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Objective We aimed to analyse the prevalence of non-criteria anti-phospholipid (aPL) antibodies and their role in the diagnosis, treatment and prognosis in a cohort of patients with clinical features consistent with a diagnosis of antiphospholipid syndrome (APS), but persistently negative for criteria aPL – anti-cardiolipin antibodies (aCL), anti-β2-glycoprotein I antibodies (aβ2-GPI) and lupus anticoagulant (LA) – named seronegative APS (SN-APS). Methods Sera from SN-APS patients were tested for aCL by TLC-immunostaining, anti-vimentin/cardiolipin (aVim/CL) and anti-phosphatidylserine/prothrombin (anti-PS/PT) by ELISA. Control groups of our study were APS patients and healthy controls. Results We enrolled 114 consecutive SN-APS patients, 69 (60.5%) resulted positive for at least one non-criteria test in two occasions 12 weeks apart. Among the persistently positive patients to these tests, 97% resulted positive for aCL by TLC-immunostaining, 52.3% for aVim/CL and 17.4% for aPS/PT. SN-APS patients with double positivity (aCL by TLC-immunostaining and aVim/CL) showed a likelihood positive ratio of 8 to present mixed thrombotic and obstetrical features. Among SN-APS patients tested positive, after the therapeutic changes, three cases of recurrent thrombosis were observed [median follow-up 41 months (IQR 39.5)]. Twenty pregnancies were recorded in 17 SN-APS patients after the detection of unconventional aPL and 12 of them (60%) experienced a good outcome under conventional treatment for APS. Conclusions This is the largest monocentric study demonstrating that aCL tested by TLC-immunostaining and aVim/CL can detect aPL positivity in SN-APS. It may encourage clinicians to monitor and provide adequate targeted therapy, which improve SN-APS prognosis.

Purpose Aim of the study was to investigate whether aPL positivity correlated with thrombosis in COVID-19 patients and whether it was transient or persistent. Methods We enrolled COVID-19 patients who underwent aPL tests: Lupus Anticoagulant (LA); IgM, IgG, IgA anticardiolipin antibodies (aCL); and IgM, IgG anti-β2-Glycoprotein-I antibodies (aβ2GPI). Results Twenty-eight out of 73 (38.4%) patients resulted positive for at least one aPL assay: 32.8% for IgA aCL, 6.8% for IgM aCL and 4.1% for IgM aβ2GPI. No patients tested positive for IgG aPL or LA at the first determination. Seven (9.6%) patients developed thrombotic events during hospitalization, with 4 of them resulting positive for aPL. In patients with thrombotic events during hospitalization the risk of death was increased 9-fold (LR+8.9, p=0.003). Patients with double positivity for aCL and aβ2GPI IgM had a LR+ of 6.3 to have thrombotic events (p=0.012) and a LR+ of 4.9 to have elevated D-dimer levels (p=0.027). In 10 out of 28 positive patients, aPL was detected in a second occasion at least 12-weeks apart and two patients confirmed the positivity. Conclusion Results suggest that double positivity for aCL and aβ2GPI IgM increases the risk of thrombosis in COVID-19, unlike IgA aCL positivity. APL positivity may be persistent, and it is advisable to monitor it over time.

Vaccine induced thrombotic thrombocytopenia is a new syndrome recently described in young adults within two weeks from the first dose of the ChAdOx1 nCoV-19 vaccine and characterized by cerebral venous thrombosis. We report two cases of malignant middle cerebral artery (MCA) infarct and thrombocytopenia within 10 days after vaccination with ChAdOx1 nCoV-19. Patient 1 was a 57-year-old woman who underwent decompressive craniectomy despite two successful mechanical thrombectomies. Patient 2 was a 55-year-old woman who developed a fatal bilateral malignant MCA infarct. Both the patients had pulmonary and portal vein thrombosis and high level of antibodies to platelet factor 4-polyanion complexes.

Objective The EULAR recommendations underline the use of MMF for Lupus Nephritis (LN) but also for the treatment of moderate/severe non-renal manifestations (NLN). This study aims at evaluating the 5-years drug retention rate (DRR) of MMF in a SLE cohort in a real-life scenario. Secondly, we investigated the MMF influence to control chronic damage progression. Methods We performed a longitudinal study including all the SLE patients starting MMF in our Lupus Clinic (from 2008 to 2020). The DRR was estimated using the Kaplan-Meier method. Results We evaluated 162 SLE patients (M/F 22/140). The most frequent indications for prescribing MMF were LN (101 patients, 62.3%) and musculoskeletal manifestations (39, 24.1%) followed by NPSLE (10, 6.2%) and other manifestations (12, 7.4%). We registered a median treatment duration of 30 months (IQR 55). At 60 months follow-up we observed a DRR of 61.1% for LN patients, which was similar to that registered for patients without renal involvement (60.5%). The DRR was higher in the subgroup of patients with joint involvement (75.4%, P non-significant). During the overall observation period, 92 patients (59.2%) discontinued MMF. The main cause of withdrawal was the achievement of remission, observed in 20 patients (21.7%). Moreover, MMF resulted able to control chronic damage progression, as demonstrated by the lack of significant increase in the median SDI values (baseline: 0.6, IQR 1; last: 0.93, IQR 1). Conclusions Our finding suggested that MMF is a safe and effective drug for SLE manifestations other than LN, especially for joint involvement. Moreover, it was able to control the chronic damage progression.

Objectives We evaluated a monocentric SLE cohort in order to assess the frequency of Lupus comprehensive disease control (LupusCDC), a condition defined by the achievement of remission and the absence of damage progression. Methods Our longitudinal analysis included SLE patients with 5-years follow-up and at least one visit per year. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and three different remission levels were evaluated (Complete Remission, CR; Clinical remission off-corticosteroids; clinical remission on-corticosteroids). Chronic damage was assessed according to SLICC Damage Index (SDI). LupusCDC was defined as remission achievement for at least one year plus absence of chronic damage progression in the previous one year. A machine learning based analysis was carried out, applying and comparing Nonlinear Support Vector Machines (SVM) models and Decision Trees (DT), whereas features ranking was performed with the ReliefF algorithm. Results We evaluated 172 patients [M/F 16/156, median age 49 years (IQR 16.7), median disease duration 180 months (IQR 156)]. SDI values (baseline mean±SD 0.7 ± 1.1) significantly increased during the follow-up period. In all time-points analyzed, LupusCDC including CR was the most frequently detected. The failure to reach this condition was significantly associated with renal involvement and with the intake of immunosuppressant drugs and glucocorticoid (GC). Ten patients (5.8%) have maintained LupusCDC during the whole 5-year follow-up: these patients had never presented renal involvement and showed lower prevalence of anti-phospholipid antibodies (p = 0.0001). Finally, the prevalence of GC intake was significantly lower (p = 0.0001). The application of machine learning models showed that the available features were able to provide significant information to build predictive models with an AUC score of 0.703 ± 0.02 for DT and 0.713 ± 0.02 for SVM. Conclusions Our data on a monocentric cohort suggest that the LupusCDC can efficaciously merge into one outcome SLE-related disease activity and chronic damage in order to perform an all-around evaluation of SLE patients.

Objective SLE is an autoimmune disease, mainly affecting women of childbearing age, with possible impact on pregnancy. In this study, we evaluated pregnancy outcomes in all pregnant patients affected by SLE, followed in the context of a rheumatology/gynaecology multi-disciplinary team. Methods Since 2008, we evaluated 70 consecutive pregnancies occurring in 50 SLE patients referring to the Lupus Clinic of Sapienza University of Rome; as controls we evaluated 100 consecutive pregnancies in 100 women without autoimmune diseases. Results By comparing SLE patients and controls, we did not find differences in terms of pregnancy outcomes, except for the occurrence of small for gestational age, which was significantly higher in the SLE group (22.8% vs 11%, P =0.003). Small for gestational age was associated with the positivity for anti-dsDNA, anti-Sm and anti-RNP (P =0.009, P =0.02, P =0.002, respectively). A disease flare was reported in 28 pregnancies (40%) and in 31 puerperium periods (44.3%). Flare during pregnancy was associated with anti-SSA (P =0.02), while puerperium relapse with previous MMF treatment (P =0.01) and haematological flare during pregnancy (P =0.03). Conclusion The present study confirms how pre-gestational counselling and a multi-disciplinary approach could result in positive pregnancy outcomes for SLE patients. The high percentage of disease relapse justifies even more the need for multi-disciplinary management.

Anti‐phospholipid syndrome (APS) is a systemic autoimmune disorder defined by the simultaneous presence of vascular clinical events, pregnancy morbidity and anti‐phospholipid antibodies (aPL). In clinical practice, it is possible to find patients with APS who are persistently negative for the routine aPL tests (seronegative APS; SN‐APS). Recently, the identification of aPL immunoglobulin (Ig)A and/or anti‐β2‐glycoprotein‐I (β2‐GPI) IgA was shown to represent a further test in SN‐APS patients. In this study we analyzed the presence of anti‐vimentin/cardiolipin (aVim/CL) IgA in a large cohort of patients with SN‐APS, evaluating their possible association with clinical manifestations of the syndrome. This study includes 60 consecutive SN‐APS patients, 30 patients with APS and 40 healthy donors. aVim/CL IgA were detected by enzyme‐linked immunosorbent assay (ELISA). Results show that 12 of 30 APS patients (40%) and 16 of 60 SN‐APS patients (26.7%) resulted positive for aVim/CL IgA. Interestingly, SN‐APS patients who tested positive for aVim/CL IgA showed a higher prevalence of arterial thrombosis (p = 0.017, likelihood positive ratio = 5.7). This study demonstrates for the first time, to our knowledge, the presence of aVim/CL IgA in sera of patients with APS. In particular, they revealed a potential usefulness in identification of a significant proportion of SN‐APS patients. Moreover, as patients tested positive for aVim/CL IgA reported a high likelihood ratio to have the clinical features of APS, this test may be considered a suitable approach in the clinical evaluation of SN‐APS., This study demonstrates the presence of aVim/CL IgA in patients with APS. They revealed potential usefulness in the identification of a significant proportion of ‘seronegative’ APS patients (SN‐APS). Patients tested positive for aVim/CL IgA showed a higher prevalence of arterial thrombosis, suggesting that this test may be considered a suitable approach in the evaluation of SN‐APS patients.

Antiphospholipid antibodies (aPL) can induce fetal loss in experimental animal models. Human studies did find hypocomplementemia associated with pregnancy complications in patients with antiphospholipid syndrome (APS), but these results are not unanimously confirmed. To investigate if the detection of low C3/C4 could be considered a risk factor for adverse pregnancy outcomes (APO) in APS and aPL carriers’ pregnancies we performed a multicenter study including 503 pregnancies from 11 Italian and 1 Russian centers. Data in women with APS and asymptomatic carriers with persistently positive aPL and preconception complement levels were available for 260 pregnancies. In pregnancies with low preconception C3/C4, a significantly higher prevalence of pregnancy losses was observed (p = 0.008). A subgroup analysis focusing on triple aPL-positive patients found that preconception low C3 and/or C4 levels were associated with an increased rate of pregnancy loss (p = 0.05). Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of APO. This has been seen only in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss.

Introduction Joint involvement represents the major determinant in quality of life (QoL)in Systemic Lupus Erhytematosus (SLE) patients. However, QoLhas been generally evaluated by non-specific questionnaires. We evaluated the relationship between SLE musculoskeletal manifestations and QoL, assessed by LupusQoL. Methods Patients with joint involvement (group A) were compared with those without this feature (group B). Disease activity was assessed by SLEDAI-2k in the whole population, while DAS28 and swollen to tender ratio were applied to assess joint activity. LupusQoL was administered to all the patients. Results Group A included 110 patients [M/F 8/102; median age 49 years (IQR 13), median disease duration 156 months (IQR 216)], group B 58 [M/F 11/47; median age 40 years (IQR 15), median disease duration 84 months (IQR 108)].We found significanlty lower values in all the LupusQoL domains except for one (burden to others) in group A in comparison with group B. A significant correlation between DAS28 values and all the LupusQoL domains in group A was found; only three domains correlated with SLEDAI-2k. Conclusions SLE-related joint involvement significantly influences disease-specific QoL. DAS28 better correlated with LupusQoL domains in comparison with SLEDAI-2k, confirming the need for specific musculoskeletal activity indices.

Background Mycophenolate mofetil (MMF) is an immunosuppressive drug currently used to treat Systemic Lupus Erythematosus (SLE). In addition to clinical efficacy, MMF use is also supported by a favorable profile of tolerance, with main side effects being nausea, diarrhea, headache, and, less frequently, leucopoenia. Acne is a relatively frequent adverse reaction to MMF that requires specific treatment and drug suspension. Investigations Herein, we describe four cases of MMF-induced acne, none reporting past medical history of acne. The patients were diagnosed with SLE and lupus nephritis and treated with MMF. They developed papulo-pustular and nodular skin lesions consistent with acne. The lesions occasionally showed the appearance of macrocomedones or of unusual, nodular, oedematous lesions in gluteal region, or they had abscess-like features. Culture test demonstrated the presence of Staphylococcus Aureus. They resolved after MMF withdrawal and therapy with tetracycline and local pseudomonic-acid. Conclusions Staphylococcus Aureus skin-localized infections inducing inflammatory/infectious acne may be a relatively frequent side-effect of MMF therapy in SLE. As soon as generalized, severe infections, due to Staphylococcus Aureus, may also occur in patients treated with MMF and even if antibiotics therapy is usually relatively effective, at least temporary MMF suspension may be suggested.

