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©2014 Turkish League Against Rheumatism. All rights reserved. Neuropsychiatric systemic lupus erythematosus (NPSLE) is a specific disease, and its clinical manifestations involves the central and the peripheral nervous system range from life-threatening manifestations to subtle abnormalities.1 Neuropsychiatric systemic lupus erythematosus may be the first indication of systemic lupus erythematosus (SLE) in patients without disease activity in other organ systems.2 It represents a major cause of morbidity and mortality in SLE patients.3-8 Therefore, recognition, early diagnosis and treatment of NPSLE are of great significance.

Lupus nephritis (LN) is a common and important manifestation of systemic lupus erythematosus (SLE). Evidence suggests higher rates of lupus renal involvement in Asian populations, and maybe more severe nephritis, compared with other racial or ethnic groups. The management of LN has evolved considerably over the past three decades, based on observations from clinical studies that investigated different immunosuppressive agents including corticosteroids, cyclophosphamide, azathioprine, mycophenolic acid, calcineurin inhibitors and novel biologic therapies. This is accompanied by improvements in both the short-term treatment response rate and long-term renal function preservation. Treatment guidelines for LN have recently been issued by rheumatology and nephrology communities in U.S.A. and Europe. In view of the racial difference in disease manifestation and response to therapy, and the substantial disease burden in Asia, a panel of 15 nephrologists and rheumatologists from different Asian regions with extensive experience in lupus nephritis - the Steering Group for the Asian Lupus Nephritis Network (ALNN) - met and discussed the management of lupus nephritis in Asian patients. The group has also reviewed and deliberated on the recently published recommendations from other parts of the world. This manuscript summarizes the discussions by the group and presents consensus views on the clinical management and treatment of adult Asian patients with LN, taking into account both the available evidence and expert opinion in areas where evidence remains to be sought.

To investigate the expressions of IL-18 and its binding protein (IL-18BP) in peripheral blood leukocytes and kidney tissues in patients with lupus nephritis (LN). SYBR-green-dye-I-based real-time quantitative PCR method was used to compare the gene expression levels (indicated as 2(-DeltaDeltaCT) value) of IL-18 and IL-18BP in the peripheral blood leucocytes of LN patients and those in normal controls. Serum levels of IL-18 were measured with ELISA method. Immunohistochemical evaluation of IL-18 and Il-18BP expression in LN was carried out on frozen renal biopsy sections. IL-18BP mRNA expression levels in LN patients were significantly lower than those of normal controls (P0.01). Serum levels of IL-18 in LN patients were significantly higher than those of normal controls (P0.01). It is noticeable that serum IL-18 levels in the patients treated with glucocorticoids and cyclophosphamide was lower than those treated with glucocorticoids only or glucocorticoids and other immune inhibitors such as chloroquine/hydroxychloroquine and azathioprine. Expression of IL-18 in renal glomeruli was higher in type-IV and type-V LN patients than in type-III LN patients. LN patients present lower IL-18BP mRNA expression and higher serum levels of IL-18 than those in normal controls. The preponderance of IL-18 in glomeruli from LN patients indicates IL-18 may be concerned with the local inflammation. Up-regulation of IL-18BP expression and control of the biological activity of IL-18 may be a therapeutic approach to LN patients.

