A positive direct Coombs’ test in the absence of hemolytic anemia predicts high disease activity and poor renal response in systemic lupus erythematosus

We determined the clinical utility of the direct Coombs’ test in the absence of hemolytic anemia as an indicator of disease activity and therapeutic response in systemic lupus erythematosus (SLE). SLE patients without hemolytic anemia who visited our hospital from January 2016 to November 2016 were retrospectively evaluated with a direct Coombs’ test. Clinical features, including SLE disease activity index (SLEDAI), treatment and laboratory findings were analyzed. For patients with lupus nephritis, we additionally evaluated the cumulative complete renal response rate over one year after induction therapy. Among 182 patients evaluated, 10 (5.8%) patients had a positive direct Coombs’ test in the absence of hemolytic anemia. They had a higher SLEDAI ( p < 0.01), higher circulating immune complex levels ( p = 0.01), higher anti-DNA titers ( p < 0.01) and a lower complete renal response rate ( p = 0.03) compared with those who were negative. Multivariate analysis indicated that SLEDAI was an independent factor correlated with the direct Coombs’ test without hemolytic anemia (odds ratio 2.4, 95% confidence interval 1.66–4.98, p < 0.01). A positive direct Coombs’ test in the absence of hemolytic anemia may therefore represent a useful biomarker for assessing disease activity and therapeutic response.

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Childhood Onset Systemic Lupus Erythematosus with Direct Coombs Test Positive in the Absence of Hemolytic Anemia – A Rare Case Report

Annals of Pathology and Laboratory Medicine ◽

10.21276/apalm.3038 ◽

2021 ◽

Vol 8 (7) ◽

pp. C105-107

Author(s):

Vani Sreekumar ◽

Mangaiyarkarasi .

Keyword(s):

Systemic Lupus Erythematosus ◽

Hemolytic Anemia ◽

Lupus Erythematosus ◽

Reproductive Age ◽

Coombs Test ◽

Childhood Onset ◽

Systemic Lupus ◽

Direct Coombs Test ◽

Positive Direct ◽

Onset Systemic Lupus Erythematosus

Systemic Lupus Erythematosus being a chronic autoimmune multisystem inflammatory disease, affects predominantly women of reproductive age group. Childhood – Onset Systemic Lupus Erythematosus is a rare disease with an incidence of 10% - 20%. Positive direct Coombs test in the absence of hemolytic anemia indicates high disease activity and severe renal damage. Herein we report a case of 11-year-old female child diagnosed as Systemic Lupus Erythematosus with positive direct Coombs test in absence of hemolytic anemia which is very rare.

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AB0007 STAT4 RS7574865 G/T POLYMORPHISM AS MARKER OF PREDISPOSITION TO SYSTEMIC LUPUS ERYTHEMATOSUS WITH JUVENILE ONSET

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.2142 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 1038.2-1039

Author(s):

M. Kaleda ◽

M. Krylov ◽

I. Nikishina

Keyword(s):