Background:In Systemic Lupus Erythematosus (SLE) patients the incidence of lupus nephritis (LN) is about 40% (1). The rate of progression to end stage renal disease (ESRD) is 4.3-10.1% (2) and renal involvement is a strong predictor of morbidity and mortality.Objectives:To describe clinical, histological features and renal outcomes of LN patients included in our single-center registry reporting data from more than 30 years. Moreover, we examined the correlation between clinical features at LN diagnosis and therapeutic lines used during the course of a 24 years follow-up.Methods:A total of 71 patients were diagnosed with LN from 1989 to 2020. Demographic features and laboratory abnormalities (serum creatinine, 24 hours urine protein, urinary sediment, ds-DNA) at the time of LN diagnosis and at last available follow-up, were evaluated. We also examined renal biopsy performed and the histological classes (proliferative vs non-proliferative). We considered the increase number of therapeutic lines adopted as a negative prognostic factor in response to therapy.Mean (SD) or median (IQR) were used according the variable distribution. T-test and Chi square and Mann-Whitney were used and p-value Results:Among 71 patients with LN, 63 (88.7%) were females and 8 (11.3%) males, with a F/M ratio of 6. Median SLE duration was 180 (162) months. The median age at the onset of nephritis was 28 (19.5) years and occurred in median after 12 (60) months from SLE diagnosis.Sixty patients underwent a biopsy: the histology showed class III or IV prolipherative glomerulonephritis in 49 patients (81.6%) and a non-proliferative class in 11 (18.3%) (p< 0.0001). Median serum creatinine value, 24 hours urine protein, urinary sediment, anti-ds-DNA at LN onset are reported in Table 1. Induction therapy was performed with cyclofosfamide in 14.5% of cases, mycophenolate in 21.1%, rituximab in 1.3%, cyclosporine A in 1.9% and azathioprine in 4.6%. The lines of therapies adopted during the follow-up ranged between a minimum of 0 and a maximum of 6 lines with a median value of 1.Overall, the median follow-up was 180 (111) months and 30 (21.3%) patients had at least 120 months of follow-up. Median serum creatinine value, 24 hours urine protein, urinary sediment and eGFR last available follow-up are reported in Table 1.Three patients underwent dialysis and 3 kidney transplantation.Eight patients underwent a re-biopsy: 7 (87.5%) had a proliferative class and 1 (12.5%) had a membranous class (p=0.01). Median serum creatinine value, 24 hours urine protein, urinary sediment at re-biopsy are reported in Table 1. In re-bioptized subgroup patients, induction therapies were cyclofosfamide in 50% of cases, mycophenolate in 12.5%, cyclosporine A in 25% and azathioprine in 12.5%.There were not statistically significant differences among the age on LN onset, the time from renal onset to the onset of the disease and the number of therapeutic lines adopted (Figure 1).Conclusion:Among patients with LN the proliferative classes are the most common. At the 15-year follow-up 2,1% had renal transplantation and 2,1% dyalisis. We did not detect any association between age at diagnosis, time from renal impairment and the number of therapeutic lines.References:[1]Fanouriakis A et al. Update EULAR/ERA–EDTA recommendations for the management of lupus nephritis. Ann Rheum Dis 2019.[2]Hanly JG et al. The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology 2016.Table 1.Laboratory features in SLE patients at LN onset, at last available follow-up and in re-bioptized patients.LN onset(n 71)AFTER 10 years long FOLLOW-UP(n 30)P valueRe-bioptized patients(n 8)Serum creatinine (mg/dl)0.81 (+/- 0.4)0.87 (+/- 0.60)0,071.05 (0.45)24 hours urine protein (mg/24 h)3000 (+/- 3707)330 (+/- 793)5068 (2392)Active urinary sediment64 patients (45,44%)2 patients (6.66%)8 patients (100%)Anti-ds-DNA +30 patientseGFR 12 patients (3.6%)Disclosure of Interests:None declared

Background:Since the beginning of the SARS-CoV-2 outbreak, antiphospholipid antibodies (aPL), a known thrombotic risk factor, have been studied in COVID-19 patients, in whom thromboembolic events have been associated with poor prognosis. To date, the pathogenetic role of aPL and the trend over time is still unknown.Objectives:Aim of the study was to investigate whether aPL positivity was correlated with thrombosis in COVID-19 patients and whether it was a transient or persistent.Methods:We included all consecutive COVID-19 patients hospitalized at Policlinico Umberto I, Sapienza University of Rome from April 1, 2020 to June 7, 2020. In these patients, serum levels of anti-cardiolipin (aCL) IgM, IgG, IgA, anti-β2glycoprotein I (aβ2GPI) IgM, IgG were measured by enzyme-linked immunosorbent assay (ELISA) and Lupus Anticoagulant (LA) was detected with coagulatory tests in patients not in treatment with anticoagulant drugs.Results:Five out of 73 (6.8%) patients resulted positive for aCL IgM, 3 of them also tested positive for aβ2GPI IgM. aCL IgA were tested positive in 14 out of 46 patients (30.4%). Overall 18 patients resulted positive for at least one test. Seven (9.6%) patients developed thrombotic events during hospitalization, 3 of them resulting positive for aPL (Table 1. below).Table 1.Clinical and demographic features of the 7 Covid-19 patients that presented thrombotic eventsFeaturesPatient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Age - yr67788343707495SexfemalefemalefemalemalemalefemalemaleMedical HistoryMalignancy, HypertensionStrokeChronic obstructive pulmonary diseaseNo medical historyChronic obstructive pulmonary disease, HypertensionMalignancy,HypertensionInitial findingsSigns and symptomsDyspneaDyspneaDyspneaFever, ageusia/anosmia, chest painFever, coughDyspneaDyspneaHRCT chest: Bilateralground glass opacityyesyesyesyesyesyesyesBaseline laboratory valuesLymphocytecount, cells x 106/L2202102330158016806001390Lactatedehydrogenase, U/L223321199227226349199Ferritin mcg/L6143172133874622455197D-dimer mcg/L7301213291228268812981097PaO2:FIO2, mm Hg132120442534348493314Anticoagulant therapy at the time of the thrombotic eventTherapeutic dosageProphylactic dosageProphylactic dosageNot administeredTherapeutic dosageTherapeutic dosageTherapeutic dosageThrombotic eventsStrokePulmonary embolismPeripheral venous thrombosisMyocardial infarctionPulmonary embolismMyocardial infarction, peripheral arterial thrombosis, peripheral venous thrombosisPeripheral venous thrombosisAntiphospholipid antibodiesnegativeAnti-cardiolipin IgM low title, anti-β2glicoprotein I IgM low titlenegativenegativenegativeAnti-cardiolipin IgM low title, anti-β2glicoprotein I IgM low titleAnti-cardiolipin IgA low titleOutcomeExitusExitusSuicideDischargedDischargedDischargedExitusAntiphospholipid antibodies tested after at least 12 weeksNPNPNPNPNPNegativeNPWe observed that patients showing double positivity for aCL IgM and aβ2GPI IgM had a likelihood positive ratio of 6.3 for thrombotic events (p=0.012) and a likelihood positive ratio of 4.9 for increased D-dimer levels (p=0.027). aCL IgA, the most prevalent aPL in this cohort, was not associated with thrombosis. Of the 18 aPL positive patients, 5 died, 3 were lost to follow-up, and 10 were tested on a second occasion at least 12 weeks, two patients confirmed positivity without clinical signs suggestive of APS.Conclusion:These results suggest that double positivity for aCL and aβ2GPI IgM increases the risk of thrombosis in COVID-19 patients, unlike aCL IgA. APL positivity may be persistent and it is advisable to monitor it over time.Disclosure of Interests:None declared

Background:The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.Objectives:To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.Methods:We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.Results:Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.Conclusion:Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.References:[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)nsDisclosure of Interests:None declared

Background:Antimalarials have been associated with QT prolongation in COVID19 patients but are generally safe in patients with rheumatologic disease.Objectives:Aim of the study was to compare the prevalence of QTc prolongation between COVID19 and Systemic Lupus Erythematosus (SLE) patients treated with hydroxychloroquine (HCQ).Methods:We included consecutive patients with SARS-CoV-2 infection confirmed by nasopharyngeal swab and patients taking HCQ for SLE. A prolonged QTc was defined as an increase in QTc intervals >60 ms (compared with baseline) or as a QTc of ≥500 ms.Results:We enrolled 58 COVID19 patients (median age 70.5 years, IQR 25). HCQ, without or with azithromycin, was given to 26 (44.8%) and 15 patients (25.9%), respectively; 17 (29.3%) had not received either drug. The median baseline QTc was 432 (IQR 36) and prolonged QTc was observed in 15 (26%) patients (12 QTc≥500 ms and 3 patients ΔQTc>60 ms). We didn’t find significant differences in QTc prolongation among the three treatment groups. Baseline QTc (OR 111.5) and D-dimer (OR 78.3) were independently associated to QTc prolongation.Compared to the 50 SLE patients (median age of 38.5 years, IQR 22), chronically treated with HCQ, patients with COVID19 showed significantly longer QTc (p < 0.001) (Table 1).Conclusion:This is the first study demonstrating that, differently from COVID19 patients, patients with SLE are not susceptible to HCQ-induced long QT syndrome and arrhythmia. The combined arrhythmogenic effect of SARS-CoV-2 infection and HCQ could account for the excess of QTc prolongation and fatal arrhythmias described in patients with COVID19.Table 1.Difference in clinical and demographic features between Systemic Lupus Erythematosus and COVID19 patients.Demographic FeaturesSLE patientsCovid-19 patientsp-ValueN°5058Female4323< 0.001Age (years)45 (17)70.5 (25)< 0.001Comorbidities N %Hypertension15 (30)24 (48)0.2Cardiovascular diseses8 (16)13 (22.4)0.4COPD1 (2)9 (15.5)0.016Thyroid disease8 (16)8 (13.8)0.75Chronic kidney disease4 (8)5 (8.6)0.91Population characteristics Median (IQR)HCQ (mg/die)400 (125)400< 0.001HCQ Time (days)3255 (5790)7< 0.001QTc (ms)SLEDAI-2KSDI432 (36.25)0 (4)0395 (80)--< 0.001--Disclosure of Interests:None declared

Pregnancy problems are common in patients with rheumatic disease; indeed, autoimmune disorders and autoantibodies can affect pregnancy progress and lead to maternal complications. Recent studies have highlighted a close association between HMGB1, chronic inflammation, and autoimmune diseases. Thus, in this investigation, we analyzed serum levels of HMGB1, an alarmin which plays a pivotal role in inducing and enhancing immune cell function. Sera from 30 patients with antiphospholipid syndrome (11 primary and 19 secondary APS), 35 subjects with pregnancy morbidity, and 30 healthy women were analysed for HMGB1 and its putative receptor RAGE (sRAGE) by Western blot and for TNF-α by ELISA. Results revealed that APS patients showed significantly increased serum levels of HMGB1, sRAGE, and the proinflammatory cytokine TNF-α, as compared to healthy women. However, also, the pregnancy morbidity subjects showed significantly increased levels of HMGB1 and sRAGE as well as TNF-α compared to healthy women. Our findings suggest that in subjects with pregnancy morbidity, including obstetric APS, elevated levels of HMGB1/sRAGE may represent an alarm signal, indicating an increase of proinflammatory triggers. Further studies are needed to evaluate the role of HMGB1/sRAGE as a possible tool to evaluate the risk stratification of adverse pregnancy outcomes.