The objective of this study is to evaluate the efficacy and safety of rhTNFR:Fc: a recombinant tumor necrosis factor receptor:Fc fusion protein compared with methotrexate (MTX) in patients with rheumatoid arthritis in China. We treated 238 patients with active rheumatoid arthritis with either twice weekly subcutaneous injection rhTNFR:Fc (25 mg) or weekly oral MTX (mean 15 mg per week) for 24 weeks (registration number: 2003L01264). Clinical responses were defined as the percent improvement in disease activity according to the criteria of the American College of Rheumatology (ACR-N). As compared with MTX-treated patients, more patients who received rhTNFR:Fc had ACR20 improvement in disease activity during the first 2 weeks (P < 0.05). Similarly, more patients treated with rhTNFR:Fc having ACR20, ACR50, ACR70 improvement in disease activity during 8 weeks (P < 0.05). At the end of 12-week treatment, patients received rhTNFR:Fc also had significant improvement at ACR20 (P < 0.05). Compared with oral MTX, patients received rhTNFR:Fc also had significant improvement at ACR70 at the end of 24 weeks treatment (P < 0.05). In conclusion, compared with oral MTX subcutaneous injection, rhTNFR:Fc acted more rapidly to release symptoms and signs of active RA in Chinese patients, and well tolerated in patients with rheumatoid arthritis in China.

Objective To explore whether there are extrinsic factors that impair the suppressive function of CD4+,CD25+ regulatory T cells in patients with untreated active systemic lupus erythematosus (SLE). Methods We studied 15 patients with untreated active SLE, 10 patients with SLE in remission, and 15 healthy control subjects. Percentages of CD4+,CD25+,FoxP3+ Treg cells and levels of forkhead box P3 (FoxP3) protein were analyzed by flow cytometry. Expression of messenger RNA (mRNA) for FoxP3 in purified Treg cell populations was assessed by real-time polymerase chain reaction analysis. Experiments examining Treg cell function in SLE were designed to distinguish primary from secondary T cell dysfunction. Levels of interferon-α (IFNα) in supernatants from the function assays were determined with an IFN-stimulated response element–luciferase reporter assay. Results The percentage of CD4+,CD25+, FoxP3+ cells in peripheral blood was significantly increased in SLE patients as compared with controls (mean ± SEM 9.11 ± 0.73% versus 4.78 ± 0.43%; P < 0.0001). We found no difference in FoxP3 expression at either the mRNA or protein level in any CD4+,CD25+ T cell subset from SLE patients as compared with controls. Antigen-presenting cells (APCs) from SLE patients were responsible for decreased Treg cell activity and could also render dysfunctional Treg cells from healthy control subjects. CD4+,CD25+ Treg cells from SLE patients exhibited normal suppressive activity when cultured with APCs from healthy controls. A partial Treg cell blockade effect was induced by the high levels of IFNα derived from SLE patient APCs. Conclusion We suggest that blockade of Treg cell–mediated suppression by IFNα-producing APCs in SLE patients may contribute to a pathogenic loss of peripheral tolerance in this disease.

Aim: To examine the effects of a novel immunosuppressant, FTY720, on BXSB lupus-prone mice, and to investigate its immune regulatory pathway by using a cDNA microarray. Methods: Male BXSB mice received oral administration of 10 mg/kg FTY720 twice a week from age 9 weeks. Levels of antinuclear antibodies in serum and histopathology of the kidney were evaluated. The gene expression profile of splenic lymphocyte was analysed by cDNA microarray. Results: FTY720 suppressed the production of antinuclear antibodies (P

1,25-Dihydroxyvitamin D3 (1,25(OH)2D3) can modulate immune responses, but whether it directly affects B cell function is unknown. Patients with systemic lupus erythematosus, especially those with antinuclear Abs and increased disease activity, had decreased 1,25(OH)2D3 levels, suggesting that vitamin D might play a role in regulating autoantibody production. To address this, we examined the effects of 1,25(OH)2D3 on B cell responses and found that it inhibited the ongoing proliferation of activated B cells and induced their apoptosis, whereas initial cell division was unimpeded. The generation of plasma cells and postswitch memory B cells was significantly inhibited by 1,25(OH)2D3, although the up-regulation of genetic programs involved in B cell differentiation was only modestly affected. B cells expressed mRNAs for proteins involved in vitamin D activity, including 1α-hydroxylase, 24-hydroxylase, and the vitamin D receptor, each of which was regulated by 1,25(OH)2D3 and/or activation. Importantly, 1,25(OH)2D3 up-regulated the expression of p27, but not of p18 and p21, which may be important in regulating the proliferation of activated B cells and their subsequent differentiation. These results indicate that 1,25(OH)2D3 may play an important role in the maintenance of B cell homeostasis and that the correction of vitamin D deficiency may be useful in the treatment of B cell-mediated autoimmune disorders.

