Exosome-delivered microRNAs promote IFN-α secretion by human plasmacytoid DCs via TLR7

The excessive production of type I IFNs is a hallmark and a main pathogenic mechanism of many autoimmune diseases, including systemic lupus erythematosus (SLE). In these pathologies, the sustained secretion of type I IFNs is dependent on the improper activation of plasmacytoid DCs (pDCs) by self-nucleic acids. However, the nature and origin of pDC-activating self-nucleic acids is still incompletely characterized. Here, we report that exosomes isolated from the plasma of SLE patients can activate the secretion of IFN-α by human blood pDCs in vitro. This activation requires endosomal acidification and is recapitulated by microRNAs isolated from exosomes, suggesting that exosome-delivered microRNAs act as self-ligands of innate single-stranded endosomal RNA sensors. By using synthetic microRNAs, we identified an IFN induction motif that is responsible for the TLR7-dependent activation, maturation, and survival of human pDCs. These findings identify exosome-delivered microRNAs as potentially novel TLR7 endogenous ligands able to induce pDC activation in SLE patients. Therefore, microRNAs may represent novel pathogenic mediators in the onset of autoimmune reactions and potential therapeutic targets in the treatment of type I IFN-mediated diseases

17 Fertility and pregnancy issues in patients with lupus nephritis

Case 1: Pre-pregnancy counselling for women with lupus nephritis Liz Lightstone An African Caribbean woman was diagnosed with systemic lupus erythematosus (SLE) in 2009 aged 21 years. At that time, she had severe Class IV lupus nephritis (LN) with crescents and acute kidney injury and was treated with steroids and cyclophosphamide. She achieved good clinical remission and was maintained for several years on low-dose prednisolone, mycophenolate mofetil (MMF), hydroxychloroquine (HCQ) and irbesartan. Antiphospholipid and lupus anticoagulant were negative, she was anti Ro positive with no extra renal manifestations. She attended for pre-pregnancy counselling in July 2017 aged 29 years. She was off steroids but still taking MMF and irbesartan. Her creatinine was 97 umol/l with eGFR 70.8 mls/min (59 mls/min not corrected for race) and she had no proteinuria. Her labs at that time were ANA 1:320; dsDNA titer 10 units/ml; C3 normal; and C4 low 0.13 g/l. The counselling addressed fertility (in light of previous cyclophosphamide), contraception, as well as medicines management; in particular, what to stop (i.e. MMF and irbesartan), what to continue (i.e. HCQ) and what treatments might be added (i.e. azathioprine, aspirin, folic acid). The evidence base for advice regarding timing, risks to her and to the baby came from the PROMISSE study, metanalyses and the Italian series (Moroni G et al). Her key risk factors for adverse pregnancy outcomes were being non-white, on an antihypertensive, and having anti Ro antibodies but she was in a good remission from her lupus. I advised her to continue to use contraception whilst weaning off her MMF and to consider trying to conceive, if all remained well, when off her MMF for at least 3 months. She presented pregnant in December 2017 but had not stopped either her MMF or irbesartan, despite the advice to do so back in July that year. We discussed the risks to the baby of first trimester exposure and she declined termination. Coincident with the pregnancy, she was serologically more active, and became symptomatic with joint pains, rising creatinine and hypertension and developed significant proteinuria. During the workshop we will discuss the pros and cons of renal biopsy in pregnancy and how we managed a really major flare. Also, the difficulty of diagnosing pre-eclampsia in a patient with active LN. The pregnancy was ultimately successful. She was treated with rituximab and MMF post-partum and again advised regarding contraception. The story continues in 2020! Case 2: Lupus nephritis in pregnancy Angela Tincani Maria is a 39-year-old woman who consulted at 21 weeks of gestation for the sudden occurrence of proteinuria (3.8 g) during a previously uncomplicated pregnancy with normal fetal growth. She had a history of undifferentiated connective tissue disease, diagnosed in 1997, because of thrombocytopenia (48,000 platelets per microliter) and Raynaud's; positive ANA, anti U1RNP. She was successfully treated with corticosteroids, which were stopped in 2000. She has had Hashimoto thyroiditis, treated with levothyroxine since 2000. In 2014 she had vaginal delivery of a female baby at 40 weeks of an uncomplicated pregnancy without any treatment. In 2016 and 2017 she had three early miscarriages at 8, 7 and 9 weeks. During our first evaluation (29th March 2019), she presented acrocyanosis and modest feet oedema. Proteinuria was 4 g with normal renal function; positive ANA and anti Sm/RNP; low titer anti ds DNA; positive anti-cardiolipin and anti β2 glycoproptein1 IgG. In the last week she was treated with prednisone 50 mg/day plus low dose aspirin (LDA) and low molecular weight heparin (LMWH). Azathioprine (AZA) was added, but because of increasing proteinuria (9.8 g) one week later she was admitted to the Obstetric Department. She was given three small pulses of methylprednisolone (250 mg), AZA shifted to tacrolimus (3 mg/bd) and HCQ started. When discharged, prednisone was reduced to 25 mg/day; LMWH, LDA, HCQ, vitamin D and levothyroxine unchanged. Proteinuria rapidly decreased (1.3 g on 15th May and 0.260 g on 10th July). On 23rd July she had vaginal delivery at 38 weeks' gestation, her baby was 3.390 kg and 51 cm high; APGAR 10/10. Tacrolimus was suspended on the delivery day and the patient continued with prednisone 5 mg every other day with LMWH during puerperium. A subsequent kidney biopsy confirmed Class V glomerulonephritis. At last evaluation (October 2019), the patient and the baby were fine, urinalysis did not show proteinuria. Discussion Points Pre-pregnancy counselling for women with a history of LN Management of acute flares of LN in pregnancy Diagnosing pre-eclampsia in women with active LN Discuss the use of immunosuppressive medications in pregnancy Learning Objectives Explain the importance of pre-pregnancy counselling in women with LN Discuss the best management of flares of LN in pregnant women Discuss how to recognise pre-eclampsia in women with LN Distinguish lupus nephritis from APS nephropath

