessments of patients that can be undertaken by any secondary care facility. As a result of this they remain at a clinical level and may not address the most important targets, which are curing disease and that would be the aspiration to move towards. The first step towards that is to move from clinically-based targets towards mechanistic targets based primarily around the pathophysiological drivers of disease. That in turn may lead to identification of specific targets that can turn off disease. The systemic vasculitides are heterogeneous and although for ANCA-associated vasculitis in the short term treatments are similar, the development of clear understanding of mechanisms and new targets may bring with it the promise of much more focused therapies that will address only individual targets and therefore personalize therapy for each individual condition and patient.

The efficacy of novel therapeutic modalities of isolated ocular vasculitis vs ocular vasculitis as a systemic disease

AIM

To evaluate the efficacy of new therapeutic modalities with the observation period of three years on patients with isolated ocular vasculitis in comparison with ocular vasculitis as a systemic disease.

METHODS

The effectiveness of the therapy was assessed based on the changes in visual acuity and degree of ocular inflammation (mild, medium, moderate, severe) with the following parameters: vitreous body cloudiness, blood vessels layering, macula oedema, blood vessels occlusion and new vascularisation

RESULTS

New therapeutic modalities resulted in reduction in the number of patients with severe inflammation in the group of isolated ocular vasculitis from 8(13.5%) to 7(12.2%) after three years, while the number of patients with mild inflammation increased from 13(20.7%) to 18 (29.3%) in the same group (p>0.05). The number of patients with severe ocular inflammation in a group of ocular vasculitis as systemic disease increased from 3(16.2%) to 4(21.6%), because of the presence of patients with Behçet's disease. The number of patients with visual acuity less than 0.1 decreased from 11(17%) to 8(13.4%) in a group of patients with ocular vasculitis as systemic disease, which was associated with the presence of Behçet's disease too (p>0.05).

CONCLUSIONS

Although the effect of new therapeutic modalities did not result in statistically significant improvement in visual acuity and reducing inflammation, systemic and intravitreal corticosteroids with steroid-sparing immunomodulatory therapy represents effective strategies in forms of isolated ocular vasculitis and ocular vasculitis as systemic disease.