key: cord-006828-i88on326
authors: nan
title: Abstracts DGRh-Kongress 2013
date: 2013-09-15
journal: Z Rheumatol
DOI: 10.1007/s00393-013-1255-1
sha: 
doc_id: 6828
cord_uid: i88on326

nan

im Namen der DGRh, der DGORh und der GKJR begrüßen wir Sie ganz herzlich zu unserem diesjährigen Kongress 

Visualisierung therapeutischer Effekte von Vasodilatantien beim sekundären Raynaud-Syndrom mittels fluoreszenzoptischer Bildgebung DI.14 Stellenwert der Gelenksonographie bezüglich Diagnose, Behandlung und Therapiekontrolle der Bursitis intermetatarsalis -einer häufig übersehenen Differenzialdiagnose. Fünf Fallbeispiele Wegen der deutlich eingeschränkten Nierenfunktion konnten therapeutisch keine NSAR angewandt werden. Wir haben mit 2×0,5 mg Colchicin täglich behandelt. Die anfänglich schwerkranke bettlägerige Patientin konnte innerhalb von 48h mobilisiert werden. Um eine abschließende Sicherung der Diagnose einer uratinduzierten Sakroiliitis erreichen zu können ist die Patientin mit einem Dual-Energy-CT (DECT) untersucht worden. Ergebnisse. Mit dieser Methode konnten Gichttophi in beiden Sakroiliakalgelenken dargestellt werden, ebenso an beiden MTP1-Gelenken. Schlussfolgerung. Aktuell liegen bisher noch keine weiteren Berichte vor, dass diese Methode auch für die Diagnostik einer Gicht im Bereich der Sakroiliakalregion zuverlässige Ergebnisse liefern kann. Zudem zeigt dieser Krankheitsverlauf, dass sich die Gicht durchaus primär im Bereich des Achsenskeletts manifestieren kann und nicht in erster Linie an den peripheren Gelenken zu entsprechenden Beschwerden führen muss.

A. Glimm 1 , S. Werner 1 , S. Ohrndorf 1 , C. Schwenke 2 , G. Schmittat 1 , G. Burmester 1 Einleitung. Typische pathologische Veränderung bei der rheumatoiden Arthritis (RA) ist die Synovialitis. Auch bei der Osteoarthrose (OA) lassen sich entzündliche Veränderungen der Gelenke finden. Diese können mittels fluoreszenzoptischer Bildgebung (FOI) und dem Gelenkultraschall (US) sichtbar gemacht werden. Ziel der Studie: Vergleich der FOI mit dem US bei Patienten mit RA und OA. Methoden. Es wurde bei 90 Patienten (67 RA, 23 OA) die FOI beider Hände sowie die US des Handgelenks (HG) und der Fingergelenke (MCP, PIP, DIP) der klinisch beschwerdeführenden Hand von dorsal und palmar sowohl im B-Bild (B-US) als auch mit Power-Doppler (PD-US) durchgeführt. Synovialitis und Tenosynovitis im US sowie die Intensität des Fluoreszenzsignals im Bereich der Gelenke in der FOI wurden qualitativ als auch semiquantitativ nach standardisierten Verfahren für den PrimaVistaMode (PVM) und drei verschiedene Phasen (P1-3; [1] ) bewertet. In der statistischen Analyse wurden anschließend Sensitivitäten und Spezifitäten für die FOI bei der RA und OA getrennt für Synovialitis und Tenosynovitis, dorsal und palmar jeweils für B-US und PD-US als Referenzmethode berechnet. Ergebnisse. In Abhängigkeit von der betrachteten Phase zeigen sich für die RA und OA moderate Sensitivitäten und Spezifitäten. Für die RA wurden in der Phase 2 des FOI die höchsten Sensitivitäten mit 68% für B-US und 77% für PD-US berechnet. Auch bei der OA ergaben sich die höchsten Sensitivitäten in der Phase 2 des FOI mit 77% für B-US und 89% für PD-US als Referenzmethode. Die höchsten Spezifitäten für beide Diagnosen wurden in der FOI in Phase 3 erreicht. Hierbei lag die Spezifität bei der RA für B-US bei 96% und für PD-US bei 90%. Der höchste Spezifitätswert bei der OA sowohl für B-US als PD-US war 88% (. Tab. 3 Background. PET is a nuclear imaging technique that depicts functional processes within the body with high sensitivity by detecting annihilation radiation from radioactive decay of a positron-emitting radionuclide that was labeled to a biologically active molecule (tracer) and introduced into the body. 18F-fluoride (18F) can be used for PET as a bone-seeking agent reflecting bone perfusion and remodeling. We inaugurated a pilot study with simultaneous PET/MR to examine whether addition of PET provides different and additional information in comparison to MRI in axSpA patients. Methods. Eleven axSpA patients, median age 39 y, disease duration range 0.5-10 y, mean BASDAI 5.3, were examined by PET/3-Tesla MRI 40 minutes after injection of a mean dose of 157 MBq of 18F using a integrated whole-body PET/MR scanner (Siemens Biograph mMR®). 3T-MRIs were scored blinded to patient's clinical characteristics by two readers (1 rheumatologist and 1 radiologist/nuclear medicine specialist) using the Berlin MRI score and also by recording inflammatory lesions on a vertebral edge (VE) level. In a second step PET/MRIs were read blindly by the same readers also based on the VE involvement of individual vertebral bodies. Results. The procedure was successful in all patients. The resulting mean effective radiation dose per patient was 3.76 mSv. Co-registration of PET/MRI fusion images was highly accurate, allowing a precise comparison of MRI and PET. In the direct comparison of the MRI and PET signal the two readers saw consistent signals in almost 90% of the sites studied. However, there were areas where signals differed, e.g. within existing syndesmophytes where PET signal was increased but conventional MRIs showed no signal, or the sternum area and lateral or posterior spinal elements such as facets and spinous processes.

Conclusion. The new technique of integrated PET/MRI provides similar imaging signals as conventional MRI. However, we observed differences between the two modalities in areas with less inflammatory activity but where bone metabolism seemed to be active or in areas with blurred resolution on conventional MRI. The possibility that PET detects osteoblastic activity in areas where no inflammatory signal is detected with MRI seems to be of interest. Einleitung. Sensitiven bildgebenden Verfahren wie der hochauflösenden Arthrosonographie kommen bei der Detektion initial entzündlicher Veränderungen im Rahmen der Frühdiagnostik der Psoriasisarthritis (PsA) eine große Bedeutung zu. Die vorliegende prospektive Studie untersucht die diagnostische und prognostische Wertigkeit der sonographischen Befunde im Vergleich zur klinischen Untersuchung auf Ebene einzelner Gelenke bei früher Psoriasis-Arthritis (PsA). Methoden. Rekrutierung von 50 Patienten mit therapienaiver früher PsA. Sonographie von 56 Gelenken mit semiquantitativer Graduierung (Grad 0-3) von B-Bild (GSUS) und Power-Doppler-Aktivität (PDUS; Baseline, 12 Monate). Klinische Parameter: Anzahl druckschmerzhafter und geschwollener Gelenke (TJC68, SJC66), visuelle Analogskala, DAS28-CRP, Health Assessment Questionnaire HAQ. Für jede Followup-Visite erfolgte eine Kategorisierung des klinischen Ansprechens nach EULAR-Response-Kriterien und der für die PsA validierten Minimal-disease-activity(MDA)-Kriterien (Coates et al.). Ergebnisse. Baseline 50 Patienten, nach 12 Monate 19 Patienten, Erkrankungsdauer (12±17,6 Monate). Patienten ohne Therapie (1), mit NSAR (1), Steroid i.a. (1) , DMARDs (10), Biologicals (6). Bei Diagnosestellung zeigte sich eine signifikante Korrelation zwischen dem US Synovitis Score und folgenden klinischen Parametern: TJC68 (r=0,52), SCJ66 (r=0,63), DAS28-CRP (r=0,34). Nach 12 Monaten zeigte sich eine gute Korrelation zwischen der relativen Veränderung des US Synovitis Scores und der relativen Veränderung folgender klinischer Parameter: TJC68 (r=0,72), HAQ (r=0,41), PASI (r=0,42), DAS28-CRP (r=0,33). Zu Baseline waren 407 von 2730 Gelenken sonographisch auffällig, davon zeigten 239 kein klinisches Korrelat (subklinisch). Nach 12 Monaten zeigten 29% der initial subklinischen Gelenke einen unveränderten Befund, 61% waren sonographisch nicht mehr auffällig und 10% wurden klinisch manifest. Bei den klinischen Respondern war der Rückgang deutlicher ausgeprägt. Schlussfolgerung. Der Ultraschall-Synovitis-Score korreliert mit klinischen Aktivitätsparametern sowohl zum Zeitpunkt der Diagnosestellung als auch im Krankheitsverlauf unter immunsuppressiver Therapie. Die subklinischen Veränderungen bilden sich unter immunsuppressiver Therapie zu einem großen Teil zurück, deutlicher bei klinischen Respondern. Ein geringer Anteil der initial subklinischen Gelenke wird im Verlauf klinisch manifest, in höherem Maße bei klinischen Non-Respondern.

T. Diekhoff 1 , K. Hermann 1 1 Charité -Universitätsmedizin Berlin, Radiologie, Berlin Einleitung. Die Gicht ist mit einer Prävalenz von 0,4-0,6% insbesondere in den Industrieländern eine häufige Erkrankungen, die mit Gelenkschmerzen einhergeht. Bei typischer Symptomatik und Laborkonstellation ist die Diagnose der Arthritis urica oft einfach zu stellen, ein atypisches Beschwerdebild kann jedoch gelegentlich die Abgrenzung zu anderen Erkrankungen erschweren. Besonders die Kalziumpyrophosphat-Kristallarthropathie (CPPD oder Pseudogicht), die selbst mit sehr variabler Symptomatik auftreten kann, ist eine relevante Differenzialdiagnose, besonders bei älteren Patienten. Methoden. Mit der Dual-Energy-Computertomographie (DE-CT) steht ein modernes, innovatives Verfahren zur Verfügung, das eine Detektion von harnsäurehaltigen Weichteilverkalkungen ermöglicht und darüber hinaus eine sichere Abgrenzung zu kalziumhaltigen Verkalkungen gewährleisten kann. Das Prinzip der DE-CT ist relativ simpel und seit Längerem bekannt: Die Messung des Untersuchungsvolumens mit zwei unterschiedlichen Röhrenspannungen macht es möglich, einen Schwächungskoeffizienten zu errechnen, der spezifisch für das untersuchte Material ist. Allerdings ermöglichten erst moderne CTs mit zwei Röntgenröhren die klinische Anwendung. In jüngster Zeit werden jedoch Anstrengungen unternommen, die DE-CT auch für Ein-Röhren-Systeme verfügbar zu machen. Ergebnisse. Mit der DE-CT können Gichttophi sicher vom Knochen aber auch von anderen Verkalkungen getrennt und zum Beispiel farblich kodiert dargestellt werden. Im Gegensatz zum konventionellen Röntgenbild verspricht die DE-CT jedoch nicht nur eine höhere Sensitivität für tophöse Veränderungen, sondern als Schnittbildverfahren auch eine bessere Abgrenzung und Einordnung von anderen morphologischen Veränderungen wie zum Beispiel von Erosionen. Schlussfolgerung. Dieser Vortrag fasst die Vor-und Nachteile der DE-CT in der Detektion und Abgrenzung von Weichteilverkalkungen bei Kristallarthropathien zusammen und gibt darüber hinaus einen Ausblick auf zukünftige Entwicklungen in diesem Gebiet. Background. Anionic glycosaminoglycans interact with a variety of soluble and membrane bound molecules. Chondroitin sulfate was shown to have anti-inflammatory properties but its role in arthritis is controversial. Methods. We have analyzed the effect of chondroitin sulfate on collagen induced arthritis starting treatment before and after induction of arthritis and in mice with established arthritis. Results. In all of these settings chondroitin sulfate significantly reduced the severity of arthritis. It prevented joint destruction, diminished the inflammatory infiltrate and reduced proinflammatory cytokines in joints and plasma. Splenocytes restimulated with collagen produced less IL-2 and more IL-10 and IL-13. The beneficial effects of chondroitin sulfate were transient and closely correlated to the suppression of the collagen-specific humoral immune response. Chondroitin sulfate, but not other glycosaminoglycans induced a direct BTK and Syk-dependent proliferation of B cells and markedly expanded the number of plasma cells in the spleen. In immunized mice chondroitin sulfate reduced the number of antigen specific plasma cells in the bone marrow and was able to suppress established humoral immune responses. Conclusion. Displacement of disease inducing plasma cells from the bone marrow might contribute to the beneficial effects of chondroitin sulfate and could be an attractive strategy to suppress antibody mediated autoimmunity. Background. In rheumatoid arthritis a functional deterioration of the HPA-axis in form of inadequately low secretion of glucocorticoids in relation to severity of inflammation can be detected. The reasons for this phenomenon are not known. The purpose of this study was to find possible reasons responsible for adrenal insufficiency during arthritis. Methods. DA rats were immunized with type II collagen in incomplete Freund adjuvant to induce arthritis. Plasma corticosterone was evaluated by RIA and plasma ACTH by ELISA. Adrenal cholesterol was quan-titatively studied by Sudan-III staining and scavenger receptor class BI (SR-BI, the HDL receptor) by immunohistochemistry. Fluorescent NBD-cholesterol uptake kinetics were analysed by flow cytometry. Ultrastructural morphology of adrenocortical mitochondria and lipid droplets was studied by electron microscopy. Results. Initially increased corticosterone and ACTH levels were reduced to baseline levels in the later phase of the disease. Serum levels of corticosterone relative to IL-1β were markedly lower in arthritic than control animals (inadequacy). Cholesterol storage in adrenocortical cells and expression of SR-BI did not differ between immunized and control rats. However, number of impaired mitochondria largely increased during the course of arthritis (maximum on day 55), and this was paralleled by reduced numbers of activated cholesterol droplets (inhomogenous droplets relevant for generation of glucocorticoids). In addition, number of normal mitochondria positively correlated with serum corticosterone levels.

Conclusion. This first study on adrenal reasons for inadequate glucocorticoid secretion in arthritis demonstrated impaired mitochondria and altered cholesterol breakdown paralleled by low corticosterone levels in relation to ongoing inflammation. Justus-Liebig Universität Gießen, Kerckhoff-Klinik GmbH, Rheumatologie u. klinische Immunologie, Osteologie, Physikalische Therapie, Bad Nauheim, 2 Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität, Klinik für Orthopädie und Unfallchirurgie, Frankfurt/Main, 3 Universitätsklinikum Gießen und Marburg, Orthopädische Klinik, Labor für Experimentelle Orthopädie, Gießen, 4 Universitätsklinikum Gießen und Marburg, Orthopädie und Orthopädische Chirurgie, Gießen, 5 Universitätsklinikum Erlangen, Medizinische Klinik 3 , Rheumatologie und Immunologie, Erlangen

Background. Obesity is a risk factor in osteoarthritis (OA), but there is limited information about the interaction between bone formation and adipose tissue-derived factors, the so-called adipokines. Adipokines such as adiponectin, resistin or visfatin are associated with the pathogenesis of rheumatoid arthritis (RA) and OA. Adipokines are produced also by other cell types than adipocytes in RA and OA joints, for example osteoblasts, osteoclasts or chondrocytes. However, in contrast to their joint-destructive role in RA, their role in OA joint remodeling is unclear. Therefore, adipokine expression in osteophyte development and bone forming cells as well as their effect on these cells was analyzed. Methods. Osteophytes and bone were obtained from OA patients during joint replacement surgery. Serial sections of bone tissue were stained (Masson trichrome, TRAP) and scored from grade one (no ossification, mainly connective tissue and cartilage) to five (ossified, mineralized osteophyte, <10% connective tissue, ossified remodeling zones). Immunohistochemistry against alkaline phosphatase, collagen-type II, adiponectin, resistin, and visfatin was performed. OA osteoblasts were stimulated with adiponectin and measurements of IL-6, IL-8 and MCP-1 were performed in cell culture supernatants. Results. Adiponectin, resistin and visfatin were detectable in osteoblasts and all osteophyte grades. In non-ossified osteophytes (grade 1), especially adiponectin and to a lower extend resistin and visfatin were localized in connective tissue fibroblasts. In ossified osteophytes (grade 2-5), resistin, visfatin and to a lower extend adiponectin protein expression was co-localized with osteoblasts. Resistin and visfatin were expressed by osteoclasts. Visfatin was found in chondrocytes of all osteophyte grades (50% of chondrocytes) and adiponectin was detectable in blood vessels. Osteoblast stimulation with adiponectin increased the release of the inflammatory mediators IL-6 (2.6-fold), IL-8 (4.9-fold), and MCP-1 (2.1-fold). Zeitschrift für Rheumatologie Suppl 2 · 2013 | Conclusion. The expression of adiponectin and visfatin expression in osteophyte connective tissue and cartilage suggests their involvement in early osteophyte formation. Resistin and visfatin expression by osteoblasts and osteoclasts in ossified osteophytes indicates a role in bone remodeling of osteophytes at later stages. Osteoblasts respond to adiponectin stimulation with the release of inflammatory mediators. Therefore, adipokines are most likely involved in osteophyte formation at different stages affecting different cell types of bone remodeling.

