Plenary Session: Plenary Session 1: Novel aspect of therapeutics of autoimmune diseases
011 Vitamin D and rheumatic diseases S.S. Yeap1
1Department of Medicine, Sime Darby Medical Centre Subang Jaya, Subang Jaya, Malaysia
Vitamin D is a fat-soluble hormone that is responsible for calcium homeostasis. However, it has paracrine and immune-modulatory effects through the widespread presence of the vitamin D receptor (VDR) in many cells including macrophages, dendritic cells, B and T lymphocytes and neutrophils. VDR activation in these cells leads to transcription of gene products that initiate a cascade of anti-proliferative, pro-differentiating and immune-regulatory processes. Dendritic cells are likely to be the primary immune target of 1,25(OH)D, affecting its role in antigen processing and presentation. Overall, 1,25(OH)D appears to suppress cell-mediated (Th1 and Th17) processes, and promote a regulatory or tolerogenic environment that may act to ÔcontainÕ autoimmune pathological mechanisms. Thus a lack of vitamin D may exacerbate autoimmune pathology.
The largest number of studies with regards to vitamin D and autoimmune diseases has been done in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). There is evidence that low vitamin D levels may increase disease susceptibility to both SLE and RA. SLE patients with low 25(OH)D levels have lower bone density, and increased SLEDAI scores. In RA, low 25(OH)D levels have been found to be negatively correlated with disease activity e.g. as measured with the Disease Activity Score (DAS28). Low 25(OH)D values were also found in those not in remission or responding poorly to treatment. However, there have been no clinical trials formally looking at vitamin D supplementation in the prevention or treatment of rheumatological disorders.
012 NK cells sustain immune tolerance at human maternal-fetal interface Z.G. Tian1, B.Q. Fu1, X.C. Li2, R. Sun1, H.M. Wei1
1University of Science & Technology of China, School of Life Sciences, Hefei, China
2Brigham and Women’s Hospital and Harvard Medical School, Transplant Research Center, Boston, USA
Natural killer (NK) cells are innate immune lymphocytes that can control several types of tumours and microbial infections. Current research highlights the fact that natural killer cells also act as regulatory cells to affect adaptive immune response. Interestingly, NK cells accumulate in large numbers at the maternal-fetal interface, but their exact roles in successful pregnancy remain poorly defined. Here, we provide evidence that TH17 cells and local inflammation can occur at the maternal-fetal interface during natural allogenic pregnancies. We found that decidual NK cells promote immune tolerance and successful pregnancy by dampening inflammatory TH17 cells via IFN-γ secreted by CD56brightCD27+ NK subset. We also found that this NK cell-mediated regulatory response is lost in patients who experience recurrent spontaneous abortions, which results in a prominent TH17 response and extensive local inflammation. This local inflammatory response further impacts the regulatory function of NK cells, leading to the eventual loss of maternal-fetal tolerance. Thus, our data identify NK cells as key regulatory cells that sustain immune tolerance at the maternal-fetal interface by suppressing TH17-mediated local inflammation.
Parallel Session: Parallel Session 1: Epidemiology and clinical presentation of autoimmune diseases
018 Antiphospholipid syndrome: lessons from the genetic study
Genetic factors are hypothesized to play a role in the susceptibility to antiphospholipid syndrome (APS) based on several family studies in patients with antiphospholipid antibodies (aPL) and/or clinical manifestations of APS. The genetics of β2-glycoprotein I (β2GPI), one of the most representative target antigens of aPL, has been extensively studied. 247 Val/Leu polymorphism can affect the conformational change of β2-GPI and the exposure of the epitopes for aCL. We found that 247 Val was correlated with anti-β2-GPI production in patients with primary APS, and 247 Val may be important for β2-GPI antigenicity. STAT4 SNP in Japanese patients with SLE and/or APS. T allele frequencies in SLE and APS were significantly elevated compared with that in healthy controls. When analyzed only in primary APS patients, T allele frequency was further higher. BANK1, BLK and SNP in 1q25.1 region were associated with not only SLE but also APS in Japanese population. These results suggest that APS and SLE, in part, share a common genetic background.
Although the genes involved in APS have not been identified because antigen specificity of aPL and the pathophysiology of APS are highly heterogeneous and multifactorial, genomewide linkage analysis and large cohort studies would lead to better understanding of the genes that might be involved in APS.