The aim of this study was to investigate the regulation of interleukin (IL)-12 and IL-23 expression in the autoimmune disease, systemic lupus erythematosus (SLE). mRNA from healthy subjects and SLE patients were prepared from peripheral blood mononuclear cells (PBMC) and quantitative real-time polymerase chain reaction was performed to quantify IL-23 specific subunit P19, IL-12 specific subunit P35, and their common subunit P40. IL-12 specific subunit P35 mRNA expression in untreated and treated SLE patients was significantly lower than healthy controls (P = 0.015 and 0.000, respectively). Compared with untreated SLE patients, treatment of SLE patients with corticosteroids or corticosteroids plus another immunosuppressor significantly suppressed P40 and P19 expression (P = 0.002 and 0.015, respectively). The mRNA levels of p19, p40, and p35 in active SLE patients (SLEDAT > 10) were significantly higher compared with those in the inactive SLE patients (SLEDAI ≤ 10) (P = 0.000, 0.000, and 0.017, respectively). These results suggest that deficiency of IL-12 and possibly upregulation of IL-23 may contribute to SLE pathogenesis and both cytokines may be therapeutic targets in SLE.

Despite growing evidence that large intergenic noncoding RNAs (lincRNAs) can regulate gene expression and widely take part in normal physiological and disease conditions, our knowledge of systemic lupus erythematosus (SLE)-related lincRNAs remains limited. The aim of this study was to detect the levels of four lincRNAs (ENST00000500949: linc0949, ENST00000500597: linc0597, ENST00000501992: linc1992, and ENST00000523995: linc3995) involved in innate immunity in the peripheral blood mononuclear cells (PBMCs) of patients with SLE and correlate these lincRNA levels with disease activity, organ damage, clinical features and medical therapies. PBMCs were obtained from 102 patients with SLE, 54 patients with rheumatoid arthritis (RA) and 76 healthy donors. lincRNA expression levels were measured by real-time quantitative polymerase chain reaction. Disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores, and organ damage was evaluated with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. linc0949 and linc0597 were significantly decreased in patients with SLE compared with patients with RA and healthy control subjects. linc0949 was correlated with SLEDAI-2K score (r = −0.329, P = 0.0007), as well as with complement component C3 level (r = 0.348, P = 0.0003). The level of linc0949 was also reduced in patients with SLE who had the presence of cumulative organ damage. In addition, decreasing expression of linc0949 was associated with lupus nephritis. linc0949 expression significantly increased after treatment, whereas neither disease activity nor organ damage correlated with linc0597 expression. Our results provide novel empirical evidence that linc0949 could be a potential biomarker for diagnosis, disease activity and therapeutic response in SLE.

Aim: To investigate the long-term prognosis of systemic lupus erythematosus (SLE) and its risk factors. Methods: An 18-year (1980–1998) clustering follow-up study of 50 patients with SLE was performed. Results: The overall survival rate at 1, 5, 10, 15 and 18 years after the onset of illness was 98%, 98%, 84%, 76%, and 70%, respectively. The two major causes of death were infection and renal failure. Cox proportional hazard regression analysis showed that the presence of ≥ 7 of the American College of Rheumatology criteria for SLE at diagnosis and vasculitis were associated with worse survival. Thirteen (26%) patients were in remission with complete discontinuation of drugs, with the mean remission duration being 12 years (range: 2–17 years). Conclusion: It is possible for patients with SLE to get long-term remission through timely and effective treatment. Prevention of infection and renal failure and reducing dosage of corticosteroids by combined treatment with immunosuppressive drugs may enhance prognosis and survival in SLE.