Free fatty acids contribute to promotion of arthritis K. Frommer 1 , A. Schäffler 2 , S. Rehart 3 , A. Sachs 3 , U. Müller-Ladner 1 , E. Neumann 1 1 Justus-Liebig Universität Gießen, Kerckhoff-Klinik GmbH, Rheumatologie u. klinische Immunologie, Osteologie, Physikalische Therapie, Bad Nauheim, 2 Universitätsklinikum Regensburg, Klinik und Poliklinik für Innere Medizin I, Regensburg, 3 Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität, Klinik für Orthopädie und Unfallchirurgie, Frankfurt/Main Background. Obesity is a known risk factor for several arthritic diseases and mechanical stress has been shown not to be the only factor. Due to increased levels of free fatty acids (FFA) in obese compared to nonobese individuals and due to the involvement of FFA in inflammatory cardiovascular and metabolic diseases, we hypothesized that FFA play a role in the promotion of arthritic diseases. Therefore, we therefore investigated the effect of FFA on various effector cells of arthritis. Methods. Rheumatoid (RA) synovial fibroblasts (SF), osteoarthritis (OA) SF, psoriatic arthritis (PsA) SF, human primary chondrocytes (HCH), human osteoblasts (OB), human macrovascular (HUVEC) and microvascular (HBdMEC) endothelial cells were stimulated in vitro with different FFA within their physiological range of concentrations. Immunoassays were used to quantify FFA-induced protein secretion. Sulfosuccinimidyl oleate sodium (SSO) was used to inhibit fatty acid translocase (FAT). Results. FFA dose-dependently increased the secretion of the proinflammatory factors (IL-6, IL 8 and MCP-1) as well as matrix-degrading enzymes (MMP-1 and MMP-3) in RASF (e.g. for lauric acid [100 µM] with RASF/IL-6: 9.1-fold increase; IL 8: 14.9 fold increase; MCP-1: 2.4fold increase; pro-MMP1: 5.1-fold increase; MMP-3: 83.6 fold increase). Saturated and unsaturated FFA had similar effects on RASF. However, saturated FFA induced strong secretion of IL-6 in chondrocytes, while unsaturated FFA only had a weaker effect on this cell type. At 100 µM, both saturated and unsaturated FFA significantly increased IL-6 secretion by osteoblasts to a similar degree as for SF. A high concentration of FFA (100 µM) significantly induced IL-6 secretion in HUVEC and HBdMEC, whereas a low concentration of FFA (10 µM) did not have a significant effect (p>0.05) on human endothelial cells. Blocking FFA transport into RASF by using SSO almost completely abolished the effect of palmitic acid on IL-8 secretion. Conclusion. FFA are not only metabolic substrates but can also directly contribute to articular inflammation and degradation mediated by various effector cells of arthritis. Our data also show that FFA transport into the cell is required for FFA-induced effects in SF. Background. Chronically inflamed tissues in RA are characterized by local hypoxia and enhanced angiogenesis. The Hypoxia inducible factor (HIF)-1 and (HIF)-2 serve as key regulators of adaptation to hypoxia thereby promoting both angiogenesis and metabolic adaptation of endothelial cells. To investigate the impact of HIF-1/HIF-2 on the angiogenic and metabolic transcriptome under hypoxia (1% O2) versus normoxia (18% O2) we performed a knockdown of either HIF-1α or HIF-2α in human microvascular endothelial cells (HMEC). Methods. Specific knockdown of either HIF-1α or HIF-2α was achieved using shRNA-technology. Angiogenic and metabolic transcriptome of HMECs was studied by performing an Agilent Human Whole Genome Microarray under normoxia vs hypoxia. Significantly regulated genes were allocated to angiogenic and metabolic processes using Panther database. Results. In comparison to normoxia the incubation of untransduced HMECs under hypoxia resulted in 73 regulated angiogenesis related genes and 17 regulated cellular metabolism related genes. In both HIF-1α and HIF-2α knockdown cells, hypoxia was still capable of inducing a differential gene expression pattern, but with a much less pronounced effect compared to control cells. Analysis of angiogenesis related processes (VEGF-pathway, HIF-activation, EGFR-pathway) showed that 74% of the differentially expressed genes are controlled by both HIF-1 and HIF-2. Another 14% of the regulated genes are controlled by HIF-1. The remaining 12% of regulated genes are under control of HIF-2. The differentially regulated genes involved in the cellular metabolism (ATPsynthesis, glycolysis, TCA-cycle) were found to be to 80% controlled by both HIF-1 and HIF-2. The remaining 20% are dependent on the presence of HIF-1. Conclusion. HIF-1 and HIF-2 are both key regulators of the adaptation of endothelial cells towards hypoxia with overlapping functions. However, they do differ in their capacity to regulate cellular energy metabolism and angiogenesis. This leads us to conclude that HIF-1 affects angiogenesis via indirect effects on cellular energy metabolism as indicated by the regulation of metabolic transcriptome to one fifth. HIF-2 does more influence angiogenesis directly via regulating the synthesis of proangiogenic factors (as has been previously shown).These findings provide new insights into the divergent regulation of angiogenesis in inflamed (hypoxic) tissues by HIF-1 and HIF-2 and are, therefore, considered to be of clinical relevance in RA. Background. Membrane bound glucocorticoid receptors (mGR) play a pivotal role in pathogenesis of chronic inflammatory diseases as indicated by clinical observations. Patients with SLE show high frequencies of mGR positive monocytes, sometimes even higher than found in patients with active RA. With increasing glucocorticoid dosages expression of mGR on monocytes of SLE-patients is downregulated, suggesting a negative feedback loop to control glucocorticoid action. These receptors represent an effective target for diagnosis and monitoring of different inflammatory diseases, but a feasible detection method is still necessary. Objectives. We compare two methods of high-sensitive immunofluorescence staining -the well established liposome procedure with the commercialized FASER-technique. Methods. HEK293T cells were cultured for 24 h with/without 5 µg/ml brefeldin A in a humidified incubator at 37°C. Human CD4 positive T cells and CD14 positive monocytes were isolated via magnetic-activated cell sorting and subsequently cultured in RPMI 1640. Monocytes were incubated for 24 h with/without 2 µg/ml LPS. For liposome based highsensitivity immunofluorescence staining cells were incubated with the monoclonal (digoxigenin conjugated) anti-GR antibody, followed by incubation with anti-digoxigenin/anti-Biotin matrix. Subsequently biotinylated Cy5 liposomes were added. FASER technique was performed as described by the manufacturer (Miltenyi Biotec). Dead cells were excluded by adding PI before cell acquisition, using a BD FACS Calibur flow cytometer. The acquired data were analyzed using FlowJo 7.6.1 software. Results. The human mGR, which cannot be reliably detected with conventional staining methods, is detectable with the liposome procedure as well as with the commercialized FASER-APC technique. Furthermore, the FASER-APC-procedure is more sensitive (94.51% vs 73.2%) and more specific (99.57% vs. 98.93%) compared to the liposome technique. Additionally, minor changes of mGR expression can also be demonstrated with the FASER technique. The FASER procedure shows technical advantages: the commercially available FASER-APC-kit is performed according to a standarized protocol and is less time consuming compared to the liposome procedure. Conclusion. The human mGR is easily detectable with the commercialized FASER kits, which represent an alternative due to a consistent quality and a standardized production. This method facilitates the analysis of the role that mGR play in the pathogenesis of chronic inflammatory diseases and perhaps provoke new insights in glucocorticoid therapy. Background. In previous studies we detected TH-positive, catecholamine-producing cells in inflamed hypoxic synovial tissue. Therefore, the aim of our study was to investigate the influence of hypoxia induced catecholamines on inflammatory responses in arthritis. Methods. Synovial cells of rheumatoid arthritis (RA) and osteoarthritis (OA) patients were isolated and cultivated under normoxia or hypoxia with/without stimulating enzyme cofactors of TH and inhibitors of TH. Expression of TH and release of cytokines and catecholamines was analyzed. The effect of TH+ cells was tested by adoptive transfer into DBA/1 mice with collagen type II-induced arthritis (CIA). TH+ cells were generated from mesenchymal stem cells by defined dopaminergic factors. Results. Hypoxia increased TH protein expression and catecholamine synthesis and decreased release of TNF in OA/RA synovial cells compared to normoxic conditions. This inhibitory effect on TNF was reversed by TH inhibition with alpha-methyl-para-tyrosine (αMPT). Incubation with specific TH cofactors (tetrahydrobiopterin and Fe2+) increased hypoxia-induced inhibition of TNF, which was also reversed by αMPT. Adoptive transfer of TH+ cells reduced CIA in mice, and 6 hydroxydopamine, which depletes TH+ cells, reversed this effect. Conclusion. In summary, this study presents that TH-dependent catecholamine synthesis exhibits anti-inflammatory effects in human RA synovial cells in vitro, which can be augmented under hypoxic condi-tions. In addition, the anti-inflammatory effect of TH+ cells has been presented the first time in experimental arthritis in mice. Background. Previously, we demonstrated that long-lived plasma cells contribute to the pathogenesis of antibody-mediated diseases and should therefore be considered as a promising therapeutic target in systemic lupus erythematous (SLE). In bone marrow stromal cells expressing the chemokine CXCL12 organize these niches that provide for the plasma cell survival. CXCL12 is the ligand of CXCR4 expressed on plasma cells. In this study we investigated the contribution of CXCL12-CXCR4 interaction to the longevity of plasma cells in the murine model of lupus. Methods. Plasma cells purified from spleens of NZB/W mice were incubated with the CXCR4 blocker AMD3100 and then adoptively transferred to immunodeficient Rag1−/− mice. After 14 days we analyzed the number of plasma cells in bone marrow. Furthermore, OVA immunized NZB/W mice were treated intraperitoneally with AMD3100 after boost; anti-OVA secreting plasma cells in bone marrow were checked on day 3 and 15 after boost. The effect of plasma cell depletion was investigated in NZB/W mice using AMD3100 alone or combined with bortebomib for two weeks. Results. Two weeks after adoptive transfer the number of plasma cells treated with AMD3100 was lowered by 60% in bone. After secondary immunization with OVA the AMD3100 treatment resulted in a significant reduction of anti-OVA secreting plasma cells in bone marrow by 33% on day 3 and by 23% on day 15. After 15 days the number of MHC class II negative anti-OVA secreting plasma cells significantly decreased by 42% in bone marrow of treated mice. AMD3100 efficiently depleted plasma cells including long-lived. After two weeks treatment, total plasma cell number was decreased by 69% in spleen and 61% in bone marrow; long-lived plasma cells were reduced by 67% in spleen and 64% in bone marrow. The combination of bortezomib with AMD3100 in NZB/W significantly enhanced the depletion of long-lived plasma cells compared to monotherapy. Conclusion. CXCR4 blockade with AMD3100 can reduce the homing of plasma cells to the bone marrow and the survival of long-lived plasma cells. The combination of bortezomib with AMD3100 shows synergistic effects on plasma cell depletion. The findings highlight the importance of the CXCR4-CXCL12 axis for the plasma cell niche. Zeitschrift für Rheumatologie Suppl 2 · 2013 | ER.09 TNFR1 expression defines synovial tissue infiltrating CD4+ T cells in patients with rheumatoid arthritis K Background. One hallmark of rheumatoid arthritis (RA) is the infiltration of the synovial membrane by CD4+ T cells. It has previously been shown that infiltrating CD4+ T cells differ from non-infiltrating ones in their increased expression of TNFR1. Furthermore, TNFR1 is expressed on a fraction of circulating CD4+ T cells from RA patients, but not from healthy controls. Aim of the study was the characterization of TNFR1+ CD4+ T cells in patients with rheumatoid arthritis. Methods. Peripheral TNFR1+ CD4+ T cells from RA patients were analyzed by flow cytometry. The expression of naive and memory T cell markers (CD45RA and CD45RO), markers for T cell activation (CD25, CD71 and CD154) and of ICAM-1 as well as the frequencies of the positive cells were determined. To identify the T helper cell signature of TNFR1+ CD4+ T cells, intracellular staining of the Th1, Th2 and Th17 master transcription factors T-bet, GATA-3 and ROR-γt, respectively, was performed. Results. Peripheral TNFR1+ CD4+ T cells have neither a preferential naive nor a memory phenotype, but showed higher expression of the activation markers CD25, CD71 and CD154 than TNFR1-CD4+ T cells. TNFR1+ CD4+ T cells express higher frequencies of the T-bet and RORγt than TNFR1-CD4+ T cells. There is no difference in GATA-3 expression between TNFR1 positive and negative CD4+ T cells. Functionally, it has been shown that the cytokine TNF acts as chemokine to attract CD4+ T cells to the rheumatoid joints. Beside this direct effect of TNF, there are known indirect effects of TNF including the upregulation of cell adhesion molecules like ICAM-1. Therefore, ICAM-1 expression of migrating TNFR1+ T cells was investigated. The results show, that migrating TNFR1+ T cells recovered from synovial tissue are more frequently ICAM-1 positive than non-migrating ones. Conclusion. TNFR1+ expression characterizes CD4+ T cells functionally capable of infiltrating the rheumatoid synovium in an ICAM-1 dependent manner. The results show, that TNFR1 expression defines a pathogenic subset of activated CD4+ T cells with Th1 and/or Th17 signature in patients with Rheumatoid Arthritis.

Hypoxia increased the production of Interleukin-1β in LPS-primed human monocytes N Background. Monocytes are major players in the innate immune system and are recruited to sites of inflammation, where the environmental conditions vary extremely compared to the interstitium under physiological conditions. For example, in rheumatoid arthritis the inflamed joints are severely hypoxic. This decreased oxygen level could be a triggering factor for the activation and survival of monocytes. Aim of the study was to analyze the influence of hypoxia on lipopolysaccharide (LPS)-induced cytokine production in primary human monocytes Methods. Immunomagnetically separated monocytes from the blood of healthy donors were cultured for 16h under hypoxic conditions (1% oxygen). Results. Cytokine measurement in the supernatant with ELISA showed increased concentrations of Interleukin-1β (0.9 ng/ml vs. 4 .35 ng/ ml, p=0.0019) and Interleukin-6 (63.8 ng/ml vs. 125.9 ng/ml, p=0.019), but not of TNF, after hypoxia and LPS-stimulation. Cleavage of the IL-1β proform to its active form is dependent on the assembly of the inflammasome and the recruitment of caspase-1 followed by their activation. When inflammasome assembly was blocked with high extracellular K+-buffer or by inhibiting intracellular Ca-signalling with the Ca-chelator BAPTA-AM, hypoxia induced IL-1β release was abrogated. Similarly, IL-1β release after culture under hypoxia was also abolished in monocytic THP1-cells, which are genetically made deficient for the inflammasome components NLRP3 and ASC. One activating signal for the inflammasome was shown to be the release of reactive oxygen species (ROS), since mitochondrial ROS staining with MitoSOX revealed an increased mitochondrial ROS release under hypoxic conditions. Accordingly, the induction of mitochondrial ROS through decoupling of the electron transport chain with Rotenone also triggered an increase of IL-1β release under normoxic conditions. Analysis of blood monocyts from RA patients showed no difference in LPS and hypoxia induced IL-1β release compared to healthy controls (1.84 ng/ml vs. 1.88 ng/ml). Conclusion. This study shows, that hypoxia leads to the activation of the inflammasome, the recruitment of caspase-1 and the subsequent cleavage and release of Interleukin-1β in human primary monocytes. Intracellular Calcium mobilization and mitochondrial ROS production were shown to be essential mechanisms triggering inflammasome assembly. Background. Cell-derived membrane-coated microparticles have been identified as important mediators in intercellular communication. During the process of apoptosis, dying cells start to dynamically release microparticles. Polymorphonuclear neutrophils are the most abundant type of leukocytes, representing 50-70% of all white blood cells. Due to their very short lifespan, they are the source of massive amounts of apoptotic cell-derived microparticles (AdMPs). While the interaction between neutrophils and T lymphocytes has been focus of extensive research, the influence of neutrophil-derived microparticles on T cells has not been analysed yet. In this study, we investigated the effect of membrane-coated microparticles released by apoptotic neutrophils on different T helper cell subsets. Methods. Different CD4+ T cell subtypes were sorted according to the expression of CD25, CD127, CD45RA and CD45RO and co-cultured with AdMPs or apoptotic cell remnants purified from UV-irradiated neutrophils isolated from the peripheral blood of healthy donors. T cells were stimulated by OKT3 and anti-CD28 antibodies and cell proliferation was measured by 3H-thymidine incorporation or PKH26-staining. Secretion of cytokines was quantified by ELISA. Results. AdMPs released by neutrophils selectively suppressed the proliferation of CD4+CD25-CD127+ Tc in a dose-dependant manner and prevented the upregulation of CD25 on the T cell surface, while maintaining the expression of CD127. The secretion of tumor necrosis factoralpha (TNFα) by T cells stimulated in the presence of AdMPs was significantly reduced. Interestingly, in contrast to AdMPs, the apoptotic cell remnants of neutrophils exerted no effect on T cells. The suppressive effect of AdMPs could be completely abrogated by the addition of interleukin(IL)-2 or IL-7 or by the presence of CD4+CD25+CD127+ T cells. Conclusion. Neutrophil AdMPs suppress the proliferation of CD4+CD25-CD127+ T cells under conditions of limiting IL-2 and IL-7 concentrations. This could represent an important mechanism to prevent inappropriate activation and expansion of resting T helper cells in the absence of sufficient stimulation and cytokine production.

T. Alexander 1 Background. Recent reports have shown dysregulated microRNAs in murine lupus models, among them increased expression of miRNA-182, which has been demonstrated to target the transcription factor FOXO1 in activated CD4+ T cells. The loss of FOXO1 activity in T cells is associated with spontaneous T cell activation, clonal expansion and autoantibody production, all of which are present in systemic lupus erythematosus (SLE). Methods. Expression levels of microRNA-182 and FOXO1 were analyzed with RT-PCR in magnetic purified peripheral blood CD4+ T cells from 9 Patients with SLE and healthy controls (HC). Multicolor flow cytometry was performed to analyze CD4+ T cell expression for CCR7, CD45RA, Ki-67, Foxp3, the interleukin-7 receptor-α and phosphorylated STAT-5a (pSTAT5). Analysis of serum IL-7 levels was performed with ELISA in 27 SLE patients and HC (R&D systems). Results. MiRNA-182 was significantly upregulated in CD4+ T cells from SLE patients compared to HC (median expression 8.89×10E-7 vs. 3.96×10E-7, p=0.008) while FOXO1 mRNA levels were decreased, yet without reaching statistical significance. Analysis of Ki-67 expression revealed an increased percentage of proliferating CD4+ T cells in SLE (5.23% vs 2.21%, p=0.006). Overall, CD4+ T cellular proliferation in SLE was associated with increased frequencies of CD45RA-CCR7-effector memory T cells and enhanced basal pSTAT5 levels (median MFI 503.5 vs 399.0, p=0.010), suggesting a recent stimulation with common gamma chain(γc)-signaling cytokines. In this regard, Tcons from SLE samples displayed decreased expression levels for the FOXO1 target gene CD127 (MFI 2021 vs. 2553, p=0.049) and serum IL-7 levels were significantly higher in SLE compared to HC (17.0 pg/ml vs. 10.2 pg/ml, p=0.001). Conclusion. MiR-182 expression has been shown to be dependent on STAT5 activation and to promote clonal expansion of activated CD4+ T cells. Our data suggest that enhanced IL 7R/STAT5 signaling mediates induction of miR 182 expression, which in turn promotes the proliferation of Tcons in SLE. The relative contribution of IL 7R/miR-182/FOXO1 axis on the enhanced proliferative capacity of SLE Tcons remains elusive and merit further investigation. Collectively, our data provide new insights in the pathophysiology of T cell hyperactivity in SLE and identifies miR-182 as a candidate target for future therapeutic approaches. Background. Cell activation and apoptotic cell death leads to the formation of membrane-coated vesicles (MCVs). MCVs have previously been identified as mediators of cell-to-cell communication and carriers of microRNA. An impaired clearance of apoptotic debris caused by an increased rate of apoptosis or a defect in phagocytic-cell clearance has been observed in SLE patients. In this study, we analyzed the microRNA content of activated and apoptotic lymphocytes and their corresponding MCVs from both normal healthy donors (NHDs) and SLE patients. Further we investigated the immunomodulatory effect of MCV uptake by monocytes. Methods. MicroRNA content of activated and apoptotic lymphocytes and corresponding MCVs of NHDs and SLE patients were compared in an Agilent microRNA array and validated by qPCR. Apoptosis was induced by UVB-irradiation. MiR-155 expression in monocytes after UV-MCVs engulfment was determined by qPCR. Expression of miR-155 target protein Tab-2 was analyzed by Western blot. Results. MiR-155* levels were decreased after apoptosis induction in lymphocytes and apoptotic MCVs compared to their viable correlates. MiR-155, miR-99a and miR-34b were decreased in apoptotic lymphocytes compared to viable ones but increased or not significantly changed in apoptotic MCVs compared to viable MCVs, indicating a directional transport of microRNA into MCVs. MiR-34a was expressed at higher levels in viable SLE lymphocytes and MCVs compared to NHDs. MiR-34b expression was decreased in UV-lymphocytes and UV-MCVs of SLE patients. Functional assays confirmed higher miR-155 levels and consecutively decreased target protein levels in monocytes after engulfment of UV-MCVs. Conclusion. Within this study we could show an unequal distribution of distinct microRNA into MCVs released by activated or apoptotic lymphocytes. Further the microRNA content was regulated in whole apoptotic cells after UVB-irradiation. This suggests a directional transport rather than a random distribution. Thus, cells regulate their microRNA as well as the microRNA content within released MCVs. We could show a microRNA and protein expression change in phagocytes after MCV engulfment. Hence, our results suggest MCVs could serve as a transport vehicle for microRNA to mediate cell-to-cell communication and influence intracellular processes in phagocytes. Disturbances of this system might contribute to the pathogenesis of SLE. Results. We found in the spleens of NZB mice 10-times higher numbers of long-lived plasma cells and megakaryocytes compared to wildtype, in NZW mice equal numbers and in NZB/W mice numbers between those for NZB and NZW or wildtype. Moreover, in the spleen a fraction of plasma cells clustered around megakaryocytes. We also detected a missense mutation in the c-mpl gene of NZB mice leading to an amino acid replacement within the essential TPO-binding site. Upon TPO stimulation of splenocyte and bone marrow cultures NZB cultures responded significantly stronger resulting in the double amount of megakaryocytes compared to NZW cultures. Conclusion. In summary, our data indicate that augmented megakaryopoiesis enables the accumulation of a greater number of autoreactive plasma cells in lupus prone NZB/W mice. Thus, we assume that enhanced megakaryopoiesis and higher megakaryocyte numbers are contributing to the development and/or pathogenesis of SLE. Background. BAFF is a cytokine important for the stimulation and survival of autoreactive B cells and therefore might play a role in several autoimmune diseases, e.g. autoimmune arthritis. In psoriasis arthritis, BAFF correlates with disease activity and testosterone, but only in male patients, suggesting a role for sex hormones in the regulation of BAFF. Therefore, we wanted to determine if BAFF production in rheumatoid arthritis and osteoarthritis fibroblasts was regulated by neuroendocrine mediators. Methods. Fibroblasts were isolated from synovial tissue of RA (n=10) and OA (n=10) patients and cultured in vitro under different conditions. BAFF was determined by ELISA. Results. Isolated fibroblasts were cultured in the presence or absence of Interferon-gamma (IFN-γ), IL-1, lipopolysaccharide (LPS), tumor necrosis factor (TNF), CpG, Poly I:C, and cortisol in different combinations for 48 and 72 hours to determine the optimal stimulation strategy for induction of BAFF production (measured by ELISA in supernatants) in fibroblasts. IFN-γ best induced BAFF in RA and OA fibroblasts. IFN-γ-induced BAFF production in fibroblasts was decreased by dihydrotestosterone in a concentration dependent manner. The effect was specifically inhibited by nilutamid, a testosterone receptor antagonist. Furthermore, stimulation of beta-adrenoceptor increased, whereas stimulation of alpha-adrenoceptors did not change INF-γ-induced BAFF in synovial fibroblasts. In general the effects were more pronounced in RA as compared to OA fibroblasts. Conclusion. Taken together, INF-γ-induced BAFF production in synovial fibroblasts is decreased by testosterone and increased by betaadrenergic stimuli. Therefore, neuroendocrine regulation of inflammation in the inflamed joint might be in part mediated by regulating BAFF production in synovial fibroblasts.

A. Grützkau 1 , C. Kyogoku 1 , B. Smiljanovic 2 , J. Grün 1 , R. Biesen 2 , T. Alexander 2 , F. Hiepe 2 , A. Radbruch 1 , T. Häupl 2 1 Deutsches Rheuma-Forschungszentrum (DRFZ), Berlin, 2 Charité -Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Berlin

Background. Gene expression profiling experiments using peripheral blood mononuclear cells (PBMCs) revealed a crucial role of type I interferon (IFN) in the pathogenesis of systemic lupus erythematosus (SLE). However, it is almost unknown how particular leukocyte subsets contribute to the overall type I IFN signature described for PBMCs. Furthermore, a detailed analysis of how IFN signatures differ in autoimmune disease from that observed after viral infection is missing so far. Therefore, we compared expression levels of 2442 IFN signature genes in peripheral CD4+ T helper cells and monocyte (Mo) subsets isolated from patients with SLE, healthy donors (ND) and ND vaccinated against yellow fever by global gene expression profiling. Methods. Peripheral blood from 8 Patients with SLE and 4 ND were recruited. Same ND were examined before and after immunization by yellow fever vaccine. After sorting cells, isolated RNA were applied to Affymetrix Human Genome U133 Plus 2.0 Array. Data analysis was done using BioRetis database, Genesis Software and Ingenuity Pathway Analysis (IPA). Results. Comparing gene expression profiles of yellow fever immunized individuals and active SLE patients it was possible to identify a "common" and an "autoimmune-specific" IFN signature. Although major IFN signature genes were commonly expressed in CD4+ T cells and Mo of patients with SLE and immunized ND, expression magnitudes of them were higher in patients with SLE compared to immunized ND. In SLE, in addition to the typical "viral-induced" IFN signature, genes that are involved in apoptosis signaling, antiviral PKR signaling, Fcγ receptor-mediated phagocytosis and IL-10-/IL-9-/IL-15-mediated JAK/ Stat signaling pathways were identified by IPA. Conclusion. This study demonstrated that IFN signature in autoimmunity and that in viral infection are quite different in the number of IFN-related genes activated and their expression magnitudes. Autoimmunity is characterized by a much stronger expression of IFN signature genes and is obviously modulated by a separate set of co-regulated genes defining the "autoimmune-specific" IFN signature. In summary, "common" and "autoimmune-specific" IFN signature genes are of potential interest as clinical biomarkers in SLE diagnostics to differentiate between a disease flare and a viral infection.

of peripheral blood lymphocytes (PBL). There is currently no data available about NK cells in GPA. The aim of this study was to evaluate the presence of NK cells in GPA granulomas and their proportions in PBL as a basis for a potential role in GPA. Methods. Paraffin sections of granulomas of 20 GPA, 5 Sarcoidosis and 5 Tuberculosis patients were stained with a CD56 monoclonal antibody. NK cell (CD3-CD56+) proportions of PBL in 30 GPA patients and 27 healthy controls (HC) were analysed by FACS analysis. Clinical data was extracted from medical records. Results. Contrary to granulomas from Tuberculosis and Sarcoidosis which showed a considerable infiltration by CD56 positive cells, there was not a single CD56 positive cell in granulomas from 20 GPA patients. Therefore, the tissue destructive character of GPA granulomas is associated with a lack of NK cells. GPA patients with inactive disease [Birmingham vasculitis activity score (BVAS) = 0, n=19] possessed a significantly higher NK cell proportion in PBL (mean ± standard deviation: 24.4±13.5%) than both GPA patients with active disease (BVAS>0, n=11, mean=10.7±5.6%) (p=0.0026) and HC (n=27, mean=14.4-7.7%, p=0.004). Thus, clinical remission is accompanied by an increase in the NK cell proportion in PBL. Interestingly, patients with inactive disease that had "normal" NK cell proportions of less than 20% of PBL (n=7) showed a more severe disease course than those with more than 20% of PBL. Conclusion. NK cells might, therefore, be helpful to limit granulomatous inflammation. Whether NK cell proportion in PBL might be a useful biomarker in GPA, e.g. as predictor for relapses, will be further evaluated in our future studies.