Background:Joint involvement is one of the most common features observed in Systemic Lupus Erythematosus (SLE), potentially involving up to 90% of patients [1]. Several patients’ reported outcomes (PROs) have been employed to measure Quality of life (QoL) in SLE patients, but frequently not specifically developed for SLE patients. More recently, the LupusQoL has been validated, a disease specific questionnaire[2,3].Objectives:We focused at assessing the relationship between musculoskeletal manifestations and QoL in a large SLE cohort, by using the LupusQoL.Methods:SLE patients with a clinical history of joint involvement (arthralgia/arthritis – group A) were enrolled in the present study. SLE diagnosis was performed according to the revised 1997 ACR criteria. As a control group, we enrolled SLE patients without history of joint involvement (group B).Disease activity was assessed by the SLE Disease Activity Index-2000 (SLEDAI-2k). The activity of joint involvement was assessed by using the disease activity score on 28 joints (DAS28ESR). The LupusQoL was administered to the enrolled patients (Group A and Group B). It consists of 34 items referring to eight domains: physical health (PH), pain (P), planning (PL), intimate relationships (IR), burden to others (BO), emotional health (EH), body image (BI) and fatigue (F).Results:Group A included 110 patients [M/F 8/102; median age 49 years (IQR 13), median disease duration 156 months (IQR 216)], while group B included 58 patients [M/F 11/47; median age 40 years (IQR 15), median disease duration 84 months (IQR 108)]. Group A showed a significantly lower disease duration and mean age in comparison with group B (P< 0.001 for both comparisons). As represented in figure 1, group A showed significantly lower values in all LupusQoL domains except for “burden to others” domain. Moreover, we observed an inverse correlation between DAS28ESRand all the LupusQoL domains in group A patients [PH (r=-0.5, P>0.0001), P (r=-0.5, PFigure 1.Conclusion:In the present study, by using a disease specific PRO, we found a poorer QoL in SLE patients with joint involvement in comparison with those without this manifestation. Moreover,DAS28ESRsignificantly correlated with all LupusQol domains, differently from SLEDAI-2k, suggesting the need to evaluate joint involvement with a specific activity index.References:[1]Cervera R et al. Medicine 1993[2]McElhone K. et al. Arthritis Rheum 2007.[3]Conti F et al. Lupus 2014Group (A)Group (B)pPH80,38 ± 21,4362,88 ± 23.28< 0.0001P82,36 ± 25.0862,30± 26.02< 0.0001PL83,04 ± 27.8270,58± 29.450.001IR84,49± 25.9965,36± 36.330.0005BO69,58 ± 28.4663,45± 28.950.129EH71,98 ± 24.6964,69± 23.050.0169F73,69 ± 24.2959,78±26.060.0004B78,14 ± 24.6156,28±30.14Disclosure of Interests:Francesco Natalucci: None declared, Fulvia Ceccarelli: None declared, enrica cipriano: None declared, Giulio Olivieri: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Simona Truglia: None declared, Francesca Miranda: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Guido Valesini: None declared

Background: Lupus nephritis (LN) occurs up to 50% of patients affected by Systemic Lupus Erythematosus (SLE) representing one of the major causes of morbidity and mortality in lupus population (1). Kidney biopsy is a fundamental tool for the diagnosis and management of lupus nephritis. The presence of pathological changes such as inflammatory infiltrate in glomeruli and/or in tubulo-interstitium are relevant in terms of prognosis and response to therapy (2). Objectives: The aim of the study was to correlate the clinical and laboratory findings and the response to therapy with presence of glomerular and/or interstitial infiltrate in kidney section of patients with a biopsy-proven LN. Methods: Kidney sections of patients with SLE undergoing a renal biopsy for diagnostically purpose were studied; samples were classified according to the 2004 International Society of Nephrology/Renal Pathology Society classification criteria (3). Clinical, laboratory and histological data were collected in a standardized, computerized and electronically filled form, including demographics, past medical history, autoantibody profile, previous and concomitant treatments. We assessed the disease activity by using SLEDAI-2K and remission in response to therapy was defined as the absence of renal impairment and as a score 0 of renal SLEDAI (proteinuria Results: We evaluated 53 kidney samples from patients with LN (F:M = 51:2, mean age at biopsy 35±7.7 years; mean disease duration at date of biopsy 8±8.3 years). Class IV (46%) was the most common class followed by class III (29%), class II (13%), class V (11.5%) and class VI (0,5%). Tubulo-interstitial infiltrate was found in 33 kidney specimens, with germinal centres (GC)-like features in 13 renal samples (Figure 1). During the follow up (6±3.8 years) the tubulo-insterstitial infiltrate, either diffuse or with GC-like feature, was negatively correlated with renal remission (P=0.03). Conclusion: Assessment and management of patients with LN are greatly facilitated by information obtained by renal biopsy. In the present study we demonstrate that the presence of tubulo-interstital infiltrate is associated with a worse outcome in response to therapy. Our data highlight the importance of tubulo-interstitium damage, scarcely considered in the current classification criteria, since it represents a key point to predict long-term prognosis. References: [1] Schwartz N, et al. Curr Opin Rheumatol. (2014) [2] Giannakakis K, et al. Clinic Rev Allerg Immunol (2011) [3] Weening JJ, et al. J Am Soc Nephrol (2004) [4] Gladman DD, et al. J Rheumatol (2002) [5] Houssiau FA, et al. Arthritis Rheum (2002) [6] Hahn BH, et al. Arthritis Care & Research (2012) Disclosure of Interests: None declared

Background The PDE4-inhibitor apremilast has been recently introduced in the treatment of Psoriatic Arthritis (PsA). It acts by down-regulating intracellular inflammatory mediators synthesis by elevating cAMP levels. Tregs, a subset of FOXP3+ CD4 T cells, play a key role in preventing immune responses and could exert their suppressive function via cAMP (1). Reduced frequencies of circulating Tregs have been observed in inflammatory disorders, nonetheless very few data are available on PsA patients. Objectives We evaluated peripheral Tregs in a cohort of PsA patients treated by apremilast. Methods Seventeen PsA patients (M/F 3/14; median age 56.0 years, IQR 20.0; median disease duration 15.0 years, IQR 11.0) with polyarticular subset treated by apremilast, were evaluated at baseline (T0) and after 6 (T1) and 12 weeks (T1). Clinimetric evaluation included DAS28, DAPSA, CDAI, and SDAI. Moreover, US assessment was performed at wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints: synovial effusion/hypertrophy and power Doppler were scored by a semi-quantitative scale (0-3), obtaining a total score (0-198). Treg frequency was assessed in peripheral blood mononuclear cells by flow cytometry, as the percentage of CD127low FOXP3+ in live CD4+ T cells (%Treg). Results At baseline we identified a median%Tregs of 4.6 (IQR 1.1), inversely correlating with DAS28 (r=-0.5, p=0.02), DAPSA (r=-0.7, p=0.003), CDAI (r=-0.6, p=0.01), SDAI (r=-0.6, p=0.003 and US inflammatory score (r=-0.6, p=0.01) (Figure 1). Treatment with apremilast was able to induce a significant improvement in all activity indices at T1 (DAS28, P=0.009; DAPSA, P=0.01; CDAI, P=0.005; SDAI, P=0.006; US score, P Conclusion The results of our study demonstrate that%Treg is a marker of disease activity in PsA patients. Moreover, the baseline value of Tregs could predict the response to apremilast after 12 weeks of treatment. Reference: [1] Chavele KMet al, FEBS Lett2011. Disclosure of Interests Fulvia Ceccarelli: None declared, Ilenia Pacella: None declared, Ramona Lucchetti: None declared, Arianna Forniti: None declared, francesca spinelli: None declared, enrica cipriano: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Simona Truglia: None declared, Francesca Miranda: None declared, Rossana Scrivo: None declared, cristiano alessandri: None declared, Vincenzo Barnaba: None declared, Guido Valesini: None declared, Silvia Piconese: None declared, fabrizio conti: None declared

Background The introduction of TNF inhibitors have revolutionized the outcome of patients affected by Rheumatoid Arthritis (RA). In the last years, pharmaco-economic implications determined the introduction of biosimilar as alternative to originator biological drugs. Phase I and head-to-head phase III clinical studies demonstrated pharmacokinetic equivalence and comparability in terms of efficacy, safety, immunogenicity and tolerability. However, biosimilar drugs demonstrated some differences related to charge and glycosylation, not influencing the function and the ability to bind the soluble TNF. To date, very few data are available concerning the use of biosimilar drugs in a real-life setting. Results from DANBIO registry suggested a lower retention rate in RA patients switchers from Etanercept originator (ETA) to biosimilar (SB4) versus the historic ETA cohort and higher in comparison with historic SB4 patients (1). Objectives To compare the efficacy of ETA versus SB4 in a cohort of RA patients in a real life setting. Methods In this monocentric case-control prospective study, we consecutively enrolled RA patients starting ETA or SB4 treatment from 2015. RA diagnosis was made according with ACR/EULAR 2010 criteria (2). Data were collected and entered into a standardized, computerized, electronically filled-in form. We included patient demographics, date of diagnosis, comorbidities and previous and concomitant medications. The clinical evaluation included the count of swollen and tender joints and the patient‘s and physician’s global disease assessment based on a visual analogue scale (VAS; range, 0 to 100 mm). Disease activity was measured according to the disease activity score in 28 joints (DAS28ESR) (3). The patients were asked to fill in the Health Assessment Questionnaire (HAQ). All the patients were evaluated at the beginning of treatment (T0) and after 4 (T1) and 12 months (T2). Clinical response to treatment was evaluated by using EULAR criteria (4). Results We evaluated 35 RA patients treated with SB4 (M/F 2/33; median age 63 years, IQR 21; median disease duration 108 months, IQR 138) and 40 with ETA (M/F 5/35; median age 60.5 years, IQR 20; median disease duration 102 months, IQR 141). Biologic drug was prescribed as first-line biological treatment in 71.4% of SB4 cohort and in 80.0% of ETA. At T0 no significant differences were observed among the two groups in terms of DAS28ESR [SB4 median 4.6 (IQR 1.8), ETA 4.3 (IQR 1.9), p=ns] and HAQ [SB4: median 1 (IQR 1.05), ETA median 1 (IQR 0.85), p=ns]. In both groups we observed a significant reduction of DAS28 values at T1 (BS4 p=0.01; ETA p Conclusion The results of our study confirmed in a real-life setting the efficacy of SB4 in RA patients, as demonstrated by the significant reduction of DAS28ESR values after 4 and 12 months of treatment, similarly to ETA. Nonetheless, ETA seems to be able to induce a remission status earlier than SB4. References [1] Glintborg B, et al. Ann Rheum Dis. 2018 [2] Aletaha D, et al. Arthritis Rheum. 2010 [3] Anderson JK, et al. Arthritis Care Res. 2011 [4] van Gestel AM, et al. Arthritis Rheum. 1996 Disclosure of Interests Ramona Lucchetti: None declared, Fulvia Ceccarelli: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Simona Truglia: None declared, Francesca Miranda: None declared, Manuela Di Franco: None declared, Valeria Riccieri: None declared, Rossana Scrivo: None declared, Antonio Sili Scavalli: None declared, francesca spinelli: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, Roberta Priori: None declared, fabrizio conti: None declared

Background Post-translational-modifications (PTMs) are implicated in the pathogenesis of autoimmune diseases, leading to the break of self-tolerance, generation of new autoantigens and production of autoantibodies. Anti-citrullinated-proteins antibodies (ACPA) play a key role in the pathogenesis of rheumatoid arthritis (RA) and many evidences showed that they are related to bone loss in RA. Osteoclasts are the primary targets of ACPA in the joint site, displaying citrullinated antigens on their surface. Carbamylation is another PTM generating the production of anti-carbamylated proteins antibodies (anti-CarP), recently proposed as a new biomarker for RA. Anti-CarP have been also studied in patients with systemic lupus erythematosus (SLE) with predominant joint involvement, showing a prevalence of 46.1%. Moreover, in SLE patients these autoantibodies have been also associated to bone erosive damage. The pathogenic mechanism of these autoantibodies is not completely clarified so far. Objectives The aim of the present study was to investigate the possible pathogenic role of anti-CarP in the induction of osteoclastogenesis. Methods Peripheral blood mononuclear cells (PBMCs) were isolated from a buffy coat from healthy donors using a Ficoll Hypaque gradient. Cells were cultured for 14 days in α-MEM complete medium, supplemented with 25 ng/ml of macrophage-colony-stimulating-factor (MCSF) and 30 ng/ml of receptor activator of nuclear-factor-kappa-β-ligand (RANKL), for the differentiation of monocytes in osteoclasts. Simultaneously, PBMCs were co-cultured in presence of anti-carbamilated-vimentin autoantibodies (anti-Vim CarP) purified from sera of 3 patients with RA and 3 patients with SLE with a predominant joint involvement at 100 ng/ml and 1 μg/ml. As control, intravenous immunoglobulin (IVIg) were used at the same concentrations. After 14 days, osteoclast differentiation was evaluated by staining cells for tartrate-resistant acid phosphatase (TRAP), using leukocyte acid phosphatase kit. Results Anti-VimCarP purified from RA patients at 100 ng/ml were able to increase the median number of osteoclasts per well significantly more than untreated and IVIg at 100 ng/ml and 1 μg/ml (P=0.0008; P=0.0009 and P=0.0009, respectively). The same results were observed treating cells with 1 μg/ml of anti-VimCarP from RA patients (P=0.0008, P=0.002 and P=0.002, respectively). Similarly, anti-VimCarP purified from SLE patients at 100 ng/ml significantly increased the median number of osteoclasts than untreated and IVIg at 100 ng/ml and 1 μg/ml (P=0.002, P=0.004 and P=0.003, respectively). Analogously, we observed similar results co-culturing cells with 1 μg/ml of anti-VimCarP from SLE patients (P=0.002, P=0.02 and P=0.006, respectively). Conclusion For the first time, we demonstrated that anti-Vim CarP purified from RA and SLE patients are able to induce osteoclastogenesis, suggesting their potential role as a biomarker of joint erosiveness in these autoimmune diseases. Disclosure of Interests Laura Massaro: None declared, Tania Colasanti: None declared, francesca spinelli: None declared, Fulvia Ceccarelli: None declared, Riccardo Mancini: None declared, Arbi Pecani: None declared, enrica cipriano: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Francesca Miranda: None declared, Simona Truglia: None declared, Francesco Natalucci: None declared, Martina Leopizzi: None declared, Valeria Di Maio: None declared, Carlo Della Rocca: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, fabrizio conti: None declared