Objective: To evaluate the differences in the renal survival of lupus nephritis (LN) diagnosed either during 1985–1994 or 1995–2004 and to analyse the possible causes. Methods: Fifty-two patients with biopsy-confirmed LN were followed up between 1985 and 1994 and 130 patients were followed up between 1995 and 2004. Renal survival was studied with Kaplan-Meier analysis and the log rank test. Status at diagnosis and treatment schedules were also analysed. Results: Renal survival was significantly better in the patients who were diagnosed between 1995 and 2004 (P = 0.0233). The mean time from initiation until first diagnosis of SLE, from the initiation of SLE until referral to our centre, and from first detection of proteinuria until kidney biopsy was significantly shorter in the later decade (P

2'5'-Oligoadenylate synthetase (OAS) was shown to be related to systemic lupus erythematosus (SLE) 20 years ago, and was rediscovered to be involved in type I interferon pathway in SLE by several microarray gene expression studies recently. The goal of this study was to investigate OAS isoform expressions in lupus patients, to evaluate whether they could become biomarkers to differentiate between disease flare and infection. Fifty-four SLE patients presented with fever or systemic inflammatory syndrome, or both, were enrolled. Gene expressions of OAS1, OAS2, and OASL were studied by using real time PCR in active SLE (SLEDAI >or=9, n=29) and in those complicated with infections (n=25). The latter group was composed of 19 patients with invasive bacterial infections, and six patients with viral infections. C reactive protein (CRP) and other clinical parameters were also measured. Twenty-nine healthy individuals made up a normal control group. The mRNA expressions of OAS1, OAS2, and OASL were higher in patients with lupus flares than those with infections (p

Lupus nephritis (LN) is a common and important manifestation of systemic lupus erythematosus (SLE). Evidence suggests higher rates of lupus renal involvement in Asian populations, and maybe more severe nephritis, compared with other racial or ethnic groups. The management of LN has evolved considerably over the past three decades, based on observations from clinical studies that investigated different immunosuppressive agents including corticosteroids, cyclophosphamide, azathioprine, mycophenolic acid, calcineurin inhibitors and novel biologic therapies. This is accompanied by improvements in both the short-term treatment response rate and long-term renal function preservation. Treatment guidelines for LN have recently been issued by rheumatology and nephrology communities in U.S.A. and Europe. In view of the racial difference in disease manifestation and response to therapy, and the substantial disease burden in Asia, a panel of 15 nephrologists and rheumatologists from different Asian regions with extensive experience in lupus nephritis - the Steering Group for the Asian Lupus Nephritis Network (ALNN) - met and discussed the management of lupus nephritis in Asian patients. The group has also reviewed and deliberated on the recently published recommendations from other parts of the world. This manuscript summarizes the discussions by the group and presents consensus views on the clinical management and treatment of adult Asian patients with LN, taking into account both the available evidence and expert opinion in areas where evidence remains to be sought.

The purpose of this study was to analyze the association between renal histopathological features and chest computed tomography (CT) findings in lupus nephritis (LN) patients. We retrospectively reviewed the medical records and chest thin-section CT findings of 152 patients with an established diagnosis of LN based on renal biopsy and 93 systemic lupus erythematosus (SLE) patients without LN between April 2009 and March 2012. The 64-detector row CT images were retrospectively evaluated by an experienced thoracic radiologist without knowledge of the patients’ clinical information except that all patients had SLE. Lupus nephritis patients have a significantly higher incidence of lung/plural disease than those without LN (61.8 versus 44.0 %, p