Systemic Lupus Erythematosus ◽

Pilot Study ◽

Lupus Erythematosus ◽

Renal Involvement ◽

Control Group ◽

Coombs Test ◽

Systemic Lupus ◽

Direct Coombs Test ◽

Positive Direct ◽

Cutaneous Lupus

Background:Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a significant genetic predisposition. Recent studies have identified STAT4 (signal transducers and transcription activators 4) as a susceptibility gene for SLE.Objectives:To investigate the hypothesis of the association of STAT4 rs7574865 G/T polymorphism with the predisposition to SLE in children and its relationship with some of SLE manifestations.Methods:The case-control pilot study included 143 children (39 with SLE and 103 healthy unrelated volunteers as a control group). Diagnosis of SLE was based on 2012 SLICC criteria. STAT4 rs7574865 G/T polymorphism was investigated using allele-specific real-time polymerase chain reaction (RT-PCR).Results:The group of pts with SLE consisted of 29 girls and 10 boys, with an average age of 11.8±3.7 years (from 3 to 17 years) and an average disease duration of 4.1±2.4 years. 79.5% pts had acute cutaneous lupus at the onset, 46.1% - nonscarring alopecia, 71.8% - arthritis, 23.1% - oral and nasal ulcers, 23.1% - serositis, 43.6% - renal involvement, 35.9% –neuropsychiatric disorders. Leucopenia/lymphopenia was found in 71.8% of pts, thrombocytopenia – in 23,1%. ANA were detected in 100% pts, anti-dsDNA – in 79.5%, anti-Sm – in 31.6%, antiphospholipid antibodies - in 7,3%, hypocomplementemia – in 61.5%, positive direct Coombs test – in 35.9 %. Macrophage activation syndrome at the onset was documented in 15.4 % of pts. The distribution of rs7574865 genotypes in the control group showed no significant deviations from the Hardy-Weinberg equilibrium. The distribution of genotype frequencies among pts had statistically significant differences compared to the control (χ2=12.95, p=0.0015): GG-30.8% and 63.1% (p=0.001), GT-56.4% and 33.0% (p=0.018), TT-12.8% and 3.9% (p=0.114), GT+TT - 69.2% and 36.9% (p=0.0005). The frequency of the mutant STAT 4 allele T (polymorphism), was significantly higher in the SLE group than in the control group (41% and 20.4%, respectively; p=0.0007). We identified an association of the T allele with some clinical, laboratory, and immunological disorders in SLE: arthritis (OR 3.9, p=0.0002), acute cutaneous lupus (OR 2.47, p=0.003), nonscarring alopecia (OR 3.12, p=0.002), renal involvement (OR 2.42, p=0.022), leucopenia (OR 2.72, p=0.003), thrombocytopenia (OR 4.88, p=0.002), anti-dsDNA (OR 2.82, p=0.0006), hypocomplementemia (OR 2.34, p=0.012), positive direct Coombs test (OR 3.38, p=0.002).Conclusion:Our pilot study confirmed that the STAT4 rs7574865 G/T polymorphism was associated with the risk of SLE in children and some of SLE manifestations.Disclosure of Interests:None declared

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POS0698 BIIB059 DEMONSTRATED A CONSISTENT THERAPEUTIC EFFECT ON SRI-4 RESPONSE ACROSS SUBGROUPS OF PARTICIPANTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS IN THE LILAC PHASE 2 STUDY

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.2570 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 597-598

Author(s):

R. Van Vollenhoven ◽

R. Furie ◽

K. Kalunian ◽

S. Navarra ◽

J. Romero-Diaz ◽

...

Keyword(s):

