Abstract Objectives B cell depletion by rituximab (RTX) is an effective treatment for anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). However, peripheral B cell phenotypes and the selection criteria for RTX therapy in AAV remain unclear. Methods Phenotypic characterization of circulating B cells was performed by 8-color flow cytometric analysis in 54 newly diagnosed AAV patients (20 granulomatosis with polyangiitis and 34 microscopic polyangiitis). Patients were considered eligible to receive intravenous cyclophosphamide pulse (IV-CY) or RTX. All patients also received high-dose glucocorticoids (GC). We assessed circulating B cell phenotypes and evaluated the efficacy after 6 months of treatment. Results There were no significant differences in the rate of clinical improvement, relapses, or serious adverse events between patients receiving RTX and IV-CY. The rate of Birmingham Vasculitis Activity Score (BVAS) improvement at 6 months tended to be higher in the RTX group than in the IV-CY group. The proportion of effector or class-switched memory B cells increased in 24 out of 54 patients (44%). The proportions of peripheral T and B cell phenotypes did not correlate with BVAS at baseline. However, among peripheral B cells, the proportion of class-switched memory B cells negatively correlated with the rate of improvement in BVAS at 6 months after treatment initiation ( r = − 0.28, p = 0.04). Patients with excessive B cell differentiation were defined as those in whom the proportion of class-switched memory B cells or IgD − CD27 − B cells among all B cells was > 2 SDs higher than the mean in the HCs. The rate of BVAS remission in patients with excessive B cell differentiation was significantly lower than that in patients without. In patients with excessive B cell differentiation, the survival rate, the rate of BVAS-remission, and dose reduction of GC were significantly improved in the RTX group compared to those in the IV-CY group after 6 months of treatment. Conclusions The presence of excessive B cell differentiation was associated with treatment resistance. However, in patients with circulating B cell abnormality, RTX was effective and increased survival compared to IV-CY. The results suggest that multi-color flow cytometry may be useful to determine the selection criteria for RTX therapy in AAV patients.
Abstract Objective MCTD manifests with microvasculopathy and overlapping clinical features of SLE, SSc and idiopathic inflammatory myopathies (IIM). The aim of this study was to investigate the clinical significance of microvasculopathy in patients with MCTD using nailfold videocapillaroscopy (NVC). Methods Fifty patients with newly diagnosed and untreated MCTD were enrolled in this multicentre, prospective and observational study. Clinical features and NVC findings were assessed at baseline and after 1 year post-intervention, along with disease controls [SLE (n = 40), SSc (n = 70) and IIM (n = 50)]. Results All MCTD patients presented Raynaud’s phenomenon and were positive for anti-U1 RNP antibodies, and 22.0% (11/50) had pulmonary arterial hypertension (PAH). The prevalence of NVC scleroderma patterns in MCTD was 38.0%, which was lower than SSc (88.6%) but higher than SLE (10.0%). In addition, when we divided MCTD patients into two groups by presence or absence of NVC scleroderma patterns, we found a higher prevalence of PAH in patients with NVC scleroderma patterns. Namely, NVC scleroderma patterns were observed in all MCTD patients with PAH, and in 21.0% of those without PAH. After intensive immunosuppressive therapy, NVC scleroderma patterns disappeared in half of the MCTD patients but were not changed in SSc patients. Conclusions MCTD differed from SLE, SSc and IIM in terms of the prevalence and responsiveness of NVC scleroderma patterns to immunosuppressive therapy. Detection of nailfold microvascular abnormalities in MCTD could contribute to predicting PAH and help us to understand further aspects of the pathogenesis of MCTD.
