Faculty Bibliography

Background Nearly 20% of pregnancies in patients with Systemic lupus erythematosus (SLE) result in an adverse pregnancy outcome (APO); early identification of women with SLE who are at high risk of APO is vital. We previously examined several regression and machine learning (ML) predictive models for APO using data from the PROMISSE Study, a large multi-center, multi-ethnic/racial study of APO in women with mild/moderate SLE and/or aPL. Penalized logistic regression (LASSO), as well as several black box ML algorithms (Random Forest, Support Vector Machine, and Super Learner) each achieved good internal cross-validated performance, with area under the receiver operating curve (AUC) of 0.77-0.78. The goal of this study was to externally validate the performance of these promising APO risk models using three independent, external cohorts. Methods The PROMISSE data set used to develop the initial APO prediction models consisted of N=385 pregnancies, 71 APO events (18.4%), and 32 known or potential APO risk factors that are routinely measured in clinical practice early in pregnancy. APO was defined as preterm delivery due to placental insufficiency or preeclampsia, fetal or neonatal death, or fetal growth restriction. Three independent prospective cohorts were provided by a team of international investigators with expertise in SLE pregnancy (Bronx, NY: N=96; NYC, NY: N=62; Pisa, Italy: N=152). Patient demographics were summarized for each cohort and missing data handled using multiple imputation with chained equations. Using the APO risk models developed with the PROMISSE data, we computed for each cohort: 1) the standard deviation (SD) of predicted risk scores to summarize the degree of heterogeneity in patient characteristics and 2) the area under the receiver operating curve (AUC) to summarize the ability of each model to discriminate patients with and without APO. Results The three external cohorts and the PROMISSE development cohort showed distributional differences in previously identified APO risk factors (table 1). Non-Hispanic White comprised 49.3% of the PROMISSE, compared to 98.7% in Pisa, 27.4% in NYC, and 0% in the Bronx. LAC positivity varied from 8.1% in PROMISSE to 22.6% in the NYC cohort, while PGA > 1 varied from 10.6% in the development cohort to 4.4% in the Bronx, NY cohort. Current antihypertensive use was 8.6% in PROMISSE, higher in the Bronx cohort (12.6%), and lower in the NYC (4.8%) and Pisa (5.3%) cohorts. APO rates were the same in PROMISSE and Pisa (18.4%) and higher in the Bronx (24%) and NYC cohorts (25.8%). Prediction risk score SD indicated similar levels of heterogeneity within each external cohort compared to the PROMISSE cohort. Model performance in external validation cohorts varied depending on the algorithm used. As expected, AUCs in the external cohorts were generally lower than cross-validated internal estimates, but still indicated satisfactory performance of the different models with the independent data sets (table 2). Super Learner, the highest performing algorithm in PROMISSE, performed well across all three external cohorts, with a minimum AUC of 0.63 in the NYC cohort and a maximum of 0.71 in the Pisa cohort (table 2). LASSO also maintained consistent external performance with minimum AUC of 0.60 and maximum of 0.66. Overall, performance was highest using data from the Pisa cohort, which was the largest and most complete of the three external validation data sets. Conclusions Penalized regression and ML approaches using variables obtained early in pregnancy show potential in discriminating pregnancies with high APO risk from those pregnancies with lower risk. This study provides confirmation of the geographic transportability of the best performing algorithms developed with PROMISSE. While Super Learner showed the most satisfactory performance across external cohorts, LASSO also performed well and yielded a parsimonious model that may be easier and more efficient to use as a risk assessment tool in practice. Data from additional external cohorts from the US and abroad will be obtained in the future for further validation and refinement of our APO prediction models