Background Women suffering from autoimmune diseases, such as Systemic Lupus Erythematosus (SLE), could develop menopause at a younger age in comparison with healthy population. In particular, a higher frequency of abnormal ovarian function has been described in SLE cohorts1-4. The presence of a cause-effect link between the disease and such modifications remains poorly understood. The role of disease activity and chronic damage, combined with the intake of some drugs, such as cyclophosphamide (CYC), has been suggested2. Objectives We evaluated the age at natural menopause and the prevalence of premature ovarian failure (POF) in a monocentric Caucasian SLE cohort. Additionally, we analyzed the possible association with the disease features. Methods We performed a cross-sectional case-control study, enrolling consecutive SLE women and reporting their clinical and laboratory data. As control group (healthy controls - HC), women without autoimmune diseases were enrolled. By using an interview, gynecological characteristics were investigated in patients and controls: in particular, we registered age at menarche, occurrence and age of menopause, history of hysterectomy. Natural menopause was defined as the absence of menses for at least 12 months in women aged ≥40 years and POF as amenorrhea of at least 12 months in women Results We enrolled 196 Caucasian women with SLE (median age 47.0 years, IQR 16.7; median disease duration 132 months, IQR 180) and 90 HC (median age 49.9 years, IQR 15.0). Ninety-four SLE patients (48.0%) and 26 HC (23.4%) referred a condition of menopause: the median age at occurrence was significantly lower in SLE than HC (47 years, IQR 8.0 versus 50.5 years, IQR 4; P=0.0001). Among the SLE patients, a natural menopause was observed in 70 subjects (74.4%), surgical in 7 (7.4%), iatrogenic in 17 (18.1%). In particular, 13 (13.8%) SLE patients referred the occurrence of menopause after CYC exposure. Excluding SLE patients with surgical menopause, we registered POF in 16 patients (17%); this prevalence was significantly higher in comparison with HC group, in which none of subjects experienced POF (P=0.0001). The comparison between SLE patients developing POF and those with natural menopause history demonstrated a significant higher prevalence of anti-Sm (31.2% versus 10.2%; P=0.0004), anti-RNP (25.0% versus 12.8%; P=0.02), anti-cardiolipin (aCL) IgG/IgM (50.0% versus 26.9%; P=0.0008) and lupus anticoagulant (37.5% versus 17.9%; P=0.002). As expected, a significant more frequent CYC treatment was identified in patients developing POF (56.0% versus 11.0%; P=0.0001). Moreover, POF subjects showed a significant more frequent history of treatment with azathioprine (62.5% versus 30.7; P=0.0001), mycophenolate mofetil (50% versus 20.5%; P=0.0001) and cyclosporine A (37.5% versus 19.2%; P=007). No significant differences were found in terms of clinical manifestations and mean SLICC/ACR damage index (SDI). Conclusion In the present study, we observed a significantly lower age at menopause in SLE patients in comparison with HC; in addition, a significantly higher frequency of POF was observed. POF was associated with a more active disease, in terms of autoantibodies prevalence and use of immunosuppressant drugs. Finally, for the first time, it was found an association between POF and antiphospholipid positivity, suggesting a possible role of these antibodies, in particular aCL, in POF development. References [1] Mayorga J, et al. Lupus 2016 [2] Malheiro, et al. Gynecol Endocrinol 2014 [3] Fatnoon NN, et al. Singapore Med J 2008 [4] Lawrenz, et al. Lupus 2011. Disclosure of Interests Valeria Orefice: None declared, Fulvia Ceccarelli: None declared, Giuseppina Perrone: None declared, Carmelo Pirone: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Simona Truglia: None declared, Francesca Miranda: None declared, viviana antonella pacucci: None declared, francesca spinelli: None declared, Paola Galoppi: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, fabrizio conti: None declared

Antiphospholipid Syndrome (APS) is the commonest treatable cause of recurrent miscarriage and pharmacological treatment of pregnant patients with antiphospholipid antibodies (aPL) should aim at preventing obstetric complications and maternal thrombotic events. Conventional treatment for patients with an established diagnosis of obstetric APS (OAPS), generally resulting in over 70-80% successful pregnancies. Since seropositive (SP)-APS and seronegative (SN)-APS patients had shown similar clinical profiles, patients with SN- OAPS, as well as SP-OAPS, should receive combined treatment in order to improve the pregnancy prognosis; indeed, current standard of care increased good pregnancy outcome in SN-APS, with similar effect to confirmed APS. The above data suggest that there are patients with the clinical manifestations of OAPS but persistently negative to conventional aPL that need to be identified to ensure adequate therapy and therefore a better prognosis. The clinical utility of non-criteria aPL in the diagnosis of SN-APS is still a matter of debate. In the last decade more and more studies have reported the presence of patients suffering from SN-APS in which non-conventional ("non-criteria") aPL might be present or antibodies may be detected using methodological approaches different from the traditional assays. To improve test standardization large prospective, multicenter, and multinational studies are needed. Therefore, when assessing a patient with clinical manifestations consistent with OAPS but aPL negative using the conventional available assays, the clinician should consider the possibility that the patient is affected with SN-APS.

Apremilast, PDE4 competitive inhibitor, has been recently introduced in the treatment of adult psoriatic arthritis (PsA) patients, but only preliminary data are available on imaging evaluation. Thus, we evaluated the response to apremilast in PsA patients by ultrasonographic (US) assessment.Thirty-four patients (M/F 7/27; median age 61 years, IQR 15; median disease duration 10 years, IQR 13) treated for polyarticular involvement were longitudinally evaluated. All the patients were assessed at baseline (T0), and after 6 (T1), 12 (T2), and 24 weeks (T3) by DAS28, CDAI, SDAI, and DAPSA. At the same time-points, US assessment was performed in 22 sites (wrists, MCPs, PIPs): synovial effusion/hypertrophy and power Doppler were scored with a semi-quantitative scale (0-3). A total score, corresponding to patient's inflammatory status, was obtained by their sum (0-198). We assessed also the presence of tenosynovitis of flexorWe found a significant reduction in the US inflammatory score values after 6 weeks (T0, median 15 (IQR 11.2); T1, 6 (10.0); P = 0.0002), confirmed at T2 (4.0 (4.0), P = 0.0002) and T3 (4.0 (6.0); P = 0.0003). Finally, US-detected tenosynovitis was observed in 44.1% of patients: a significant improvement in tenosynovitis score was identified at 6 weeks (T0, median 4 (IQR 4); T1, 1 (2); P 0.0001) and maintained at T2 (0 (IQR 1); P 0.0001) and T3 ((IQR 1.25); P 0.0001).Apremilast is able to induce an early and sustained improvement of ultrasonographic inflammatory status at articular and peri-articular level. Key points •Apremilast induces a significant, early, and sustained improvement of inflammatory joint status in psoriatic arthritis patients. •Ultrasonographic assessment is able to monitor articular and peri-articular response to apremilast.

Background Autophagy has emerged as a key mechanism in the survival and function of T and B lymphocytes, and its activation was involved in apoptosis resistance in rheumatoid arthritis (RA). To investigate whether the relationship between autophagy and apoptosis may impact the response to the therapy, we analyzed ex vivo spontaneous autophagy and apoptosis in patients with RA subjected to treatment with anti-tumor necrosis factor (TNF) drugs and in vitro the effects of TNFα and anti-TNF drugs on cell fate. Methods Peripheral blood mononuclear cells (PBMCs) from 25 RA patients treated with anti-TNF drugs were analyzed for levels of autophagy marker LC3-II by western blot and for the percentage of annexin V-positive apoptotic cells by flow cytometry. The same techniques were used to assess autophagy and apoptosis after in vitro treatment with TNFα and etanercept in both PBMCs and fibroblast-like synoviocytes (FLS) from patients with RA. Results PBMCs from patients with RA responsive to treatment showed a significant reduction in LC3-II levels, associated with an increased apoptotic activation after 4 months of therapy with anti-TNF drugs. Additionally, the expression of LC3-II correlated with DAS28. TNFα was able to induce autophagy in a dose-dependent manner after 24 h of culture in RA PBMCs and FLS. Moreover, etanercept caused a significant reduction of autophagy and of levels of citrullinated proteins. Conclusions Our results show how the crosstalk between autophagy and apoptosis can sustain the survival of immune cells, thus influencing RA progression. This suggests that inhibition of autophagy represents a possible therapeutic target in RA. Electronic supplementary material The online version of this article (10.1186/s13075-019-1818-x) contains supplementary material, which is available to authorized users.

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disease characterized by arterial and/or venous thrombosis, pregnancy morbidity in the presence of circulating “anti-phospholipid antibodies” (aPL). One of the main target antigens of aPL is β2-glycoprotein I (β2-GPI). APS may occur as a primary syndrome or associated with Systemic Lupus Erythematosus (SLE). High Mobility Group Box 1 (HMGB1) is a nuclear non-histone protein which is secreted from different type of cells during activation and/or cell death and may act as a proinflammatory mediator through ligation to its receptors, including RAGE. There is accumulating evidence that HMGB1 contributes to the pathogenesis of inflammatory and autoimmune diseases, especially SLE. In a previous study we demonstrated increased serum levels of HMGB1 in both primary and secondary APS patients. In this work we analyzed: (i) in vitro whether anti-β2-GPI antibodies from APS patients may induce both a HMGB1 cellular relocation by activation of its putative receptor RAGE in platelets and monocytes and, (ii) ex vivo, serum levels of HMGB1/soluble RAGE (sRAGE) in APS patients and their possible correlation with clinical manifestations. Platelets and monocytes from healthy donors were incubated with affinity purified anti-β2-GPI antibodies. HMGB1 and RAGE expression were analyzed by Western Blot. Sera from 60 consecutive APS patients (primary or secondary), diagnosed according to the Sydney Classification Criteria, were enrolled. As a control, 30 matched healthy subjects were studied. Serum levels of HMGB1 and sRAGE were analyzed by Western Blot. In vitro results showed that anti-β2-GPI antibodies were able to induce RAGE activation and HMGB1 cellular relocation in both monocytes and platelets. HMGB1 and sRAGE serum levels were significantly increased in APS patients in comparison with healthy subjects (p

Background Rheumatoid arthritis (RA) is associated with a high prevalence of atherosclerosis. Recently increased levels of microparticles (MPs) have been reported in patients with RA. MPs could represent a link between autoimmunity and endothelial dysfunction by expressing tumor necrosis factor alpha (TNFα), a key cytokine involved in the pathogenesis of RA, altering endothelial apoptosis and autophagy. The aim of this study was to investigate TNFα expression on MPs and its relationship with endothelial cell fate. Methods MPs were purified from peripheral blood from 20 healthy controls (HC) and from 20 patients with RA, before (time (T)0) and after (T4) 4-month treatment with etanercept (ETA). Surface expression of TNFα was performed by flow cytometry analysis. EA.hy926 cells, an immortalized endothelial cell line, were treated with RA-MPs purified at T0 and at T4 and also, with RA-MPs in vitro treated with ETA. Apoptosis and autophagy were then evaluated. Results RA-MPs purified at T0 expressed TNFα on their surface and this expression significantly decreased at T4. Moreover, at T0 RA-MPs, significantly increased both apoptosis and autophagy levels on endothelial cells, in a dose-dependent manner. RA-MPs did not significantly change these parameters after 4 months of in vivo treatment with ETA. Conclusions Our data demonstrate that MPs isolated from patients with RA exert a pathological effect on endothelial cells by TNFα expressed on their surface. In vivo and in vitro treatment with ETA modulates this effect, suggesting anti-TNF therapy protects against endothelial damage in patients with RA. Electronic supplementary material The online version of this article (10.1186/s13075-018-1768-8) contains supplementary material, which is available to authorized users.

