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ObjectiveDispersion, or variability in an individual’s performance across multiple tasks at a single assessment visit, has been associated with cognitive dysfunction (CD) in many neurodegenerative and neurodevelopmental disorders. We aimed to compute a dispersion score using neuropsychological battery (NB) tests and determine its association with CD in patients with SLE.MethodsCD was defined as a z-score of ≤−1.5 on ≥2 domains of the NB. To compute a type of dispersion score known as the intraindividual SD (ISD), the SD of age-adjusted and sex-adjusted z-scores was calculated for each visit in each patient. To estimate the association between ISD and cognitive status (CD and non-CD), we used multilevel logistic regression, adjusting for clinically important covariates.ResultsA total of 301 adult patients with SLE completed the NB at baseline, 187 of whom were reassessed at 6 months and 189 at 12 months. CD was observed in 35.2% of patients at baseline, 27.8% at 6 months and 28.0% at 12 months. Prior to covariate adjustment, the mean ISD for non-CD was 1.10±0.31 compared with 1.50±0.70 for CD. After adjusting for ethnicity, education, employment, socioeconomic status and anxiety/depression, there was a statistically significant association between ISD and CD (OR for one-unit increase in ISD: 13.56, 95% CI 4.80 to 38.31; OR for 1/10th-unit increase in ISD: 1.30, 95% CI 1.17 to 1.44). Findings were valid across multiple sensitivity analyses.ConclusionThis is the first study to show that patients with SLE who were classified as having CD by the NB had more variability across the NB tests (ie, higher ISD score) compared with those who were not classified as having CD.

Objective:To study the longitudinal expression of interferon (IFN)-inducible genes in systemic lupus erythematosus (SLE) and determine their suitability as disease biomarkers.Methods:RNA was isolated from the peripheral blood of 94 patients with SLE and 11 controls and reverse transcribed into cDNA. The expression levels of five IFN-responsive genes (LY6E, OAS1, IFIT1, ISG15 and MX1) were determined by quantitative PCR, normalised to GAPDH and summed to generate a global IFN score. Patients were followed longitudinally for a period of 3–12 months, and the association between disease activity, as measured by the SLE disease activity index (SLEDAI-2K), and other clinical and laboratory variables was examined.Results:The expression of all five IFN-responsive genes was significantly higher in patients with SLE than in controls. The expression of LY6E, OAS1, IFIT1 and the global IFN score was associated with high disease activity. The global IFN score was also associated with active renal disease, a decreased C3, and the presence of anti-dsDNA or anti-RNA binding protein antibodies at a single point in time. However, there was a poor correlation between changes in this score and changes in disease activity, C3 or anti-dsDNA antibody levels in patients followed longitudinally. In most patients the levels of IFN-induced gene expression remained relatively stable over 3–12 months despite marked changes in disease activity. Nevertheless, in patients with low/moderate disease activity, those with high IFN scores had a more recent history of sustained high disease activity.Conclusion:The findings indicate that IFN-induced gene expression has limited clinical utility as a biomarker of acute changes in disease activity.