Objectives The differences of efficacy between each Janus kinase (JAK) inhibitors have not been clarified in the patients with rheumatoid arthritis (RA) in clinical practice. Here, we compared the efficacy between tofacitinib (TOFA) and baricitinib (BARI) in clinical practice. Methods The efficacy of TOFA (n=156) in patients with RA was compared with BARI (n=138). Selection bias was reduced to a minimum using propensity score-based inverse probability of treatment weighting (IPTW). The Clinical Disease Activity Index (CDAI) trajectory for patients who started TOFA or BARI was analysed using growth mixture modelling (GMM). Results No significant difference was observed in patient characteristics between the TOFA and BARI groups in after adjustment by propensity score-based IPTW. The BARI group had a significantly higher rate of CDAI remission at week 24 after the introduction of JAK inhibitors than the TOFA group. The treatment-resistant group defined by GMM, comprising patients who did not achieve low disease activity at week 24, was more likely to include those who had received many biological disease-modifying antirheumatic drugs (bDMARDs) before the introduction of JAK inhibitors and those who received TOFA. Among patients with RA who received TOFA, those who had received ≥4 bDMARDs before the introduction of TOFA were more likely to be classified into the treatment-resistant group. Conclusions BARI showed a similar safety profile and better clinical outcome when compared with TOFA after reduction to a minimum of selection bias. However, these were observed in a small population. Accordingly, further investigation is required in an accurately powered head-to-head trial.
The fitting of oxygen mask affects the performance of it such as oxygenation or CO₂ elimination. The intersurgical EcoLite™ adult high-concentration oxygen mask (EcoLite with a reservoir, Intersurgical, UK) was developed to give well-fitting. The purpose of this study is to evaluate the performance of EcoLite with a reservoir compared to the conventional mask.
The aim of this study was to assess the therapeutic effects of biological DMARDs (bDMARDs) on the diversity of immune cell phenotypes in peripheral blood of patients with RA. Peripheral immune cell phenotypes were determined in 108 RA patients who were non-responsive to conventional DMARDs and 33 healthy control subjects by eight-colour flow cytometry. We also examined the correlation between the phenotypes and clinical findings and assessed the effects of 24-week treatment with bDMARDs. The proportions of T follicular helper (Tfh) cells, IgD− CD27− double negative B cells and plasmacytoid dendritic cells (pDCs) were higher in patients with active RA than in healthy control. The percentages of memory T cells, Th17 and Tfh cells correlated with autoantibody titres, whereas that of plasmablasts correlated with disease activity scores. Treatment with TNF inhibitors reduced the proportion of pDCs, while tocilizumab reduced the proportion of double-negative B cells but increased naïve and activated Treg cells. Abatacept treatment resulted in marked decrease in the proportion of activated Tfh but slightly reduced Th17 and Treg cells. The proportion of Tfh cells was an independent and significant predictor of the response to abatacept therapy. Molecular targeted therapies induced different changes in different immune cell phenotypes. Among the phenotypes, Tfh cells seem a potential target for abatacept. Immunophenotypic analysis might be useful for prediction of the response to bDMARDs.
A 29-year-old woman was admitted to our hospital for treatment of fulminant type 1 diabetes (FT1D) with diabetic ketoacidosis. The phenotype of peripheral blood lymphocytes was analyzed using an 8-color flow cytometer. An analysis of the CD4-positive T cells showed a tendency for higher proportions of effector and central memory T cells and a normal proportion of regulatory T (Treg) cells, compared to healthy control. An analysis of B cell differentiation showed higher proportions of switched memory B cells and plasmablasts. The differences in lymphocyte phenotypes between our case and previously reported cases suggest a diversity of FT1D pathology.
Abstract Objectives: B-cell depletion by rituximab (RTX) is an effective treatment for anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). However, peripheral B cell phenotypes and the selection criteria for RTX therapy in AAV remain unclear. Methods: Phenotypic characterization of circulating B cells was performed by 8-color flow cytometric analysis in 54 newly diagnosed AAV patients (20 granulomatosis with polyangiitis and 34 microscopic polyangiitis). Patients were considered eligible to receive intravenous cyclophosphamide pulse (IV-CY) or RTX. All patients also received high-dose glucocorticoids (GC). We assessed circulating B cell phenotypes and evaluated the efficacy after 6 months of treatment. Results: There were no significant differences in the rate of clinical improvement, relapses, or serious adverse events between patients receiving RTX and IV-CY. The proportion of effector or class-switched memory B cells increased in 24 out of 54 patients (44%). The proportions of peripheral T and B cell phenotypes did not correlate with BVAS at baseline. However, among peripheral B cells, the proportion of class-switched memory B cells negatively correlated with the rate of improvement in BVAS at 6 months after treatment initiation ( r = -0.28, p = 0.04). Patients with excessive B cell differentiation were defined as those in whom the proportion of class-switched memory B cells or IgD - CD - B cells among all B cells was >2 SDs higher than the mean in the HCs. The rate of Birmingham Vasculitis Activity Score (BVAS) remission in patients with excessive B cell differentiation was significantly lower than that in patients without. In patients with excessive B cell differentiation, the survival rate, the rate of BVAS remission, and dose reduction of GC were significantly improved in the RTX group compared to those in the IV-CY group after 6 months of treatment. Conclusions: The presence of excessive B cell differentiation was associated with treatment resistance. However, in patients with circulating B cell abnormality, RTX was effective and increased survival compared to IV-CY. The results suggest that multi-color flow cytometry may be useful to determine the selection criteria for RTX therapy in AAV patients.