Background Mitochondria are intracellular organelles derived from the endosymbiosis between an a-proteobacterium and a primitive eukaryotic cell. Mitochondria thus display proinflammatory and antigenic properties, when released into the extracellular milieu. Several cross-sectional studies reported increased levels of anti-mitochondrial antibodies (AMAs) in patients with systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). These autoantibodies also displayed correlations with the SLE disease activity index 2000 (SLEDAI-2K) and associations with various clinical manifestations (e.g. lupus nephritis, thromboses, carotid plaque). In the present study, we aim to detect AMAs against either whole organelles (AwMA), mitochondrial DNA (mtDNA) or RNA (mtRNA) through time in samples from patients included in the SLICC cohort. Methods Clinically relevant variables (e.g., sociodemographic variables, disease-specific outcomes including death and arterial vascular events (AVE)) were documented and biosamples were harvested upon patient enrolment in the SLICC cohort, as well as at each follow-up visit. AMA levels were measured by in-house direct ELISAs whereas SLE autoantibodies were detected by clinical laboratories. Healthy individuals, defined as having no known illnesses and infectious symptoms at the time of the blood draw, were recruited. 90% confidence intervals were calculated for both limits of the 95% nonparametric two-sided reference intervals for values measured in healthy donors. AMA values were segregated into 3 categories: Normal values were determined as within the inner limits of the range while values outside this range were characterized as abnormal, either lower or higher than the reference interval. (figure 1). Marginal Cox models with AMAs in 3 categories were adjusted for covariables and are presented as [hazard ratio (95% CI)]. Interactions with sex were tested in models with the AMAs as continuous variables. Results Sera from healthy individuals (n=126) or SLE patients included in the SLICC cohort, from their inclusion, up to 7 years of follow-up (n=1114 patients at baseline, 3577 samples in total). AwMA displayed lower correlations with antibodies to mitochondrial nucleic acids (versus AmtDNA: rs=0.37, and vs AmtRNA: rs=0.38), while antibodies to mitochondrial DNA or RNA shown higher correlations (rs=0.59). During our preliminary analyses on the distribution of the variables, We made intriguing observations regarding patients with AMA levels that were either lower or higher than those of healthy individuals. This information led us to categorize SLE patients as described in the methods and in figure 1. For each of the three antibodies assessed, SLE patients displayed more abnormal AMA levels at baseline than controls. The percentage of patients with higher levels of AwMA and AmtRNA increased at subsequent follow-up visits, while a slight decrease was observed for AmtDNA (figure 2). SLE patients with higher levels of AwMA showed higher risks of death [2.12 (1.18-3.83)]. It is of interest that an inverse relationship was found between AmtRNA and AVEs, with a small subset of patients with low levels of AmtRNA (n = 4), this autoantibody was associated with increased risks of this manifestation [4.46 (1.71-11.66)]. Additionally, patients with higher levels of AmtDNA and AmtRNA displayed increased risks of lupus nephritis [respectively: 3.05(2.05-4.54), and 1.56(1.12-2.18)]. Interestingly, there was an interaction with sex for AmtRNA levels effect on AVEs [males: 0.32 (0.11-0.99). Females: 1.56 (1.11-2.19)], and AmtDNA association with nephritis was only significant in female patients [4.00 (2.51-6.36)] (table 1). Conclusion These results show that AMAs display different associations with disease manifestations in various clusters of patients. These results prompt for further analyses by machine-learning in order to delineate clusters of clinical interests by adding AMAs in the routine serological assessment of SLE autoantibodies. Acknowledgements We acknowledge the contribution of the study participants, individual center support staff as well as investigators of the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort project who for the past 20 years have made this study possible. LAY ABSTRACT The mitochondrion is a part of the cell that controls various biological mechanisms (e.g., energy supply, whether the cell should live or die, control, or produce various cellular components). They are derived, through evolution, from a microbe. Mitochondria may sometimes be jettisoned out of their host cell and subsequently elicit immune reactions - including the production of antibodies. Previous studies indicated that patients with autoimmune conditions such as systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS) have antibodies against mitochondria in their blood stream. Presence of these antibodies was associated with increased disease activity and clinical manifestations of these diseases (e.g. kidney disease, arterial vessel disease). In this study, we studied blood samples harvested by an international group dedicated to the study of SLE [i.e., the SLE International Collaborating Clinics (SLICC) cohort] and observed that patients may be clustered into groups, upon their levels of antibodies and/or sex, allowing to have a better appreciation of their risks of death, vascular events, and kidney disease. These results might lead to improved diagnosis and/or prognosis in SLE and thus, in improved care and quality of life for the people living with lupus