Disease Activity ◽

Lupus Erythematosus ◽

Response Rate ◽

Small Sample ◽

Statistical Testing ◽

Type I ◽

Phase 2 ◽

Systemic Lupus ◽

Research Support ◽

Chemokine Production

Background:Type I interferons and other inflammatory mediators derived from plasmacytoid dendritic cells (pDCs) are implicated in systemic lupus erythematous (SLE) pathology. BIIB059 is a humanized monoclonal antibody that targets blood dendritic cell antigen 2 (BDCA2), a pDC-specific receptor. The binding of BIIB059 to BDCA2 leads to rapid internalization of BDCA2 from the surface of pDCs and subsequent inhibition of interferon, cytokine, and chemokine production. In Part A of the 2-part, phase 2 LILAC study (NCT02847598), BIIB059 significantly reduced SLE activity, as evidenced by reduced total active joint count (primary endpoint) and higher SLE Responder Index (SRI-4)1 response (a secondary endpoint) versus placebo.2Objectives:To evaluate SRI-4 response for BIIB059 versus placebo at Week 24 in SLE participant subgroups.Methods:Enrollment in LILAC Part A was open to adults fulfilling ≥ 4 of 11 revised 1997 ACR criteria for classification of SLE, with ≥ 4 tender and ≥ 4 swollen joints, active skin disease, and positive lupus antibodies. Participants were randomized to receive either BIIB059 450 mg or placebo subcutaneously every 4 weeks for 20 weeks (with an additional dose at Week 2). SRI-4 response at Week 24 was analyzed in subgroups, though analyses were limited by small sample sizes and were not powered for statistical testing.Results:In LILAC Part A, 64 and 56 participants were dosed with BIIB059 450 mg and placebo, respectively. At week 24, SRI-4 response rate was observed in favor of BIIB059 regardless of the baseline disease activity, such as SLEDAI-2K <10 versus ≥10, presence of BILAG-2004 grade A or B arthritis, oral corticosteroid usage, positivity for anti-ds DNA autoantibody and/or complement status, with point estimates for least-squares mean differences as well as corresponding 95% CIs consistently favoring BIIB059 (Figure 1). The incidence of adverse events in the overall study population was similar between the placebo and BIIB059 groups.2Conclusion:BIIB059 treatment was associated with greater SRI-4 response rate, consistent among different subgroups of baseline disease activity as measured by SLEDAI-2K and BILAG-2004, glucocorticoid dosage, and serology. These findings provide additional evidence of the potential benefit of BIIB059 for the treatment of patients with active SLE.References:[1]Furie RA, et al. Arthritis Rheum. 2009;61(9):1143-1151. 2. Furie RA, et al. Arthritis Rheumatol. 2020;72(suppl 10). Abstract 0935.Acknowledgements:This study was sponsored by Biogen (Cambridge, MA, USA). Writing and editorial support was provided by Excel Scientific Solutions (Fairfield, CT, USA); funding was provided by Biogen.Disclosure of Interests:Ronald van Vollenhoven Consultant of: AbbVie, AstraZeneca, Biotest, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Arthrogen, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Pfizer, UCB, Richard Furie Consultant of: Biogen, Grant/research support from: Biogen, Kenneth Kalunian Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, Equillium, Genentech, Gilead, ILTOO, Janssen, Nektar, Roche, Viela, Grant/research support from: Lupus Research Alliance, Pfizer, Sanford Consortium, Sandra Navarra Speakers bureau: Astellas, Johnson & Johnson, Novartis, Pfizer, Consultant of: Biogen, Grant/research support from: Biogen, Juanita Romero-Diaz Consultant of: Biogen, Boehringer Ingelheim, Victoria Werth Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, EMD Serono, Gilead, GlaxoSmithKline, Janssen, Kyowa Kirin, Resolve, Viela, Grant/research support from: Biogen, Celgene, Gilead, Janssen, Viela, XIAOBI HUANG Shareholder of: Biogen, Employee of: Biogen, HUA CARROLL Shareholder of: Biogen, Employee of: Biogen, Cristina Musselli Shareholder of: Biogen, Employee of: Biogen, Catherine Barbey Shareholder of: Biogen, Employee of: Biogen, NATHALIE FRANCHIMONT Shareholder of: Biogen, OMass Therapeutics, Employee of: Biogen

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Differences in Clinical Features and Mortality between Childhood-onset and Adult-onset Systemic Lupus Erythematosus: A Prospective Single-center Study

The Journal of Rheumatology ◽

10.3899/jrheum.151129 ◽

2016 ◽

Vol 43 (8) ◽

pp. 1490-1497 ◽

Cited By ~ 21

Author(s):

Young Bin Joo ◽

So-Yeon Park ◽

Soyoung Won ◽

Sang-Cheol Bae

Keyword(s):