Left ventricular function in rheumatoid arthritis during anti-TNF-α treatment: a speckle tracking prospective echocardiographic study

Aim. Rheumatoid arthritis (RA) shows a high risk for cardiovascular disease, including heart failure. Although TNF-α has been implicated in the pathogenesis of myocardial remodelling, TNF-α inhibition did not show any efficacy in patients with advanced heart failure and should be contraindicated in RA with cardiac complications. We aimed to assess global left ventricular (LV) systolic function using global longitudinal strain (GLS) as a measure of myocardial deformation, in a group of RA patients before and during anti-TNF-α treatment. Methods. 13 patients (female:male 7:6) affected by RA were prospectively followed for one year during anti TNF-α treatment. Every subject underwent echocardiography before starting anti-TNF-α drugs and after one year of treatment, to evaluate LV ejection fraction (EF), telediastolic diameter, telediastolic volume and global longitudinal strain (GLS) that was calculated using 2D speckle tracking as the mean GLS from three standard apical views (2, 3 and 4 -chambers). The patients showed a mean age of 43 years at RA onset (SD: 13) and a mean follow-up of 7.3 years (SD: 4.8). Steroid and methotrexate were used in 84.6% and 100%, respectively, in association with etanercept (6 cases), adalimumab (4 cases) and infliximab (3 cases). Results. Patients globally showed a normal EF before and after one year of treatment (mean: 65% and 65.7%, respectively). GLS did not differ before or after anti-TNF-α treatment (mean: -15.8% and -16.7%, respectively). Conclusion. Anti-TNF-α treatment did not significantly modify myocardial contractility after 12 months. </p

Improved pregnancy outcome in patients with Rheumatoid Arthritis who followed an ideal clinical pathway

Among women with rheumatoid arthritis (RA) we aimed to assess the effect of optimal management of pregnancy, on a composite outcome of miscarriage and complicated birth

Anti-cyclic citrullinated peptide antibodies in systemic lupus erythematosus patients with articular involvement: a predictive marker for erosive disease?

summary A small number of systemic lupus erythematosus (SLE) patients develops an erosive disease. Some studies have suggested an association between anti-cyclic citrullinated (anti-CCP) antibodies and this pattern of arthritis, but their exact significance in SLE patients remains unclear. The aim of this study was to evaluate the prevalence of anti-CCP antibodies in SLE patients with different subsets of articular disease. Among 521 SLE patients followed in this center from 1976 to 2011, those with articular involvement (n=298) were selected to take part in the study. We searched for anti-CCP2 IgG antibodies in 198 patients using a commercial enzyme linked immunosorbent assay (Immunoscan RA, Eurodiagnostica). In 174 patients the results for rheumatoid factor (RF) by nephelometry were retrospectively collected. C reactive protein (CRP) was obtained from clinical records. Patients were classified into 3 groups: erosive, non-erosive deforming, non-erosive non-deforming arthritis. Results of the different tests were compared among the groups. P<0.05 was considered statistically significant. Anti-CCP antibodies were significantly associated with erosive disease. We also found that RF positivity and increased CRP were more frequent in erosive arthritis and erosive or non-deforming arthritis, respectively, than in non-erosive non-deforming arthritis. This study supports the evidence that anti-CCP antibodies could be a useful marker of erosive disease in SLE patients. Increase in RF and CRP could be an additional means of identifying lupus patients with arthritis at risk of a worse prognosis