020 DEVELOPMENT OF PATIENT-BASED RA DISEASE ACTIVITY INDEX M.H. Leung1
Standard disease activity measures in rheumatoid arthritis such as the Disease Activity Score in 28 joints (DAS28) are based on evaluators and have high inherent inter-observer variability. Other commonly used simplified versions are improved mainly in the arithmetic. The other limitation is the dependency for blood tests on inflammatory indices, the result of which may not be readily available upon clinic visit. Moreover, patients cannot monitor their own disease activity at home, in a way similar to ambulatory blood pressure and home haemoglucostix monitoring in other chronic illnesses.
Patient-based disease activity score (PDAS1 [with erythrocyte sedimentation rate ESR] & PDAS2 [without ESR]) in rheumatoid arthritis (RA) are developed in an attempt to overcome these limitations. In the developmental cohort, the PDAS with ESR (PDAS1) and without ESR (PDAS2) achieved excellent fit with the DAS28. The results were validated in another validation cohort. The PDAS and DAS28 had similar sensitivity to change, determined using effect sizes and standardized response means.
Status and responder criteria of European League Against Rheumatism (EULAR) DAS28 had also been mapped to PDAS. Remission, low, moderate and high disease activities, good and moderate responses to treatment were determined. They have comparable agreement and performance to standard criteria based on DAS28 and Clinical Disease Activity Index (CDAI).
PDAS appears suitable for clinical decision-making, epidemiologic research, and clinical trials.
021 Introduction of Korean nationwide RA cohort and Clinical implication Sang-Cheol Bae, MD, PhD, MPH
Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul 133-792, Korea
A large national prospective cohort can be crucial in performing clinical research. In South Korea, KORean Observational study Network Arthritis (KORONA) has been established by Clinical Research Center for Rheumatoid Arthritis (CRCRA) at Hanyang University funded by the Ministry of Health and Welfare in 2008. KORONA has been investigated by using prospective protocol including patientsÕ demographics, clinical features, laboratory and radiologic data, health-related outcomes, treatment side effects, resource utilization, and health behaviors in 23 University Hospitals. CRCRA have implemented annual monitoring, auditing, staff training and provides standard operation protocol. Currently, 5,376 RA patients were enrolled and approximately 80% of their follow-ups are going on.
Prospective cohort study can provide the information that cross-sectional study or randomized clinical trials (RCTs) cannot provide and it also enables to reflect clinical practice. For example, it enables researchers to investigate how patientsÕ characteristics (i.e. genetic factors) could affect the disease outcomes and to investigate both research subjects that cannot be conducted by RCTs and excluded patients in RCTs (i.e. patients with old age or comorbidities who excluded in RCT). In addition, cohort study can reflect real clinical practice and provide long-term patients-oriented outcomes (PROs).
In this talk, I would like to introduce KORONA cohort and present the important results of our studies using this cohort.
022 IS ATHEROSCLEROSIS AN AUTOIMMUNE DISEASE? H. Tse1, X. Zhao1, R. Thummel2, M. Shaw1
1Immunology and Microbiology, Wayne State University, Detroit, USA
2Anatomy and Cell Biology, Wayne State University, Detroit, USA
Background and Aims: Atherosclerosis is a chronic inflammatory disease of the arterial wall with immune implications. Both innate and adoptive immunity are involved. Initially, autoantibodies against oxidized low density cholesterol (oxLDL) are found in the sera of atherosclerotic mice and human. T cells of all subclasses are also identified at the lesion sites. In addition, studies with gene-deficient mice further demonstrate the role of T cells in the development of disease. Despite these studies, however, there are no data demonstrating the cause-and-effect relationship of T cells and atherosclerosis. Specifically, the nature of the atherogenic T cells remains elusive. To identify atherogenic T cells, we reason that T cells are antigen specific and identification of the atherogenic epitopes of an autoantigen should lead us to identification of the atherogenic T cells themselves. Methods: Applying the mouse H-2b-binding motif published by Liu et al., we scanned over the entire 4500 amino acid sequence of the murine autoantigen, apoB100, and identified 18 sequences that fit the motif characteristics. Six such sequences were selected for synthesis and for functional studies. Results: One of the peptides, peptide6, significantly elevated the aortic plaque burden of Western Diet-fed ApoE-/- mice immunized with the peptide emulsified in CFA. Lymph node cells from P6-immunized mice and P6-specific T cell clones also successfully adoptively transferred enhanced atherosclerosis to na•ve recipients fed a WD diet. P6 is the first ever identified atherogenic T cell epitope of apoB100. Conclusions: These studies lend strong support to the concept that atherosclerosis is an autoimmune disease.