Background Patients with systemic autoimmune rheumatic diseases (SARD) often have a prolonged pre-clinical phase during which they are anti-nuclear antibody (ANA)+ but lack clinical symptoms. It has been proposed that progression from asymptomatic autoimmunity to clinical disease is accompanied by immunologic changes that could be used as predictors of disease development. Previous studies indicate that a number of B cell phenotypic changes are seen in SARD patients including changes in the proportions of various naive and memory B cell subsets, increased B cell activation and elevated levels of plasmablasts/plasma cells. Objectives To determine whether ANA+ individuals who lack sufficient symptoms for a SARD diagnosis have B cell phenotypic changes similar to those seen in SARD. Methods Healthy controls (HC) and ANA+ individuals who: 1) lacked clinical symptoms of SARD (ANS); 2) had at least one clinical symptom of SARD (UCTD); or 3) had a recently diagnosed steroid and immunosuppressive naive SARD (SLE, SS, SSc, MCTD, DM) were recruited. PBMCs were isolated over a Ficoll gradient, stained with various combinations of fluorescently labeled antibodies and analyzed by flow cytometry. Anti-nuclear antibodies were measured through the hospital laboratory. Whole blood IFN signature and BAFF RNA levels were measured by NanoString. Results B cell phenotypes were examined for 32 HC, 38 ANS, 28 UCTD, and 59 early SARD (24 SS, 26 SSc, 6 SLE, 2 MCTD, 1 DM) patients. Patients with early SARD had a number of changes in their naive and memory B cell subsets, as previously reported for patients with established disease, including: increased proportions of mature naive B cells (SSc); increased proportions of T1T2 cells (SLE and SS); and trends to decreased proportions of switched memory B cells (CD27+IgD–) in all SARD. Similar decreases in the proportion of switched memory B cells were seen in ANS and UCTD patients, and as seen for the SARD patients, these cells were activated with elevated levels of CD86 as compared to HC. Significantly increased activation of the CD27–IgD– memory compartment was also seen in ANS, UCTD, SLE and SjD patients. Although significantly increased proportions of plasmablasts and/or CD138+ plasma cells were seen in all SARD patients (except those with SSc), these were not seen in ANS and UCTD patients. Nevertheless, in pre-SARD individuals (ANS + UCTD) there was a significant positive correlation between the size of these cell subsets, as well as the proportion of T1T2 cells, and ANA titer and the number of different anti-nuclear antibodies specificities. As observed for early SARD patients, there was a trend to increased BAFF levels as compared to HC in pre-SARD individuals, which achieved statistical significance in UCTD patients. However, there was no association between the levels of BAFF and any of the B cell phenotypes, whereas the IFN signature was positively associated with the proportion of T1T2 cells. Conclusions B cell phenotypic abnormalities precede the onset of clinical disease in ANA+ individuals and have a pattern suggesting ongoing activation through T-B collaboration. Disclosure of Interest None declared

Background The relapsing and remitting nature of lupus nephritis (LN) poses a challenge to clinicians who must balance the risk of long term kidney damage with the side effects of treatment. Management of this condition would be greatly aided by the identification of biomarkers that accurately reflect and predict treatment responses. We previously identified and validated a panel of urinary biomarkers that are specifically elevated in SLE patients with active LN as compared to active patients without LN or LN patients in remission. Objectives To determine whether changes in the levels of these urinary biomarkers predict treatment responses. Methods 21 SLE patients with biopsy-proven LN were followed longitudinally for a minimum of 2 years after treatment. Levels of 15 urinary biomarkers including Clusterin, Cystatin C, NGAL, PF4, vWF,sVCAM-1, GM-CSF, GRO, IL-15, IL-6, MCP-1, Adiponectin, PAI-1, MMP-7, and TIMP-1, were measured by Luminex. Patients were classified as having a complete response (n=12), partial response (n=4), or treatment (Tx) failure (n=5) at 2 years following initiation of treatment, based upon previously established criteria. Urinary biomarker levels were considered abnormal if they were >2 SD above the mean for 24 healthy controls. Data were analyzed using non-parametric statistics. Results At 3–6 months following treatment, the changes