V. Gerl 1 Background. Plasmacytoid dendritic cells (pDCs) are considered a crucial element in SLE pathogenesis due to their potency to produce high levels of IFN-α. This innate immunological function of pDCs is lost by terminal differentiation into a professional antigen-presenting cell (pDC-derived DC), thereby upregulating costimulatory molecules and downregulating innate characteristics, e.g. BDCA-2 and IFN-α expression. pDC-derived DCs have not been described in vivo yet, probably due to the fact that they lose their specific markers during differentiation. Furthermore, pDCs can differentiate into myeloid DCs by various stimuli. In SLE, where low expression of BDCA-2 is commonly seen, this differentiation could be relevant and point to such a lineage switch as well as to an activated state of pDCs. Aim. To characterize pDC subsets of differentiation/activation in human peripheral blood and to study their impact on autoimmune inflammation in SLE. Methods. 8-color-flowcytometric analyses were performed on whole blood of healthy donors and SLE patients. pDCs were identified by CD3-/CD19-/CD14-/CD123high//BDCA-2+/HLA-DR+ expression and characterized for CD11c, BDCA-1 and the macrophage-associated Siglec-1, expressed on monocytes of active SLE patients in an IFN-α dependent manner. CD86 and CD83 expression were measured in parallel. Results. We found a small subpopulation of Siglec-1 expressing pDCs in human peripheral blood. Compared to Siglec-1 negative pDCs, Siglec-1 positive pDCs express significantly lower BDCA-2 and CD123, higher HLA- DR Background. Agonistic autoantibodies against the angiotensin II receptor type 1 (AT1R) and the endothelin receptor type A (ETAR) have been identified in patients suffering from systemic sclerosis (SSc). Here we examined the expression of AT1R and ETAR in human immune cells and pathological effects mediated through these receptors by corresponding autoantibodies (Aabs). Methods. AT1R and ETAR protein expression on peripheral blood mononuclear cells (PBMCs) from healthy individuals and SSc patients was analyzed using flow cytometry, mRNA expression was examined by real-time PCR in PBMCs from healthy donors. In addition, PBMCs from healthy donors were stimulated in vitro with affinity-purified immunoglobulin G (IgG) fractions from SSc patients positive for AT1Rand ETAR-Aabs, and with IgG from healthy donors serving as control. Alterations in cell surface marker expression, cytokine secretion and chemotactic motility were analyzed using flow cytometry, ELISA, and chemotaxis assays, respectively. Results were correlated with characteristics/clinical findings of the IgG donors. Results. Both AT1R and ETAR were expressed on human peripheral lymphocytes and monocytes. Protein expression of both receptors was decreased in SSc patients when compared to healthy donors and correlated negatively with disease duration. In addition, IgG fractions of SSc patients induced T cell migration in an anti-AT1R and anti-ETAR Aab level-dependent manner. Moreover, IgG of SSc patients was capable of stimulating PBMCs to produce more IL-8 and CCL18 than IgG of healthy donors. All effects could be significantly abrogated by the application of selective AT1R and ETAR antagonists. Statistical analysis revealed a negative correlation between SSc IgG-induced IL-8 concentrations and disease duration, between SSc IgG-induced CCL18 concentrations and time since onset of lung fibrosis as well as an association of CCL18 concentrations with vascular complications of the corresponding SSc IgG donors. Conclusion. We demonstrated the expression of both, AT1R and ETAR, on human peripheral T cells, B cells and monocytes and found signs for a chronic receptor activation in SSc patients. The inflammatory and profibrotic effects upon Aab stimulation in vitro, and their associations with clinical findings suggest a role for autoantibody-mediated activation of immune cells mediated through the AT1R and ETAR in the pathogenesis or even the onset of the disease.

The bioenergetic role of HIF-1 and HIF-2 during angiogenesis of human microvascular endothelial cells Background. Hypoxia and angiogenesis are features of inflamed and injured tissues. The transcription factors Hypoxia inducible factor (HIF)-1 and (HIF)-2 regulate the cellular and metabolic responses to reduced oxygen tensions thereby promoting angiogenesis with implications on the pathogenesis of RA. We investigated the effects of a knockdown of either HIF-1α or HIF-2α in human microvascular endothelial cells (HMEC) on angiogenesis and bioenergetics under hypoxia (1% O2) versus normoxia (18% O2). Methods. Specific knockdown of either HIF-1α or HIF-2α was conducted by shRNA-technology. To assess angiogenesis of HMECs both tubuli and node formation under hypoxia versus normoxia were investigated. Expression of hypoxia driven genes involved in the metabolic response to hypoxia (GAPDH/PGK/GLUT1/LDHA) was quantified by realtime RT-PCR. The bioenergetic status of the cells was quantified via ATP/ADP measurements. Results. Knockdown of HIF-1α/HIF-2α resulted in a loss of hypoxia induced angiogenesis. Focusing on bioenergetic aspects, we found hypoxia to significantly induce PGK, LDHA and GAPDH in control cells. Knockdown of HIF-1α and HIF-2α, respectively, did not affect the hypoxic induction of PGK and LDHA. In HIF-1α and HIF-2α knockdown-cells, hypoxia was still capable of inducing GAPDH, with a less pronounced effect in HIF-1α knockdown-cells. Hypoxia did not significantly up-regulate GLUT1, neither in control nor in HIF-1α or HIF-2α knockdown-cells. The knockdown of HIF-2α resulted in significantly decreased expression of GLUT1 under hypoxia. We also found the ATP/ ADP ratio to be similar in control, HIF-1α and HIF-2α knockdown-cells under normoxia. Under hypoxic conditions HIF-1α knockdown-cells showed significantly reduced ATP/ADP ratios -indicating that less ATP is available -compared to HIF-2α knockdown-cells. Conclusion. HIF-1α and HIF-2α are both key regulators of angiogenesis. However, they do differ in their potency to regulate cellular energy metabolism. This leads us to conclude that HIF-2α does directly influence angiogenesis via regulating the synthesis of proangiogenic factors (as previously shown), whereas HIF-1α affects angiogenesis via effects on cellular energy metabolism as indicated by the reduced expression of GAPDH and the diminished ATP/ADP ratio. These findings provide new insights into regulation of angiogenesis in inflamed (hypoxic) tissues and are, therefore, considered to be of clinical relevance in RA.

Low baseline complement levels, autoantibody persistence and delayed thymic reactivation are risk factors for development of relapses after hematopoietic stem cell transplantation for refractory SLE Background. Our previous research has provided the evidence that an autoreactive immune system can be "reset" into a healthy, tolerant state by immunoablative treatment to eradicate pathogenic effector cells, followed by transplantation of hematopoietic progenitor cells (HSCT). Nevertheless, disease flares may occur in a subset of these patients posttransplantation. Here, we longitudinally analyzed the immune reconstitution of these patients to identify markers for favorable long-term responses.

Methods. Since 1998, 10 Patients with refractory SLE received a CD34+selected autologous stem cell transplantation after immunoablation with antithymocyte-globulin (ATG) and cyclophosphamide as part of a monocentric phase I/II clinical trial. Autoantibody titers were evaluated with ELISA, peripheral T-and B lymphocyte subsets immunophenotyped using multicolor flow cytometry. Results. Clinical remission (SLEDAI ≤3) could be achieved in all patients, despite immunosuppressive drug withdrawal, associated with disappearance of anti-dsDNA antibodies and marked reduction of protective antibodies in serum. Unfortunately, two patients died due to transplant-related infections. From the remaining eight patients, five patients are in long-term clinical remission for up to 14 years after HSCT, while three patients suffered a relapse of SLE at 18, 36 and 80 months post-transplantation, respectively. Patients with early relapses (≤36 months) had decreased baseline complement levels, showed persistence of antinuclear antibodies (ANA), less significant reduction in protective antibody levels and had slower repopulation of CD31+ CD45RA+ thymic-derived CD4+ T cells after HSCT (<100/µl at 18 months) when compared to long-term responders. In addition, flow cytometric analyses revealed an expansion of circulating plasmablasts and increased coexpression of Siglec-1 on monocytes (as surrogate marker for type-I interferon signature), preceding the clinical flares by ~6 months. Conclusion. Low baseline complement levels, persistence of ANA and delayed thymic reactivity post-transplantation could be identified as risk factors for development of lupus flares after HSCT. Since ATG-mediated cell lysis is complement-dependent, we conclude that low serum complement is directly associated with incomplete depletion of immunologic memory cells in these patients, which provides a rationale for complement substitution before immunoablation. Moreover, lupus flares may be predicted individually by flow cytometry with plasmablast expansion and recurrence of type-I interferon signature. Background. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the generation of pathogenic antibodies directed against a variety of autoantigens. We have previously shown that long-lived autoreactive plasma cells can contribute to chronicity and refractoriness of SLE. Our study is aimed to develop new methods for depletion of long-lived plasma cells in NZB/W mice, a model of SLE. Methods. We studied different treatment protocols on plasma cell survival: irradiation-based and more selective depletive treatments. 10-12 week-old NZB/W F1 mice were exposed to three different irradiation doses (10, 14, and 15 Gy in two splitted doses with a 3-h interval). The following protocols were also investigated: 1) two bortezomib (Bz) injections (0,75 mg/kg, i.v.) combined with anti-mouse CD20 (10 mg/kg, i.v.), 2) three bortezomib injections combined with anti-mouse CD20, 3) three bortezomib injections combined with anti-LFA-1 and anti-VLA-4 antibodies (affecting directly the plasma cell niche; 200 µg, i.p.) in a 2-d interval, plus anti-mouse CD20 and anti-B220 (250 µg, i.v.). The plasma cells were analyzed in spleen and bone marrow by FACS and ELISPOT. Results. The frequency of remaining plasma cells in bone marrow after 10, 14 and 15 Gy irradiation were 52, 14 and 0,7% respectively, and in spleen were almost 50, 10 and 0,2%. Short-term treatments with agents that affect plasma cells (bortezomib, anti-LFA1 plus anti-VLA4) effectively deplete plasma cells including long-lived plasma cells in spleen and bone marrow of NZB/W mice. Because of the B cell hyperactivity in NZB/W mice, we observe a rapid regeneration of autoreactive plasma cells in spleen and bone marrow. Therefore, plasma cell depletion protocols were combined with B cell depletion. Especially, the combination of plasma cell targeting with bortezomib, anti-LFA1 and anti-VLA4 with B cell targeting (anti-CD20 plus anti-B220) interrupted the repopulation of autoreactive plasma cells in spleen and bone marrow. Conclusion. Very high doses of irradiation result in effective depletion of long-lived plasma cells but lower doses not. Depletion of long-lived plasma cells can be achieved by the proteasome inhibitor bortezomib and by targeting both adhesion molecules LFA1 and VLA4. The combination with B cell depletion is needed to prevent regeneration of autoreactive plasma cells.

Varicella-zoster-virus(VZV)-specific lymphocytes and IgG antibody avidity in patients with juvenile idiopathic arthritis or rheumatoid arthritis Background. Varicella zoster virus (VZV) is a herpes virus that establishes a life-long latent infection with risk of reactivation (shingles) particularly in immunosuppressed patients with autoimmune disorders. Patients with rheumatoid (RA) or juvenile idiopathic arthritis (JIA) have a high risk for disseminating varicella zoster virus (VZV) infection or herpes zoster. This study was aimed to investigate the humoral and cellular immune response to VZV including assessment of IgG-anti-VZV avidity and VZV-specific reactivity of lymphocytes in RA (n=56) or JIA patients (n=75) on different treatments, including biologic agents, such as anti-tumor-necrosis-factor(TNF)-alpha or anti-interleukin-6 (IL-6) receptor inhibition (tocilizumab), compared to 37 healthy adults (HA) and 41 children (HC). Methods. IgG-anti-VZV concentrations and avidities were quantified by an adapted ELISA. VZV-specific Interferon-gamma-producing lymphocytes (spot forming units, SFU/1,000,000 cells) were analyzed by ELISPOT. Results. No significant differences in the VZV-IgG concentrations or avidities were found between the groups. However, lower IgG-anti-VZV concentrations were found in tocilizumab-treated RA compared to HA and RA without biologic agents. RA showed lower median SFU (15/1,000,000 cells) than HA (57/1,000,000 cells), with lowest SFU in adalimumab-treated RA (10/1,000,000 cells). SFU were not altered in tocilizumab-treated RA and after incubation with anti-IL-6 in vitro. No differences regarding IgG-anti-VZV concentrations, RAI and cellular reactivity were found between JIA and HC. Conclusion. Our study demonstrated that RA and JIA patients are still able to maintain humoral and cellular immune responses to VZV despite immunosuppressive therapy or biologic agents. In RA, the role of lower cellular reactivity for risk of herpes zoster has to be considered for recommendations on vaccination.

CMV-specific CD8+ T cells from RA patients contribute to autoimmune disease 41 Zeitschrift für Rheumatologie Suppl 2 · 2013 | 1. Increased frequency of LIR-1 (also called CD85j or ILT2) on CD8+ T cells has been associated with autoimmune disease. Furthermore, it has been shown that latent cytomegalovirus (CMV) infection contributes to the expansion of CD28− T cells. Hence we were interested in the influence of CMV infection on the LIR1 expression on T cells in RA patients. Methods. We were interested in the role of LIR1+ T cells in RA patients, which potentially contribute to the autoreactive T cell pool, especially in CMV+ patients. Therefore, we investigated the expression and function of LIR-1 on CD8+ T cells in peripheral blood mononuclear cells (PBMC) from patients with rheumatoid arthritis by flow cytometry and cytotoxicity assay. Results. Flow cytometry analysis revealed higher frequencies of LIR-1+ CD8+ T cells in CMV seropositive RA (n=49, mean%: 10.4) compared to CMV+ HD (n=51, mean%: 7.5, p=0.043). Using HLA-A*0201/CMVpp65 dextramers we analyzed CMV-specific CD8+ T cells. Patients with RA had higher frequencies of CVM specific CD8+ T cells (n=8; mean%: 3.28) compared to healthy individuals (n=12; mean%: 1.35, p=0.04). Phenotypically, CMV-specific CD8+ T cells are mainly CD28 negative and express LIR-1. Analysis of the cytolytic potential by CD107a expression revealed higher numbers of CD107a+CD8+ T cells in RA patients (n=3, mean%: 0,57) compared to healthy donors (n=3, mean%: 0,17). Importantly, we found a significant correlation (p=0.034) of high numbers of CD8+LIR-1+ T cells with high disease activity score (DAS28) in RA patients without immunosuppressive treatment (n=14, r=0,568) . Tab.5 . Conclusion. This is the first demonstration of significantly increased frequencies of LIR-1+CD8+ T cells and of CMV-specific CD8+ T cells in patients with rheumatoid arthritis. These cells are characterized by a terminally differentiated phenotype. The higher cytolytic potential of CMV-specific T cells likely can be attributed to their function in containing latent CMV infection and to prevent CMV disease, but might potentially contribute to disease severity in RA patients. Background. Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by an acquired IL-2 deficiency, which leads to a homeostatic imbalance between regulatory T cells (Treg) and effector T cells (Tcon; Humrich et al. 2010). We recently demonstrated that Treg homeostasis in lymphoid organs of diseased (NZBxNZW) F1 mice can be restored by treatment with recombinant IL-2 (IL-2) resulting in an amelioration of kidney disease. The aim of this study was to investigate the impact of IL-2 therapy on intrarenal Foxp3+ Treg and kidney infiltrating conventional CD4+ T cells (Tcon) in the (NZBxNZW) F1 mouse model of lupus nephritis. Methods. (NZBxNZW) F1 mice with active nephritis were treated with recombinant IL-2 either for a short period of 5 days or for a longer period of 30 days in total. Absolute numbers, phenotype and proliferation of kidney infiltrating CD4+ T cell subsets were determined by flow cytometry at different time points. Results. Short-term IL-2 treatment resulted in an enhanced proliferation and increased numbers and frequencies of intrarenal CD4+Foxp3+ Treg compared to untreated control mice. On the other hand, long term IL-2 treatment did not result in a persistent expansion of the intrarenal Foxp3+ Treg population. However, total numbers of kidney infiltrating CD4+ Tcon with a memory/effector phenotpye were diminished and CD4+ Tcon showed markedly reduced signs of cellular activation. Conclusion. Our data indicate that short term IL-2 treatment is able to expand the size of the intrarenal Treg pool. In contrast, long term IL-2 treatment decreases the numbers of kidney infiltrating memory/ effector T cells and reduces cellular hyperactivity suggesting that Treg suppress the activation and expansion of infiltrating Tcon. These results may in part explain the amelioration of disease induced by treatment with IL-2 and underline the important role of intrarenal Treg for the suppression of kidney disease in lupus mice. These results also provide additional important rationales for an IL-2 based immunotherapy of human disease.

From transcriptome to protein biomarkers in RA: joint compartment and monocytes outperform serum and whole blood Background. A main challenge in disease-management of RA is to establish objective criteria relevant for diagnosis and therapeutic stratification of patients. This study focused on global approaches in dissecting inflammation in RA including transcriptome analyses of synovial tissue and blood monocytes and proteome analyses of synovial fluid and serum. Methods. Gene-expression profiles from synovial tissues and blood monocytes of RA and osteoarthritis (OA) patients were generated by Affymtetrix arrays. ELISA and multiplex immunoassays were used for validation of 30 candidate markers at the protein level in synovial fluid (SF) from RA and OA patients and in serum from the same group of patients and healthy donors. Results. Transcriptome analyses of synovial tissues from RA and OA revealed more than 1000 differentially expressed genes. To avoid difficulties in sampling synovial tissue and to avoid fluctuation in cellular composition of various cell types in blood, the transcriptome analyses from peripheral blood was focused on a specific cell population. Monocytes were selected as the favourable cell type involved in the production of cytokines, which are often considered as therapeutic targets in RA. Comparisons between RA and OA monocytes disclosed differential expression of more than 100 genes. In total, 30 genes that were up-regulated in synovial tissues and/or monocytes were used for validation at the protein level as potential biomarkers for RA. Among these 30 biomarkers, chemokines (CXCL13, CCL18, IP10), adhesion molecules (VCAM1, ICAM1, E-and P-Selectins), proteolytic enzymes (MMP1, A1AT), and the shedding form of cell surface molecules (CD14, CD163) Background. Idiopathic membranous nephropathy (IMN) is a common cause of nephrotic syndrome in adults and has recently been identified as an autoimmune-mediated disease [1] . Autoantibodies directed towards the M-type phospholipase A2 receptor (PLA2R) are fairly specific for idiopathic MN and only found to a small percentage in sera from patients with secondary MN [2] . The outcome of patients with IMN is quite diverse: about one third of patients have spontaneous remission, another third progress to require dialysis and the last third continue to have proteinuria without progression to renal failure. We performed serological profiles of 162 IMN patients in order to compare antibody profiles to antibody frequencies found in the normal healthy population and to hopefully identify factors that help to predict disease course in IMN.

Methods. Serum samples of 162 Patients with IMN were assayed for a variety of autoantibodies by ELISA, addressable laser bead immunoassay (ALBIA) and to dsDNA by Crithidia luciliae assay.

Results. The prevalence of autoantibodies found in our IMN cohort is summarized in Tab. 1. Anti-PLA2R antibodies were found in about 54% of IMN patients whereas the frequency of other antibodies was mostly below 2%. The one exception is anti-DFS70 that was found in 16.05% of IMN patients. Conclusion. The prevalence of anti-PLA2R positive patients in our IMN cohort matches what has been previously described [3] . The frequency of the other antibodies that we determined is comparable to what has been reported in the normal healthy population. It is important to note that anti-DFS70 antibodies are more prevalent in healthy individuals compared to patients with systemic autoimmune rheumatic diseases (SARD; [4] ) whereas anti-Ro52 reactivity is often regarded as a marker for SARD. The absence of anti-Ro52 and the high prevalence of anti-DFS70 confirms that IMN is a rather organ specific autoimmune disease. Background. Activity and the quality of movement belong to the most fundamental diagnostic parameters for neurobehavioural analysis but in the past it has been difficult to include this information into pre-clinical murine disease models. Here we tested the applicability of a radiofrequency identification (RFID) based automated tracking system in the experimental murine model of ovalbumin induced arthritis. Methods. C57BL/6 mice were immunized twice with cationized ovalbumin in Freund's Complete Adjuvant and onset of arthritis was induced two weeks after the last immunization by direct injection of cationized ovalbumin into the knee joint of the right hind leg. Severity of arthritis was assessed through measurement of joint swelling and evaluation of histological changes. Additionally mice were implanted with a RFID transponder and throughout the experiment their activity level was monitored by an ID-Grid sensor plate placed underneath the homecage.

Results. The joint inflammation in the ovalbumin induced arthritis model showed a quantifiable impact on the activity levels of the mice. Our experiments could also show that movement activity correlates with disease severity as evaluated by clinical and immunological parameters.

In the past employing behavioral methods was often limiting by group size, observation time and reproducibility and the stress of handling and new surroundings made results difficult to interpret. In our experiments a RFID-based automated tracking system allowed us to monitor individual activity long-term without removal of the mice from their homecage environment. This allowed for the correlation of clinical parameters to behavioral factors and adds another level of analysis to an established murine model.

Progranulin antibodies in a wide spectrum of autoimmune diseases Results. Autoantibodies against progranulin, a secreted and direct inhibitor of TNF-α receptors 1&2 were frequently identified in primary vasculitides. In detail, progranulin-antibodies were found during the course of disease in giant cell arteritis/polymyalgia rheumatica (14/65), Takayasu's arteritis (4/13), classical panarteritis nodosa (4/10), Behcet's disease (2/8), in granulomatosis with polyangiitis (31/81), Churg-Strauss syndrome (7/31) and in microscopic polyangiitis (6/17). In extended screenings progranulin-antibodies were also frequently detected in autoimmune connective tissue disorders, in rheumatoid and psoriatic arthritis and in inflammatory bowel disorders. In contrast progranulin-antibodies were only detected rarely in healthy controls (1/97), patients with obesity (0/40), residents of nursing homes (1/48), not in patients with cutaneously limited psoriasis (0/100), not in patients undergone sepsis (0/22), and not in patients with melanoma (0/98). A significant association of progranulin-antibodies with active disease states in granulomatosis with polyangiitis suggested a pro-inflammatory activity of progranulin-antibodies. This was supported by an observed neutralizing effect of progranulin-antibodies on the levels of circulating progranulin in ELISA and Western-blot. Moreover, functional assays revealed, that progranulin-antibody containing sera render WEHI-S cells far more sensitive to effects of administrated TNF-α, providing evidence for the suspected pro-inflammatory effect of progranulin-antibodies.

Conclusion. Progranulin-antibodies occur in a widespread spectrum of autoimmune diseases and have a pro-inflammatory effect by neutralizing the physiologic TNF-blocker progranulin. Background. Flow cytometry (FCM) is widely used in research for molecular characterization at single cell level. Conventional analysis is a semiautomated process of user defined gating and investigation in 2-D projections. For multiple parameter analysis with hundreds of marker combinations, this manual process is most limiting and impedes high throughput analysis. Therefore, we developed a new algorithm for automated and standardized analysis of multiplex FCM data. Methods. Automation included asinh-transformation of data, cell grouping, population detection and population feature extraction. For grouping of cells, an unbiased unsupervised model based t-mixture approach with Expectation Maximization (EM)-iteration was applied. Populations were identified by meta-clustering of several experiments according to position and extension of cell-clusters in multi-dimensional space and by including a General Procrustes Analysis (GPA) step. For validation, peripheral leukocytes from healthy donors and patients with rheumatoid arthritis (RA) were prepared by hypoosmotic erythrocyte lysis and stained with different sets of lineage-specific antibodies. In parallel, different leukocyte samples were depleted of one of these populations by magnetic beads. Qualitative and quantitative characteristics of major populations were compared with conventional manual analysis. Results. Whole blood leukocytes stained simultaneously with up to 7 markers were correctly distinguished in all major populations including granulocytes, T cells and their subpopulations, monocytes, B cells, and NK-cells. The result was comparable to the "gold standard" of manual evaluation by an expert. The new technology is able to detect subclusters and to characterize so far neglected smaller populations based on the new parameters generated. Automated clustering did not require fluorescence compensation of data. Cell-grouping is applicable even for large FCM datasets of at least 10 parameters and more than 1 million events. Comparing the cell-clusters between RA and healthy controls, differences were detectable in several cell (sub-)populations, stable enough to perform correct classification into controls and disease.

Conclusion. This new approach reveals promising results for automated and time-saving analysis of large datasets from multiplex FCM. The algorithm avoids operator-induced bias, is able to detect unexpected sub-clusters and to characterize so far neglected populations. This may reveal not only new markers for disease activity but also for therapeutic stratification. Background. Lasp-1 localizes at focal adhesions, along stress fibres and leading edges of migrating cells regulating metastatic dissemination of different tumors. Since RASF have been implicated in the spreading of disease by leaving cartilage destruction sites, migrating via the bloodstream and re-initiating the destructive process at distant articular cartilage surfaces, the underlying mechanisms are of special interest. Therefore, we investigated the role of Lasp-1 in SF migration and its effects on RA.