Background:Lupus nephritis (LN) occurs in up to 60% of patients affected by Systemic Lupus Erythematosus (SLE). The presence of inflammatory infiltrates in glomeruli and/or in tubulo-interstitium (TI) plays an important role in terms of prognosis (1). Ectopic lymphoid structures (ELSs) are clusters of organized lymphoid infiltrates forming at sites of chronic inflammation in non-lymphoid organs (2). Data on ELSs in kidneys of SLE patients are scant (3-5).Objectives:The aim of the study was to evaluate the tubule-interstitial infiltrates (TI-I) organization and to investigate the presence of ELSs.Methods:Kidney sections of SLE patients undergoing a renal biopsy for diagnostic purpose were studied; LN was diagnosed according to the 2003 International Society of Nephrology / Renal Pathology Society classification criteria. Clinical, laboratory and histological data were collected in a standardized, computerized and electronically filled form, including past medical history. The presence of lymphoid aggregates and ELS in the kidney sections were firstly evaluated by hematoxylin-eosin (HE). By using immunohistochemistry (IHC), we characterized the infiltrates by identification of T cells (CD3), B cells (CD20) and follicular dendritic cells (CD21).Results:By HE we evaluated 53 kidney samples from LN patients (F:M = 51:2, mean age at biopsy ± SD years 35±7.7; mean disease duration at date of biopsy ± SD 8±8.3 years). TI-I were found in 33 kidney specimens. By HE we identified a well-defined infiltrate pattern resembling ELS in 13 renal samples. In these samples, we confirmed the presence of organized infiltrates by IHC, with evidence of segregated T and B cells areas in most of them. In one sample, the CD21 staining was positive confirming the presence of ELS (Figure 1). Interestingly, this last patient, who failed ciclophosphamide and mycofenolate, responded to rituximab administration and is now in complete LN remission. Moreover TII was negatively correlated with renal remission after induction therapy (P=0.03) independent of the histological class and the induction treatment.Figure 1.Biopsy specimens showing tubulo-interstitial ELS by IHC (10x).Conclusion:Assessment and management of LN patients are greatly facilitated by information obtained by renal biopsy. In the present study the evaluation by HE of 53 kidney samples from patients with LN showed TI-I in 62% of the specimens and a well-defined infiltrate pattern with GC-like features in 39% of those specimens with TI-I, confirmed in IHC. The presence of TII was associated with a worse outcome in response to therapy. Our preliminary results obtained by IHC suggest that ELS could be considered as a biomarker of renal response to B-cell depleting therapy supporting the importance of TI disease.References:[1]Giannakakis K. & Faraggiana T. Histopathology of Lupus Nephritis. Clinic Rev Allerg Immunol 2011[2]Bombardieri M et al. Ectopic lymphoid neogenesis in rheumatic autoimmune diseases. Nat Rev Rheumatol 2017[3]Chang A et al. In situ B cell-mediated immune responses and tubulointerstitial inflammation in human lupus nephritis. J Immunol 2011[4]Shen Y et al. Association of intrarenal B-cell infiltrates with clinical outcome in lupus nephritis: a study of 192 cases. Clin Dev Immunol 2012[5]Neusser MA et al. Intrarenal production of B-cell survival factors in human lupus nephritis. Mod Pathol 2011Disclosure of Interests:viviana antonella pacucci: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Konsantinos Giannakakis: None declared, Serena Colafrancesco: None declared, Simona Truglia: None declared, Fulvia Ceccarelli: None declared, Cristina Garufi: None declared, cristiano alessandri Grant/research support from: Pfizer, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Background:The main outcomes in SLE patients management are represented by the remission achievement and chronic damage prevention. Even though activity and damage are intimately connected, to date indices including both these outcomes are not available.Objectives:In the present study, we aimed at assessing the application of a new index, the Lupus comprehensive disease control (LupusCDC), including disease activity and chronic damage progression.Methods:We performed a longitudinal analysis, including SLE patients according to ACR 1997 criteria, followed-up in the period between January 2014 and December 2018, and with at least one visit per year. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and three different remission levels were evaluated, as reported in Table 1 (1).Table 1.Remission levels considered in the study (1).Remission levelDefinitionComplete Remission(CR)No clinical and serological activity (SLEDAI-2K=0) in corticosteroid-free and immunosuppressant-free patients (antimalarials allowed)Clinical remission off-corticosteroids(ClR-GCoff)Serological activity with clinical quiescent disease according to SLEDAI-2K in corticosteroid-free patients (stable immunosuppressive therapy and antimalarials allowed)clinical remission on-corticosteroids(ClR-GCon)Clinical quiescent disease according to SLEDAI-2K in patients on prednisone 1–5 mg/day (stable immunosuppressants and antimalarials allowed)Chronic damage was registered according to SLICC damage index (SDI). All the patients were evaluated at baseline (T0) and every 12 months (T1, T2, T3, T4). At each time-point, we calculated the prevalence of LupusCDC, defined as remission achievement plus absence of chronic damage progression in the previous one year. We calculated this outcome including separately the different remission levels.Results:According with inclusion criteria, 172 SLE patients were evaluated in the present analysis [M/F 16/156, median age 49 years (IQR 16.7), median disease duration 180 months (IQR 156)]. At first assessment, we observed a mean±SD SDI value of 0.7±1.1. In details, 56 patients (32.5%) showed damage in at least one organ/system and the presence of damage was significantly associated with age (pIn figure 1A and 1B we reported the proportion of patients achieving the different levels of remission and LupusCDC, respectively. In particular, the LupusCDC definition including CR was the most frequently detected in all time-points evaluated (T1: 18.0%; T2: 31.9%; T3: 27.9%; T4: 24.4%), with a significant difference at T2 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.0002; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.0002)], T3 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.03; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.006], T4 [LupusCDC(CR)versusLupusCDC(ClR-GCon), p=0.002]. No significant differences were found when comparing the prevalence of different remission levels and the prevalence of LupusCDC including the corresponding remission.Conclusion:In the present analysis we proposed for the first time a new index including disease activity and chronic damage, in order to evaluate the proportion of SLE patients reaching a comprehensive disease control. We found that CR is most frequently associated with the absence of damage progression.References:[1]Zen M et al. Ann Rheum Dis 2017.Disclosure of Interests:Fulvia Ceccarelli: None declared, Giulio Olivieri: None declared, Lorenzo Dominici: None declared, Alessandra Ida Celia: None declared, enrica cipriano: None declared, Cristina Garufi: None declared, Silvia Mancuso: None declared, Francesco Natalucci: None declared, Valeria Orefice: None declared, Carlo Perricone: None declared, Carmelo Pirone: None declared, viviana antonella pacucci: None declared, Francesca Morello: None declared, Simona Truglia: None declared, Francesca Miranda: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Background:Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease, affecting prevalently women in childbearing age. Thanks to pre-gestational counseling and multi-disciplinary approach, adopted in daily clinical practice, SLE patients are experiencing even more uncomplicated pregnancies.Objectives:Here, we evaluated pregnancy outcome in a large SLE cohort, compared to a control group including pregnant women without autoimmune diseases.Methods:Pregnant SLE patients (diagnosis made according to ACR 1997 criteria) were included in the present study, conducted in the context of a joint rheumatology/gynecology multi-disciplinary team. For each patient we collected demographic information, medical history, treatments, disease activity (SLEDAI-2K) chronic damage (SLICCdamage index), clinical and laboratory data, including serum complement level and autoantibodies. Pregnancy outcomes were reported longitudinally as well as disease relapses occurring during pregnancy and puerperium. Flares were defined as new onset or worsening disease-related manifestation in any organ/system.Results:Since 2008, 70 consecutive pregnancies occurred in 50 SLE patients [(median age at diagnosis 25 years (IQR 12.2), median age at first pregnancy 33 years (IQR 7), median disease duration 72 months (IQR 120)]. As controls, we evaluated 100 consecutive pregnancies in 100 women without autoimmune diseases [(median age 31 years (IQR 9)]. Table 1 reports the obstetric, fetal and neonatal outcomes of SLE patients compared to control group. A positive outcome in terms of live born infants was experienced in 88.6% of SLE pregnancies and in 88% of control group (p=NS). There were no statistically significant differences in any of the pregnancy outcomes evaluated; however, the percentage of small for gestational ages (SGA) was significantly higher in SLE group (22.8%versus11.0% P=0.003). A statistical association was found between SGA and positivity for anti-dsDNA, anti-SSA ed anti-SSB (p=0.0001, p=0.01, p=0.04 respectively). Miscarriage was significantly associated with disease-related serologic abnormalities [anti-dsDNA (p=0.0001), low C3 (p=0.0001) and low C4 (p=0.006)] and past smokinghabitus(p=0.0001); preterm birth was associated with anti-dsDNA, anti-CL and anti-B2GPI (p=0.001, p=0.0005, p=0.01 respectively). A disease flare was reported in 28 pregnancies (40%) and in 31 puerperium (44.3%). Figure 1 reports SLE relapses divided according to organ involvement. Flare during pregnancy was associated with positivity for anti-SSA (p=0.001), anti-SSB (p=0.01) and a-CL (p=0.006), whilepuerperiumrelapses were associated with previous renal involvement (p=0.0005), flare during pregnancy (p=0.01) and chronic damage (p=0.0001).Table 1.Pregnancy outcomes in 50 SLE and 100 controls.LES(Pregnancies N=70)Controls(Pregnancies N=100)POBSTETRIC OUTCOMEPreterm birth N/%18/25.719/19NSGestational hypertension N/%5/7.13/3NSGestational diabetes N/%5/7.15/5NSPre-eclampsia N/%2/2.91/1NSFETAL OUTCOMEMiscarriages N/%8/11.412/12NSPR interval elongation N/%4/6.4––IUGR N/%3/51/1NSNEONATAL OUTCOMESGA< 10° centile N/%16/22.811/110.003Weight at birth median-I.Q.R.2850-6883250-8140.003Apgar 1’ median-I.Q.R.8-18-1NSApgar 5’ median-I.Q.R.9-110-1NSFigure 1.Disease flares during and after 70 SLE pregnancies divided according to organ involvement.Conclusion:The present study confirms the role of pre-gestational counseling and a multi-disciplinary approach in the outcome of SLE pregnancies. Moreover, the high prevalence of disease relapse even more justifies the need for a combined rheumatology/gynecology multi-disciplinary approach.Disclosure of Interests:Carmelo Pirone: None declared, Fulvia Ceccarelli: None declared, Aikaterini Selntigia: None declared, Carlo Perricone: None declared, Simona Truglia: None declared, viviana antonella pacucci: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, Giuseppina Perrone: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Background:Seronegative antiphospholipid syndrome (SN-APS) is the term proposed to describe patients with clinical signs highly suggestive of APS but persistently negative for conventional antiphospholipid antibodies (aPL) assays. Therefore, new antigenic targets or different methodological approaches have been investigated to detect aPL in SN-APS [1].Objectives:The aim of this study was to describe the clinical follow-up of a monocentric cohort of SN-APS patients.Methods:The study included all consecutive SN-APS patients examined from 2014 to 2018. In all patients other possible causes of thrombosis or obstetric morbidity were ruled out. APL were investigated through two tests: 1. anti-cardiolipin/vimentin antibodies (aCL/Vim) by enzyme-linked immunosorbent assay (ELISA) 2. anti-cardiolipin antibodies (aCL) by thin-layer chromatography (TLC)-immunostaining.Results:We enrolled 121 patients (all Caucasian except one Asian and one Hispanic women). Clinical and demographic characteristics are reported in Table 1.Table 1.Clinical and demographic characteristicsFeaturesSN-APSn= 121 (%)Male/Female14/107Mean age in years (from-to)42.58 (16-78)PAPS/SAPS78/43 (64.5/35.5)SLE28 (23.1)Others autoimmune diseases15 (12.4)Pregnancy morbidity56/107 (52.3) Spontaneous abortions49 (45.8) Normal fetus deaths22 (20.6) Premature births7 (6.54)Thrombosis72 (59.5) Arterial thrombosis36 (29.8) Venous thrombosis48 (39.7) Recurrent thrombosis28 (23.1)Thrombosis + Pregnancy morbidity8 (6.6)Non-criteria APS features45 (37.2) Livedo reticularis18 (14.9) Thrombocytopenia12 (9.9) Migraine19 (15.7) Seizures5 (4) Others11 (9)Cardiovascular risk factors50 (41.3) Hypercholesterolemia8 (6.6) Smoking22 (18.2) Hypertension22 (18.2) OC/HRT7 (5.8) Diabetes4 (3.3)Sixty-nine out 121 patients (57%) resulted positive for at least one non-conventional test in two occasions more than 12 weeks apart (Figure 1). The agreement between first and second test resulted respectively of K=0,703 e K=0,655 (Cohen’s K test). Figure 2 shows the prevalence of aCL (TLC-immunostaining) and aCL/Vim. We found a significant correlation between aCL (by TLC-immunostaining) and aCL/Vim (p= 0.027), brain MRI ischemic changes (p= 0.012) and age (p= 0.023). ACL/Vim was significantly correlated with livedo reticularis (p = 0.015).Patients with double positivity showed a higher prevalence of mixed thrombotic and obstetrical features than patients with single positivity (p < 0.001, likelihood positive ratio 8.2).Non-conventional aPL positivity better supported the diagnosis of APS and, following the therapeutic changes implemented, in a median follow up of 41 months (IQR 39.5) only 3 cases of recurrent thrombosis (2 cases of arterial thrombosis during treatment with antiaggregant therapy and one case of venous thrombosis in treatment with new oral anticoagulant therapy) were observed. During the follow-up, 35 patients with obstetric morbidity who resulted positive for the tests had 20 pregnancies; 12 of them (60%) experienced a good outcome under conventional treatment for classical APS.Conclusion:The results demonstrate that new methods – TLC-immunostaining – or new antigens - CL/Vim – allow to detect aPL in so-called “SN-APS” patients and, consequently, to prescribe the most appropriate therapy.References:[1]Conti F et al. The Mosaic of “Seronegative” Antiphospholipid Syndrome. J Immunol Res. 2014;2014:389601Disclosure of Interests:Silvia Mancuso: None declared, Simona Truglia Speakers bureau: Lilly, BMS, Serena Recalchi: None declared, Gloria Riitano: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fulvia Ceccarelli: None declared, Maurizio Sorice: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