in biomarker levels from the first visit were not significantly different between complete responders and partial responders or Tx failures. However, at 1 year (11–16 months) following treatment, 5 urinary biomarkers, sVCAM-1, Adiponectin, IL-15, vWF, and MCP-1, demonstrated significantly different changes from baseline in complete responders as compared to Tx failures, with the majority of responders demonstrating improvement and the majority of Tx failures demonstrating worsening. As urinary biomarker levels not corrected for urinary osmolality correlated best with clinical outcomes, subsequent analyses were done with the uncorrected values. Normalization of urinary Adiponectin by 11–16 months was the best predictor of a complete response, with 11 of 12 patients who normalized being complete responders and 1 a partial responder. Similar but slightly less discriminative results were obtained for the other 4 urinary biomarkers. Conversely, the presence of an abnormal urinary vWF at 11–16 months was the strongest predictor of an adverse outcome with 4 of 6 patients with abnormal levels being Tx failures. Notably, all patients that were Tx failures that had normal levels of urinary biomarkers at 11–16 months subsequently developed abnormal levels, whereas patients who were complete responders eventually normalized the majority of these 5 biomarkers. Partial responders demonstrated normalization with delayed kinetics. Conclusions Measurement of urinary biomarkers can provide valuable insight into treatment responses in lupus nephritis. Disclosure of Interest None declared

Background The systemic autoimmune rheumatic diseases (SARD; Systemic Lupus Erythematosus, Rheumatoid Arthritis, Sjogren9s Disease, Systemic Sclerosis) are proposed to have a prolonged period of pre-clinical autoimmunity culminating in clinical disease. Evidence from disease-specific studies (e.g., SLE, RA) suggests that the pre-clinical phase is marked by the accrual of immunological abnormalities such as pathogenic auto-antibodies (auto-Ab). Little is known about the cellular derangements that accompany the transition from benign to pathological autoimmunity. Abnormalities in T cell subsets including invariant NKT (iNKT) and T follicular helper (T FH ) cells are implicated in the development of systemic autoimmunity. Both a decrease in iNKT cells and an increase in T FH cells are found in patients with established SARD. Objectives To determine if T cell abnormalities associated with SARD are present in pre-clinical autoimmunity. Methods Patients (n=87) who were ANA + (titer ≥1:160) and healthy controls (HC, n=37) were recruited. Patients were stratified into clinical subsets: (1) no defining SARD symptoms (n=24); (2) undifferentiated connective tissue disease (UCTD, n=17), one or more SARD defining symptom; and (3) early SARD (n=46), fulfilling ACR criteria for a SARD diagnosis. Patients were immunosuppressive and steroid naive. PBMCs were isolated over a Ficoll gradient, stained with combinations of fluorescently labeled antibodies and analyzed by flow cytometry. ANA titer and auto-Ab profile were determined. Results A statistically significant decrease in the proportion of iNKT cells (CD3 + Vα24Jα18 TCR + ) was found for all ANA + patients relative to HC (p=0.0001). Similar results were found for each patient subset when compared to HC; ANA + asymptomatic (p=0.001), UCTD (p=0.02) and SARD (p=0.001), with no differences amongst groups. The proportion of T FH (CD4 + CXCR5 high PD-1 high ) cells was significantly elevated (p=0.01) in patients versus HC. While the proportion of T FH cells was similar between asymptomatic ANA + patients and HC, there was a significant expansion of T FH in UCTD as compared to both groups (p=0.02 and p=0.04, respectively). SARD patients had a non-significant trend to increased proportions of T FH as compared to UCTD. Patients (n=50) with higher ANA titers (≥1:640) had a significant increase (p=001) in T FH when compared to individuals (n=13) with lower ANA levels (1:160). A positive correlation (p FH and the number of auto-Abs within the patient population was found. No significant differences were noted in the iNKT or T FH cell proportions between SARD patients stratified by specific disease diagnosis. Conclusions A decrease in the iNKT cell subset is present at the earliest phase of pre-clinical autoimmunity (asymptomatic ANA + ) suggesting that loss of this T cell subset contributes to a breach of tolerance to nuclear antigens. In contrast, increases in the T FH compartment appear to parallel the onset of clinical symptoms and accrual of auto-Abs. These results suggest that an incremental development of T cell abnormalities marks the progression towards clinically significant autoimmunity. Disclosure of Interest None declared