Methods. To identify Lasp-1 expression and its sub-cellular distribution in human SF as well as in hind paws of wt and hTNFtg mice, we performed Western blots and immunofluorescence. The migration of SFs derived from wt, Lasp-1-/-, hTNFtg and Lasp1-/-/hTNFtg mice was studied in a modified scratch assay as well as in live cell imaging studies. Furthermore, a transmigration assay using SF from all four genotypes and murine endothelioma cells (bEnd.5) as an endothelial barrier was carried out. SF transmigration under inflammatory conditions was also evaluated by TNF-alpha stimulation of the endothelial cells in vitro.

Results. Lasp-1 expression was up regulated in RASF and in SF from hTNFtg mice compared to healthy controls and was found at structures of cell adhesion and invasion. The scratch assay as well as the live cell imaging studies showed a significantly reduced migration of Lasp- (1 ng/ml) was applied. In parallel, IL-2 stimulation significantly amplified the expression of anti-apoptotic Bcl-2 in SLE Treg but not Tcon. Conclusion. In analogy to our previous findings in lupus-prone mice, Treg from SLE patients show the classical hallmarks of IL-2 deficiency with loss of CD25 expression and a homeostatic imbalance between Treg and Tcon. These findings could be associated with a reduced IL-2 expression by CD4+ T cells in SLE patients. On the other hand, low-dose IL-2 stimulation in vitro could restore these defects, underlying the potential of IL-2 as a novel therapeutic option in SLE.

The glucocorticoid-dependent modulation of immune-mediated inflammatory arthritis by osteoblasts in mice is T cell independent Background. At present, the role of adiponectin in rheumatoid arthritis is still controversial. There is some evidence indicating anti-inflammatory effects, for example adiponectin reduces the TNF release by macrophages. In contrast to its anti-inflammatory role, adiponectin also exerts pro-inflammatory effects locally in joints, inducing for example pro-inflammatory factors and matrix-degrading enzymes in RA synovial fibroblasts. Moreover, our immunohistochemical analysis of RA bone tissue showed a co-localization of adiponectin with key cells of bone remodelling (osteoblasts, osteoclasts). However, the role of adiponectin in bone remodelling of RA still needs to be defined. In this study, we therefore focussed on adiponectin and its immunomodulatory properties on RA osteoblasts and osteoclasts. Methods. Human osteoblasts and osteoclasts were isolated from bone tissue and blood samples of RA patients. Immunocytochemistry and RT-PCR were used to analyze the expression of adiponectin and its receptors in osteoblasts and osteoclasts. Osteoblasts and osteoclasts were treated with adiponectin (10 µg/ml). Adiponectin-mediated effects on the cytokine expression in osteoblasts and osteoclasts were analyzed using ELISA.

Results. The expression of adiponectin and its receptors (ADIPOR1, ADIPOR2, and PAQR3) by cultured RA osteoblasts and osteoclasts could be confirmed on translational and transcriptional level. Stimulation of primary RA osteoblasts and osteoclasts with adiponectin resulted in an alteration of cytokine release. Osteoblasts showed a time-and dose-dependent increase in IL-6 production. Furthermore, adiponectin induced the secretion of IL-8 and Gro-alpha and significantly increased the IL-6 and MCP-1 production (IL-6: 5-fold, p=0.004; MCP-1: 6-fold, p=0.004). Stimulation with adiponectin resulted in an increase in IL-6 production in pre-osteoclasts (5-fold) but not in osteoclasts. The secretion of IL-8 was increased in pre-osteoclasts (18-fold) and osteoclasts (2-fold).

The results of the present study confirm the pro-inflammatory potential of adiponectin in RA. The cytokines released after adiponectin treatment by osteoblasts and osteoclasts promote osteoclastogenesis or the migratory potential of osteoclasts and monocytes. Together with the finding that adiponectin is present in the bone compartment of RA suggest an involvement of adiponectin in articular destruction.

Acknowledgement: Funded by the German Research Society (SPP1468, IMMU-NOBONE, NE1174/6-1).

Novel mechanisms of glucocorticoid therapy in arthritis Anti-inflammatory acting glucocorticoids (GCs) are an important component of rheumatoid arthritis (RA) therapy. But their beneficial usefulness, especially in RA therapy, is hampered by severe side effects like glucocorticoid-induced osteoporosis (GIO). Until now the molecular mechanisms underlying the beneficial and side effects of GC therapy are poorly understood. GCs exert their actions via the glucocorticoid receptor (GR) that alters gene expression by either binding as a dimer to GC response elements in the promoter region of target genes or by interacting with and thus interfering with other transcription factors. For a long time GR dimerization was considered as the molecular base of side effects. Interference of pro-inflammatory transcription factors, such as AP-1 and NF-κB by the GR monomer was believed to contribute to the therapeutic effects of GCs.

In a model of GIO we previously showed that unexpectedly interaction of the GR monomer with AP-1, but not NF-kB in osteoblasts is decisive for bone loss (Cell Metabolism 2010 11:517). In contrast, in antigen-induced arthritis (AIA), we could demonstrate that GCs act in the acute inflammation of RA via the dimerized GR. Particularly, GC therapy suppressed TH1 and TH17 cell derived pro-inflammatory cytokines in a dimerization dependent manner. Furthermore TH17, rather than TH1 cells seem to be the most crucial targets for an efficient GC therapy since IL-17-/-mice were resistant to GC therapy whereas IFNγ-/-mice responded as efficient as wild type mice to steroid treatment (PNAS 2011 108:19317).

In a more chronic arthritis model, the K/BxN serum transfer induced arthritis, we demonstrate now that, unexpectedly, dimerization of the GR in non-hematopoietic cells also contributes to the anti-inflammatory effect of GCs. Thus, for immunosuppression of arthritis the GR is required in distinct cell types. Taken together, for anti-inflammatory actions the GR dimerization dependent gene regulation is decisive in RA, whereas GIO depends on the suppression of AP-1 dependent gene expression. Intriguingly for anti-inflammatory activities of GCs immune and non-immune cells are involved. Our approaches give new insights into GC action on arthritis and bone that can be translated into new concepts for anti-inflammatory therapies preventing GIO. Background. New bone formation and ankylosis are a hallmark of ankylosing spondylitis (AS). The impact of cytokines and different mechanisms of new bone formation (endochondral vs. membranous) to syndesmophyte formation and joint ankylosis in AS are still poorly understood. In order to analyze cartilage hypertrophy -as a potentially important element of endochondral bone formation -and to assess the possible influence of cytokines, we performed an immunohistochemi-cal study of the hyaline articular cartilage of facet joints of AS patients in comparison to autopsy controls and patients with osteoarthritis (OA). Methods. The cytokines interleukin(IL)-6, IL-10 and IL-22, as well as the marker of cartilage hypertrophy runt-related transcription factor 2 (Runx2), matrix metalloproteinase 13 (MMP13) and collagen type 10 (COL10) were determined in facet joints from 13 Patients with AS (undergone correction surgery of rigid hyperkyphosis), 11 OA patients (undergone surgery of the lumbar spine, because of neurological deficits) and 12 controls (autopsies without spinal diseases). Immunohistochemistry was performed and the entire cartilage area was analyzed for the frequency of positively stained chondrocytes. Background. Immunization with Glucose-6-phosphate isomerase (G6PI) induces arthritis in susceptible strains of mice. Depletion of regulatory T cells (Tregs) prior to immunization switches the usually acute, self-limiting course to a non-remitting, destructive arthritis. This provides a possibility to study molecular switches for the transition from acute, self-limiting to chronic, destructive arthritis within one mouse model. To examine the role of fibroblast-like synoviocytes (FLS), which are known to modulate immune responses via the production of pro-and anti-inflammatory mediators, the phenotype and function of FLS from mice with either acute, self-limiting or non-remitting, destructive arthritis was studied. Methods. FLS from DBA/1 mice that developed either the acute or the chronic form of arthritis were isolated from joints over a time course of 56 days. To investigate the phenotype of FLS ELISA studies as well as zymography have been performed. For the functional clarification of those cells the matrix-associated transepithelial resistance invasion (MATRIN) assay and a cartilage attachment assay have been used. Furthermore, FLS have been transferred in vivo into the knee joints of immunodeficient mice and the joints have been scored histologically.

Results. FLS from Treg-depleted mice produced significantly more cytokines (e.g. Interleukin 6 (IL-6)) upon stimulation with other cytokines, growth factors and TLR ligands. This increased susceptibility to cytokine stimulation in chronic animals compared to acute ones is observable throughout the disease course (56 days). Furthermore, the secretion and activity of matrix metalloproteases (MMPs) was enhanced in the FLS from chronic mice compared to samples from acute ones. Additional functional differences include the collagen-destructive potential and the potential to attach and eventually invade wild type cartilage. Here, FLS from Treg-depleted chronic arthritic mice showed a higher invasive and destructive potential. Ultimately, FLS from Treg-depleted mice were able to destroy cartilage in immunodeficient mice. Conclusion. Our results are compatible with the hypothesis that uninhibited inflammation in the early phase of Treg-depleted mice causes the acquisition of an autonomously aggressive phenotype of synoviocytes which contribute to the switch from acute to chronic arthritis even in the absence of late support from T and B lymphocytes.

Collagen-induced arthritis modulates reactivity to sympathetic neurotransmitter stimuli during osteoclastogenesis of bone marrow-derived macrophages from DA rats Background. Osteoclast(OC)-mediated bone destruction contributes to increased disease burden in Rheumatoid Arthritis. Simultaneously, changes in synovial tissue innervation occur, leading to a reduction in catecholaminergic nerve fibres. Studies on sweat gland innervation revealed that catecholaminergic fibres are capable of phenotypic transition to cholinergic nerves. The sympathetic neurotransmitters norepinephrine (NE) and acetylcholine (ACh) affect osteoclastogenesis oppositely prompting us to study osteoclastogenesis at different phases of collagen-induced arthritis (CIA) in an altered neurotransmitter microenvironment. Methods. For induction of experimental arthritis, DA rats were immunized with bovine collagen type II while controls received isotonic NaCl solution. To generate OC, bone marrow-derived macrophages (BMM) were isolated and differentiated with recombinant M-CSF and Rank ligand. The influence of NE and ACh stimulation on osteoclast differentiation and activity was compared between arthritic and control animals at the acute (20 days post immunization, pI) and the chronic (40 days pI) disease state. As the nicotinic α7 ACh receptor subunit is involved in the cholinergic anti-inflammatory reflex, we also applied a specific agonist, ARR-17779. Additionally, the gene expression profile for NE and ACh neurotransmitter receptors was analyzed. Results. ACh stimulation generated significantly more osteoclasts in controls (40 days pI). ARR-17779 mediated effects were similar to ACh. NE decreased osteoclastogenesis via β-adrenoceptors and enhanced via α-adrenoceptor stimulation. Cells from arthritic animals were less affected by NE and ACh stimulation.OC from arthritic animals showed tendentially decreased activity in an enzymatic cathepsin K activity assay. ACh and ARR-17779 stimulation decreased cathepsin K activity 20 days pI, but the effect disappeared 40 days pI, representing the chronic arthritis state. NE stimulation significantly inhibited enzyme activity 20 days pI, but has little effect under chronic conditions. The receptor gene expression profile changed in the time course of arthritis. 20 days past immunization muscarinic ACh receptors M3 and M5 were significantly upregulated whereas after 40 days adrenoceptors α1D and α2B were significantly downregulated. Conclusion. We conclude that CIA differentially modulates neurotransmitter influence during OC differentiation and activation but the underlying processes remain still unknown. The observed time pointdependent changes in neurotransmitter receptor gene expression may constitute a regulatory mechanism to counteract alterations in the local neurotransmitter composition. Background. The generation of memory T lymphocytes allows effective and fast immune responses during antigen re-challenge and represents a hallmark of adaptive immunity. Previous work from our group has demonstrated that murine memory CD4+ T cells reside in specific bone marrow niches and are characterized by the high expression of CD69 and Ly-6C. These cells were designated as resting in the context of gene expression and proliferation. Here, we aimed to phenotypically and functionally characterize human memory T lymphocytes in peripheral blood and bone marrow of healthy individuals. Methods. Mononuclear cells were isolated from paired blood and BM samples from individuals undergoing hip replacement surgery. Phenotypic analysis and cytokine profile of distinct memory T cell subsets were assessed by flow cytometry. Proliferation and cell cycle status were analyzed using Ki-67 and propidium iodide (PI) staining, respectively. Results. Distinct populations of CD69-expressing CD8+CD45RA-and CD4+CD45RA-T cells were detected in bone marrow but not in the periphery. CCR7 and CD62L expression was reduced on bone marrow CD69+CD4+CD45RA-and CD69+CD8+CD45RA-T cells compared to their CD69-counterparts in bone marrow and peripheral blood. Cell cycle analysis and Ki-67 expression levels demonstrated the nonproliferative state of bone marrow memory T cells. Furthermore, bone marrow resident memory T cells showed reactivity against various pathogenic agents, such as tetanus, measles and CMV. Conclusion. We have identified a population of CD69-expressing CD8+CD45RA-and CD4+CD45RA-T cells in the bone marrow. Despite CD69 expression, which is generally regarded as early activation marker, the cells were resting in terms of proliferation. Bone marrow CD69+ memory T cells have downregulated CCR7 and CD62L indicating reduced homing capacity to secondary lymphoid organs. Our data underline the role of the bone marrow as a major reservoir for resting memory T lymphocytes. therapeutic methods exerted an influence on satisfaction and future expectations in patients with rheumatoid arthritis (RA).

Methods. When visiting their rheumatologist, patients with RA were asked to complete a questionnaire at home after the consultation and then return it to an independent opinion research centre, where the data was collected and analysed. The form comprised various areas, namely demography, aspects of the diagnosis, medical care, therapeutic measures, and the illness in a personal context. Results. 127 Patients (122 females/25 males) from the whole of Austria with a particular emphasis on Lower Austria, Upper Austria and Tyrol completed the questionnaire (of 150 distributed), resulting in a response rate of 85%. 63% of the patients lived in settlements of under 5,000 inhabitants; a further 18% in settlements of under 50,000 inhabitants.. The rheumatologist attended could be reached within one hour for 90% of the patients and within 30 minutes for 41%. In slightly fewer than 30% of the respondents the diagnosis was made within three months, in 44% within six months. In 75%, the diagnosis was made by a rheumatologist. After experiencing the first symptoms, 80% contacted their general practitioner. A high degree of satisfaction appears to originate from the information supplied by the rheumatologist attended. Most patients felt they were involved in decisions regarding their therapy. 77% of the respondents were employed prior to their illness; as a consequence of the disease 27% had to leave their jobs. Conclusion. The majority of the respondents came from rural areas. The correct diagnosis was made within six months for almost half of the patients questioned. Most patients felt well informed by their rheumatologists and involved in therapeutic decision-making. , combinational therapy of synthetic DMARDs (9.6; 5.1-14.1), and biological-monotherapy (6.07; 0-13). All of these differed significantly on later observation periods. Comparing the prescriptions separately by sequential treatments there were no differences in retention rates for the individual DMARD classes. Regarding retention, in the first treatment synthetic DMARDs showed the longest retention, but from the second on this was the case for TNFi-combinational treatment and non-TNFi-biologicals (. Abb.12) Conclusion. Traditional DMARDs are the starting point of therapy and MTX is the anchor drug for the first and all subsequent courses. Already at the second sequential course, the combination therapies of MTX+TNFi become numerically more relevant, and their retention is better than MTX. 