023 DETECTION OF OXIDIZED LIPOPROTEINS ACCUMULATED IN ATHEROSCLEROSIS LESIONS BY IMAGING MASS MICROSCOPY (IMS) L. Shen1, W. Arum Tri2, K. Kobayashi1, T. Sasaki1, Y. Matsunami2, F. Takenaka1, E.I.J.I. Ando3, T. Yamamoto4, K. Ogata3, E.I.J.I. Matsuura1
1Collaborative Research Center (OMIC), Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
2Department of Cell Chemistry, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
3Life Science Business Department, Shimadzu Corporation, kyoto, Japan
4Applications Development Center, Shimadzu Corporation, kyoto, Japan
Background: β2-Glycoprotein I (β2GPI) is a major antigen for pro-thrombotic autoantibodies characteristically present in patients with antiphospholipid syndrome. β2GPI particularly binds to oxLDL via 7-ketocholesteryl-9-carboxynonanoate (oxLig-1) to form pro-atherogenic oxLDL/β2GPI complexes. Anti-β2GPI autoantibodies enhance the uptake of oxLDL/β2GPI by macrophages via Fcγ receptors. We studied the in vitro intracellular accumulation of lipids by cultured macrophages (J774A.1), and in aortic lesions containing atherosclerotic plaques by MALDI-TOF-mass spectrometry (MALDI-TOF-MS) and the novel imaging mass microscope (iMS). Methods: Purified LDL from LDL-/- mice fed with a high fat diet was oxidized by CuSO4 treatment, and the resulting oxLDL incubated with J774A.1 cells to promote phagocytosis. A profile of oxidized lipids was obtained by MALDI-TOF-MS, and the distribution of lipids within atherosclerosis plaques was imaged by iMS. Results and Conclusion: A positive ionization mass spectrum (m/z 369; from cholesterol) was detected in all specimens (aortic tissue and plasma). In contrast, m/z 383 corresponding to the mass size of 7-ketocholesterol appeared in oxidized lipoprotein fractions and in oxLDL-loaded J774A.1 cells. Finally, 2-dimentional iMS visualized aortic atherosclerotic plaques in the Watanabe heritable hyperlipidemic rabbits and in LDL-/- mice. Thus, MALDI-TOF-MS and iMS techniques may create new era in methodology for pathophysiological studies of lipid metabolism.
Parallel Session: Parallel Session 2:Cutting edge in therapy of autoimmune disease
027 Is the proteasome a valuable target for treating autoimmune diseases? J. Kalden1, R. Voll2
1Division for Molecular Immunology, University of Erlangen-Nuremberg, Erlangen, Germany
2Department for Rheumatology and Clinical Immunology, University of Freiburg, Freiburg, Germany
Inhibition of the immuno proteasome has been recently demonstrated tohave a potential therapeutic effect especially in patients sufferingfrom SLE. Studies in experimental animal models for SLE proved to showthat the inhibition of the proteasome not only prevented thedevelopment of the disease, but also in animals with manifest SLEsyndromes showed a significant improvement in antibody titors andkidney function. Studies on the function of the inhibition of theproteasome revealed that specifically long-lived plasma cells will beaffected, and as more recently shown, that the interferon alphaproduction by plasmacytoid dendritic cells will be significantlyinhibited (H. Travis Ichikawa et al. Arthritis Rheum 2012, 64:493-503).Severe side effects observed in the experimental animal models wereacceptable. There was no major influence by the inhibition ofbortezomib on T cell function.
More recently, an open, multicenter trial in SLE patients has beeninitiated in Germany. First data indicate that Bortezomib is ofclinical efficacy in patients with a severe form of disease includingkidney involvement. However, more data are necessary to show thebeneficial effect of a inhibition of the proteasome on a long run. Atthe moment it looks like that the inhibition of the proteasome might bea valuable option for the treatment start and for the treatment offlaires of SLE patients.
Since bortezomib as shown by the treatment of myeloma patients cancause polyneuropathies new molecules for inhibiting the proteasome havebeen developed and are presently under clinical investigation.