The present study was conducted to diagnose obstetric anti-phospholipid syndrome (OAPS) in patients with clinical signs suggestive of anti-phospholipid syndrome (APS), but persistently negative for conventional anti-phospholipid antibodies (aPL). Sera from 61 obstetrical seronegative APS (SN-APS) patients were analyzed for anti-cardiolipin antibodies (aCL) using thin-layer chromatography (TLC)-immunostaining, for anti-cardiolipin/vimentin antibodies (aCL/Vim), anti-phosphatidylserine/prothrombin antibodies, IgA anti-β2glycoprotein I antibodies (aβ2GPI), and IgA aCL antibodies by enzyme-linked immunosorbent assay. Taken together, our findings show that in 50 out of 61 SN-APS (81.9%) at least one aPL/cofactor antibody was detected using the assays under test. Results revealed that 76% of SN-APS patients resulted positive for aCL by TLC-immunostaining, 54% for aCL/Vim, 12% for aPS/PT, 4% for IgA aβ2GPI, and 2% for IgA aCL. Thirty-five out of 61 patients were followed up and the tests were repeated on two occasions, at least 12 weeks apart. Twenty-six out of 35 SN-APS (74.3%) were positive at least one non-conventional test; only 2 patients (5.7%) did not confirm the positivity to the second test. These findings suggest that non-conventional tests, mainly aCL/Vim and aCL detected by TLC-immunostaining, seem to be the most sensitive approaches for finding out aPL in patients with obstetric SN-APS. The use of these tests can be useful for accurate and timely diagnosis of patients with obstetrical APS who are negative for conventional laboratory criteria markers.

This longitudinal retrospective study aims at describing the safety profile and the reasons for discontinuation of antimalarials in patients with systemic lupus erythematosus (SLE) and discoid lupus erythematosus (DLE), focusing on ocular toxicity. We analyzed the clinical data of 845 SLE and DLE patients; 59% of them were taking antimalarials: 1.4% chloroquine (CQ), 88.5% hydroxychloroquine (HCQ) and 10.1% both. The mean therapy duration was 82.5 ± 77.4 months. At least one side effect was reported by 19.4% of patients, leading to temporary or permanent withdrawal in 9.1% and 10.3% of cases, respectively; 19.3% of patients experienced side effects with HCQ and 8.6% with CQ. In 55.1% of cases, the adverse event was mild or moderate. Ophthalmological alterations were reported by 8.5% but were confirmed by the ophthalmological examination in 5.5% of cases. Retinal alterations were associated with age, disease duration and duration of the antimalarial therapy, but not to drug dose and comorbidities or lupus nephritis. This is the largest monocentric longitudinal study confirming the good safety profile of antimalarials in DLE and SLE patients. The main adverse events during the therapy were mild or moderate, but maculopathy—reported in a low percentage of patients—remains the main cause of treatment withdrawal.

Background Systemic lupus erythematosus (SLE) is an autoimmune disease showing a strong predilection for reproductive age women (female/male ratio 9:1). This is in part due to the effects exerted by sexual hormones on immune system. The term ovarian reserve has been used traditionally to describe the number and quality of oocytes in women. This is assessed by detection of FSH, AMH and Estradiol (E2) and by ultrasonographic (US) evaluation of antral follicolar bilateral count (AFC), as recommended by the Society of Reprodutive Medicine. The evaluation of AFC should be conducted in the early follicular phase of the menstrual cycle. An AFC lower than 3–4 follicles is highly specific (73%–97%) of poor ovarian function. Data from the literature about ovarian reserve in SLE showed contrasting results. Objectives We aimed at assessing ovarian reserve in a SLE cohort, by US determination of AFC and by analysing serum levels of AMH, FSH, E2. Methods In this case control study, we enrolled consecutive SLE patients in reproductive age ( Results Nineteen SLE patients (median age 35 years, IQR 6.0; mean disease duration ±SD 12.2±7.7 months) and 8 HS were evaluated. A mean ±SD SLEDAI-2K of 2.5±1.5 was registered; 3 patients had a chronic damage (SDI=1). FSH values were significantly higher in SLE patients compared with HS ([SLE: median (IQR) 35;6 HS: median (IQR) 3 (1.5); p=0.01]. Concerning the AFC, we found significantly lower values in SLE patients than in HS [SLE: median (IQR) 13;11 HS: median (IQR) 22.5 (10.5); p=0.03]. The Spearman analysis demonstrated a negative correlation between AFC and BMI (r=−0.5, p=0.02), FSH (r=−0.5, p=0.04) and age (r=−0.5, p=0.02) (figure 1). AFC: antral follicolar bilateral count; BMI: body mass index; FSH: follicle-stimulating hormone Conclusions The preservation of fertility is a crucial point in SLE patients and the evaluation of ovarian reserve should be included in the patients’ management in order to assess ovarian function. Moving from these premises, in the present study we demonstrated an impaired ovarian reserve in SLE patients in terms of AFC values and a negative correlation with hormonal and some demographic features. Disclosure of Interest None declared

Background Systemic Lupus Erythematosus (SLE)is a chronic disease requiring long-term treatment. Even though immunosuppresive therapies improved the survival rate,a great percentage of SLE patients exhibit a persistently active disease, or disease flares. Belimumab (BLM), is currently the only biological drug approved for the treatment of active SLE patients not responding to standard of care, without active kidney or neuropsychiatric (NP)involvement. Objectives Aim of the study was to analyse 36 months survival of BLM treatment, causes of withdrawal in a monocentric cohort of SLE patients followed-up in a daily practice setting. Methods The study was proposed to all the patients strarting BLM. After the informed consent was obtained, demographic, clinical and serological data, indication to BLM and concomitant therapies were registered. At baseline and at 6,12,24,36 months of follow-up, disease activity (SLEDAI 2K), DAS28, C3 and C4 levels, anti-dsDNA status and weekly dose of glucocorticoids were recorded. Data were expressed as median-interquartile range; after 6,12,24,36 months, differences in all parameters compared to baseline were evaluated (Student t test)The treatment survival was evaluated by Kaplan-Meier analysis. P value Results We enrolled 39 Caucasian individual, 38 females, 1 male, with median age of 43 (IQR 7.5) years and median disease duration 14.5 (5.5) years. Indications for starting BLM were: mucocutaneous involvement (n=11,28%), arthritis (n=25,64%), systemic symptoms (n=3,7%) and lung involvement (1 pt,2%). At baseline, all the patients were taking PDN;97% hydroxychloroquine,23% mycophenolate mofetil,23% azathioprine, 5% cyclosporine, 7% methotrexate and 2% thalidomide. Table 1 summarises trend of SLEDAI 2K, C3 and C4, DAS28 (for articular involvement), prednisone dose and percentage of patients positive for anti-dsDNA during the follow-up. Fourteen out of the 39 patients (35.8%) reached 12 months of observation and only 4 the 24 months, 3 the 36 months. Figure 1 shows the survival curve of Belimumab. In 8 patients (20%) adverse events were the cause of BLM withdrawal (severe infection in one patient, severe bradychardia in one and acute infusion reaction in another one). In 4 patients (10%) BLM was discontinued for lack of efficacy(articular and skin manifestations)after 4, 8, 12 and 23 months respectively; in 6 patients (15%) for loss of efficacy; one patient developed a severe NP flare after 2nd BLM infusion and was admitted in our hospital for depression. One patient was lost during the follow-up. Two patients withdrew BLM therapy to plan a pregnancy. We found significant reduction of PDN week levels, and improvement of C4 and aDNA levels at T6; as for disease activity, we found significant reduction of DAS28 at T6, and of SLEDAI-2k at T6 and T12. Conclusions In our monocentric cohort of SLE patients, BLM demonstrated to be effective on disease activity and serology and led to a significant decrease of glucocorticoids dose; the main causes of BLM withdrawal were adverse events or disease flares. Disclosure of Interest None declared

Background Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterised by the presence of at least one clinical event among vascular thrombosis and/or pregnancy morbidity, in the presence of circulating antiphospholipid antibodies (aPL). High-mobility group box-1 (HMGB1) is a non-histonic protein belonging to the family of alarmins. It is associated with chromatin and has a dual function depending on the cell state: in basal conditions it is located in the nucleus and promotes the interaction of some transcription factors with DNA, in inflammatory conditions it is secreted in the extracellular space and exerts the functions of a pro-inflammatory cytokine. One of the main receptor system responsible for the HMGB1 activity is the ”receptor for advanced glycation end products” (RAGE). Increased serum HMGB1 levels have been reported in patients with Systemic Lupus Erythematosus and pre-eclampsia, as other alarmins are increased in patients with early abortions. Objectives To evaluate the serum levels of HMGB1 and soluble RAGE (sRAGE) in patients with obstetric and thrombotic APS. Methods 43 consecutive patients with APS, diagnosed according to the Sapporo criteria, were enrolled. The study cohort included both primary APS (=15) and APS associated with SLE (=28). In addition, 30 healthy subjects (HC) matched for age and sex were studied as controls. Serum levels of HMGB1 and sRAGE were analysed by Western blot. Results The clinical features of the enrolled patients (40 females and 3 males, mean age 40.98±13.48 years,) are reported in table 1. HMGB1 and sRAGE serum levels were significantly increased in APS patients in comparison with controls (p Conclusions In this study, we investigated for the first time the serum levels of HMGB1 and sRAGE in patients with APS, showing increased levels in both primary and secondary APS compared to controls. Larger studies are needed to assess whether monitoring serum HMGB1/sRAGE levels could be a useful tool for risk stratification in patients with APS. Disclosure of Interest None declared

Background The treatment of neuropsychiatric systemic lupus erythematosus (NPSLE) is extremely challenging and only a few clinical trials have been performed to establish optimal management. Objectives To describe the therapeutic approach and the short-term outcome of a multi-centre cohort of patients with NPSLE, enrolled at the time of the first NP event. Methods This is a retrospective cohort study. All NP events were defined according to American College of Rheumatology (ACR) case definition and divided into 3 clusters: central/diffuse (C/D), central/focal (C/F) and peripheral (P). A validated attribution algorithm was used to determine the attribution of all NP events. Demographic variables, global SLE disease activity Index 2000 (SLEDAI-2K), cumulative organ damage (SLICC/ACR Damage Index (SDI)) and treatment adopted for NP manifestations were collected. The clinical outcome of all NP events was determined by a physician-completed seven-point Likert scale (1=patient demise, 2=much worse, 3=worse, 4=no change, 5=improved, 6=much improved, 7=resolved). The relationship between the variables of interest and the outcome was analysed by crude and adjusted logistic models and reported as Odds Ratio (OR) and 95% confidence intervals (95% CI). Results 461 SLE patients with at least one NP event were included. 91.8% of patients were female, mean (SD) age 35.4 (13.6) years. 19.7% (91) of events were observed at diagnosis of SLE, 13.4% (62) before and 66.8% (308) after the diagnosis. 111 events (24.1%) were C/F, 286 (62%) C/D and 64 (13.9%) P. 198 (42.95%) of all NP events were attributed to SLE. The overall probability of immunosuppressive therapy was 28.4% (95% CI 24.3–32.8), 38.7% (95% CI 29.6–48.5) in C/F, 21.3% (95%CI 16.7–26.5) in C/D and 42.2% (95%CI 16.7–26.5) in P manifestations. The probability of immunosuppressive therapy was 47.9% (95% CI 40.8–55.2) in attributed events. The one-year outcome was available in 355 patients. Physician assessment indicated resolution (76 patients) or improvement (150 patients) in 49% (226/461) of cases. The crude and adjusted OR of attributed NP events and immunosuppressants on a favourable outcome is illustrated in Figure 1. The multivariable logistic regression analysis was done adjusting for age at diagnosis of SLE [OR 0.96, 0.94–0.98] p=0.001, female gender [OR 0.97, 0.33–2.7] p=0.959, SDI [0.85, 0.68–1.08] p=0.202, SLEDAI-2K [1.06, 1.01–1.11] p=0.008 and type of event (F/C [REF], C/D [0.37, 0.16–0.83] p=0.016, P [0.54, 0.21–1.42] p=0.215). Conclusions In our study, the therapeutic immunosuppressive approach was mostly used in attributed, C/F and P manifestations. In patients treated with immunosuppressants, the favourable outcome was lower in C/D phenotype. Disclosure of Interest None declared

Systemic lupus erythematosus(SLE) is a chronic autoimmune disease,characterised by alterations in both the innate and adaptive immune system ultimately leading to the loss of immunologic tolerance and occurrence of autoantibodies against nuclear material. Lupus nephritis is one of the most severe features of SLE determining an increase in morbidity e mortality rates.Renal biopsy still represent a fundamental diagnostic and prognostic tool for LN.Therefore, non-invasive surrogate biomarkers of active LN are urgently needed.Circulating, heterogeneous subcellular microparticles(MPs) are released from cells and platelets constitutively and upon cellular activation or apoptosis.Such MPs may reflect the state of their parental cells and tissues, and could serve as markers of pathology. Particularly in SLE, MPs are potential biomarkers and triggers of autoimmunity.Recent studies have demonstrated increased of plasmatic EMPs in patients with SLE active disease and their reduction after treatment. The aim of this study was to investigate levels of EMPs in a cohort of SLE patients with and without renal involvement compared to healthy controls. MPs were isolated from plasma and urine and characterised by flow cytometry using AnnessinV (a probe that binds to the exposed phosphatidilserine – PS)and antibodies against surface markers endothelial cells(CD31 +CD41-). Sixty SLE patients and 29HC were studied. Twenty-eight patients had renal involvement. The total number of plasmatic MPs was lower in SLE patients than HC(p=0.001). In contrast there was no significant difference EMPs between the two groups. When the patients were divided according to renal involvement, the patients with active-LN(A-LN) showed lower plasmatic EMPs in comparison to inactive LN(I-LN) (p=0.01), while the patients with I-LN had higher EMPs than HC(p=0.002).There was no significant difference of total urinaryMPs between SLE patients and HC. UrinaryEMPs were higher in SLE and in LN patients than HC. The results of the present study show increased EMPs in patients with LN in remission. Circulating-EMPs have been considered as a potential biomarker of endothelial activation and damage in several autoimmune disorders, and higher EMP have been detected in patients with vasculitis and associated with disease activation. According to our results, plasmatic EMPs are higher in inactive-LN patients than in HC. These results may suggest a potential role of EMP as a biomarker of LN.