Therapie der rheumatoiden Arthritis im letzten Jahrzehnt -was hat sich verändert? Abb.13 | EV.198 Anzahl eingeschlossener Patienten nach Einschlussjahren und Therapie sowie zeitlichen Entwicklungen im DAS28 und der EULAR-Response cal features of RA (erosive arthritis with classical radiological features) plus specific laboratory markers (CCP-antibodies). The third patient, a 48-year-old female presented initially with features of RA and SLE simultaneously (alopecia, subcutaneous nodules, leucopenia, positive CCP-antibodies, high titres of ANA and DNA-antibodies). The fourth patient, a 40-year-old patient presented with severe polyarthritis in the upper and lower limbs, subcutaneous nodules, fever and cervical lymphadenopathy, she had high titres of CCP-antibodies (170 U/ml by a normal range of less than 5 IU/ml), ANA of 5120 (normal less than 80), and DNA of 290 IU/ml (normal less than 100 IU/ml). Conclusion. The take home massage of this presentation is to be aware of Rhupus if the SLE patient develops erosive arthritis or subcutaneous nodules, or if the RA patient develops features of SLE like leucopenia, active urine sediment, or clinically significant serositis. Rhupus seems to be a distinctive entity and should be kept in mind while dealing with patients having RA or SLE as it can affect the treatment and outcome. Vorgeschichte. Bei der Abklärung eines akuten Thoraxschmerzes sind auch seltene Ursachen, so zum Beispiel der Einbezug thorakaler Organe in eine entzündliche Systemerkrankung, zu bedenken. Anhand eines besonderen Falles möchten wir den Weg zur Diagnose bei einem schwer kranken Notfallpatienten zeigen. Leitsymptome bei Krankheitsmanifestation. Ein 57-jähriger Mann wird bereits zum dritten Mal mit akuten Thoraxschmerzen in die Notaufnahme aufgenommen, jeweils war eine kardiale Ischämie ausgeschlossen und ambulante Diagnostik empfohlen worden. Nach der Schmerzcharakteristik, der Vorgeschichte von rezidivierenden Thoraxschmerzen und entsprechenden Risikofaktoren wird bei massiver Symptomatik jetzt von einem akuten Koronarsyndrom ausgegangen und die invasive Diagnostik durchgeführt. Eine akute koronare Ischämie kann jedoch ausgeschlossen werden. Fieber, hohe Entzündungszeichen, Hinfälligkeit und Gewichtsverlust von mehr als 10 kg in den letzten Wochen lassen dann eine infektbedingte oder tumorbedingte Ursache vermuten, Abdomensonographie und Röntgen-Thorax sowie ausführliches Labor samt Immunologie führen nicht weiter. Wegweisende weitere Organbefunde finden sich nicht. Die Behandlung mit Antibiotika hat keinerlei Effekt auf Klinik oder Entzündungsparameter. Nach 3 Tagen wird der Krankheitsverlauf kritisch evaluiert, eine nichtinfektiöse Ursache der Beschwerden wird in Betracht gezogen, eine transösophageale Echokardiographie wird zum Ausschluss einer Endokarditis und zur Beurteilung der Aorta (Leitsymptome Thoraxschmerzen und Fieber!) durchgeführt. Dabei zeigen sich die Klappen sämtlich unverdächtig, die Aorta ascendens weist eine massive echoarme Wandverdickung auf. Zum sicheren Ausschluss eines intramuralen Hämatoms wird sofort eine CT der thorakalen Aorta durchgeführt, die eine ausgeprägte zirkuläre Wandverbreiterung ohne Hinweise auf Dissektion zeigt. Diagnose. Riesenzellarteriitis mit Aortitis. Therapie. Steroide, Einleitung einer remissionsinduzierenden Therapie mit Cyclophosphamid Boli. Weiterer Verlauf. Innerhalb von 2 Tagen ist der Patient beschwerdefrei, die Entzündungsparameter sind halbiert, der bettlägerige Patient lässt sich mobilisieren und verlässt nach 10 Tagen die Klinik. Bei der Diffe-renzialdiagnose des akuten Thoraxschmerzes sollten eine unklare Entzündungsserologie und eine B-Symptomatik frühzeitig an eine Aortitis denken lassen. In diesem Fall fand sich bereits in TEE und CT ein ausgeprägter Befund, der sich am ehesten durch den langen Verlauf vor Diagnosestellung erklären lässt. Einleitung. Die progressive familiär intrahepatische Cholestase (PFIC) gehört zu einer heterogenen Gruppe seltener, autosomal rezessiv vererbter Erkrankungen der Gallensäurenexkretion mit intrahepatischer Cholestase, hohem Risiko der Leberzirrhose bereits im Kindesalter und hepatozellulärem Karzinom. Das Auftreten eines SLE bei PFIC ist bisher in der Literatur nicht beschrieben. Methoden. Wir berichten über eine jetzt 23-jährige Patientin mit genetisch gesicherter PFIC-2 (Defekt der ATP abhängigen Gallensalz-Exportpumpe BSEP), Biliostomaanlage im Kindesalter, Therapie mit UDCA und kontinuierlicher hepatologischer Betreuung. 12/2011 manifestierte sich ein SLE mit AZ-Minderung, florider Polyarthritis, Polyserositis, Splenomegalie, Anämie und Leukozytopenie. Die ANA waren mit >1:5120 homogen erhöht, die DNS-AK im ELISA mit 6738 U/ml, ENA und Antiphospholipid Antikörper waren negativ. Eine Steroidtherapie wurde mit Prednisolon 30 mg/Tag begonnen. Bei guter Verträglichkeit und stabilen Cholestaseparametern wurde die Therapie um Chloroquin mit 250 mg an 3 Tagen der Woche ergänzt. Die Betreuung wurde interdisziplinär fortgesetzt. Ergebnisse. Unter der Steroidtherapie waren Gelenkbeschwerden und Serositis gebessert, das CRP, die Leukozytopenie und Anämie normalisiert. Die DNS-Antikörper fielen auf 1977 U/ml, C3 und C4 stiegen um 20%. Es persistierten lediglich physiotherapeutisch behandelte muskuläre Schmerzen und Schonatmung nach Pleuritis. Bei Steroidreduktion unter 10 mg traten die Gelenkbeschwerden wieder auf, die DNS-Antikörper stiegen auf 4549 U/ml und C3/C4 fielen um 10%, das CRP blieb normal. Die Steroiddosis wurde auf 15 mg/Tag und die Chloroquindosis auf 5×250 mg/Woche erhöht. Neue Organkomplikationen im Rahmen des SLE sind nicht aufgetreten. Die Gallensäuren waren mit 47 µmol/l (Norm <8) im Jahr 2009 (letzte Messung vor Manifestation des SLE) deutlich erhöht, bei Manifestation des SLE mit 12 µmol/l bereits deutlich gebessert und unter hoch dosierter Steroidtherapie mit 4,7 µmol/l nach 1 Woche sowie 5,4 µmol/l nach 1 Monat normalisiert. Unter Prednisolon 15 mg/Tag stiegen sie bei inaktiviertem SLE auf 15 µmol/l nach 4 Monaten an, bei Steroidreduktion unter 10 mg auf 69 µmol/l. Nach erneuter Steroiddosiserhöhung auf 15 mg Prednisolon/Tag fielen sie auf 12 µmol/l ab. Schlussfolgerung. Die PFIC-2 schützt nicht vor der Manifestation eines SLE. Eine Behandlung mit Steroiden und Chloroquin ist auch bei PFIC sicher und wirksam. Der floride SLE und die höher dosierte Steroidtherapie senken trotz bestehenden genetischen Defekts unabhängig voneinander und synergistisch die Gallensäurenspiegel im Serum bei genetischer Störung der ATP-abhängigen Sekretionspumpe BSEP. Augenentzündungen. Eine ausgeprägte B-Symptomatik mit Fieber, Nachtschweiß und Abgeschlagenheit seit ca. zwei Jahren hatte sich jeweils unter der Therapie der Hörstürze verflüchtigt. Die MR-Angiographie der Aortenwand zeigte den typischen Befund eines ausgeprägten Wandenhancements der thorakalen Aortenwand sowie der supraaortalen Gefäße, duplexsonographisch fand sich eine zirkuläre Wandverdickung der proximalen und mittleren ACC beidseits ohne relevante Stenosen. Bei fehlendem Nachweis zerebraler vaskulitischer oder embolischer Veränderungen im kraniellen MRT und bei normalem EEG wurde der cerebrale Krampfanfall als Gelegenheitsanfall DD im Rahmen der hochaktiven Grunderkrankung interpretiert. Diagnose. Takayasu-Arteriitis mit assoziiertem Cogan-Syndrom und rezidivierender Polychondritis. Therapie. Steroidstoß, darunter rasche Reduktion der Entzündungszeichen und promptes Ansprechen der B-Symptomatik, Beginn einer steroidsparenden Therapie mit MTX. Bei anhaltender Krankheitsaktivität und hohem Steroidbedarf wird der Patient aktuell mit Tocilizumab behandelt. Schlussfolgerung. Der präsentierte Fall zeigt, dass mittels neuer bildgebender Verfahren gelegentlich eine Großgefäßvaskulitis detektiert werden kann, obwohl das klinische Bild (hier: Kopfklinik) eine Kleingefäßvaskulitis vermuten lässt. Das Cogan-Syndrom ist häufig mit einer Großgefäßvaskulitis assoziiert, in diesem Fall auch mit einer Polychondritis. Umgekehrt erweitert sich unser Wissen um das Befallsmuster der Großgefäßvaskulitiden, die zwar überwiegend große, aber auch mittelgroße und kleine Gefäße einbeziehen können. In unserem Zentrum ist dies der zweite Fall einer Takayasu-Arteriitis mit assoziiertem Cogan-Syndrom in einem Kollektiv von 8 Fällen. Diagnostik. Im Rahmen einer Vorstellung in unserer rheumatologischen Ambulanz zur Abklärung eines möglichen Sjögren-Syndroms, konnte in der Lungenfunktionsdiagnostik eine leichte Restriktion und Überblähung festgestellt werden. In einem auswärtig durchgeführten MRT der Halsweichteile zeigten sich die Glandula parotis und submandibularis beidseits inhomogen und kräftig kontrastiert, ebenfalls mehrere grenzwertig große Lymphknoten. Aufgrund der erneut pathologischen Lungenfunktion und dem Verdacht auf eine Lungenbeteiligung bei Sjögren-Syndrom erfolgte ein CT-Thorax. Hier zeigte sich eine zysti-sche Rarefizierung vor allem der zentralen Lungenanteile, differentialdiagnostisch mit einer Langerhans-Zell-Histiozytose vereinbar. Auch erschien der Diabetes insipidus passend zur Histiozytose. Die immunologischen Untersuchungen waren unauffällig, insbesondere konnten keine SSA-/SSB-Antikörper oder eine Hypergammaglobulinämie nachgewiesen werden. Somit erschien ein Sjögren-Syndrom unwahrscheinlich. Zur weiteren Abklärung erfolgte eine Bronchoskopie, in den Biopsaten konnte immunhistochemisch eine Langerhans-Zell-Histiozytose nachgewiesen werden. In einer pathologischen Nachuntersuchung auswärtiger Parotis-Biopsate bestätigte sich diese, zudem konnte eine Mutation des BRAF-Proto-Onkogens nachgewiesen werden. Im abschließend durchgeführten PET-CT konnte eine vermehrte Kontrastmittelaufnahme des Hypophysenstiels, eine vermehrte Stoffwechselaktivität der Parotis beidseits sowie kutan axillär links diagnostiziert werden. Abschließend lag somit eine Langerhans-Zell-Histiozytose mit Befall von Hypophyse, Lunge, Parotis, Haut, Lymphknoten sowie einem fraglichen Befall des Darms vor. Therapie. In Absprache mit der adulten Langerhans-Zell-Histiozytose Studiengruppe erfolgt nun eine Therapie mit Cytarabin. Weiterer Verlauf. Der weitere Verlauf nach geplantem Therapiebeginn bleibt abzuwarten. Einleitung. Die Anti-GBM-Erkrankung (Goodpasture-Syndrom) ist eine prototypische Autoimmunerkrankung mit ernster Prognose, wenn sie als "pulmorenales Syndrom" mit der Trias rapid-progressive Glomerulonephritis, alveoläre Hämorrhagie und Nachweis von Autoantikörpern gegen glomeruläre Basalmembranen (anti-GBM-AK) auftritt. Über weniger aggressive Verläufe ist wenig bekannt. In der Literatur wird die Bedeutung der frühen Diagnosestellung für die Prognose der Patienten betont. Wir berichten über eine 36-jährige Patientin, die sich mit Abgeschlagenheit, Müdigkeit und Blutbeimengungen im Sputum vorstellt. Sie betreibt einen Nikotinabusus. Methoden. Wir sehen eine blasse Patientin (Hb 4,0 mmol/l, normochrom, normozytär), die keine weiteren auffälligen Befunde in der körperlichen Untersuchung zeigt. Die apparative Diagnostik mittels Endoskopie und Sonographie ergibt keine Befunde, die die Anämie erklären können; in der Bronchoskpie zeigt sich das Bild einer alveolären Hämorrhagie ohne aktive Blutungszeichen. Neben der ausgeprägten Anämie bestehen eine milde Proteinurie mit 300 mg/d sowie eine geringe Erythrozyturie. Die immunologische Diagnostik ergibt gering erhöhte anti-GBM-AK, negative ANA und ANCA. Die Nierenbiopsie zeigt eine rapid-progressive Glomerulonephritis mit Halbmondbildung in einem Glomerulum, zusätzlich können lineare IgG-Ablagerungen in der Immunfluorenz dargestellt werden. Es ist ein Glomerulum in der Biopsie betroffen, die anderen Glomeruli sind unauffällig. Es bestehen einzelnen Erythrozytenzylinder, diffuse Entzündungszeichen lassen sich nicht nachweisen. Die nachträglich durchgeführte Immunfluoreszenz in der Lungenbiopsie bestätigt den Befund linearer IgG-Ablagerungen. Ergebnisse. In unserem Fall sehen wir eine junge Patientin in einem relativ guten Allgemeinzustand mit gering erhöhten anti-GBM-Antikörpern und einer gering ausgeprägten Nierenschädigung mit einem befallenen Glomerulum in der Biopsie. Es wird angesichts des jungen Alters der Patientin und der geringen Ausprägung der Erkrankung eine Therapie mit Cyclophosphamid nach dem "Euro-Lupus-Protokoll" von F. Hossiau eingeleitet. Im Verlauf steigt der Hb auf 5,6 mmol/l, die alveoläre Hämorrhagie sistiert und die Proteinurie ist rückläufig. Schlussfolgerung. Das Goodpasture-Syndrom mit einer Inzidenz von 0,5-1,0/1 Mio. Einwohner und Jahr ist eine sehr seltene Autoimmunerkrankung mit ernster Prognose. Möglicherweise spielen Umweltfaktoren (hier: Nikotinabusus) eine Rolle für die Manifestation der Erkrankung. Interessant ist, dass die Erstbeschreibung im Rahmen einer Influenza-Epidemie -wie auch in diesem Jahr bei unserer Patientinerfolgte. Über die Therapie gibt es wenige Informationen. Die meisten Empfehlungen gibt es zum pulmorenalen-Syndrom, über weniger aggressiv verlaufende Manifestationen gibt es nur wenige Informationen. Einleitung. Wir berichten über einen 46-jährigen Raucher mit akut aufgetretener Polyarthritis und neu aufgetretenem Raynaud-Phänomen. Auffallend war die Diskrepanz zwischen nur geringer systemischer Entzündungskonstellation und einer hochaktiven Polyarthritis mit schwerem Raynaud-Phänomen. Im Verlauf kam es zu einer spontanen Thrombophlebitis der V. cephalica. Methoden. Pathologische Werte: CRP maximal 1,4 mg/dl (Norm <0,6), Zellzahl im Gelenkpunktat 20.000 Leukozyten/µl. Im Normbereich lagen: BSG 12 mm/1 h, ANA, ENA, ds-DNS-AK, Rheumafaktoren, ANCA, Kälteagglutinine, Kryoglobuline, Tumorsuche initial ohne Befund (CT-Thorax, Bronchoskopie, CT Abdomen und Becken, Coloskopie, Gastroskopie, Skelettszintigraphie), FDG PET-CT: zwei suspekte Lymphknoten rechts cervical sowie suspekte rechte Tonsille. Ergebnisse. Selbst unter 60 mg Prednisolon weiterhin hochaktive Polyarthritis. Nach unauffälliger initialer Tumorsuche veranlassten wir ein FDG-PET CT mit Nachweis zweier suspekter Lymphknoten rechts cervical sowie einer suspekten rechten Tonsille. Die Biopsie der klinisch sich nur in der Palpation diskret induriert darstellenden Region ergab ein gering differenziertes, gering verhornendes Plattenepithel mit 98%iger Sequenzhomologie mit HPV Typ 16. Nach Resektion des Tumors und Radiatio sistierten sowohl die Polyarthritis als auch das Raynaud-Phänomen ohne weiteres Rezidiv auch nach Absetzen der Glukokortikoide.

Schlussfolgerung. Eine akut auftretende hochaktive Polyarthritis mit hohem Glukokortikoidbedarf in Kombination mit einem Raynaud-Syndrom, auffallend niedriger systemischer Entzündungsaktivität und fehlendem Autoantikörpernachweis sollte insbesondere bei einem langjährigen Raucher Anlass zu einer intensiven Tumorsuche geben. Ein FDG-PET-CT kann bei okkulten Tumoren zielführend sein. Bemerkenswert ist hier der Nachweis von HPV-16 im Tumor als weiterer Risikofaktor neben dem Zigarettenrauch. Methoden. Bei der klinischen Untersuchung fielen ein beidseits positives Menell-Zeichen und deutlicher Klopfschmerz über dem lumbosakralen Übergang auf. Labordiagnostisch konnte ein erhöhtes C-reaktives Protein und ein positiver HLA-B27 nachgewiesen werden. Der Bath Ankylosing Disease Activity (BASDAI) Index betrug 6,875. Die Beckenübersichtsaufnahme zeigte eine definitive bilaterale Sakroiliitis Grad 3 gemäß den modifizierten New-York-Kriterien. Der Befund der kontrastmittelunterstützten MRT der Iliosakralgelenke bewies das Vorliegen einer bilateralen floriden Sakroiliitis. Bei gesicherter HLA-B27 positiver Ankylosierender Spondylitis wurde die Indikation zur Einleitung einer Biologikatherapie mit einem TNFα-Inhibitor gestellt. Während der Abklärung von Kontraindikationen wurde in der konventionellen Röntgen-Thorax-Aufnahme eine rundliche, glatt begrenzte zystische Läsion mit Flüssigkeitsspiegeln im rechten Mittellappen entdeckt. Die weitere Abklärung mittels nativer Thorax-CT, Bronchoskopie und Biopsieentnahme bestätigte den Verdacht auf eine bronchogene Zyste. Die Erregerdiagnostik in der bronchoalveolären Lavage zeigte lediglich eine Kontamination mit der residenten Standortflora. Ergebnisse. In Anbetracht der geplanten immunsuppressiven Therapie, die mit einem erhöhten Infektionsrisiko einhergeht, wurde die bronchogene Zyste im September 2012 operativ entfernt. Zur Linderung der Beschwerden erhielt die Patientin eine Schmerztherapie mit NSAR. Als sich die Patientin sechs Monate später erneut zur Einleitung der Biologikatherapie vorstellte, berichtete sie, dass die Schmerzen etwa einen Monat nach der operativen Resektion praktisch verschwunden seien. Die klinische Untersuchung war unauffällig, der BASDAI-Index lag bei 1,2. Auch das zur Verlaufskontrolle angefertigte MRT der ISG zeigte im Vergleich zur Voruntersuchung einen deutlichen Rückgang der Floridität. Schlussfolgerung. Es handelt sich um den ersten Fall einer kompletten klinischen und radiologischen Remission einer HLA-B27-positiven ankylosierenden Spondylitis nach operativer Entfernung einer bronchogenen Zyste als potenziellen entzündlichen Fokus. Bei der systemischen Verlaufsform der Erkrankung treten neben kutanen Erscheinungen zusätzlich muskuloskeletale, hämatopoetische (20-60%), renale (ca. 50%), kardiale, cerebrale und pulmonale (4-9%) Manifestationen auf. Eine Polyserositis (11-60%) ist häufig. Mit 8-40% werden im SLE-Schub abdominelle Schmerzen beschrieben. Nur in seltenen Fällen (Amerika 0,9%, Asien 2,2-9,7% aller SLE-Patienten) kommt es zum Bild einer lupusassoziierten mesenterialen Vaskulitis (LMV). Die Ätiologie der LMV ist weitestgehend unklar, eine genetische Präsidsposition sowie auslösende Faktoren (bakterielle Darminfektionen, Medikamente wie NSAR, Phosphodiesterasehemmer) werden diskutiert. Pathogenetisch wird eine mesenteriale Ischämie durch eine Mikroangiopathie (Arteriolen, Venolen) bei inflammatorischer Immunkomplexpräzipitation sowie thrombembolischen Ereignissen angenommen. Radiologisch/sonographisch zeigt sich ein segmentales Darmwandödem mit Darmdilatation. Endoskopisch dominieren oberflächliche Ulzerationen, perifokale Hämorrhagien bis hin zur Gangrän. Eine erhöhte Perforationsneigung wird beschrieben. Mikroskopische Befunde zeigen eine fibrinoide Nekrose subseröser Gefäße mit Leukozytoklasie der Gefäßwand bzw. ein submuköses Ödem mit nur diskreter Invasion mononukleärer Zellen. Die Prognose der LMV scheint abhängig von genetischer Prädisposition, raschem Beginn einer Immunsuppression sowie restriktivem Einsatz operativer Interventionen und wird je nach Literaturquelle mit einer Letalität bis zu 50% angegeben. Background. We report a patient with TMA in the context of SLE treated successfully with the C5 inhibitor Eculizumab. The patient had SLE with lupus nephritis (LN). Before she developed TMA with renal failure and neurologic manifestations, she was treated with various immunosuppressive regimens for mucocutaneous and musculoskeletal manifestations and later for LN. The diagnosis of atypical hemolytic uremic syndrome (aHUS) was made based on the presence of Coombs-negative hemolytic anemia, thrombocytopenia, renal failure, seizures due to cerebral ischemia and signs of TMA in the renal biopsy. Plasma exchange and hemodialysis were started immediately and could stabilize her condition. Six weeks after the beginning of plasmapheresis but still severely compromised renal function and thrombocytopenia, complement inhibition with Eculizumab became a therapeutic option. After the first infusions, renal function, anemia and thrombocyte counts markedly improved. Dialysis could be stopped. Extensive genetic testing of mutations associated with the overactivation of the alternative complement pathway was negative. After 7 months, when the patient was still in remission, eculizumab infusion intervals were widened and it was finally stopped after 12 months of treatment. Since then, renal function remained stable with nearly normal glomerular filtration rates. Background. IL-6 signaling plays an important role in inflammation but is restricted by different regulatory mechanisms. These mechanisms include the decreased availability of gp130, the signal transducing chain of the IL 6 receptor, on the cell surface. The aim of this study was to determine whether the inflammatory environment in the arthritic joint has an impact on monocytic gp130 surface expression and the extent to which regulatory processes in the synovial fluid (SF) can be transferred to an in vitro model.

Flow cytometry and live cell imaging were used to measure the cell surface expression and internalization of gp130. STAT3 phosphorylation was monitored by flow cytometry and western blotting.

Results. The level of cell surface gp130 expression on SF monocytes was reduced compared to peripheral blood (PB) monocytes from patients with juvenile idiopathic arthritis (JIA). This reduction could be reproduced by stimulating PB monocytes from healthy donors with SF and was dependent on p38 MAPK. The induction of p38 by IL-1β in PB monocytes interfered with IL-6 signaling due to the reduced cell surface expression of gp130.

The results suggest that p38-mediated pro-inflammatory stimuli induce the downregulation of gp130 on monocytes and thus restrict gp130 mediated signal transduction. This regulatory mechanism could be relevant in the inflamed joints of patients with JIA.

KR.08 SJIA patient characteristics of those who successfully discontinued corticosteroids during Canakinumab treatment: secondary analysis from a pivotal phase 3 trial Background. Interleukin-1β (IL-1β) is a key driver in the pathogenesis of systemic juvenile idiopathic arthritis (SJIA). Canakinumab (CAN), a selective fully human anti-IL-1β monoclonal antibody, has been shown to be efficacious in the treatment of SJIA [1] . Corticosteroids (CS) are a mainstay of therapy for SJIA, however due to the well-known long-term side effects, reduction of CS dosage is desirable. Objectives. To assess patient features associated with CS discontinuation during CAN therapy. Methods. Patients (2-19 years of age) with active SJIA received s.c. CAN (4 mg/kg to 300 mg max) every four weeks during the maximum 20week CS-tapering phase [1] . CS tapering was to be initiated when at least an adapted ACR50 was achieved and no fever. A 12-year-old boy presented with nocturnal tingling paresthesia affecting his feet and his calves. No excessive leg movements were noted at night. Within a few months, his symptoms worsened. The paresthesia occurred both during the day and at night. Moreover, the paresthesia came to be triggered by merely standing up. Affecting a sharply demarcated area not corresponding to dermatomes, symptoms resolved promptly with movement. The paresthesia was associated with local skin erubescence in spots that slowly began spreading all over the affected area. Symptoms did not occur while the patient was seated. Mild painless swelling around both of the ankles was noticed in the evenings. Approximately one and a half years after the initial manifestation, painful triphasic color changes of all fingers and toes triggered by cold or stress occurred. The family history was positive only for psoriasis. Extensive laboratory studies excluded inflammatory and hematological conditions as well as occlusive arterial diseases known to be associated with secondary Raynaud's phenomenon. Polyneuropathy and other neurological disorders were excluded as well. Inflammatory joint disease suspected from the initial imaging with magnetic resonance of the feet and ankles was not confirmed by repeated investigations and scintigraphy. The only consistent abnormality was a reduced pulse amplitude corresponding to vasospasm, which was revealed by photoplethysmography of toe vessels. Additionally, paradoxical amplitude reduction after application of nitroglycerine was seen in finger vessels. Placing his hands or feet in cold water did not trigger Raynaud's phenomenon. Initial treatment with non-steroid anti-inflammatory drugs, topical isosorbiddinitrate and local steroid instillation (suspicion of inflammation of tibialis posterior tendon) was ineffective. Systemic therapy with the calcium channel blocker amlodipine was initiated. The initial dosing of 5 mg (0.09 mg/kg/day) was slowly increased to 15 mg (0.27 mg/kg/day) which lead to complete resolution of the patient's ailments. After three years of pharmacotherapy and 1.5 years in remission, a weaning off the treatment is planned. Based on the patient's positive response to calcium channel blocker, we conclude that the lower-leg paresthesia was of vascular origin and can be considered an atypical presentation of Raynaud's phenomenon. Background. The initial treatments of choice for JDM are high-dose corticosteroids and methotrexate. However, no consensus exists about second line therapeutic options in refractory or recurrent cases. Results. We present a 9-year-old boy who was diagnosed with JDM due to severe proximal muscle weakness, dysphagia, a heliotrope rash, Gottron's sign, nail teleangiectasia and a characteristic muscle biopsy. Creatine kinase levels were within normal range and no antinuclear antibodies were present. Over a period of seven years, the patient was treated with high-dose corticosteroids, methotrexate, intravenous immunoglobulins, oral steroids, mycophenolate mofetil, rituximab and infliximab. Despite all treatment efforts, skin and muscle inflammation persisted and the boy developed severe subcutaneous calcifications, rendering him wheelchair-bound. As IL-6 production correlates with disease activity in adult and juvenile DM, treatment with tocilizumab (8 mg/kg every 4 weeks) was initiated, leading to a complete resolution of skin inflammation within 6 months. Within 12 months of treatment, the Disease Activity score (DAS) decreased from 16 to 9 (out of 20), the Childhood Myositis Assessment scale (CMAS) increased from 17 to 27 (out of 52) and the Kendall Manual Muscle test (MMT) increased from 60 to 75 (out of 80). In daily life the wheelchair was no longer necessary.

Treatment was well tolerated but accompanied by a moderate increase in liver transaminase activities. Interestingly, therapy with rituximab was associated with a decline in IgM levels only, whereas IgG and IgA stayed markedly elevated. In contrast, following initiation of tocilizumab treatment, IgG levels rapidly declined to normal range, emphasizing the role of the humoral immune system in the pathogenesis of DM. Conclusion. Taken together, treatment of a severely affected JDM patient with tocilizumab was safe, well tolerated and led to a significant improvement in disease activity. Further investigations of IL-6-blocking agents as a treatment option in otherwise therapy-resistant JDM patients are warranted.

Functional capacity of JIA patients with an initial adjustment to an anti-TNF-alpha therapy Background. Thirty three percent of patients with polyarticular JIA are treated with biologics [2] . Despite substantial improvement achieved by anti-TNF-α treatment according to disease activity [1] patients have joint-specific impairments. This factor should be considered when analyzing the functional effects on joint limitations while performing daily activities.

Methods. In a prospective study on polyarticular JIA patients treated with anti-TNF-α therapies plus functional therapies we study the longitudinal effects on joint function. The measurements include 3-d gait analysis (eight Vicon F40 cameras, OMG, London, balance control (S3-check, TST, Großhoeflein), pedobarography (emed plate (4sensors/ cm², Novel, Munich), daily activity assessment (Step Watch, Orthocare Innovations, OK USA), ACR pedi and joint mobility testing. We here present the cross-sectional data of the first 17 Patients (15.0±3.1 yrs, 162.7±14.6 cm, 60.0±17.2 kg, pain-level: 4.8±1.7/10 VAS, active joints: 6.2±5.9, CHAQ: 0.4±0.4). Results. Preliminary results demonstrate that the ability to walk is slightly limited. Patients have a reduced push off power generation within the ankle joint (patients: 3.4±1.4 W/kg; healthy controls: 4.5±0.9 W/ kg). Further on they show limited sensory motor control and stability in comparison to patients with an inactive disease status while performing balance tests (patients: sensory index: 2.9±1.0, stability-index: 3.7±1.1, patients with inactive status: sensory-index: 2.1±0.8, stability index: 3.0±1.0 (p<0.05). Note: lower indices values are better results. Conclusion. It is one of the first studies which show functional joint-specific deficits during every day activities in patients who receive an initial anti-TNFα-therapy. The limited stability and motor control might be due to limited joint integrity in the ankle joint. This is supported by the impaired push off function while walking. The next study step will show possible effects of the anti-TNFα-therapy. Background. The role of sport as a therapeutic tool in treating patients with JIA is becoming more important recently [2] . Effects of exercise therapy are reviewed beneath others by Takken et al. [3] . They state that short-term effects look promising but the effects of long-term studies remain unknown. Methods. The preventive mobility workout (PMW) is a whole body home-exercise-therapy (10 min each day) for patients with an inactive diseases status. It counteracts the deficits which were observed during functional studies in the past [1] . It consists of exercises for muscular strengthening (squads: hamstring to quadriceps ratio), hamstring flexibility (lift and raise), core stability (prone bridge -time-to-failure), shoulder griddle mobility (horizontal extension) and ankle joint integrity (mechanical power while walking . For statistical analysis an Anova was calculated and the level of statistical significance was set to p<0.05. Results. Preliminary results show a group effect of the PMW for the hamstring to quadriceps ratio (h-q-r) for the right side (p<0.05) and a tendency for the left side (p=0.065). The h-q-r for the right side has changed in the tg and cg from 1.6±0.3 to 2.0±0.6 and from 2.1±0.6 to 1.6±0.3, respectively. It has changed for the left side in the tg and the cg from 1.9±0.5 to 1.6±0.3 and from 1.5±0.2 to 1.7±0.3, respectively. All other parameters regarding flexibility or joint integrity show low or no effects.