Systemic Lupus Erythematosus ◽

Disease Activity ◽

Hemolytic Anemia ◽

Clinical Features ◽

Lupus Erythematosus ◽

Adult Onset ◽

Single Center ◽

Childhood Onset ◽

Systemic Lupus ◽

Onset Systemic Lupus Erythematosus

Objective.To compare clinical features and mortality between childhood-onset systemic lupus erythematosus (cSLE) and adult-onset SLE (aSLE) in a prospective single-center cohort.Methods.A total of 1112 patients with SLE (133 cSLE and 979 aSLE) were enrolled and followed from 1998 to 2012. The 2 groups were compared regarding American College of Rheumatology (ACR) classification criteria for SLE, autoantibodies, disease activity measured by the Adjusted Mean SLE Disease Activity Index (AMS), damage measured by the Systemic Lupus International Collaborating Clinics/ACR Damage Index (SDI), and medication. The standardized mortality ratio (SMR) was calculated. Predictors of mortality in SLE were evaluated using Cox proportional hazard models.Results.After a mean followup of 7.6 years, patients with cSLE had a higher number of cumulative ACR criteria and a higher AMS (p < 0.001 each), but there was no difference in SDI (p = 0.797). Immunosuppressants were used more frequently by patients with cSLE (p < 0.001). The SMR of cSLE was 18.8 (95% CI 8.6–35.6), significantly higher than that of aSLE (2.9, 95% CI 2.1–3.9). We found cSLE to be an independent predictor of mortality (HR 3.6, p = 0.008). Moreover, presence of hemolytic anemia (7.2, p = 0.034) and antiphospholipid antibody (aPL; 3.8, p = 0.041) increased the magnitude of risk of early mortality more in the patients with cSLE than in those with aSLE.Conclusion.The clinical course of cSLE as measured by number of clinical manifestations and disease activity is worse than that of aSLE. Also, cSLE patients with hemolytic anemia and aPL are at greater risk of death than patients with aSLE who have those features.

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Effect of Autoantibodies to Erythropoietin Receptor in Systemic Lupus Erythematosus with Biopsy-proven Lupus Nephritis

The Journal of Rheumatology ◽

10.3899/jrheum.151430 ◽

2016 ◽

Vol 43 (7) ◽

pp. 1328-1334 ◽

Cited By ~ 6

Author(s):

Akinori Hara ◽

Kengo Furuichi ◽

Junya Yamahana ◽

Haruka Yasuda ◽

Yasunori Iwata ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Nephritis ◽

Disease Activity ◽

Lupus Erythematosus ◽

Significant Risk ◽

Serum Levels ◽

Erythropoietin Receptor ◽

Response To Treatment ◽

Systemic Lupus ◽

Renal Response

Objective.We examined the clinical significance of autoantibodies to the erythropoietin receptor (EPOR) in patients with systemic lupus erythematosus (SLE) who had biopsy-proven lupus nephritis (LN).Methods.Forty-six Japanese patients with SLE with LN who had undergone renal biopsy during 1993–2014 were enrolled in this study and followed for a mean of 83 months. Sera from those patients were screened for anti-EPOR antibodies using ELISA.Results.Anti-EPOR antibodies were detected in 18 (39%) of the 46 patients with SLE with anemia. Anti-EPOR antibodies were associated with low hemoglobin concentrations and reticulocytopenia. In addition, anti-EPOR antibodies were positively correlated with SLE disease activity, even though serum levels of the complement factors 3 and 4 did not differ between the 2 groups. In patients with International Society of Nephrology/Renal Pathology Society 2003 class IV LN, anti-EPOR antibodies were associated with active lesions including cellular crescents in glomeruli. Decrease in renal function was more frequently observed in patients without complete or partial renal response than in patients with it, and serum levels of the antibodies as well as renal response to treatment were significant risk factors for progression of renal dysfunction.Conclusion.The present study suggests that anti-EPOR antibodies might be involved in overall disease activity and active renal lesions, as well as in the impaired erythropoiesis in patients with SLE with LN. Further, the levels of anti-EPOR antibodies may be an additional predictor for renal injury.