028 ADVANCEMENTS IN THE TREATMENTS OF MULTIPLE SCLEROSIS K.H. Chan1
1Medicine, The University of Hong Kong, Hong Kong, Hong Kong China
Multiple sclerosis (MS) causes neurological disability. Experimental autoimmune encephalomyelitis (EAE) is an animal model of MS. Human bone-marrow mesenchymal stem cells (hMSCs) possess anti-inflammatory and immunosuppressive effects. We studied whether hMSCs affect CD1dhighCD5+ regulatory B cells activity in EAE. EAE is induced in C57BL/6N mice by immunization with MOG35-55 peptide. hMSCs are injected intravenously into EAE mice at day 3 and day 12 after first immunization. Mice were sacrificed at day 26. Immunohistochemistry of spinal cord, serum cytokines levels, production of cytokines by cultured splenic cells, and flow cytometry for splenic Th17 and CD1dhighCD5+ regulatory B cells were studied. We found that EAE mice with hMSCs treatment as day 3 and day 12 had reduced EAE scores from day 14 to 26 compared to EAE mice without hMSCs treatment, and reduced infiltration of inflammatory cells and demyelination in spinal cord. EAE mice with hMSCs treatment at day 3 and day 12 had 1) lower serum levels of IL-6, TNF-α (p<0.0005) and IL-17 (p<0.005 for day 3, p<0.0005 for day 12), 2) reduced splenic cell production and secretion of IL-6, TNF-α (p<0.05) and IL-17 (p<0.05), and increased splenic production of IL-10, 3) reduced splenic Th17 cells (p<0.05 for day 3, p<0.005 for day 12) and 4) increased CD1dhighCD5+ regulatory B cells (p<0.005) than EAE mice without hMSCs treatment. hMSCs treatment at day 3 and 12 suppresses EAE severity. The underlying mechanisms involve downregulation of Th17 cells and upregulation of CD1dhighCD5+ regulatory B cells activity.
029 Can suppression of inflammation prevent progression of premature atherosclerosis in rheumatic diseases? L.S. Tam1
1Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
Tumor necrosis factor-α (TNF-α) antagonists are effective in suppressing inflammation in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). However, it is debatable if they have favorable effects on the cardiovascular (CV) system. The use of surrogate end points instead of actual CV events may provide more evidence on whether rheumatic disease patients may benefit from potent anti-inflammatory treatment such as anti-TNF-α therapy on the prevention of premature atherosclerosis. Surrogate markers including carotid intima media thickness (cIMT) has been widely used to assess subclinical atherosclerosis; while pulse wave velocity (PWV) and aortic augmentation index (AIx) are the gold standards to assess arterial stiffness. Published data suggest that TNF-α blockers probably are effective in preventing or even reversing the progression of IMT in patients with RA, AS and PsA who are responding to treatment. With regards to arterial stiffness, PWV was either significantly reduced or remained unchanged in most studies following TNF-α antagonist treatment; nonetheless, most studies in RA reported significant improvement of PWV. In contrast, AIx remained unchanged in the majority of the studies. The balance of evidence suggests that TNF-α antagonists may have a beneficial effect on preventing the progression of subclinical atherosclerosis and arterial stiffness. Consequently, this may have a beneficial effect on CV risk. However, longer term cohort studies are needed to confirm these promising results.
031 HELLP SYNDROME: COMPLICATION OR A NEW AUTOIMMUNE ENTITY? C. De Carolis1, C. Perricone2, R. Perricone3, F. Crescenzi1
1Obstetrics and Gynecology, S. Giovanni Addolorata Hospital Rome Italy, Rome, Italy
2Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia Sapienza Università di Roma, Rome, Italy
3Dipartimento di Medicina Interna, Rheumatology/Allergology and Clinical Immunology Tor Vergata University of Rome Rome Italy, Rome, Italy
Recurrent spontaneous abortion (RSA) is defined as two or more consecutive spontaneous abortions, which may occur at any stage of pregnancy. Among various causes of RSA, autoimmune abnormalities can play a relevant role - the most significantly implicated being antiphospholipid antibodies (aPL). However, in several cases, no evident explanation is found and recurred abortion is reported to be unexplained. A deeper insight into apparently unexplained RSA shows increasing evidences supporting also an alloimmunologic mechanism, a condition in which natural killer (NK) cells may play a relevant role when in too high concentrations. Given the poor understanding of the precise mechanisms underlying RSA and unexplained RSA, therapy so far has been empirical and not evidence based. Treatment modalities for RSA include aspirin, heparin, progesterone, prednisone and intravenous immunoglobulins (IVIGs). Different immunomodulatory effects have been reported for IVIG and, among others, antigen neutralization, Fc-receptor blockade and anti-idiotypic interactions, changes in distribution and function of T-cell subsets, antibodies to autoantigens and mild activation of complement. Furthermore, it is known that IVIGs affect cytokine production in T lymphocytes and monocytes/ macrophages, all mechanisms of potential benefit in RSA. Our study compared intravenous immunoglobulins (IVIG) and prednisone in treating pregnant women with a history of recurrent fetal loss in terms of live-birth rate and maternal and perinatal morbidity. The results of this study will be discussed.