We have re-tested n=18 out of 75 so far and the PMW training show little training-effects. The preliminary results might be a reasonable proof for long-term effects. A possible reason for the little effects might be that patients are supposed to train every day but the training diaries show that they exercise approximately three times a week.

The authors would like to thank the "Deutsche Kinder-Rheumastiftung" for supporting the study. Conclusion. We will validate these proposed definitions prospectively in a JIA associated uveitis cohort. Based on the results, we will weight these measures to develop an overall scoring system. Background. 6 minute walk is a primary outcome measure in studies in pulmonary hypertension. Currently we have a two of sets of data [1, 2] regarding test results in the 6 minute walk test (6MWT) in healthy children with a large span in the norm values in the different age groups. Aim of the study was to establish norm values for healthy German children for the 6 minute walk test.

Methods. The team of an occupational therapist and a study nurse were visiting schools. Permission from the parents was give before the test. Always just probands from one class were invited to participate. The test were performed according the international guidelines [3] . The demographic data of the probands were collected and the parents filled out a short survey regarding the physical activity and the health condition. Children with chronic diseases, which decrease the stamina were excluded.

Up till now 611probands participated from the age 5 to 14 years. 343 of them were female. The mean 6 minute walk continuously increased with age (. Tab Background. Juvenile idiopathic arthritis (JIA) is the most common chronic disease in pediatric rheumatology which often results in foot impairments [1] . Patients with JIA are reported to have smaller pressure loads underneath the foot while walking [2] . The aim of the study was to analyze the peak plantar pressure distribution of a well described cohort of JIA patients with an active symmetrical ankle joint arthritis and no history of foot involvement. [1] ) wurden in Bezug auf Therapie und Outcome anhand der Wallace-Kriterien beurteilt: "active disease" (AD), "inactive disease" (ID), "clinical remission under medication" (CRM), "clinical remission off medication" (CROM; [2] 

Background. Familial Mediterranean fever (FMF) is one of the most common autoinflammatory diseases (AID). Pathogenomic relevant mutations in the MEFV gene show autosomal recessive inheritance, but co-dominant mutations have been described. We aimed to evaluate correlations between ethnic origin, phenotype and genotype for FMF patients in the German AID-Net-registry. Methods. We used two common scoring systems modified for children (Mor et al., Pras et al.) to assess disease severity in 243 FMF patients of the AID-Net-registry. For the five most frequent mutations, we tested for a correlation of the genotype with the phenotype, mean CRP and ethnic origin, respectively. Furthermore, we evaluated the applicability of the two severity scores for children.

Results. Among the 243 Patients, we detected a total of 433 pyrin mutations and 22 different sequence variants, including one new mutation (p.Gly488Asp). The five most frequent alterations were p.Met694Val (55%, n=238), p.Met680lle (12%, n=52), p.Val726Ala (10%, n=44), p.Glu148Gln (8%, n=34) and p.Met694Ile (2.3%, n=10). Ethnic origin could be determined in 224 cases; the prevailing ancestry was Turkish (83%, n=185), 8% (n=18) were Lebanese. P.Met694Val in homozygous form (30%, n=73) was correlated with a more severe disease activity, based on the score by Mor, as well as with a higher mean CRP (74 mg/l, n=60, 31 mg/l, n=59) compared to patients without this mutation (p=0.01 and p<0.01, respectively). The score suggested by Pras did not yield a significant genotype-phenotype correlation; indeed, the two scoring systems were inconsistent with each other (κ<0.07). Although a typical distribution of mutations in different ethnic populations was obvious, this trend was not statistically significant, probably due to the divergent number of cases. Conclusion. The homozygous p.Met694Val substitution was associated with a more severe disease activity. There was no origin-genotype correlation in this FMF population. The well-known severity scores for children (Mor, Pras) are inconsistent. The AID-Net is working on a new scoring system. 3. All patients with RP should be investigated by capillaroscopy. Capillaroscopy will be classified into "normal", "aspecific changes" or "scleroderma pattern". 4. All patients who have additional symptoms pointing to a definite connective tissue disease should be evaluated according to disease specific guidelines. 5. ANA-negative and capillaroscopy-negative patients should be followed-up at least every 6 months. 6. ANA positive patients without disease-specific antibodies and with negative capillaroscopy findings should be followed-up at least every 6 months. 7. ANA and disease-specific antibody positive patients should have organ specific evaluation according to symptoms, examination and relevant to that particular disease e.g. patients who are ANA and Scl-70 positive may need organ specific evaluation for JSSC as per the juvenile systemic sclerosis inception cohort protocol (www.juvenilescleroderma.com). 8. ANA-positive patients, who have no disease specific antibody but have positive capillaroscopy results, should be followed-up at least every 3 months. 9. ANA-negative patients with positive capillaroscopy result should be followed-up at least every 6 months. 10. The group could not reach an agreement regarding treatment, due to a lack of data for the paediatric age group. The group agreed that implementation of adult recommendations Conclusion. The group made a suggestion for a standard of good clinical practice for RP in children. Our aim is that this will facilitate a large multicentre prospective follow-up study of children with RP. Background. Chronic non-bacterial osteomyelitis (CNO) is an inflammatory disorder of the skeletal system of unknown etiology. Long-term follow-up and response to treatment data have rarely been reported. The aim of the study was to characterize the clinical, radiological, histological and laboratory data at juvenile CNO onset, and to analyze the long term treatment response.

Methods. The course of disease of 95 juvenile patients with non-bacterial inflammatory bone lesions was evaluated retrospectively. Clinical, radiological, histological and laboratory data were assessed at disease onset and for a median time of disease of 40 months. Results. The mean age at disease onset was 11.7 years, the mean time between the first symptoms and the diagnosis of CNO was 9 months. 84% of the patients had multifocal bone lesions. Biopsy was performed in 80 Patients. Only when bone biopsy was taken within 12 months of symptom onset, cellular infiltrates could be observed. At later time points, fibrosis, hyperostosis and bone edema predominated. The initial treatment consisted of non-steroidal anti-inflammatory drugs (NSAIDs). 39% of the patients required second line therapy consisting of sulfasalazine and short term oral corticosteroids, 8% of the patients required bisphosphonates or TNF-blocking agents. The number of clinical lesions decreased to 50% within 3.1 months and reached 18.8% after 24 months of treatment. The number of radiological lesions, however, declined to only 66.5% after 24 months of treatment. In detail analysis of the tre-atment response revealed that initiation of sulfasalazine treatment in NSAID non-responders led to a significant and sustained decline of the clinical, as well as the radiological number of lesions. Conclusion. The rapid clinical improvement in CNO, following initiation of therapy with NSAIDs, is not accompanied by a likewise decrease of the number of radiological lesions. Treatment with sulfasalazine is effective in childhood CNO. Background. Exercise has a wide variety of beneficial health effects. It stimulates bone formation and maintains bone strength as well as decreases the risk of falls. Moreover, exercise at regular intervals is also assumed to positively affect immune functions. Conversely, in more than 50% of the astronauts during/after space flight and under simulated weightlessness immune functions are suppressed. To assess the effects of simulated weightlessness during the 2nd Berlin BedRest Study (BBR-2) on immunological parameters. Furthermore, to compare the effects of two different exercise performances (resistive vibration exercise and resistance exercise without vibration). Methods. 24 physically and mentally healthy male volunteers (20-45 y) experienced 60 days of six degree head down tilt bed rest. They were randomized to 3 groups: resistive vibration exercise (n=7), resistance exercise without vibration (n=8), inactive controls (n=9). Blood samples were taken 2 days before bed rest, on day 19 and 60 after beginning of bed rest. Composition of immune cells was analyzed by flow cytometry. Cytokines and neuroendocrinologic parameters were analyzed by a multiplex suspension array/ ELISA in plasma. General changes over time were identified by paired t-test, exercise-dependent effects by 2-group repeated measurements ANOVA.

Results. For all cases pooled, the number of granulocytes (p<0.05), NKT cells (p<0.01) and hematopoietic stem cells (p<0.01) increased during the study; the concentrations of DHEA (p<0.01) and Eotaxin (p<0.05) decreased. Different impacts of the specific types of exercise on the change over time were shown for lymphocytes, NK cells, NKT cells, Tcell subpopulations and the concentrations of IP-10 and RANTES. Conclusion. We found immobilization/simulated weightlessness to significantly impact immune cell populations, and cytokine and neuroendocrine factor concentrations. Exercise was able to specifically influence immunologic parameters. Interestingly, these changes resemble those found during the aging process. Background. Novel therapies have made remission and low disease activity (LDA) achievable goals in RA. We assessed the impact of treatment with subcutaneous abatacept or adalimumab on these goals and on functional and radiographic outcomes in AMPLE (Abatacept versus adaliMumab comParison in bioLogic-naïvE RA subjects with background methotrexate), the first head-to-head trial of biologics in RA patients with inadequate response to MTX (MTX-IR). Methods. AMPLE is a 2-year, Phase IIIb, randomized, investigator-blinded study. Biologic-naïve RA patients with MTX-IR were randomized to receive 125 mg abatacept weekly or 40 mg adalimumab biweekly, combined with a stable dose of MTX [1] and radiographic non-progression (defined as change in modified Total Sharp Score ≤2.8) were analysed in patients achieving or not achieving remission or LDA at Days 85 or 169. Results. Baseline clinical characteristics of abatacept and adalimumab treatment groups were balanced, as was clinical, functional and radiographic efficacy and safety at Day 365 [1] . The proportions of patients meeting each of the remission criteria or LDA at Day 365 were similar for both groups, but significantly more patients achieved DAS28 (CRP) remission compared to CDAI, SDAI or RAPID3 remission, and the smallest proportion achieved Boolean remission. Compared to remission, a higher proportion of patients achieved LDA. Across all definitions of remission or LDA, >60% of the patients achieving remission at Days 85 and 169 were HAQ responders at Day 365. More than 80% of patients achieving remission or LDA at Days 85 and 169 were radiographic nonprogressors at Day 365. Improvement in physical function and radiographic outcomes were consistent between the two treatment groups in both remission and LDA populations (. Tab.11). Conclusion. Through 1 year, patients treated with subcutaneous abatacept or adalimumab in AMPLE achieved comparable rates of remission and LDA. Similar improvements in physical function and radiographic outcomes were observed. These data help to illustrate the relationship between remission, LDA and functional and radiographic outcomes independent of treatment with subcutaneous abatacept or adalimumab. Background. Previous small studies suggest that responses to some immunizations may be attenuated by intravenous abatacept but remain clinically meaningful [1, 2] . We investigated the magnitude of response to pneumococcal and influenza vaccination in a larger number of patients receiving subcutaneous (SC) abatacept therapy. The objective of the study was to evaluate the antibody response to the standard 23-valent pneumococcal polysaccharide vaccine and the 2011-2012 seasonal influenza trivalent vaccine in adult patients with RA on SC abatacept and background DMARDs.

These multicentre, open-label sub-studies of the 23-valent pneumococcal polysaccharide vaccine and seasonal influenza vaccine enrolled patients in the ACQUIRE (pneumococcal and influenza) or ATTUNE (pneumococcal) studies. Patients were enrolled at any point during their SC abatacept treatment cycle after completion of ≥3 months' abatacept treatment. All patients received fixed-dose SC abatacept 125 mg/week with background DMARDs. A pre-vaccination blood sample was collected and vaccines administered, while continuing background SC abatacept and DMARDs. After 28±3 days, a post-vacci- Background. In real life, dosage increases are common with biologic agents [1] . Intravenous abatacept is administered by patient body weight (10 mg/kg) 2 and 4 weeks after the first infusion and every 4 weeks the-reafter [2] totalling 8 infusions over the first 6 months. No adjustments to this schedule are recommended. Abatacept retention rates, efficacy and safety over 12 months in ACTION (AbataCepT In rOutiNe clinical practice) have been reported previously [3, 4] This study was designed to assess adherence to recommended dosing of abatacept over the first 6 months in ACTION. Methods. ACTION is an ongoing, 2-year, international, non-interventional, prospective cohort of RA patients treated with intravenous abatacept. All patients on abatacept treatment for ≥6 months, and with infusion data available at initiation and at 6 months, were considered in this analysis. Good adherence was defined as correct dose by patient body weight and number of actual-to-recommended infusions within the range 80-120% (i.e. 7-9 infusions). Results. In total, 783/1120 (69.9%) patients received abatacept ≥6 months and had the infusion data available. Most had established RA and failed ≥1 anti-TNF agent (87.5%). Of 774 Patients with body weight data available at initiation, 87.6% received the recommended initial dose, 6.5% a lower dose and 5.9% a higher dose than recommended. Good adherence to the abatacept treatment schedule was found in 670/783 (85.6%) patients. Over 6 months, 34.0% of patients received 7 infusions, 50.1% received 8 infusions and 1.5% had 9 infusions. Change in dosage over time was assessed in 680/774 Patients with data available at both time points. The majority of patients (86.6%) maintained the recommended dosage. 500/680 (73.5%) patients received abatacept at the recommended dose for body weight and at the recommended treatment schedule over 6 months. Conclusion. In the real-world ACTION study, adherence to the recommended abatacept treatment regimen over 6 months was good. Few patients received changes in dose and/or frequency of administration over this time period. Background. In rheumatoid arthritis (RA), synovial fibroblasts (SF) secrete large amounts of IL-6, IL-8 and matrix metalloproteinases (MMPs) which are crucial for cartilage destruction. RASFs are sensitive to the action of cannabinoids and they express cannabinoid receptors type I and II (CB1 and CB2), the vanilloid receptor (TRPV1) as well as endocannabinoid degrading enzymes. Cannabinoids are regarded as antiinflammatory and since anandamide (AEA) is found in RA synovial fluid we investigated how this endocannabinoid affects adhesion, proliferation, and production of inflammatory mediators of RASF.

Methods. Adhesion was assessed by the XCELLigence system. Proliferation was quantified by the amount of incorporated fluorescent dye into cellular DNA. MMP-3 and cytokines were detected by ELISA.

In OASF, AEA dose-dependently decreased the IL-1β induced production of MMP-3 (by 23%) in a TRPV1-mediated manner. IL-6 and IL-8 levels were only weakly modulated. In RASF however, AEA decreased IL-1β induced production of IL-6 (23%), IL-8 (18%) and MMP-3 (20%). The effects of AEA were not inhibited by CB1, CB2 or GPR55 antagonists but were blocked by the TRPV1 antagonist capsazepine. The inhibitory capacity of AEA was enhanced by cyclooxygenase-2 inhibition in RASFs and OASFs, but was unaltered or even slightly reduced by FAAH inhibition. AEA was even more potent in reducing above mentioned mediators when RASFs but not OASFs were incubated under hypoxic conditions and treated with TNF. Furthermore AEA increased adhesion of OASFs and RASFs to fibronectin. Adhesion was modulated by CB1, GPR55, and TRPV1 antagonists. Combined FAAH and cyclooxygenase-2 blocked the stimulatory effect of AEA on adhesion. Proliferation was decreased by AEA in RASFs and OASFs via a cyclooxygenase-2 but not via CB1, CB2 or TRPV1 dependent mechanism. Conclusion. In conclusion, AEA promotes an antiinflammatory phenotype of RASFs and OASFs by activating TRPV1. CB1, TRPV1, and GPR55 act in concert to modulate adhesion of SFs and this is highly dependent on the intracellular concentration of AEA. Additionally, cyclooxygenase-2 metabolites of AEA exert their anti-proliferative effects independent of CB1 and CB2. Fc. It has been reported that lower levels of CZP, compared to ADA or IFX, are transferred from treated mothers to the neonate [1] . This discrepancy may be due to active transport of antibodies across the placenta thought to be mediated by the neonatal Fc receptor (FcRn). However, anti-TNF binding to FcRn, and FcRn-mediated transcytosis have not been studied. The objective of this study is to quantify binding of CZP, IFX, ADA and ETA to FcRn and to measure FcRn-mediated transcytosis.

A Biacore™ assay was used to determine binding of CZP, ADA and IFX to human FcRn. Anti-TNFs were passed over an FcRn-coated chip .MDCK-II cells transfected with human FcRn were used to measure FcRn mediated transcytosis. The anti-TNFs and the control antibody (P146), which possessed a Fc modified to prevent binding to FcRn, were biotinylated to allow visualization. The amount of each anti-TNF transcytosed across the cell layer over 4 hours was measured by MSD assay.

Results. IFX (132 nM) and ADA (225 nM) had high binding affinity to FcRn while the binding affinity of ETA to FcRn was 5-10-fold lower (1500 nM). In contrast, CZP did not bind to the FcRn with any measurable affinity. The levels of transcytosis seen with IFX and ADA were 249.6 ng/mL and 159.5 ng/mL, respectively (mean of 3 experiments). Transcytosis of ETA (81.3 ng/mL) was lower than that of ADA and IFX. In contrast, the level of CZP transcytosis was significantly lower, at 3.2 ng/mL, than that observed with the other anti-TNFs and comparable to the control P146 (5.9 ng/mL). Conclusion. CZP didn't bind to FcRn and thus no FcRn-mediated CZP transcytosis was detected. In contrast, ADA and IFX had a relatively high binding affinity to FcRn and were actively transcytosed. ETA showed lower binding affinity and transcytosis, but FcRn-mediated transport could still be measured. These results explain the previously observed active transport of anti-TNFs across the placenta seen in patients treated with IFX and ADA, whereas only low levels were observed with CZP [1]. Background. Anti-cyclic citrullinated peptide (CCP) status was reported previously as predictive of abatacept response [1] . Predictors of retention with abatacept have not been published previously. This study was designed to identify predictors of abatacept retention after failing ≥1 biologic agent. In rOutiNe clinical practice) is an ongoing, 2-year, international, non-interventional, prospective cohort including patients with RA treated with intravenous abatacept [2, 3] . Patients from Canada, Germany, Greece and Italy, where patient numbers were sufficient to explore between-country effects, were included. At data cut-off (February 2012), all patients had 1-year follow-up (interim analysis). Abatacept discontinuations were reported by the investigator at any time point during follow-up. Socio-demographics, disease characteristics and medical history at abatacept initiation, and previous and concomitant treatments were deemed potential predictive variables. Clinically relevant variables and those with p≤0.2 (univariate analysis) were entered into a multivariate Cox proportional-hazards regression model, adjusted for clustered data from one investigator. Using backwards selection, variables with p≤0.1 were retained in the final model. . There were no interactions or effects of C-reactive protein level, rheumatoid factor status, type of previous anti-TNF failure, infection at initiation and abatacept monotherapy. Sensitivity analysis, including all variables significant in univariate analysis, was consistent. Conclusion. In this first report of real-world predictors of abatacept patient retention, anti-CCP positivity and failing <2 prior anti-TNF agents were associated with higher retention. Differences in retention between some countries may reflect specificities in healthcare systems and populations. Abatacept, a biologic agent with no contraindications or special warnings for cardiac comorbidity, seems to be a good option for these patients.

Weekly subcutaneous abatacept confers comparable onset of treatment response and magnitude of efficacy improvement over 6 months when administered with or without an intravenous abatacept loading dose 109 Zeitschrift für Rheumatologie Suppl 2 · 2013 | Methods. Patients from the intent-to-treat populations of the ACQUI-RE [2] and AMPLE [3] studies randomized to subcutaneous abatacept plus MTX were included. All patients received fixed-dose subcutaneous abatacept 125 mg/week; in ACQUIRE but not AMPLE, patients also received an intravenous loading dose (~10 mg/kg based on weight range) on Day 1. For this post-hoc analysis, assessments included ACR20 and HAQ-DI response (improvement ≥0.3) over 6 months, with patients who discontinued considered non-responders. Mean changes from baseline over 6 months in DAS28 (CRP) were assessed in patients with DAS28 >5.1 at baseline (last observation carried forward) to account for differences in baseline disease activity between the two studies. Results. All patients were biologic naïve at baseline, with mean disease duration of 7.6 and 1.8 years, DAS28 (CRP) 6.2 and 5.5, and HAQ-DI 1.72 and 1.5 in ACQUIRE and AMPLE, respectively. Efficacy was compared throughout the study. For patients treated with subcutaneous abatacept with and without an intravenous loading dose, ACR20 response rates were similar (. Tab.18). HAQ-DI response rates were also similar with and without the intravenous loading dose (. Tab.18). For the overall populations, mean (standard deviation [SD]) changes from baseline to Day 169 in DAS28 were −2.57 (1.30) and −2.09 (1.38) in ACQUIRE and AMPLE, respectively. For patients with baseline DAS28 >5.1, mean (SD) changes in DAS28 from baseline to Day 169 were −2.65 (1.29) and −2.49 (1.35) in ACQUIRE and AMPLE, respectively. Conclusion. Time to onset and magnitude of ACR20 and HAQ-DI responses and DAS28 improvements were generally similar with subcutaneous abatacept with or without intravenous loading in patients with RA and an inadequate response to MTX. The findings from this posthoc analysis suggest that subcutaneous abatacept can be given effectively without an intravenous abatacept loading dose. Background. RA is associated with pain and impairment of physical function, significantly impacting a patient's health-related quality of life (HRQoL) and ability to perform daily activities. Patient-reported outcomes (PROs) related to HRQoL and daily activity have become an essential part of assessment in RA. We continue to report here comparative findings from PROs assessed with subcutaneous abatacept or adalimumab on background MTX in the first head-to-head study, AMPLE. We compared changes in PROs at 1 year in patients with RA treated with abatacept or adalimumab, both on background MTX. Methods. AMPLE is a Phase IIIb, randomized, investigator-blinded study of 24 months' duration. Biologic-naïve patients with active RA and inadequate response to MTX were randomized to either 125 mg abatacept weekly or 40 mg adalimumab biweekly in combination with MTX. PROs evaluated through Day 365 included: HRQoL, assessed using Short Form-36 (SF-36; including Physical and Mental Component Summary subscores [PCS and MCS]); activity limitation over the previous 30 days, using the Activity Limitation Questionnaire (ALQ; [1] ); productivity, using the work productivity and activity impairment questionnaire for RA [2] ; physical and psychosocial independence, captured using items from HAQ, SF-36 score; and ALQ [3] . Other PROs previously reported from AMPLE include: patient pain, patient global assessment, fatigue, and physical function [4] . All efficacy analyses were done using the intent-to-treat population, which included all patients who were randomized and received at least one dose of study drug. Baseline characteristics were analysed descriptively and changes in PROs from baseline were assessed using ANCOVA. Results. Baseline demographic and clinical characteristics of the abatacept and adalimumab treatment arms were similar. Improvements in all domains of the SF-36, including PCS and MCS observed at Day 