Vimentin is a cytoskeletal protein expressed by mesenchymal cells, including endothelial and renal tubular cells. Antibodies to vimentin were described in 10%–53% of patients with Systemic Lupus Erythematosus (SLE). Vimentin has been proposed as a target of the in situ immune response in lupus nephritis. Post-translational modifications increase the immunogenicity of vimentin, as demonstrated by the detection of anti-modified-vimentin antibodies in rheumatoid arthritis. Carbamylation is a non-enzymatic post-translational modification (addition of a cyanate group on lysine and arginine residues), which has been linked to NETosis. The role of carbamylated vimentin (Car-Vim) as an antigenic target in SLE has not been evaluated yet. Aim of the study was to assess the prevalence of anti-Car-VIm and to investigate any association with clinical and serological features in SLE patients. We enrolled SLE diagnosed according to 1997 ACR criteria. Clinical features, autoantibodies profile and disease activity – according to SLEDAI 2K – were collected. Patients’ sera were tested for anti- Car-Vim by a home-made enzyme-linked immunoassay. Data were expressed as mean ±standard deviation or median (interquartile range) when appropriate. Mann-Whitney and Chi square test were applied to investigate differences in anti-carbamylated vimentin prevalence and serum levels. P value We enrolled 109 SLE patients (102F:7M, mean age 39.4±12.6 years, mean disease duration 10.5±9.5 years, mean SLEDAI 2K 5±5.5). Table 1 summarises the main clinical and serological features. Overall, 30/109 patients (27.5%) were positive for anti-Car-Vim. The prevalence of anti-Car-Vim was significantly higher in patients with lupus nephritis (18/44) compared to those without (12/66) (41.8% vs 18.2%, p=0.006); moreover, anti-Car-Vim serum levels were significantly higher in patients with lupus nephritis [2561 (1783) OD] compared to those without [1970 (1123) OD; p=0.0178]. No difference was found in prevalence or titre of anti-Car-Vim in presence/absence of other clinical or serological manifestations. No correlation between anti-Car-Vim serum levels and SLEDAI 2K was found. Higher prevalence and serum levels of anti-carbamylated vimentin antibodies in patients with lupus nephritis confirm the role of vimentin as a target of the immune response in glomerulonephritis and suggest their possible role as a biomarker of kidney involvement in SLE.

Systemic lupus erythematosus (SLE) is the prototype of systemic autoimmune disorders. Interferon alpha is a pleiotropic cytokine that can affect multiple cell types involved in lupus. Dendritic cells (DC) have a special role in the production of IFN and are the main sources of serum interferon. IFN has the potential to dramatically influence the development, progression, and pathogenesis of SLE as it can influence the function and activation state of most major immune cell subsets and function as a bridge between innate and adaptive immunity. Circulating microparticles (MPs) are ubiquitous in the blood of healthy individuals, These MPs play an active role in coagulation and intercellular communication and assist in activation or suppression of the immune system, depending on their parental cell origin. Changes in the concentration and/or composition of circulating Mps have been described in various autoimmune diseases, including rheumatoid arthritis (RA) systemic sclerosis (SSc) and SLE. For SLE, the reported microparticle-related changes remain somewhat inconclusive. To better understand the role of MPs in SLE patients, we analysed the presence of IFN-alpha on MPs surface. MPs were isolated from citrate-treated plasma; blood cells were removed by two steps of centrifugation process (2500 g for 15 min at 20 C two time). The resulting platelet-poor-plasma (PPP), was analysed by flow cytometry with specific antibody against IFN-alpha 20 consecutive SLE patients (10 with active lupus nephritis) and 10 sex- and age-matched healthy control subjects (HC) were included in the study. We found that MPs from SLE patients carry on their surface IFN alpha. Moreover, the percentage IFNalpha +MPs was higher in SLE patients and in lupus nephritis patients than in HC, but there was not significant difference between patients with and without renal involvement. The results of the present study show for the first time the presence of IFN-alpha on MPs surface. We may assume that INF+MPs derive from DC. In lupus nephritis patients the increased recruitment of DC was at tubular interstitial level, with subsequent IFN-alpha production. Interestingly, MPs (containing RNA and DNA) could stimulate type I IFN production in plasmacytoid dendritic cells and subsequently the release of MPs from DC.

Microparticles (MPs) are small membrane vesicles released by many cell types under physiological and pathological conditions. In the last years, these particles were considered as inert cell debris, but recently many studies have demonstrated they could have a role in intercellular communication. Increased levels of MPs have been reported in various pathological conditions including infections, malignancies, and autoimmune diseases, such as rheumatoid arthritis (RA). RA is an autoimmune systemic inflammatory disease characterized by chronic synovial inflammation, resulting in cartilage and bone damage with accelerated atherosclerosis increasing mortality. According to the literature data, also MPs could have a role in endothelial dysfunction, contributing to atherosclerosis in RA patients. Moreover many researchers have shown that a dysregulated autophagy seems to be involved in endothelial dysfunction. Autophagy is a reparative process by which cytoplasmic components are sequestered in double-membrane vesicles and degraded on fusion with lysosomal compartments. It has been shown in many works that basal autophagy is essential to proper vascular function. Taking into account these considerations, we hypothesized that in RA patients MPs could contribute to atherosclerosis process by dysregulation of endothelial autophagy process.

Central nervous system (CNS) involvement in systemic lupus erythematosus (SLE) is reported in about 50% of patients. Among the neuropsychiatric features of SLE, myelopathy, including acute transverse myelitis (ATM) or acute longitudinal myelitis (ALM), represents an uncommon event. A possible vascular aetiology of SLE myelopathies has been hypothesized and it seems to be much more associated to SLE-associated antiphospholipid syndrome (APS). Furthermore, a possible infectious cause of ATM or ALM in healthy subjects has been described. SLE patients are susceptible to infection due to the disease itself or to the immunosuppressive therapy. Cryptococci non-neoformans have been rarely associated to infections in humans. Here we describe the case of a 47-year-old woman with SLE and Sjögren Syndrome who developed an ALM concurrently with a Cryptococcus laurentii pneumonia. The patient was treated with antimycotics, high doses of glucocorticoids and intravenous immunoglobulins with a significant clinical and radiological improvement. As far as we know, this is the first case of Cryptococcus laurentii infection and ALM in a patient with SLE who later developed a seronegative APS. Even though myelopathy may be considered primarily associated to SLE, a possible role of the infection in ALM development cannot be excluded.

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease presenting with a wide array of clinical manifestations and incompletely understood pathogenesis. SLE is characterized by alterations in both the innate and adaptive immune system ultimately leading to the loss of immunologic tolerance and occurrence of autoantibodies against nuclear material. Lupus nephritis is one of the most severe features of SLE determining an increase in morbidity e mortality rates. Renal biopsy still represent a fundamental diagnostic and prognostic tool for LN. Therefore, non-invasive surrogate biomarkers of active LN are urgently needed. Circulating, heterogeneous subcellular microparticles (MPs) are released from cells and platelets constitutively and upon cellular activation or apoptosis. Such MPs may reflect the state of their parental cells and tissues, and could serve as markers of pathology. Particularly in SLE, MPs are potential biomarkers and triggers of autoimmunity. Recent studies have demonstrated increased levels of plasmatic EMPs in patients with SLE active disease and their reduction after treatment. Objectives The aim of this study was to investigate plasmatic and urinary levels of endothelial microparticles in a cohort of SLE patients with and without renal involvement compared to healthy controls. Methods Consecutive SLE patients and sex- and age-matched HC were included in the study. MPs were isolated from plasma and urine and characterized by flow cytometry using AnxV (a probe that binds to the exposed phosphatidilserine - PS) and antibodies against surface markers endothelial cells (CD31+CD41-). Mann-Whitney and Spearman correlation tests were used. A p value Results Sixty SLE patients (55F:5M, age 41,7±9.6 Y disease duration 149±112 months) and 29 healthy controls were studied. Twenty-eight patients had renal involvement.The total number of plasmatic MPs was lower in SLE patients than HC (p=0.001). In contrast there was no significant difference in levels of EMPs between the two groups. When the patients were divided according to renal involvement, the patients with active lupus nephritis (A-LN) showed lower plasmatic level of EMPs in comparison to inactive LN (I-LN) (p=0.01), while the patients with I-LN had higher levels of EMPs than HC (p=0.002). There was no significant difference of total urinary level of MPs between SLE patients and HC. Urinary levels of EMPs were higher in SLE and in lupus nephritis patients than HC. Conclusions The results of the present study show increased urinary and plasmatic levels of EMPs in patients with lupus nephritis in remission. Circulating EMPs have been considered as a potential biomarker of endothelial activation and damage in several autoimmune disorders, and higher EMP levels have been detected in patients with vasculitis and associated with disease activation. According to our results, plasmatic EMPs levels are higher in inactive LN patients than in healthy donors. These results may suggest a potential role of EMP as a biomarker of lupus nephritis Disclosure of Interest None declared

Background Belimumab (BLM), a fully human monoclonal antibody directed against B lymphocyte stimulator (BLyS), is currently the only biological drug approved for the treatment of active Systemic Lupus erythematosus (SLE) patients not responding to standard of care. Data from RCTs and observational studies have demonstrated its efficacy, especially in patients with joint involvement. Focusing on this specific manifestation, the response has been also demonstrated by using Disease Activity Score on 28 joints (DAS28) (1). No data are available about the response to BLM in terms of synovitis, assessed by ultrasonography (US). Objectives In the present 6-months longitudinal study, we evaluated the response to BLM in SLE patients treated for joint involvement, by using clinimetric indices and US assessment. Methods SLE patients starting BLM in the period between August 2013 and December 2016 were prospectively examined. The present analysis was restricted to patients requiring BLM for joint involvement. A complete physical examination and US assessment were performed at baseline (T0) and after 3 (T3) and 6 months (T6). At each time, we assessed the global disease activity by Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) and the joint involvement activity by DAS28. US evaluation of 12 joints (I-V metacarpophalangeal, I-V proximal interphalangeal, wrist and knee bilateral) was performed to identify inflammatory features (synovial effusion and hypertrophy, power Doppler) according to the OMERACT definitions. These elementary lesions were scored according to a semi-quantitative scale (0=absent, 1=mild, 2=moderate and 3=severe) and a total score, corresponding to the patient9s inflammatory status (0–216) was obtained by their sum. Results Moving from 35 SLE patients starting BLM, 14 (14 female; mean age±SD 48.4±8.6 years; mean disease duration±SD 255.4±124.2 months) were treated for prevalent joint involvement. At baseline, the mean DAS28±SD was 4.5±1.1, the mean SLEDAI-2K±SD was 6.1±1.5 and the mean daily prednisone±SD was 7.8±3.5 mg. After 3 months of treatment we observed a significant reduction in mean DAS28 (3.1±0.8 vs 4.5±1.1, P=0.007) and in mean SLEDAI-2K (3.5±2.1 vs 6.1±1.5, P=0.003) compared to baseline. The mean daily prednisone significantly decreased at T6 (4.7±1.4 vs 7.8±3.5 mg, P=0.03) while the rest of the therapy remained stable for 6 months. Of note, the mean total US score significantly decreased at T3 compared to T0 (13.7±24.4 vs 22.2±22.6, P=0.001). This result was maintained in 12 patients (85.7%) after 6 months with a statistically significant difference compared to T0 (7.9±6.6 vs 22.2±22.6, P=0.003) (Figure 1). Conclusions The results of the present study demonstrated the efficacy of BLM in SLE-related joint involvement, evaluated by SLEDAI-2K and DAS28, confirming previous data reported in the scientific literature. For the first time, we demonstrated an early response to BLM as proved by the reduction of the total US synovitis score after 3 months, reflecting the improvement of the joint inflammatory status. References Iaccarino L et al. Effects of Belimumab on Flare Rate and Expected Damage Progression in Patients With Active Systemic Lupus Erythematosus. Arthritis Care Res. 2017; 69:115–123. Disclosure of Interest None declared