Acute promyelocytic leukemia (APL) is a unique subtype of acute myeloid leukemia (AML). The prognosis of APL is changing, from the worst among AML as it used to be, to currently the best. The application of all-trans-retinoic acid (ATRA) to the induction therapy of APL decreases the mortality of newly diagnosed patients, thereby significantly improving the response rate. Therefore, ATRA combined with anthracycline-based chemotherapy has been widely accepted and used as a classic treatment. It has been demonstrated that high doses of cytarabine have a good effect on the prevention of relapse for high-risk patients. However, as the indications of arsenic trioxide (ATO) for APL are being extended from the original relapse treatment to the first-line treatment of de novo APL, we find that the regimen of ATRA, combined with ATO, seems to be a new treatment option because of their targeting mechanisms, milder toxicities and improvements of long-term outcomes; this combination may become a potentially curable treatment modality for APL. We discuss the therapeutic strategies for APL, particularly the novel approaches to newly diagnosed patients and the handling of side effects of treatment and relapse treatment, so as to ensure each newly diagnosed patient of APL the most timely and best treatment.

The molecular characterization of cytogenetic abnormalities has not only provided insights into the mechanisms of leukemogenesis but also led to the establishment of new treatment strategies targeting these abnormalities and thereby further improve the prognosis of patients. We analyzed the prognosis of 1091 Chinese patients with newly diagnosed acute lymphoblastic leukemia (ALL) and explored the prognostic impacts of a large number of cytogenetic/molecular abnormalities. It was demonstrated that, in both B- and T-ALL settings, the prognosis was negatively correlated to the age as reported to date. For childhood T-ALL patients, it was also documented that the HOX11 expression represented a favorable prognostic factor as it was in adult ones. We identified CRLF2 overexpression as an intermediate-risk marker and Ik6 variant of IKZF1 gene as a high-risk one when stratifying pediatric B-ALL cases according to cytogenetic/molecular risks. We also found that Ik6 variant and CRLF2 overexpression had an important role in dictating the prognosis of Ph-negative patients, which may be useful markers in guiding the treatment of ALL in the future, with tyrosine kinase inhibitors on the other hand reversing the fate of Ph-positive ALL patients.

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease that predominantly affects women. Previous findings that duplicated Toll-like receptor 7 (Tlr7) promotes lupus-like disease in male BXSB mice prompted us to evaluate TLR7 in human SLE. By using a candidate gene approach, we identified and replicated association of a TLR7 3′UTR SNP, rs3853839 (G/C), with SLE in 9,274 Eastern Asians (P combined = 6.5 × 10 -10), with a stronger effect in male than female subjects [odds ratio, male vs. female = 2.33 (95% CI = 1.64-3.30) vs. 1.24 (95% CI = 1.14-1.34); P = 4.1 × 10 -4]. G-allele carriers had increased TLR7 transcripts and more pronounced IFN signature than C-allele carriers; heterozygotes had 2.7-fold higher transcripts of G-allele than C-allele. These data established a functional polymorphism in type I IFN pathway gene TLR7 predisposing to SLE, especially in Chinese and Japanese male subjects., link_to_OA_fulltext

To evaluate the prevalence of atherosclerosis in Chinese premenopausal women with systemic lupus erythematosus (SLE) and study possible associations between traditional and nontraditional risk factors with premature atherosclerosis.We evaluated 111 premenopausal women with SLE and 40 healthy controls without clinical cardiovascular disease. B-mode ultrasound was used to measure carotid plaque and intima-media wall thickness (IMT). The frequency of risk factors for atherosclerosis in patients and controls was compared, and the relationship between the patients' clinical characteristics and carotid plaque was examined. At the same time, we used B-mode ultrasound to measure flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD) in the brachial artery to assess for difference in endothelial function between SLE patients and controls.Carotid plaque was more frequent in patients with lupus (16 of 111 patients) than in control subjects (0 of 40 subjects) (P = 0.007). The mean IMT was significantly higher in patients than in controls. Compared with controls, SLE patients were found to have a significantly higher prevalence of hypertension (P = 0.001), hypercholesterolemia (P = 0.022), and hypertriglyceridemia (P0.001). As compared with patients without plaque, patients with plaque were significantly older, had longer disease duration, higher body mass index, raised blood pressure, shorter prothrombin time, raised C-reactive protein, higher Systemic Lupus International Collaborating Clinics damage index score, higher cumulative prednisone dose, used less hydroxychloroquine, had higher mean IMT, lower FMD, and NMD. In logistic regression analysis, older age, higher body mass index, and higher Systemic Lupus International Collaborating Clinics damage index score were independently related to the presence of plaque. Using multiple regression analysis, we found SLE (P = 0.003) to be significantly associated with impaired FMD.In our Chinese SLE group, patients presented a higher prevalence of carotid atherosclerosis plaque than healthy controls. SLE patients have significant endothelial dysfunction. We found that risk factors identified in other SLE populations were associated with atherosclerosis in our Chinese group.