Parameter Baseline Woche16 Woche32

ITT-Gesamt DAS28, MW ± SD 5,7±1,0 (n=507) 2,6±1,3 (n=423) 2,7±1,4 (n=150) VAS DA Pat., MW ± SD 63,3±20,6 (n=509) 26,3±22,5 (n=429) 28,9±25,3 (n=155) SJC28, MW ± SD 8,3±4,9 (n=509) 3,2±3,6 (n=425) 3,0±3,9 (n=152) VAS Schmerz, MW ± SD Zielsetzung der OLE-Studie beinhaltete die Beurteilung der Verträglichkeit und der Wirksamkeit von CZP. Die Retentionsraten sowie die Wirksamkeit wurden bis Woche 280 und die Verträglichkeitsdaten bis Woche 364 beobachtet. In die Verträglichkeitsanalyse wurden alle Pat einbezogen, die in die OLE-Studie eintraten und CZP erhielten (N=402; n=276 Kombitherapie; n=126 Monotherapie), einschließlich der Plazebo/CZP-Patienten, die die Ausgangsstudien erfolgreich abgeschlossen/abgebrochen haben. Bezüglich der Wirksamkeit wurden folgende Analysen vorgenommen: 1) CZP Pat, die die Ausgangsstudien erfolgreich beendet haben und zu irgendeinem Zeitpunkt während der Ausgangsstudien oder OLE-Studie andere DMARDs eingenommen haben (n=123; Kombitherapie Completer); 2) CZP Pat, die die FAST4WARD Studie erfolgreich beendet haben und zu keinem Zeitpunkt andere DMARDS eingenommen haben (n=48; Monotherapie Completer). Ergebnisse. Verteilung und Häufigkeit der unerwünschten Ereignisse (UE), einschließlich der Reaktionen an der Injektionsstelle (Ereignisse/100 Patientenjahre: Monotherapie 1,4, Kombitherapie 0,9) und der schwerwiegenden unerwünschten Ereignisse (SUE) waren mit dem vergleichbar, was bisher für CZP berichtet wurde (. Tab.21) . Das Auftreten von schwerwiegenden Infektionen (SI) und Malignitätsraten war niedrig. Es wurden 11 Todesfälle berichtet: 7 kardiovaskuläre Ereignis-se, 2 Infektionen, 1 Unfall und 1 Tumorerkrankung. Die Retentionsraten der Pat, die die Ausgangsstudien erfolgreich beendet haben, waren zur W280 in der CZP Monotherapie-(24/48, 50%) und der CZP Kombitherapie-Gruppe (67/123; 55%) vergleichbar. Der durchschnittliche DAS28-3(CRP)-Wert und dessen Abweichung vom Baseline-Wert der Ausgangsstudien zum Zeitpunkt des Eintrittes in die OLE-Studie und nach 280 W der Monotherapie-Completer und der Kombitherapie-Completer, sowie die zugehörigen HAQ-Werte sind in . Tab.22 dargestellt. Schlussfolgerung. Vorliegende OLE-Studie konnte das günstige Risiko-Nutzen-Profil der CZP-Monotherapie bestätigen. Die Langzeitwirksamkeitsdaten zeigten keine Unterschiede zwischen Pat, die CZP als Monotherapie erhielten und Pat, die CZP in Kombination mit anderen DMARDS erhielten. Background. Rheumatoid arthritis (RA) is the most common disease of joints that non-or deficiently treated leads to functional loss and premature cardiovascular death within years. But nearly 50% of the RA patients fail to treatment with TNFα-inhibitor (TNFi) indicating a switch to Rituximab (RTX). The urgency of personalized promising treatment in time presupposes predictive parameter. Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs; especially ACCP) are shown to be better diagnostic than less theranostic biomarkers. In that context we investigated the role of antibody subtypes against mutated citrullinated vimentin (AMCV) that determine response outcome in RTX-treatment. Methods. A cohort of 50 only AMCV IgG positive RA patients was tested for AMCV subtype IgM and IgA (additionally for RF IgG, IgM, IgA and ACCP IgG) by ELISA at baseline (after failure to first approach with TNFi) and at week 24 (after first RTX cycle). Responders were characterized by a difference in their DAS28 of ≥1.2 (EULAR good-response) between baseline and week 24. The cohort comprises 37 responders (RR) and 13 non-responders to RTX (NRR). Results. AMCV IgG, IgM and IgA showed higher treatment related decreases compared to RF and ACCP Ig subtypes and additionally even diverged in both groups depending on response outcome: Especially AMCV IgA exhibited a higher mean titer decline of RR by 67% at lo- wer baseline titers (90.14 to 29.84 U/ml) and a mean titer increase of NRR by nearly 20% at higher baseline titers (182.51 to 218.57 U/ml). At baseline RR displayed relatively more negative IgA titers (68%; n=25/37) than NRR, who in return showed more IgA positive titers (69%; n=9/13). AMCV IgA positive patients were more likely to show positively for RF IgA (80%) and IgM (70%), what could be inversely detected for IgA negative patients with seronegativity of RF IgA (68%) and IgM (60%). Conclusion. AMCV Immunoglobulin subtypes showed treatment dependent changes contrary to already known antibodies (ACCP). Especially AMCV IgA reflects response outcome: AMCV IgA negativity at baseline and decreasing titers during treatment are predictive for good EULAR-response to RTX. Einleitung. Im Rahmen der Abklärung eines unter Tocilizumab-Therapie aufgetretenen Arzneimittelexanthems erfolgte die Bestimmung von C3c und C4 -beide Parameter waren erniedrigt. Bei recht geringer und nur kurz andauernder Ausprägung des Exanthems wurde die Therapie komplikationslos fortgeführt. Die Komplementfaktoren wurden im Verlauf bestimmt und blieben erniedrigt. Im weiteren Verlauf erfolgte die konsekutive Messung bei weiteren Patienten. Methoden. Nephelometrische Bestimmung von C3c und C4 im Serum vor und während der Therapie mit Tocilizumab (jeweils vor der nach 4 Wochen anstehenden Infusion) bei Patienten mit gesicherter Rheumatoider Arthritis (RF+, CCP+). Ergebnisse. C3c-und C4-Komplement wurden bei 13 konsekutiven Patienten mit Rheumatoider Arthritis vor und unter Tocilizumab-Therapie bestimmt. Bei allen Patienten fielen sowohl C3c, als auch C4 unter der Therapie mit Tocilizumab (8 mg/kg KG) ab. 8/13 Patienten hatten eine C3c-Erniedrigung (bestimmter Wert unterhalb des laborinternen Normbereichs). 4/13 Patienten hatten eine C4-Erniedrigung (bestimmter Wert unterhalb des laborinternen Normbereichs). Drei Patientinnen entwickelten unter der Therapie ein Exanthem, davon hatten 2 eine Komplementerniedrigung. Keine "offensichtlich" erhöhte Infektneigung in Abhängigkeit von Komplementspiegeln. Bei verlängerten Infusionsintervallen aufgrund von Infekten zeigte sich, dass der Effekt von Tocilizumab auf die Komplementspiegel reversibel ist.

Durch Blockade des IL-6-Rezeptors Tocilizumab kann ein erworbener Komplementmangel induziert werden. Ähnliche Daten wurden im Rahmen einer Pilotstudie an SLE-Patienten erhoben, die mit Tocilizumab behandelt wurden. Der Effekt ist bei der Rheumatoiden Arthritis nicht vorbeschrieben. Der genaue Umfang des Komplementmangels ist bisher nicht untersucht (andere Bestandteile der Kaskade?) wurde in der SLE-Studie ausführlicher untersucht. Da die verschiedenen Komplementbestandteile erniedrigt waren wurde auf eine Synthesestörung und nicht auf einen gesteigerten Verbrauch geschlossen, was auch in dieser Kohorte der Fall zu sein scheint. Der erworbene Komplementmangel könnte einen Teil der infektiösen Komplikationen unter der Therapie erklären. Eine Korrelation ist aber aufgrund der geringen Fallzahl nicht möglich. Schlussfolgerung. Anhand dieser Studie konnte eine exzellente Korrelation zwischen den Parametern der DXR und des BX verifiziert werden. Mittels der neu entwickelten voll digitalisierten BX-Technik ist somit eine Quantifizierung der periartikulären Demineralisation möglich und als Surrogatparameter der radiologischen Progression bei einer RA eingesetzt werden. 3 Jahre, die RA bestand im Median seit 7,8 Jahren. 74,7% der Patienten waren mit TNF-alpha-Blockern vortherapiert, 23,7% ausschließlich mit DMARDs. Der mittlere DAS28 lag zur Baseline bei 5,3. Zur Woche 76 zeigten 34,0% der Patienten eine DAS28 Remission (<2,6) und 29,1% bzw. 56,9% der Patienten ein gutes bzw. moderates Ansprechen gemäß EULAR-Kriterien. Über den Beobachtungszeitraum stieg der Anteil der TCZ-Monotherapiepatienten von 40,1% auf 58,4%. Die MTX-Komedikation sank im gleichen Zeitraum um 13,3%. 21,9% der Patienten, die TCZ zunächst zusammen mit einem DMARD erhalten haben, konnten dieses absetzen. TCZ zeigte in der Mono-und Kombinationstherapie eine vergleichbare Wirksamkeit: 18,3% bzw. 20,3% der Patienten erreichten eine CDAI Remission (≤2,8). Der Anteil von Patienten ohne Glucocorticoid(GC)-Begleittherapie stieg über den Beobachtungszeitraum um 8,2% auf 25,6% an, der Anteil mit einer Tagesdosis ≤5 mg auf 76,2%. Bei 49,4% war eine Reduktion der GC-Dosis möglich, nur bei 10,1% war eine Erhöhung notwendig. Bei 14,5% der Patienten, die zur BL mit GC behandelt wurden, konnten diese komplett abgesetzt werden. Die mittlere GC-Tagesdosis verringerte sich kontinuierlich von 9,2 (BL) auf 5,9 mg/d (W76). Schlussfolgerung. Diese Interimsanalyse der nichtinterventionellen Studie ICHIBAN zeigt bei den ersten 490 Patienten mit mittelschwerer bis schwerer RA über die bisherige Beobachtungsdauer von 76 Wochen deutliche Verbesserungen der Aktivitätsparameter, sowie eine Reduktionen der begleitenden DMARD-Therapien und des Bedarfs von Glucocorticoiden unter Behandlung mit TCZ. Vergleichbar mit den kontrollierten Studien ist die TCZ-Monotherapie auch unter Praxisbedingungen der Kombination mit DMARDs ebenbürtig. Diese anhaltende Wirksamkeit wird erstmals in rheumatologischen Praxisdaten für den Langzeitverlauf von 1,5 Jahren gezeigt. Zeitschrift für Rheumatologie Suppl 2 · 2013 | Einleitung. Die Arteriosklerose (AS) steht als häufigste Todesursache im besonderen Fokus der medizinischen Forschung. Neuere Erkenntnisse weisen auf einen starken Zusammenhang zwischen Parametern der systemischen Entzündung und der Pathogenese der AS hin. Patienten mit rheumatoider Arthritis (RA) haben daher ein stark erhöhtes kardiovaskuläres Risiko. Ziel: Untersuchung des Zusammenhangs zwischen verschiedenen RA-krankheitsspezifischen Risikofaktoren und dem Auftreten einer Arteriosklerose bei RA-Patienten. Methoden. 139 RA-Patienten, davon 77% weiblich, 64±11,6 Jahre alt, wurden hinsichtlich der Krankheitsaktivität (Krankheitsdauer 13,8±0,9; DAS28 3,5±0,1; Serum-CrP 8,1±0,9 mg/dl,; anti-CCP-Antikörper 80,4±8,8 U/ml, radiologisches Stadium 1,8±0,1; davon 50,5% mit Erosionen), sowie klassischer kardiovaskulärer Risikofaktoren der AS erfasst, welche durch den SCORE-Wert (Systematic Coronary Risk Evaluation) zusammengefasst wurden. Zur AS Darstellung wurde eine Carotis-Duplexsonographie mittels eines 7 MHz-Schallkopfes (GE Vivid 7 Pro) durchgeführt. Die mittlere Intima-Media-Dicke (IMD) der A. carotis communis wurde durch ein softwaregestütztes Messverfahren ermittelt. Ergebnisse. Plaques waren bei 54 Patienten (39%) nachweisbar. Diese korrelierten mit einer erosiven Form der RA (p=0,05), einer längeren Krankheitsdauer (p=0,03) und höheren anti-CCP-Antikörpern (p=0,02). Die mittlere IMD betrug 0,67±0,11 mm. Je ausgeprägter die radiologischen Veränderungen sind, umso höher war die Wahrscheinlichkeit der Plagues (p=0,02). Mittels altersadjustierter partieller Korrelationsanalyse wurde der DAS28 als altersunabhängiger Einflussfaktor auf die IMD ermittelt (p=0,02). Mittel-und hochgradige Stenosen zeigten sich bei fünf RA-Patienten (3,4%), welche ausnahmslos eine erosive Verlaufsform aufwiesen. Normalbefunde stehen in Zusammenhang mit einem CRP-Wert unter 5 mg/dl (p=0,04). Auch die traditionellen kardiovaskulären Risikofaktoren haben signifikanten Einfluss auf AS. Der SCORE-Wert erwies sich als äußerst verlässlicher Prädiktor für Plaques (p<0,01), IMD-Verdickung (p=0,01) und Stenosen (p<0,01). Durch Elimination der traditionellen Risikofaktoren mittels partieller SCORE-adjustierter Korrelationsanalyse bestätigte sich erneut die Assoziation von pathologischen Ultraschallbefunden mit dem DAS28 (p=0,03). Schlussfolgerung. Die Erhebung klassischer Risikofaktoren bei RA-Patienten ist unerlässlich. Die Nutzung des SCORE-Werts als Screening-Parameter ist besonders effektiv. Zusätzlich sollten Parameter der Krankheitsaktivität von RA zum Management von Arteriosklerose herangezogen werden. Besonders aussagekräftig hierfür sind der DAS28, ein erosiver Krankheitsverlauf, die CrP-Werte und die Erkrankungsdauer Background. Apremilast, an oral small molecule specific inhibitor of phosphodiesterase-4, works intracellularly to modulate inflammatory mediators. The PALACE 1-3 trials compared the efficacy and safety of apremilast vs placebo in patients with active PsA despite prior DMARDs and/or biologics. The overall safety and tolerability of apremilast was assessed in a pooled analysis of the PALACE 1, 2 and 3 placebo-controlled phases. Methods. Safety data was pooled from 3 phase 3, randomized, placebo-controlled studies; patients with active PsA despite prior DMARDs and/or biologics were randomized 1:1:1 to placebo, apremilast 20 mg BID (APR20), or apremilast 30 mg BID (APR30) stratified by baseline DMARD use. At week 16, patients with <20% reduction in swollen and tender joint counts were required to be re-randomized (early escape) to APR20 or APR30 (placebo group) or remained on initial apremilast dose through week 24. Stable concurrent DMARD therapy was allowed (MTX, sulfasalazine, leflunomide, or combination). The analysis comprises data from the placebo-controlled periods (weeks 0-24).

Results. 1493 Patients were randomized to placebo (n=495), APR20 (n=501), or APR30 (n=497) and included in the safety population. Baseline demographic and disease characteristics and prior/concurrent therapy were comparable across treatment groups; 22.4% had prior biologic exposure. Adverse events (AEs) occurred in 47.5% (placebo), 61.5% (APR20), and 60.8% (APR30) of patients. AEs occurring in ≥5% of any treatment group were diarrhea, nausea, headache, and URTI (. Tab.27); most occurred within the first 2 weeks of treatment and nearly half resolved within 2 weeks. Of patients with these AEs, most (93-96%) were mild or moderate. Rates of discontinuation due to AEs were low: 4.2% (placebo), 5.6% (APR20), and 7.2% (APR30). Serious AEs occurred in 3.8% (placebo), 3.4% (APR20), and 3.8% (APR30) of patients. One death occurred (APR20) due to multiorgan failure not suspected to be treatment-related. No cases of serious systemic opportunistic infections, lymphoma, vasculitis, or reactivation/de novo TB were reported. There were no clinically meaningful differences between apremilast and placebo in terms of major cardiovascular AEs, changes in blood pressure, malignancies, or effects on laboratory measurements. Conclusion. Apremilast was generally well-tolerated with no new safety concerns identified compared with the known profile. The aim of the current study was to investigate the relationship between worsening of functional status, clinical disease parameters and radiographic spinal progression over two years in patients with early axial spondyloarthritis (axSpA). Methods. In total, 160 Patients with early axSpA (91 with AS and symptom duration ≤10 years, and 69 with non-radiographic axSpA (nr-ax-SpA) and symptom duration ≤5 years) from the German Spondyloarthritis Inception Cohort (GESPIC) were included in the current analysis based on the availability of radiographic data and data on the functional status at baseline and after 2 years of follow-up. Spinal radiographs were scored according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Functional status was assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI), and clinical disease activity by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Results. BASFI worsening in ≥1 point after 2 years (n=44, 27.5%) was significantly associated only with higher BASDAI worsening over 2 years in comparison to those without functional worsening: 1.2±1.4 vs -0.6±1.6, p<0.001. BASFI worsening by ≥2 points (n=20, 12%) was, however, associated not only with BASDAI change (1.5±1.6 vs -0.3±1.6, p<0.001), but also with a higher rate of radiographic spinal progression measured by the proportion of patients with mSASSS worsening by ≥2 units (35.0% vs. 13.6% in patients without BASFI worsening, p=0.024), or with new syndesmophyte formation (25.0% vs. 6.4%, p=0.018). Importantly, in the multivariate analysis both BASDAI increase and progression of structural damage in the spine remained statistically significantly associated with BASFI worsening. No other disease-related parameters (e.g. sex, HLA-B27 positivity, symptom duration etc) were found to be significantly associated with BASFI worsening over two years. Conclusion. In this prospective study we could demonstrate that only 2 factors were significantly associated with worse functional outcome over two years in patients with early axSpA: 1) increase of disease activity and 2) progression of structural damage.

Elevated serum vascular endothelial growth factor is highly predictive for radiographic spinal progression in patients with axial spondyloarthritis who are at high risk for progression Background. Vascular endothelial growth factor (VEGF) is an essential mediator of the endochondral ossification and, therefore, might play a pathogenetic role in the process of syndesmophyte formation in axial spondyloarthritis (axSpA). The aim of the study was to investigate the role of serum VEGF as a predictor of radiographic spinal progression in patients with axSpA. Methods. Altogether 172 Patients with definite axSpA [95 with ankylosing spondylitis (AS) and 77 with non-radiographic axSpA] from the German Spondyloarthritis Inception Cohort (GESPIC) were included in the current study. Radiographic spinal progression was defined as 1) worsening of the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) by ≥2 units after 2 years, and 2) development of a new syndesmophyte or progression of existing syndesmophytes after 2 years. Serum VEGF levels were detected at baseline. Results. Mean baseline VEGF values were significantly higher in patients with mSASSS worsening by ≥2 units after 2 years (n=22) as compared to those without progression (562±357 vs. 402±309 pg/ml, respectively, p=0.027) and in patients with syndesmophyte formation/ progression (n=18) as compared again to those without progression (579±386 vs. 404±307 pg/ml, respectively, p=0.041). Area under the curve (AUC) was 0.646, p=0.027 for the mSASSS worsening ≥2 units and 0.648, p=0.041 for syndesmophyte formation/progression. Importantly, the performance of VEGF as a predictor of radiographic spinal progression was clearly in patients who were already at high risk for such a progression due to the presence of syndesmophytes at baseline (n=48): AUC was 0.812, p=0.001, and 0.772, p=0.003, respectively. VEGF serum level of >600 pg/ml in high-risk patients had a sensitivity of 53%, a specificity of 97%, and an odds ratio (OR)=36.6 (95%CI 3.9-341.5) as a predictor of mSASSS worsening by ≥2 units over 2 years. The same serum level of Results. Immediately after the second session of plasmapheresis, therapy with infliximab 5 mg/kg resumed. After 2 weeks of hospitalization with repeated administration of infliximab had good dynamics (BAS-DAI 5.6, ASDAS (CRP) = 3.8, BASFI 7.8), significantly reduced pain in the joints and spine, stiffness, increased mobility in the joints and spine. The treatment continued: holding plasmapheresis followed by infliximab. After 6 infusions patient experienced a good effect -BASDAI 3.6, ASDAS (CRP)=2.2, BASFI 6.2. Conclusion. Plasmapheresis in some patients could be effective by reducing activity and dealing with secondary TNF inhibitors failure, since this procedure deletes the macromolecular blood proteins, including TNF-, IgG antibodies, and circulating immune complexes Results. There were still signs of osteitis in sacroiliac joints in 5 Patients at week 24, in 1 Patient the MRI-determined sacroiliitis has resolved completely. The patient has improved clinically and fulfilled ASAS40 improvement criteria. There was a minor decrease in SPARCC sacroiliitis score (from 16 to 10) in 5 Patients at week 24, indicating reduction of inflammation in sacroiliac joints. SPARCC sacroiliitis score stayed the same in the remained patient. Conclusion. Rituximab may be of some benefit in decreasing MRI-evident sacroiliitis in patients with highly active AS, even in patients in whom TNF-α inhibitors have failed. Background. Despite the differences in the pathogenesis of RA and AS, neck pain is a frequent clinical symptom in both diseases. We evaluated the correlation between subjective reports of neck pain and objective signs of inflammation as assessed by f bone marrow edema (BME) on MRI in RA and AS patients. Methods. STIR-MRI of the cervical spine of 40 Patients (34 RA, 6 AS) were included. MRIs were scored by two blinded readers using a recently published MRI scoring system, with quantification of the extension of BME in the atlantoaxial region, corpus, facet joints and processus spinosus of all cervical vertebrae, ranging from 0-57 points. The presence or absence of degenerative changes was also recorded. Conclusion. The majority of patients with RA and AS had objective signs of BME but also degenerative changes on MRI at different cervical locations. Assessment of BME in the atlantoaxial region is important in clinical practice, in addition to degenerative changes, since its presence seems to influence the intensity of neck pain reported by these patients.

X. Baraliakos , 13 having MRI data at W94. Of these 13, ten were treated with secukinumab and 3 with placebo in the core study. MRIs were rescored for this study. ASspiMRI-a scores and the occurrence of vertebral edges (VE) inflammatory and fatty lesions were evaluated by an independent blinded reader. Results. All 13 pts completed this exploratory MRI substudy. In pts receiving 2×10 mg/kg secukinumab followed by 14×3 mg/kg (n=10) secukinumab, spinal inflammation was reduced compared to BL at W28 -similar to the results of the core study -and this reduction was sustained up to W94 (Abb. 1). Also in 3 pts who had initially received placebo switching to secukinumab at W28, MRI inflammation at W94 was reduced. Of the 920 VEs evaluated, the proportion of VEs with inflammatory lesions was reduced from 9.9% (n=91) at BL to 3.7% (n=34) at W28 and 3.6% (n=33) at W94. In contrast, the proportion of fatty lesions at BL (13.5%, n=124) remained largely unchanged at W28 (14.3%, n=132) and W94 (13.7%, n=126). Secukinumab reduced MRI inflammation at W28 and W94.

Conclusion. MRI analysis suggests that the IL-17A inhibitor secukinumab can reduce spinal inflammation and this effect may be sustained for up to 2 years. Unlike reports with TNF blockers, secukinumab appeared to leave the proportion of fatty lesions unchanged. The potential impact of these preliminary findings on radiographic progression under secukinumab therapy will be studied in larger trials. Schlussfolgerung. Es zeigen sich keine signifikanten Unterschiede in der Krankheitsaktivität der beiden Gruppen (vor Einleitung der ADA-Therapie nach DMARD-und nach anti-TNF-Versagen). Auch bei der Patientengruppe mit mehreren Vortherapien mit TNF-Inhibitoren können keine signifikanten Unterschiede in der Ausprägung der Erkrankung nachgewiesen werden. Im Trend wurde ein früheres Einsetzen der Haut-und Gelenkmanifestation sowie eine stärkere systemische Entzündungsreaktion in den Patienten mit vorheriger TNF-Therapie festgestellt werden, während die Dauer der Erkrankung und der BMI mit den Charakteristika der Patienten mit ausschließlicher DMARD-Vortherapie vergleichbar sind.