Background Patients with systemic autoimmune rheumatic diseases (SARD) often have a prolonged pre-clinical phase during which they are anti-nuclear antibody (ANA)+ but lack clinical symptoms. It has been proposed that progression from asymptomatic autoimmunity to clinical disease is accompanied by immunologic changes that could be used as predictors of disease development. Elevated levels of interferon (IFN)-induced gene expression, termed the IFN signature, are found in several SARD conditions, and IFNs appear to play an important role in disease pathogenesis. Objectives To determine whether ANA+ individuals who lack sufficient symptoms for a SARD diagnosis share the IFN-signature. Methods ANA+ individuals who: 1) lacked clinical symptoms of SARD (ANS); 2) had a least one clinical symptom of SARD (Undifferentiated Connective Tissue Disease, UCTD); or 3) had a recently diagnosed SARD (Systemic Lupus Erythematosus, SLE; Sjogren9s Disease, SjD; Scleroderma, SSc; Mixed Connective Tissue Disease, MCTD; Dermatomyositis, DM) were recruited from clinics at UHN/MSH hospitals. None of the patients were on corticosteroids or DMARDs with the exception of hydroxychloroquine. Healthy controls (HC) were also recruited. RNA was prepared from blood archived in Tempus tubes. Expression of 5 IFN-induced genes was quantified by Nanostring, normalized to expression of housekeeping genes, and summed to generate an IFN5 score. ANAs and levels of specific autoantibodies were measured by the hospital laboratory. Results To date we have measured the IFN signature on 95 individuals (21 HC, 21 ANS, 16 UCTD, 22 SjD, 7 SSc, 6 SLE, 1 MCTD, 1 DM). There was a trend to higher mean IFN score in all groups as compared to HC (mean ± SD: HC 7,071±6,321; ANS 27,245±36,037; UCTD 27,624±24,827; SSc 34,940±40,940; SjD 61,877±33,404; SLE 62,769±50,233; MCTD/DM 97,716±24,973), which achieved statistical significance for ANS, UCTD, SjD, and SLE (corrected p=0.044, 0.003, Conclusions An IFN signature is seen in a subset of ANA+ individuals prior to a confirmed diagnosis of SARD and appears to correlate with the type and number of specific ANAs rather than onset of clinical disease. Disclosure of Interest None declared

Background Nephritis is a major cause of morbidity and mortality in SLE. One of impediments to optimal management of this condition is a lack of biomarkers that forecast development of renal disease or that can be used to determine the response to therapy. Objectives In this study we used gene expression microarrays to contrast the gene expression profile in active lupus patients with and without nephritis to identify potential biomarkers and immune mechanisms associated with nephritis. Methods Affymetrix Human Gene 2.0ST arrays were used to assay gene expression in total RNA isolated from blood archived in PAXgene tubes for 38 active SLE patients with ≥4 ACR SLE classification criteria (25 biopsy proven nephritis, 13 active without nephritis) and 17 healthy controls. Data were analyzed with linear modeling, with corrections for multiple testing. Results were validated in a largely independent cohort of 22 healthy controls and 170 SLE patients (129 active (89 with and 40 without nephritis), 41 nephritis in remission), using Nanostring technology. Results Comparison of gene expression between healthy controls and all SLE patients revealed 27 genes that were increased >1 log 2 fold-change in SLE, the majority of which (25) were IFN-induced. When active SLE patients with and without nephritis were compared, there were 25 probes that demonstrated a >1 log 2 fold-change with a false discovery rate of q Conclusions Patients with lupus nephritis have higher levels of LDG gene expression than those without nephritis. Given the high rate of spontaneous NETosis in this cell population, the findings are consistent with the concept that high levels of NETosing neutrophils promote renal disease in SLE. Disclosure of Interest J. Wither Grant/research support from: CIHR and Eli Lilly and Company, S. Prokopec: None declared, B. Noamani: None declared, D. Bonilla: None declared, Z. Touma: None declared, H. Reich: None declared, J. Scholey: None declared, P. Fortin Grant/research support from: CIHR and Eli Lilly and Company, P. Boutros: None declared, C. Landolt-Marticorena: None declared