Association Between Changes in BLyS Levels and the Composition of B and T Cell Compartments in Patients With Refractory Systemic Lupus Erythematosus Treated With Belimumab

Introduction: Belimumab is a monoclonal antibody against soluble BLyS used for treatment of refractory Systemic Lupus Erythematosus (SLE). Although B cells are the main target of this therapy, a BLyS-dependent T cell activation pathway has also been demonstrated. The aim of the study is to analyze B and T cells phenotype modifications in a cohort of SLE patients treated with belimumab in correlation with serum BLyS levels.Materials and Methods: Fourteen SLE patients were enrolled in the study. Lymphocyte immunophenotyping by flow cytometry and determination of serum BLyS levels by high sensitivity ELISA were performed before the first infusion of belimumab, after 6 and 12 months of treatment. Sex and age-matched healthy controls were enrolled for the comparisons.Results: Baseline number of total B cells, especially switched memory B cells, were lower in SLE patients compared to control subjects. After 6 months of treatment, the total number of B cells, particularly, naive and transitional B cells, was significantly reduced in correlation with the reduction of BLyS levels. No significant association was found between baseline counts of B cells and reduction of SLEDAI-2K over time. In terms of response prediction, a significant association between SLEDAI-2K improvement at 12 months and the decrease of total number of B cells within the first 6 months of therapy was observed. Concerning the T cell compartment, the baseline percentage number of CD8+ effector memory was associated with SLEDAI-2K at baseline and with its improvement after 12 months of therapy. Furthermore, T cell lymphopenia and low number of circulating recent thymic emigrants were also observed compared to control subjects measured at baseline.Discussion: The effects of belimumab on B cell subpopulations could be explained by the direct blockage of soluble BLyS, while the mild effects on T cells might be explained indirectly by the reduction of disease activity by means of therapy. B cell immunophenotyping during belimumab might be useful for monitoring the response to treatment

9A.07: CARDIOVASCULAR TARGET ORGAN DAMAGE IN PREMENOPAUSAL SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS AND IN CONTROLS. ARE THERE ANY DIFFERENCES?

OBJECTIVE: In patients with systemic lupus erythematosus (SLE) a greater prevalence of structural and functional cardiovascular (CV) alterations has been described, possibly explaining the higher incidence of CV events, as compared to subjects matched for age and sex.Aim of this study was to analyze the presence of target organ damage in premenopausal women with SLE and in controls matched not only for demographic characteristics but also for other cardiovascular risk factors. DESIGN AND METHOD: 34 patients with SLE clinically stable (SLEDAI Score 2.5 +/- 1.5) (mean age 32 ± 7 years, range 19-44) and 34 controls matched for sex, age, body mass index (BMI), clinic blood pressure (BP) and antihypertensive treatment (if present), underwent: 24 hours BP monitoring, echocardiography with tissue Doppler analysis (TDI) for the evaluation of left ventricular (LV) structure and of systolic and diastolic function, carotid ultrasound for intima-media thickness (IMT) and carotid distensibility measurement, and pulse wave velocity measurement for aortic stiffness (PWV). RESULTS: By definition no difference was observed for age, sex, BMI and clinic BP values and a similar Framingham risk score was observed between SLE and controls (1.3 ± 2.7 vs 1.5 ± 2.3%, p = ns). No significant differences were observed for all echocardiographic parameters except LV longitudinal systolic function (Sm), an early index of LV systolic dysfunction (see Table). Carotid IMT and distensibility, as well as PWV and the prevalence of an abnormal aortic stiffness were both similar in the two groups. At the logistic analysis, PWV was independently associated with LV mass in controls and with the steroid weekly dose in SLE patients.(Figure is included in full-text article.) CONCLUSIONS: In patients with SLE and low activity index of the disease we did not observe significant vascular alterations as compared to controls with similar cardiovascular risk. The early LV systolic impairment observed in this group of patients needs confirmation in larger cohorts

P136 SLEDAI response prediction to belimumab therapy by baseline levels of BLyS, APRIL and CD8+ effector memory T-cells

n/