Aberrant and persistent production of type I interferon (IFN) is known to play a pivotal role in the pathogenesis of systemic lupus erythematosus (SLE), and plasmacytoid dendritic cells (pDCs) are the major source of type I IFN upon toll-like receptor 7 (TLR7) and TLR9 stimulation. However the respective impacts of TLR7 and TLR9 responses on type I IFN production in SLE has not been addressed.To investigate the precise function of pDCs in SLE patients, we shed light upon the differential regulation of TLR7/9 responses during type I IFN production from pDCs.
Methods
PBMCs from SLE patients and healthy controls were analysed in the presence of a TLR7 agonist loxoribine and a TLR9 agonist CpG2216. The IFN-α production in Lin-HLA-DR+CD123+CD11c- pDCs was detected by flow cytometry.
Results
We demonstrated that TLR7-mediated IFN-α production were up-regulated and were positively correlated with disease activity, conversely, TLR9-mediated IFN-α production were down-regulated in SLE. The differential regulation of TLR7/9 responses of pDCs was not dependent on expression levels of TLR7/9. Furthermore, in vitro experiments revealed that up-regulation of TLR7 response was caused by pre-treatment with type I IFNs, conversely, down-regulation of TLR9 response was caused by pre-treatment with type II IFN.
Conclusions
This is the first report demonstrated the differential regulation of TLR7- and TLR9- mediated IFN-α production from pDCs in SLE, namely, caused by priming effects of type I and type II IFNs. Taken together, TLR7-, but not TLR9-, mediated IFN-α production contributes the pathogenesis of SLE, and TLR7 could be a potential therapeutic target for SLE.
Abstract Objectives The efficacy of belimumab (BEL) during maintenance therapy in patients with SLE remains unclear in the real-life clinical setting. This study investigated the efficacy and safety of BEL in patients with SLE during maintenance therapy. Methods In this retrospective observational study, maintenance therapy was defined as low-dose glucocorticoid (GC) therapy (prednisolone equivalent dose of ≤0.2 mg/kg/day) in patients with a Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI) score <10. Participants comprised patients with SLE on HCQ or MMF [standard-of-care (SoC) group: n = 103] and those on BEL plus SoC (BEL+SoC group: n = 100). Selection bias was minimized using propensity score-based inverse probability of treatment weighting (IPTW). GC dose trajectories were modelled using growth mixture modelling (GMM). The primary end point was GC dose at 52 weeks. Results No significant difference was observed in patient characteristics between the two groups after IPTW adjustment. The BEL+SoC group exhibited a significant decrease in GC dose. GC dose at 52 weeks and relapse rate were significantly lower in the BEL+SoC group than in the SoC group. The proportion of patients in one of four groups defined by GMM for which GC dose was tapered to 0 mg within 52 weeks (GC tapering-discontinuation group) was significantly higher in the BEL+SoC group than in the SoC group. In the BEL+SoC group, low SELENA-SLEDAI score and low GC dose at baseline were associated with being GC dose-tapering discontinuation. Conclusion The present study suggests that BEL is suitable for patients with SLE during maintenance therapy.
Systemic lupus erythematosus (SLE) is characterized by a wide diversity of clinical manifestations, and the etiology may vary among patients. Immunophenotyping of peripheral blood has revealed dysregulation in the differentiation of B cells compared to that in healthy individuals. However, the correlation between these differences and clinical symptoms remains unclear. Moreover, the appropriate sub-grouping of lupus patients holds the potential to pave the way for precision medicine.
Objectives:
The purpose of this study was to identify peripheral blood immunological abnormalities in SLE, assess their diversity, and attempt to subgroup lupus patients. Additionally, we investigated the relationship between these subgroups and clinical symptoms as well as prognosis.