The aim of the study was to investigate the characteristics of adult clinically amyopathic dermatomyositis (CADM) with rapid progressive interstitial lung disease (ILD). Hospitalized patients with dermatomyositis (DM) and polymyositis (PM) between 1998 and 2005 in the Shanghai Renji Hospital were retrospectively studied. One hundred and forty-five patients were classified into CADM, classic DM or PM according to the modified Sontheimer's definition or Bohan-Peter's classification criteria. They were further stratified based on the presence or absence of clinical ILD. The Kaplan-Meier survival analysis and COX regression were performed. The predictive factors for ILD and other clinical properties of CADM-ILD were explored. The presence of clinical ILD was a significant risk factor for the poor outcome of DM/PM (OR = 4.237, CI 95%: 1.239-14.49, p = 0.021). Other risk factors are the presence of rashes and elevated urea nitrogen. Patients with DM/PM complicated by ILD had different clinical courses. Patients with CADM-ILD showed a rapidly progressive pattern with 6-month survival rate of 40.8%. The DM-ILD manifested a progressive pattern with a 5-year survival rate of 54%, while PM-ILD was chronic with 5- and 10-year survival rate of 72.4% and 60.3%, respectively. Better preserved muscle strength, elevated erythrocyte sedimentation rate, and hypoalbuminemia may herald ILD in DM/PM. Patients with CADM-ILD who later died had lower PO(2), higher lactate dehydrogenase, and prominent arthritis/arthralgia compared with those who survived. The presence of antinuclear antibody seems to be protective. Rapid progressive CADM-ILD is refractory to conventional treatment. ILD is a common complication in over 40% of our hospitalized DM/PM cohort and is also a prominent prognostic indicator. CADM is a special phenotype of DM/PM. CADM-ILD, which is usually rapidly progressive and fatal, requires further investigation.

The purpose of this study is to describe the etiology, characteristics and outcomes of central nervous system (CNS) infections in patients with systemic lupus erythematosus (SLE), while also identifying prognostic and risk factors. Thirty-eight SLE patients with CNS infections were identified from review of all charts of patients with SLE hospitalized from January 1995 to June 2005. These patients were divided into 3 groups, i.e., Mycobacterium tuberculosis (TB), non-TB bacterial and fungal infection groups. Of the 38 SLE cases with CNS infections, TB was identified in 19 patients, Listeria monocytogenes in 3 patients, Klebsiella pneumoniae in 1 patient, Staphylococcus aureus in 1 patient, Gram's stain positive bacteria in 1 patient, Cryptococcus neoformans in 12 patients, and Aspergillus fumigatus in 1 patient. The rate of unfavorable outcome in patients with fungal infection was lower than in patients with TB (P=0.028) and non-TB bacterial CNS infections (P=0.046). SLE patients with TB or fungal CNS infections had a more insidious or atypical clinical presentation. Compared to SLE patients without CNS infections, those with CNS infections were more likely to have low serum albumin levels (P=0.048) and have been receiving higher doses of prednisolone at the onset of CNS infection (P=0.015) or higher mean doses of prednisolone within the previous year (P=0.039). In conclusion, low levels of serum albumin and higher doses of received prednisolone are important risk factors for the development of CNS infections in SLE patients.