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Efficacy and safety of belimumab in paediatric and adult patients with systemic lupus erythematosus: an across-study comparison

RMD Open ◽

10.1136/rmdopen-2021-001747 ◽

2021 ◽

Vol 7 (3) ◽

pp. e001747

Author(s):

Hermine I Brunner ◽

Carlos Abud-Mendoza ◽

Masaaki Mori ◽

Clarissa A Pilkington ◽

Reema Syed ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

Disease Activity ◽

Lupus Erythematosus ◽

Response Rate ◽

Activity Index ◽

Adult Patients ◽

Phase Iii ◽

Efficacy And Safety ◽

Systemic Lupus ◽

Link Type

ObjectiveTo assess the efficacy and safety of belimumab in paediatric versus adult patients with systemic lupus erythematosus (SLE).MethodsWe performed across-study comparisons of patients with active SLE who received belimumab or placebo, plus standard therapy, in PLUTO (paediatric phase II) and BLISS-52, BLISS-76, BLISS-NEA and EMBRACE (adult phase III). Analysed efficacy data included Week 52 SLE Responder Index (SRI)-4 response rate (EMBRACE: SRI with modified Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) proteinuria scoring (SRI-S2K)); SRI-4 response rate (EMBRACE: SRI-S2K) according to baseline disease activity indicators (Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score; anti-dsDNA/C3/C4 levels); Week 52 SRI-6 response rate; and time to first severe flare (SELENA-SLEDAI Flare Index) over 52 weeks. Safety data were compared for all aforementioned studies along with adult LBSL02 (phase II) and BLISS-SC (phase III).ResultsSRI-4 response rates were similar across the paediatric and adult studies; more belimumab-treated patients achieved SRI-4 responses versus placebo (PLUTO: 52.8% vs 43.6%; BLISS-52: 57.6% vs 43.6%; BLISS-76: 43.2% vs 33.8%; BLISS-NEA: 53.8% vs 40.1%; EMBRACE: 48.7% vs 41.6%). Across all studies, SRI-4 response rates were generally greater in patients with baseline SELENA-SLEDAI scores ≥10 than in patients with baseline SELENA-SLEDAI scores ≤9. A similar proportion of belimumab-treated patients achieved SRI-6 across all studies (PLUTO: 41.2%; BLISS-52: 46.2%; BLISS-76: 33.1%; BLISS-NEA: 43.9%; EMBRACE: 37.5%). Belimumab reduced the risk of severe flare versus placebo in all studies. The incidence of adverse events was similar across all studies.ConclusionsThese analyses demonstrate consistent efficacy and safety of belimumab plus standard therapy across paediatric and adult patients with SLE.Trial registration numbersPLUTO (NCT01649765); BLISS-52 (NCT00424476); BLISS-76 (NCT00410384); BLISS-NEA (NCT01345253); EMBRACE (NCT01632241); BLISS-SC (NCT01484496); and LBSL02 (NCT00071487).

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A 21-Year-Old Woman with Thrombotic Thrombocytopenic Purpura as Initial Symptom of Systemic Lupus Erythematosus and a Literature Review.

Blood ◽

10.1182/blood.v110.11.3963.3963 ◽

2007 ◽

Vol 110 (11) ◽

pp. 3963-3963

Author(s):

Rongfu Zhou ◽

Jian OuYang ◽

Ming Zhou ◽

Qiguo Zhang ◽

Yong Xu

Keyword(s):