Methods:
Immunophenotyping of immunocompetent cells in peripheral blood, encompassing T cells, B cells, NK cells, dendritic cells, and monocytes, was conducted using multicolor flow cytometry following the antibody set proposed by NIH/FOCIS. The analysis included 123 untreated patients with SLE and 75 healthy subjects. The immunophenotypes were assessed as a percentage within peripheral blood mononuclear cells. The outcomes underwent cluster analysis, employing both the Ward's method with Euclidean distance to stratify the patient population. Based on the tree diagram, the number of clusters was set to four. Visualization of the clusters was performed using Uniform Manifold Approximation and Projection (UMAP) method. Clinical symptoms and recurrence rates at 3 years were evaluated within each subgroup.
Results:
All patients in the study were untreated, with a median age of 42 years. The median disease duration was 5 months. The disease activity, as measured by SLEDAI, averaged 11, and 66% of the patients had either one BILAG A or two Bs (BILAG A1 or B2). Overall, lupus patients exhibited an elevation in double-negative B cells (1.4% vs 0.6%) and plasmablasts (1.4% vs 0.2%) in peripheral blood compared to healthy controls. In T cells, there was an elevation in activated CD4 (1.8% vs 0.6%), activated CD8 (4.7% vs 0.6%), and activated Th1 cells (0.8% vs 0.3%). Additionally, there was a reduction in CD16+ NK cells (5.6% vs 10.3%). Cluster analysis based on this immunophenotype stratified untreated SLE patients into four major groups and visualized them using UMAP (Figure 1). One of the four clusters exhibited an almost identical immunophenotype to that of healthy controls and comprised the smallest number of patients (cluster 1). The remaining three clusters were nearly evenly distributed, distinguished by a relatively low proportion of plasmablasts with a notable increase in double-negative B cells (cluster 2), a tenfold increase in plasmablasts (cluster 3), and an elevation in activated regulatory T cells (cluster 4). Cluster 2 was the youngest in terms of age, with no differences observed in disease duration or gender. In these four clusters, cluster 1 exhibited the lowest disease activity, with BILAG A1 or B2 at 40%, whereas cluster 3, characterized by markedly elevated plasmablasts, showed high disease activity, with BILAG A1 or B2 at 88%, and hypocomplementemia was also prevalent. An analysis of the 3-year clinical course of patients undergoing high-dose glucocorticoid therapy revealed that cluster 1 did not experience a single relapse, while cluster 3 had more than 20% relapses. The remaining clusters exhibited approximately 10% relapses.
Conclusion:
Immunophenotyping facilitated the stratification of untreated lupus patients into four distinct groups. While SLE is characterized by an elevation of double-negative B cells and plasmablasts, these immune cell subsets exhibited differential behavior within the SLE population. Cluster characterized by a significant increase in plasmablasts exhibited notably high disease activity and relapse rates.
REFERENCES:
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Acknowledgements:
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Disclosure of Interests:
Satoshi Kubo has received speaking fees from Eli Lilly, GlaxoSmithKline, Bristol-Myers, Abbvie, Eisai, Pfizer, Astra-Zeneca, has received research grants from Daiichi-Sankyo, Abbvie, Boehringer Ingelheim, and Astellas., Shingo Nakayamada has received speaking fees from Bristol-Myers, UCB, Astellas, Abbvie, Eisai, Pfizer, and Takeda, has received research grants from Mitsubishi-Tanabe, Novartis, and MSD, Yusuke Miyazaki has received epeaking fees from Astra-Zeneca, speaking fees, and/or honoraria from Eli Lilly and GlaxoSmithKline, Yasuyuki Todoroki: None declared, Masanobu Ueno: None declared, Katsuhide Kusaka: None declared, Satsuki Matsunaga: None declared, Hiroaki Tanaka: None declared, Naoaki Ohkubo: None declared, Hidenori Sakai: None declared, Ippei Miyagawa: None declared, Kentaro Hanami: None declared, Yoshiya Tanaka has received speaking fees and/or honoraria from Eli Lilly, AstraZeneca, Abbvie, Gilead, Chugai, Behringer-Ingelheim, GlaxoSmithKline, Eisai, Taisho, Bristol-Myers, Pfizer, Taiho, has received research grants from Mitsubishi-Tanabe, Eisai, Chugai, Taisho.