Background Erythrocytes (RBCs) hold a crucial role in hemostasis and their integrity is influenced by different stimuli including circulating inflammatory mediators. Even though RBCs do not have nuclei and mitochondria, they have developed a process allowing them to undergo a rapid self-destruction named eryptosis. The exact mechanism of erythrocytes cell death is not fully clarified yet but it seems to involve Ca2+ and ceramide formation, leading to cell shrinkage and externalization of phosphatidylserine (PS) (1). Interaction between platelets and erythrocytes could participate in an increasing risk of thrombotic episodes typical of several diseases including antiphospholipid syndrome (APS). In fact, not only signals triggering eryptosis are involved in thrombosis activation, but also recent studies have demonstrated how PS-exposing erythrocytes are able to adhere to the vascular wall causing an impairment of circulation (2,3). Objectives Enhanced eryptosis is known to contribute to several pathological conditions (1) but the involvement of this process in APS has not been investigated yet. For this reason the aim of the study was to evaluate eryptosis levels in APS, healthy subjects positive for antiphospolipid antibodies without clinical manifestations (aPL carriers), autoimmune haemolytic anaemia (AIHA) and healthy donors (HD). Methods 27 patients with primary APS (M/F 5/22, mean age 51.1±7.6 years), 14 aPL carriers (M/F 3/11, mean age 48.9±8.4 years) were recruited after written informed consent. Moreover 10 AIHA patients and 12 HD were also enrolled as positive and negative control group respectively. RBCs were isolated from whole blood after centrifugation and eryptosis levels were analysed by flow cytometry, evaluating the percentage of annexin V-positive cells (PS-exposing cells). Flow cytometry was also use to estimated cellular volume from forward scatter (FSC). Results APS patients showed higher levels of eryptosis compared to HD (p=0.01). Interestingly, the percentage of annexin V-positive RBCs was lower in aPL carriers respect to APS patients (p=0.001). Moreover, an inverse correlation between RBCs volume and eryptosis was found in APS patients (r=-0.4, p=0.03). No clinical correlation between eryptosis and clinical manifestations were noticed. As expected, eryptosis was upregulated in AIHA patients compared to all populations studied (p Conclusions Our study provides for the first time evidence of eryptosis enhancement in APS patients suggesting a possible contribution of RBCs apoptosis in the pathogenesis of the disease. References Lang E, Lang F. Triggers, inhibitors, mechanisms, and significance of eryptosis: the suicidal erythrocyte death. Biomed Res Int. 2015;2015:513518. Borst O, Abed M, Alesutan I, Towhid ST, Qadri SM, Foller M, Gawaz M, Lang F. Dynamic adhesion of eryptotic erythrocytes to endothelial cells via CXCL16/SR-PSOX. Am J Physiol Cell Physiol. 2012;302:C644-C651. Pretorius E, du Plooy JN, Bester J. A Comprehensive Review on Eryptosis. Cell Physiol Biochem. 2016;39:1977–2000. Disclosure of Interest None declared

Background The prevention of chronic damage represents one of the most important target in the management of patients affected by Systemic Lupus Erythematosus (SLE). About 50% of patients develop chronic damage, especially in the early disease phase, due to disease activity, treatment adverse events and comorbidities. Longitudinal studies demonstrated a progressive increase of damage, evaluated by using SLICC Damage Index (SDI). Objectives Moving from these evidences, we aimed at evaluating the progression of chronic damage in a monocentric SLE cohort with at least 5-year follow-up and identifying the factors associated with damage progression. Methods We analyzed 658 SLE patients diagnosed according to the ACR 1997 revised criteria, referring to a dedicated outpatient clinic. For the present analysis, we evaluated only patients with a minimum follow-up of 5 years and at least one visit per year. Clinical and laboratory data were collected in a standardized, computerized and electronically-filled form, including demographics, past medical history, comorbidities and concomitant treatments. In all patients, chronic damage was determined by using SDI, with the evaluation of 12 organ systems. Disease activity was evaluated by SLEDAI-2K. Furthermore, we calculated the number of flares during the follow-up, defined as an increase in SLEDAI-2K score ≥4 from the previous visit, with a minimum interval of 2 months between visits. Results According with the inclusion criteria, we analyzed data deriving from 198 SLE patients (17 M/181 F, mean±SD age 46.8±12.1 years, mean±SD disease duration 131±99.7 months). At the first visit 60 patients (30.3%) showed SDI>0; in particular SDI=1 was identified in 65%, SDI=2 in 18.3%, SDI=3 in 10%, SDI=4 in 6.7%). At baseline, the presence of chronic damage was significantly associated with age (P Conclusions In our study, we observed a progression of chronic damage in almost 30% of SLE patients after 5 years. In particular, the presence of previous chronic damage seem to be a risk factor for new damage development. Moreover, the lack of disease control and the presence of comorbidities allows damage progression. Taken together, the results of this study underline the need of a better management of SLE patients in order to prevent damage accrual. Disclosure of Interest None declared

Background Lupus nephritis (LN) is one of the most severe features of systemic lupus erythematosus (SLE). Several cytokines and chemokines are secreted locally in case of glomerular inflammation. Interleukin 32 (IL32) is a newly described cytokine that exhibits several properties typical of proinflammatory cytokines. Ex vivo and in vitro studies supported the role of Toll like receptors (TLRs) in LN pathogenesis and recent investigations demonstrated that Poly I:C, a ligand for (TLR) 3, strongly induced IL32 production from several cell populations. Objectives To investigate serum and urinary levels of IL32 in a cohort of LN patients compared to SLE patients without renal involvement and healthy controls (HC). In addition, we investigated kidney expression of IL32 and in vitro ability of LN patients9 serum IgG to stimulate IL32 production by TLR3 activation in human embryonic kidney 293 cells line stably transfected with a TLR3 plasmid (Hek293/T3). Methods Serum and urinary IL32 concentrations were measured using ELISA; a polyclonal rabbit anti-human IL32 was used to evaluate the expression of IL32 in renal biopsies. To assess the production of IL32 induced by patients9 IgG and the transduction pathway of TLR3 we performed Western Blot analysis for IL32, TBK1 and NFkB. Results We recruited 60 LN patients, 50 SLE patients without renal involvement and 30 HC; 40 LN patients had an active disease (a-LN) and the remaining 20 were in remission (r-LN). IL32 serum levels were significantly higher in patients with r-LN (median 1368, IQR 3910) and HC (median 721, IQR 2271) compared to SLE patients without renal involvement (median 203, IQR 662.8 pg/ml) (p=0.03 and p=0.018, respectively). There were no significant differences in urinary IL32 levels among LN patients, SLE patients without renal involvement and HC. In LN patients a direct association between IL32 serum levels and disease duration (p=0.02; r 0.2978) was observed. Immuno-histochemical analysis performed on renal biopsies of 20 a-LN and 8 HC showed that IL32 was strongly expressed in renal samples of LN patients, especially in patients with class IV, compared to controls. Western Blot analysis showed that antibodies isolated from LN patients induced in vitro production of IL32 in Hek293/T3 cells as well as the phosphorylation of NFkB and TBK1. Conclusions The results of the present study show increased IL32 serum levels in r-LN patients as well as increased expression of such cytokine in renal tissues of a-LN patients. IL32 renal expression and its production by Hek293/T3 cells after patients9 IgG stimulation, probably mediated by TLR3, may suggest the production of IL32 directly at renal level in course of LN. Disclosure of Interest None declared

Background Joint involvement represents one of the most frequent manifestations in Systemic Lupus Erythematosus (SLE) patients (incidence 69–95%), with different degrees of severity. Currently, there are no validated indices to evaluate joint involvement in SLE. Musculo-skeletal ultrasonography (US) has been widely applied in patients affected by different arthropathies. US-detected synovitis reflects the inflammatory state at the joint level, as demonstrated by the correlation with histological modifications. Furthermore, US-synovitis significantly correlated with disease activity indices, such as DAS28. Objectives In the present study, we aimed at assessing a correlation between the composite indices DAS28 (Disease Activity Score 28), CDAI (Clinical Disease Activity Index), SDAI (Simplified Disease Activity Index), STR (Swollen to Tender Ratio) and the US-detected synovitis in a cohort of SLE patients with joint involvement. Methods One hundred seven patients (M/F 7/100, mean age ±SD 48.4±13.8 years, mean disease duration ±SD 156.0±129.6 months) with at least one tender joint were enrolled. We registered the number of swollen and tender joint count (0–28) and the patient9s/physician9s disease activity on visual analogue scale (0–100). DAS28-ESR, CDAI, SDAI and STR were calculated. The US evaluation of 12 joints (I-V metacarpophalangeal, I-V proximal interphalangeal, wrist and knee bilateral) was performed to identify inflammatory features (synovial effusion, synovial hypertrophy and power Doppler) according with OMERACT definitions. These elementary lesions were scored according to a semi-quantitative scale (0 = absent, 1 = mild, 2 = moderate and 3 = severe). The sum of the semi-quantitative scores allows obtaining a total score of the patient9s inflammatory state (0–216). Results As reported in Figure 1, by using the Spearman analysis, a positive correlation between US-score and SDAI (r=0.33, P=0.02), CDAI (r=0.29, P=0.03) and STR (r=0.42, P=0.0005) was identified. In particular, SLE patients with high disease activity according with STR value (>1) showed a higher US score (16.3±19.3) in comparison with moderate (7.7±4.5, P=NS) or low disease activity (7.1±7.9, P=0.02). Moreover, US score resulted significantly lower in patients with DAS28 remission compared to those with an active disease (4.5±4.4 versus 7.05±5.1, P=0.03; Mann-Whitney test). Conclusions We analyzed a large SLE cohort with articular involvement identifying a significant correlation between US scoreand the composite indices CDAI, SDAI and STR. Furthermore, US-score may be able to discriminate DAS28-remission patients. Taken together, these results suggest the ability of composite indices in detecting the joint activity in SLE patients and the possibility to use them in clinical practice to assess this frequent and potentially disabling manifestation. Disclosure of Interest None declared

Background Systemic lupus erythematosus (SLE) is the prototype of systemic autoimmune disorders. In the late 1970s, increased serum levels of interferon (IFN) were shown for the first time to be significantly associated with SLE and to correlate with disease activity. IFNα is a pleiotropic cytokine that can affect multiple cell types involved in lupus.Plasmacytoid dendritic cells have a special role in the production of IFN and are the main sources of serum interferon. IFN has the potential to dramatically influence the development, progression, and pathogenesis of SLE as it can influence the function and activation state of most major immune cell subsets and function as a bridge between innate and adaptive immunity.Lupus-prone mouse models, indicates that the type I interferon system may play a pivotal role in the pathogenesis of several lupus and associated clinical features, such as nephritis, neuropsychiatric and cutaneous lupus.Circulating microparticles (MPs) are ubiquitous in the blood of healthy individuals, These MPs play an active role in coagulation and intercellular communication and assist in activation or suppression of the immune system, depending on their parental cell origin. Changes in the concentration and/or composition of circulating microparticles have been described in various autoimmune diseases, including rheumatoid arthritis (RA) systemic sclerosis (SSc) and systemic lupus erythematosus (SLE). For SLE, the reported microparticle-related changes remain somewhat inconclusive. Objectives To better understand the role of MPs in SLE patients, we analyzed the presence of interferon alpha on MPs surface. Methods MPs were isolated from citrate-treated plasma; blood cells were removed by two steps of centrifugation process (2500g for 15min at 20 C two time). The resulting platelet-poor-plasma (PPP), was analyzed by flow cytometry with specific antibody against IFN alpha Results 20 consecutive SLE patients (10 with active lupus nephritis) and 10 sex- and age-matched healthy control subjects were included in the study. We found that MPs from SLE patients carry on their surface IFN alpha.Moreover, the percentage IFNalpha + MPs was higher in SLE patients and in lupus nephritis patients than in HC, but there was not significant difference between patients with and without renal involvement. Conclusions The results of the present study show for the first time the presence of IFN alpha on MPs surface.We may assume that INF+ MPs derive from dendritic cells. In lupus nephritis patients the increased recruitment of dendritic cells was at tubular interstitial level, with subsequent IFN alpha production. Interestingly, MPs (containing RNA and DNA) could stimulate type I IFN production in plasmacytoid dendritic cells and MPs releasing. Disclosure of Interest None declared