Systemic Lupus Erythematosus ◽

Thrombotic Thrombocytopenic Purpura ◽

Lupus Erythematosus ◽

Treatment Time ◽

Clinical Manifestations ◽

Initial Symptom ◽

Coombs Test ◽

Systemic Lupus ◽

Thrombocytopenic Purpura ◽

Direct Coombs Test

Abstract We describe a 21-year-old woman with systemic lupus erythematosus (SLE) who first presented with an thrombotic thrombocytopenic purpura (TTP), and compare the clinical manifestations and prognosis between SLE patients with thrombotic thrombocytopenic purpura in the reported literature. At the time of admission, she was suffering from petechia, purpura and had neurological symptoms. Laboratory findings demonstrated haemolytic anaemia, thrombocytopaenia and high levels of fragmentocytes. Serological test results were highly positive for antinuclear antibodies (ANA) with a particle fluorescent pattern, and also detected antibodies against Smith antibody, RNP antibody and SSA antibody but was negative for dsDNA. Direct Coombs-test was positive and D-dimer was negtive. The activity of ADAMTS13 was significantly reduced even after 4 times plasmapheresis. TTP as presenting sign in the patient with SLE was diagnosed. After 5 times plasmapheresis treatments and immunosuppressive therapy she recovered and abnormal laboratory tests were gradually returned to normal. With a follow-up of 20 months, she had a normal life. Compared with other reports, TTP can be differentiated from other thrombotic microangiopathic syndromes by its normal levels of prothrombin time, partially activated thromboplastin time (APTT), fibrinogen and direct Coombs-test. But TTP might also be a complication of SLE and the manifestations of TTP are similar to those in SLE. The detection of the fragmentation of peripheral red blood cells helped the early diagnosis of TTP. Coomb’s test might be positive when patient with TTP had SLE. ADAMTS13 and its inhibitory antibody had an important role in the pathogenesis of TTP. Plasma exchange combined with corticosteroid and cyclophsphamide should be used as early as possible in TTP patient with SLE. The prognosis was related to the treatment time and methods including plasmapheresis.

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A pivotal phase III, randomised, placebo-controlled study of belimumab in patients with systemic lupus erythematosus located in China, Japan and South Korea

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2017-211631 ◽

2018 ◽

Vol 77 (3) ◽

pp. 355-363 ◽

Cited By ~ 51

Author(s):

Fengchun Zhang ◽

Sang-Cheol Bae ◽

Damon Bass ◽

Myron Chu ◽

Sally Egginton ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

South Korea ◽

Disease Activity ◽

Lupus Erythematosus ◽

Response Rate ◽

Phase Iii ◽

Controlled Study ◽

Systemic Lupus ◽

North East ◽

Point Reduction

BackgroundIntravenous belimumab plus standard of care (SoC) is approved in the USA and Europe for treatment of active, autoantibody-positive systemic lupus erythematosus (SLE).MethodsThis phase III, multicentre, randomised, double-blind, placebo-controlled study (BEL113750; NCT01345253) was conducted in 49 centres across China, Japan and South Korea (May 2011–September 2015). Patients with SLE were randomised 2:1 to intravenous belimumab 10 mg/kg or placebo, plus SoC, every 4 weeks until Week 48. The primary endpoint was the SLE Responder Index (SRI) 4 response rate at Week 52. Secondary endpoints were the percentage of patients with ≥4 point reduction in Safety of Oestrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI), SRI7, time to first severe flare and number of days prednisone (or equivalent) dose ≤7.5 mg/day and/or reduced by 50% from baseline. Safety was assessed.ResultsThe modified intent-to-treat population included 677 patients (belimumab n=451, placebo n=226). At Week 52, the SRI4 response rate was higher with belimumab versus placebo (53.8% vs 40.1%; OR: 1.99 (95% CI: 1.40, 2.82; P=0.0001)). The percentages of patients with a ≥4 point reduction in SELENA-SLEDAI and an SRI7 response were significantly greater for belimumab versus placebo. Patients in the belimumab group had a 50% lower risk of experiencing a severe flare than those receiving placebo (P=0.0004). In patients with baseline prednisone dose >7.5 mg/day, there was a significant reduction in steroid use favouring belimumab (P=0.0228). The incidence of adverse events was similar between groups.ConclusionsIn patients with SLE from North East Asia, belimumab significantly improved disease activity, while reducing prednisone use, with no new safety issues.

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