Introduction Fetal cardiac disease is strongly associated with maternal anti-SSA/Ro antibodies, but gaps in our knowledge include the influence of antibody specificity and titer, maternal diagnosis, overall non-cardiac adverse pregnancy outcomes (APOs), optimal surveillance protocols, and efficacy of rapid treatment. Methods The multi-center Surveillance and Treatment To Prevent Fetal AV Block Likely to Occur Quickly (STOP BLOQ) study recruited pregnant women with commercially positive anti-Ro antibodies and stratified them into high and low titers of anti-Ro60 and Ro52 based on a research ELISA, using a cutoff defined by that obtained for 50 mothers with previous AVB offspring. Mothers with anti-Ro60 and/or 52 antibodies at or above 1,000 I.U. were trained to perform FHRM. From 17-25 weeks of gestation, FHRM was completed 3x/day in addition to weekly or biweekly fetal echocardiograms (echo). Mothers texted all audio sounds to the coordinating center. Texts deemed abnormal by mothers were immediately sent to an on call pediatric cardiologist who either reassured if FHRM was normal or referred for emergency fetal echo in < 6 hours if abnormal. Results 250 anti-Ro pregnant women (22% Hispanic, 50% white, 12% Black, 12% Asian, 4% other) have been consented, including 28 whose previous child had AVB. Of mothers tested to date, 153 were provided home monitors given high titer anti-Ro60 and/or 52 antibodies (26 high titer anti-Ro60 alone, 21 high titer anti-Ro52 alone,105 high titer antibodies to both antigens). The 83 patients with low titers were surveilled with echos per local standard of care. Regarding maternal diagnosis, of 161 assessed to date, 39% were asym/UAS, 11% RA, 31% SS, 19% SLE. Antibody titers did not significantly differ by ethnicity, race or diagnosis (table 1). Non-AVB APOs occurred in 18% and were not predicted by Ro60 or 52 titers but rather SLE diagnosis (table 2). In total, 24,759 FHRM audiotexts were received from 131 patients (90 of whom have delivered) during the monitoring period. Of these, 22 were evaluated by the on-call pediatric cardiologist, who prompted an emergency echo (all completed in < 6 hrs). In 11 cases, the emergency echo was normal. In 9, there were premature atrial contractions, confirming the mother's perception. In 2 with 2degree block on urgent echo (both treated per protocol with IVIG and dexamethasone), 1 reverted to normal sinus rhythm and the other progressed to 3degree block. In 2 others, the mother did not perceive abnormal FHRM for > 24 hrs, echo identified 3degree block, and retrospective cardiology review of FHRM audio captures identified an abnormality prior to obtaining the echo. All 4 AVB developed in fetuses of mothers with high titer antibodies to both Ro60 and 52 (mean 32,451 and 34,991 respectively). Of the 18 mothers with a previous AVB child who followed the 400mg hydroxychloroquine PATCH protocol, 1 developed AVB in accord with the results of Step 1 in that study. Conclusion These data support that APOs in this clinically diverse group of mothers are not influenced by anti-Ro titer or specificity, but rather SLE diagnosis. All conduction defects were initially identified by FHRM and in mothers with high titer anti-Ro60 and 52. Hydroxychloroquine continues to show efficacy in reducing the AVB recurrence rate with rapid intervention of emergent block being promising

Objectives We previously reported in a single centre prevalent SLE cohort that antibodies against the cytokinesis-associated protein M-Phase Phosphoprotein 1 (anti-MPP-1) were associated with SLE-related cranial neuropathy (CN), a rare manifestation of neuropsychiatric SLE (NPSLE). The purpose of this study was to assess whether anti-MPP-1 is a biomarker for CN or other NPSLE manifestations using an international SLE inception cohort. Methods SLE patients fulfilling the updated 1997 ACR classification criteria for SLE were included. Anti-MPP-1 antibody testing was performed on baseline samples (within 15 months of diagnosis) or first annual assessment using an addressable laser bead immunoassay (ALBIA) with purified recombinant human protein with results expressed as median florescence units (MFU). Based on healthy controls, a dilution of >=1:500 MFU was considered positive. NPSLE manifestations occurring over the first 5 years of follow up were documented annually based on ACR case definitions using published NPSLE attribution rules1). The frequency of anti-MPP-1 positivity between patients with versus without each of the 19 NPSLE manifestations was compared using univariate logistic regression. For any NPSLE manifestations where anti-MPP-1 positivity differed between patients with versus without the manifestation, baseline demographic and clinical characteristics were compared using t-tests and twosample tests of proportions. For NPSLE manifestations associated with anti-MPP-1 positivity in the univariate analysis, multivariable logistic regression analysis using penalized maximum likelihood estimates was then performed to assess the relationship between anti-MPP-1 and the NPSLE manifestation, adjusting for age at anti-MPP-1 testing, female, White race/ethnicity, and significantly different baseline clinical characteristics. Results Seven hundred and ninety-five SLE patients were assessed; 29.8% were anti-MPP-1 positive, 88.7% female, and 52.1% White. The frequency of anti-MPP-1 positivity differed only for those with versus without CN (70.0% vs. 29.3%; odds ratio [OR] 5.16, 95%CI 1.44, 18.54) (table 1). Compared to patients without CN (n=785), patients with CN (n=10) were more likely to fulfill the ACR hematologic (difference: 23.9%, 95%CI 5.0%, 42.8%) and antinuclear antibody criteria (difference: 4.3%, 95%CI 2.9%, 5.8%) (table 2). (Table Presanted)In the multivariate analysis, anti-MPP-1 remained associated with CN (OR 5.24, 95%CI 1.44, 19.09) after adjusting for age at anti-MPP-1 testing, female, White race/ethnicity, hematologic disorder, and antinuclear antibody (table 3). Conclusion Anti-MPP-1 is a potential biomarker for CN. Although anti-MPP-1 is differentially expressed in a variety of neurological cells and tissues, the link to a pathogenic role requires further study

OBJECTIVE:In systemic lupus erythematosus (SLE), disease activity and glucocorticoid (GC) exposure are known to contribute to irreversible organ damage. We aimed to examine the association between GC exposure and organ damage occurrence. METHODS:We conducted a literature search (PubMed (Medline), Embase and Cochrane January 1966-October 2021). We identified original longitudinal observational studies reporting GC exposure as the proportion of users and/or GC use with dose information as well as the occurrence of new major organ damage as defined in the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. Meta-regression analyses were performed. Reviews, case-reports and studies with <5 years of follow-up, <50 patients, different outcomes and special populations were excluded. RESULTS:We selected 49 articles including 16 224 patients, 14 755 (90.9%) female with a mean age and disease duration of 35.1 years and of 37.1 months. The mean follow-up time was 104.9 months. For individual damage items, the average daily GC dose was associated with the occurrence of overall cardiovascular events and with osteoporosis with fractures. A higher average cumulative dose adjusted (or not)/number of follow-up years and a higher proportion of patients on GC were associated with the occurrence of osteonecrosis. CONCLUSIONS:We confirm associations of GC use with three specific damage items. In treating patients with SLE, our aim should be to maximise the efficacy of GC and to minimise their harms.

High levels of autoimmune antibodies are observed in COVID-19 patients but their specific contribution to disease severity and clinical manifestations remains poorly understood. We performed a retrospective study of 115 COVID-19 hospitalized patients with different degrees of severity to analyze the generation of autoimmune antibodies to common antigens: a lysate of erythrocytes, the lipid phosphatidylserine (PS) and DNA. High levels of IgG autoantibodies against erythrocyte lysates were observed in a large percentage (up to 36%) of patients. Anti-DNA and anti-PS antibodies determined upon hospital admission correlated strongly with later development of severe disease, showing a positive predictive value of 85.7% and 92.8%, respectively. Patients with positive values for at least one of the two autoantibodies accounted for 24% of total severe cases. Statistical analysis identified strong correlations between anti-DNA antibodies and markers of cell injury, coagulation, neutrophil levels and erythrocyte size. Anti-DNA and anti-PS autoantibodies may play an important role in the pathogenesis of COVID-19 and could be developed as predictive biomarkers for disease severity and specific clinical manifestations.