Long-term (52-week) results of a phase 3, randomized, controlled trial of apremilast, an oral phosphodiesterase 4 inhibitor, in patients with psoriatic arthritis (PALACE 1) Background. Apremilast, an oral phosphodiesterase 4 inhibitor, works intracellulary to modulate a network of pro-and anti-inflammatory mediators. The PALACE 1 study assessed the efficacy and safety of apremilast in patients with active psoriatic arthritis (PsA) despite prior DMARDs and/or biologics. Methods. Patients were randomized 1:1:1 to placebo, apremilast 20 mg BID (APR20), or apremilast 30 mg BID (APR30). At week 16, patients with <20% reduction from baseline in swollen/tender joint counts were required to be re-randomized (early escape) to APR20 or APR30 (placebo group), or remained on their initial apremilast dose. At week 24, all remaining placebo patients were re-randomized to APR20 or APR30 through week 52. Results. 504 Patients were randomized. At week 16, significantly more APR20 (31.3%; p=0.0140) and APR30 Patients (40.0%; p<0.0001) achieved an ACR20 vs placebo (19.4%). At week 52, all patients had a minimum 28 weeks of apremilast exposure. Response to apremilast was generally maintained over the treatment period. At week 52, ACR20 was achieved by 63.0% (APR20) and 54.6% (APR30) of patients (Table) . Exposure-adjusted incidence rates for adverse events (AEs), severe AEs, and serious AEs were comparable between 0-24 and 0-52 weeks. The proportion of patients remaining on apremilast to week 52 who first reported the most common GI disturbances (e.g., diarrhea, nausea, and vomiting) after week 24 was low (ranging from 0.6-3% for APR20 and 0-1.8% for APR30). There were no clinically meaningful laboratory findings with exposure up to 52 weeks. No deaths beyond the 1 previously reported in the 0-24 week period were observed in the 24-52 week period. No safety signals with respect to major cardiac events, malignancies, and opportunistic infections were observed, consistent with the 0-24 week period. No cases of lymphoma, tuberculosis, or tuberculosis reactivations were reported for the 52-week period (. Tab.30). Conclusion. Apremilast administered to patients with PsA beyond 24 weeks continued to demonstrate meaningful clinical response. For patients who completed 52 weeks of the study, ACR20 response rates up to 65% were observed. Apremilast continued to be well tolerated with an acceptable longer-term safety profile. Methods. To identify how conventional CD4+ and CD8+ T cells and regulatory T cells are recruited into the inflamed kidneys in LN, serum and urine samples of 98 SLE patients were analyzed for 18 chemokines using multiplex assays. Based on the assay's results a group of 8 corresponding chemokine receptors (CCR1-6, CXCR3 and CXCR6) was chosen, whose frequencies on urinary T cells were subsequently determined in 9 Patients with acute LN by flowcytometry.

Results. 12 chemokines (CCL2, CCL3, CCL4, CCL5, CCL7, CCL8, CCL11, CCL20, CXCL9, CXCL10, CXCL16 and CX3CL1) were significantly elevated in the urine of patients with active LN when compared to the control group. The other 6 chemokines (CCL1, CCL17, CCL22, CXCL1, CXCL5) and CXCL11 showed no significant differences between the groups. CCR5 and CXCR3 were the most prominent receptors on both urinary CD4+ and CD8+ T cells, although CD4+ T cells also expressed high amounts of CCR4 and CCR6. However, when compared to T cells in the blood, urinary CD4+ T cells showed significantly higher expression of all examined chemokine receptors but CCR2 while urinary CD8+ T cells only had higher expression of CCR1 and CCR5. The chemokine receptor expression on CD4+FoxP3+CD127-regulatory T cells (Treg) differed from conventional CD4+ T cells as well. Treg expressed significantly more CCR4 and significantly less CXCR6. Conclusion. CCR5 and CXCR3 are the primary receptors in the mechanism of recruiting T cells into the inflamed kidney. Key chemokines are CCL3, CCL4, CCL5 and CCL8 as well as CXCL9 and CXCL10. However, at least for CD4+ T cells, there are secondary pathways of recruitment involving CCR4/CCL2 and CCR6/CCL20. Also, Treg recruitment seems to rely more on CCR4 than that of conventional CD4+ T cells. Methods. Observe is a multicenter, retrospective medical chart review study. Rheumatologists from German academic and non academic centers who treat >10 SLE patients annually and have >5 years of practice experience were randomly recruited. Physicians identified consecutively all their adult SLE patients who had received belimumab as part of usual-care. Index date was the first belimumab infusion date. The primary outcome was the change in overall SLE disease manifestations 6 months after index date based on physician judgment. The overall response rates as well as reasons for early treatment discontinuation within 6 months were assessed. Changes in formal disease area indices, e.g. SELENA-SLEDAI if available and changes in oral steroid dose are also reported. Results. Previous analyses from US patients treated with belimumab have described significant clinical improvement across relevant organ systems based on clinical judgment and formal Disease Activity Indices and marked reductions in corticosteroid use in patients that received at least 8 infusions of belimumab. The current study is the first description of patient characteristics and outcomes after 6 months of therapy with belimumab outside of the US. It is also the first time overall responder rates and reasons for discontinuation with belimumab have been described in a real world setting.

The study provides insights into the effectiveness and safety of belimumab in an ex-US clinical setting. Larger, prospective observational studies are needed to confirm the results.

Commercial support grant disclosure: Research funded GlaxoSmithKline.

Background. Toll-like receptor 9 (TLR-9) signaling is considered to play an important role in B cell hyperreactivity in SLE. B cells from SLEpatients express significantly more TLR-9 than those from healthy donors (HD), especially if patients have positive dsDNA-antibodies and high disease activity. TLR-9 stimulation of B cells is tightly linked to their differentiation into plasma blasts and memory cells. The objective of this study was to analyze in a comprehensive manner the effect of TLR-9 signaling on cytokine production by B cells from SLE-patients, in comparison to B cells from HD, and in relation with disease activity. Methods. B cells from 19 SLE-patients and 13 HD were stimulated in vitro using CpG for 48 hours, and culture supernatants were then tested for 28 cytokines and chemokines (Bio-Plex). The cytokine responses were compared between both groups. In addition, within SLE patients, the patterns of cytokines produced by B cells were compared with indices of disease activity. Results. CpG-stimulation significantly increased cytokine production (24 out of 28 parameters; p<0.05) compared to baseline. Striking increases were found for IL-1ra (94±40 pg/ml), IL-6 (431±225 pg/ml), IL10 (72±37 pg/ml) and IP-10 (361±289 pg/ml; p<0.001). There was no significant difference between both groups. Remarkably, production of IL-2, IL-4, IL-7, IL-12p70, IL13, IL-15, IL-17A, Eotaxin, Basic FGF, G-CSF, GM-CSF, IFN-γ, IP-10, MIP-1α, and VEGF correlated inversely with the SLEDAI (p<0.05) and even more (additionally IL-1β, IL-1ra, MIP-1β and TNF-α) with anti-dsDNA antibody titers. The frequency of CD27+ memory B cells showed a positive correlation between the production of IP-10 and TNF-α in SLE, whereas the levels of IL-1β, IL-7, MIP-1α, and MIP-1β showed a positive correlation with CD27+ B cells in HD. Conclusion. The current data indicate hitherto unknown perturbations of cytokine/chemokine production by B cells in active SLE. The inverse correlation of cytokines/chemokines produced by B cells from SLE patients with SLEDAI and anti-dsDNA titer suggests that the known enhanced B cell proliferation and differentiation upon TLR9-stimulation possibly diminishes cytokine production. Background. Several cytokines, including IFN-γ, IL-18, IL-12, and IL-23 have been implicated in the pathophysiology of autoimmune disease. IL-18, a potent inducer of IFN-γ, enhances Th1 responses that are thought to be synergistic and dependent on IL-12. We tested the hypothesis that intra-renal IL-18 mediates kidney and systemic disease in MRL-Faslpr mice.

Methods. By constructing IL-12p40/IL-23-/-MRL-Faslpr mice and using an ex-vivo gene transfer to deliver IL-18 intra-renally, we determined that IL-18, independent of IL-12 and/or IL-23, incites kidney disease in MRL-Faslpr mice. Moreover, we provide the novel finding that local intra-renal IL-18 mediates systemic disease (lung pathology, systemic auto-Abs).

Results. Thus, our data indicate that IL-18 is a potential therapeutic target for immune mediated kidney and systemic disease in MRL-Faslpr mice. Using a caspase-1 inhibitor, that inhibits the release of active IL-18 and IL-1β, we successfully treated kidney (improved renal function, pathology) and systemic disease (skin lesions, lymphadenopathy, and splenomegaly) in MRL-Fas lpr mice, while administration of an IL-1 receptor antagonist did not influence disease progression. Probing further we found that inhibition of IL-18 activation results in an amelioration of lupusnephritis by a reduction of intra-renal infiltrating leukocytes (macrophages and T cells) and reduced activation of these leukocyte populations. Moreover, Caspase-1 inhibition resulted in decreased INF-y and IL-17 production, indicating an altered balance of Th17 and Th1 cell responses in this model. Conclusion. Taken together, our findings indicate that IL-18, independent of IL-1β, IL-12 and/or IL-23, is the major mediator of kidney and systemic disease MRL-Faslpr mice. Therefore, caspase-1 inhibition is a potential therapeutic target for autoimmune disease in the MRL-Faslpr mice. Background. In the treatment of giant cell arteritis (GCA) glucocorticoid-related adverse effects occur frequently, particularly in patients with relapsing disease.

A 50-year-old woman presented with a 2 month history of fever, chills, arthralgias and cephalgias and markedly elevated serum inflammatory markers. Whereas further evaluation including ultrasound of the temporal arteries was unremarkable, a positron emission tomography-computed tomography (PET-CT) demonstrated an intense fluorodeoxyglucose uptake of the aorta, the subclavian, carotid and femoral arteries. GCA was diagnosed and treatment with high dose prednisone was begun.

Results. Because of disease flares at prednisone dosages below 20 mg/ day and the occurrence of vertebral fractures, cyclophosphamide and methotrexate (MTX) were added as glucocorticoid-sparing agents. As these treatments had to be stopped because of intolerance and MTXpneumonitis, respectively, we started TCZ infusions (8 mg/kg body weight). The clinical status rapidly improved. After 2 infusions of TCZ follow-up PET scan showed resolution of the previously seen uptake and we were able to taper the daily dose of prednisone to 5 mg. Treatment was well tolerated. However, the patient developed mild hyperthyroidism with a rapid rise of the initially normal levels of anti-thyroid peroxidase and anti-thyroid antibodies, anti-TSH receptor antibodies remained normal. Thyroid function normalized and the antibody-levels fell without further treatment in the following months.

In conclusion, this case demonstrates the successful treatment of a patient with relapsing giant cell arteritis with TCZ. For the first time, we report the occurrence of a transient autoimmune thyreoiditis possibly induced by TCZ. 

Klinik für Pädiatrie mit Schwerpunkt Pneumologie und Immunologie, Sektion Rheumatologie, Berlin, 4 Vestische Kinder-und Jugendklinik der Universität Witten/Herdecke

13 Deutsches Zentrum für Kinder-und Jugendrheumatologie

Organización Médica de Investigación

Arthr Care Res

AR&T in press SP

Division of Rheumatology

Diagnosesicherung: a + b) MR-morphologisch myositistypische Veränderungen (OS) Histologie + c) generalisierte Myalgien und laborchemisch dtl. elevierter CK, sowie positivem Nachweis von ANA und Jo-1-Ak, pulmonales CT mit diffusen Milchglasinfiltraten, in bronchoalveolärer Lavage Neutrophile Alveolitis. Ergebnisse. Vormedikationen: a) Glukocorticoidmonotherapie, MTX-Monotherapie, MTX in Kombination mit Etanercept, Cyclophosphamidboli, und zuletzt intravenöse Immunglobuline (IVIG) in Kombination mit Mycophenolatmofetil . b) MTX-Monotherapie, MTX in Kombination mit Glukokortikoiden, Cyclophosphamidboli, intermittierend intravenöse Immunglobuline, Cyclophosphamid per os (FAU-CI). c) Cyclophosphamidboli

Jeweils gutes Ansprechen des CK-Wertes auf jeweilige Rituximabgaben mit ebenfalls Ansprechen des klinischen Bildes mit guter Regredienz des aus Myalgien resultierenden Schmerzniveaus. Im Fall a keine Beatmung mehr notwendig. Im Fall von c) auch gute Regredienz subjektiver Dyspnoesymptomatik und Besserung wichtiger Lungenfunktionsparameter, Regredienz CTmorphologischer Milchglasinfiltrate, im Verlauf fehlender Nachweis Neutrophilie in BAL. Weitere Rituximabgaben bei a, b und c im Verlauf zum Remissionserhalt nach jeweiligem klinischem Befund

Production of cytokines by B cells in response to TLR9 stimulation inversely correlates with disease activity in SLE-patients

Berlin Zeitschrift für Rheumatologie Suppl 2 · 2013 | das muskuloskeletale System, eines der am häufigsten betroffenen Organsysteme bei SLE (bei 53-95% der SLE-Patienten). Das Ziel dieser Analyse war es

Um diejenigen Parameter zu identifizieren, die zu diesem Effekt beigetragen hatten, wurde jeder der 9 Einzel-Parameter zur Untersuchung und Symptom-Erfassung innerhalb des muskuloskeletalen BILAG-Organsystems analysiert. Die Post-hoc-Analyse umfasste nur Patienten, bei denen ein Parameter zu Studienbeginn als vorhanden gewertet wurde, und jeder Parameter erforderte ≥20 Patienten-Beobachtungen pro Kohorte um einen Vergleich zu erstellen

Dadurch wurde die Zahl der Patienten mit einer initialen Beteiligung des muskuloskeletalen Systems aufgedeckt, die eine in Woche 52 Auflösung der Manifestation aufwiesen

Auch im SELENA-SLEDAI-Score war die Rate der Verbesserung bei dem Arthritis-Parameter in der Belimumab-Gruppe mit 1 mg/ kg (58,3%; n=362) und 10 mg/kg (56,6%; n=364) signifikant höher als

Die Daten weisen darauf hin, dass 10 mg/kg Belimumab effektiv auf muskuloskeletale Organmanifestationen sind

Akzeptiert als Posterbeitrag auf dem EULAR

Klinische Forschergruppe für Rheumatologie (KFR), Freiburg i. Br., 10 Universitätsklinikum Ulm, Klinik für Dermatologie und Allergologie

Die Physikalische Therapie (PT) ist ein wesentlicher Bestandteil der medizinischen Versorgung von SSc-Patienten

Patientenregister des DNSS erfasst prospektiv, jährlich klinische Verlaufsdaten zur Organbeteiligung und Therapie von Patienten mit systemischer Sklerodermie. Die mittels Freitext erfassten Angaben zur verordneten PT wurden ausgewertet

Hivamat n=50 (3,7%) und Hylase n=54 (3,9%) Anwendung. Die Anzahl der Verfahren, die die Patienten zeitgleich erhielten, variierte zwischen mind. 1 und max. 8. Über 50% der Patienten erhielten 2 Anwendungen gleichzeitig. Insgesamt wurden 39 Therapiearten genannt. 12,5% der Patienten mit Gelenkkontrakturen zeigten nach einem Jahr physikalischer Therapie eine signifikante Verbesserung der Symptomatik (p=0,027) gegenüber den Patienten die keine physikalische Therapie erhielten. Nach drei Jahren waren es 15,7% der Patienten (p=0,023). Bei den Patienten mit Muskelschwäche zeigten 11% der Patienten eine signifikante Symptomverbesserung (p=0,048)

dieser Studie kann erstmals gezeigt werden, dass PT-Symptome wie Gelenkkontrakturen und Muskelschwäche bei SSc-Patienten signifikant verbessern kann. Dennoch erhält weniger als die Hälfte der SSc-Patienten eine physikalische Therapie

punkten zur Kontrolle einer MMF-Therapie in der klinischen Praxis zu untersuchen

Bei 15 Patienten (12-mal SLE, je 1-mal systemische Sklerose, Sharp-Syndrom und primäres Sjögren-Syndrom) die MMF erhielten, wurde 40, 120 und 180 min nach Einnahme von MMF die MPA-Konzentrationen im Serum per HPLC bestimmt. Die MPA-AUC wurde durch die mathematische Methode der Bayes

20%) und in der Standarddosis von 2 g/Tag bei 6 von 9 Patienten (66%) eine MPA-AUC von >35 µg.h/ml. Bei zwei Patienten wurde nach der Messung die Dosis adjustiert: Eine Patientin mit einem SLE mit diffus-proliferativer Lupusnephritis hatte trotz einer MMF-Dosis von 2 g/Tag nur eine MPA-AUC von 32,9 µg.h/ ml. Die Dosis wurde daraufhin auf 3 g/Tag erhöht. Der MPA-AUC stieg danach auf max. 54,9 µg.h/ml und die Krankheitsaktivität nahm ab (SLEDAI von 8 auf 0, Proteinurie von 550 auf 150 mg/24 h und Prednisondosis von 6 auf 4 mg/Tag)

Pharmakokinetic study of mycophenolate mofetil in patients with systemic lupus erythematosus and design of Bayesian estimator using limited sympling strategies

Mycophenolic acid area under the curve correlates with disease activity in pupus patients treated with mycophenolate mofetil

Colony Stimulating Factor-1 (CSF-1) -neuer Aktivitätsmarker der Lupusnephritis?

Brigham and Wome's Hospital, Boston, Renal Division

The authors would like to thank Pfizer for supporting the study. Furthermore the authors would like to thank the "Deutsche Kinder-Rheumastiftung". 

Einleitung. Bei Patienten mit früher axialer Spondyloarthritis (SpA) mit einer Krankheitsdauer von<5 Jahren und Nachweis von akut-entzündlichen Veränderungen in der Ganzkörper-Magnetresonanztomographie (MRT) in der Wirbelsäule und/oder den Sakroiliakalgelenken (SIG) zu Baseline [1] untersuchten wir die Langzeit-Effektivität über vier Jahre. Methoden. In der ESTHER-Studie wurden Patienten mit Etanercept (ETA, n=40) vs. Sulfasalazin (n=36) behandelt [1] . Ab dem zweiten Studienjahr wurden alle Patienten mit ETA behandelt (einige Patienten unterbrachen zwischenzeitlich die Therapie (n=12) zur Untersuchung der Biologika-freien Remission und wurden dann (erneut) mit ETA behandelt) [2] . Klinische, laborchemische und MRT-Daten der Patienten, die zu den jeweiligen Studienzeitpunkten vorhanden waren, wurden im vierten Studienjahr analysiert (As-observed-Analyse). Ergebnisse. Von 76 Patienten, die zu Baseline eingeschlossen wurden, erreichten 52,6% das Ende von Jahr 4 (n=40). In der Gesamtgruppe zeigte sich ein gutes bis sehr gutes Ansprechen, wobei etwa 50% eine ASAS partielle Remission und etwa 60-70% eine ASDAS inaktive Erkrankung erreichten (. Tab.29). Der Anteil der Patienten mit normalem CRP ("CRP-Remission") stieg von 43,7% zu Screening auf 90,2% zu Woche 216, während der Anteil der Patienten mit negativem MRT ("MRT-Remission" definiert als Fehlen akut-entzündlicher Veränderungen in den SIG und der Wirbelsäule gemäß beider Scorer) auf von 0% auf 18,4% anstieg. 10,5% der Patienten zu Woche 216 waren sowohl in ASAS-Remission, im Status einer ASDAS inaktiven Erkrankung als auch in MRT-Remission. Das Ansprechen nach vier Jahren war sehr ähnlich in den Gruppen unabhängig davon, ob im ersten Jahr Sulfasalazin gegen wurde oder die Therapie im Jahr 2 unterbrochen worden war (Ergebnisse werden nicht gezeigt).Schlussfolgerung. Es zeigte sich ein konstantes und anhaltendes Ansprechen bei Patienten mit früher axialer SpA, die mit Etanercept behandelt wurden. Das Ansprechen scheint besser zu als bei Patienten mit etablierter Ankylosierender Spondylitsi mit einer langen Krankheitsdauer (>10 Jahren; [3] ). Einleitung. In einer 12-wöchigen placebokontrollierten Studie mit 40-wöchiger offener Verlängerung bei 46 Patienten mit aktiver nichtröntgenologischer axialer Spondyloarthritis (nr-axSpA) wies Adalimumab eine gute Effektivität auf [1] . Bei Patienten, bei denen es zum Wiederauftreten der Krankheitsaktivität nach Absetzen des Medikaments in Woche 52 kam, wurde die Therapie wiederbegonnen Ziel der Studie war es, die Langzeiteffektivität nach Wiederaufnahme der Therapie von Adalimumab nach Stopp über 5 Jahre zu evaluieren. Methoden. Bei 46 ursprünglich in die Studie eingeschlossenen Patienten wurde die Therapie nach 52 Wochen beendet und 23 Patienten (52% männlich, mittleres Alter 32 Jahre, Range 24-45, mittlere Krankheitsdauer vor Therapiebeginn 4 Jahre, Range 1-10, 74% positiv für HLA-B27) hatten, definiert durch Erreichen eines 40% Ansprechens gemäß der Assessments in Spondyloarthritis Society-Kriterien (ASAS40), gut auf die Therapie angesprochen. Bei Wiederauftreten von Krankheitsaktivität (definiert durch nicht mehr Erreichen von ASAS40) wurde Adalimumab 40 mg alle 2 Wochen über 5 Jahre (Woche R264) weitergeführt. Die ASAS Kriterien und der Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) wurden in Form einer Completer-Analyse berechnet. Ergebnisse. 19 der 23 Patienten mussten wiederbehandelt werden: 17/19 (90%) erreichten Jahr 3, 16/19 (84%) erreichten Jahr 4 und 11/19 (58%) der Patienten erreichten Jahr 5 der Wiederbehandlung. Nach 3 Jahren Wiederbehandlung mit Adalimumab erreichten 13/17 (77%) wieder ASAS 40 und 11/17 (65%) erreichten partielle Remission gemäß der ASAS-Kriterien. Nach 4 Jahren erreichten 11/16 (81%) und nach 5 Jahren 9/11 (91%) ASAS 40. ASAS partielle Remission wurde nach 4 Jahren von 9/16 (56%) und nach 5 Jahren von 7/11 (64%) Patienten erreicht. In der Completer Analyse fiel der mittlere BASDAI von 5,1±1,8 zum Zeitpunkt der Wiederbehandlung auf 1,6±1,6 im Jahr 3 (p<0,001), 2,2±2,1 (p=0,001) im Jahr 4 und auf 1,5±1,8 (p=0,001) im Jahr 5 der Wiederbehandlung ab. Schlussfolgerung. In dieser Gruppe von 19 Patienten mit aktiver nr-axSpA, die ein gutes Therapieansprechen über 52 Wochen mit Adalimumab erreicht hatten und die bei Wiederauftreten von Krankheitsaktivität nach Stopp der Therapie in Woche 52 weiterbehandelt werden mussten, sprach die Mehrheit der Patienten, die in der Studie verblieben, gut und anhaltend auf das Fortsetzen der Therapie an.

Tab. 29 | SP-17 Langzeit-Effektivität über 4 Jahre Etanercept-Therapie bei Patienten mit früher axialer Spondyloarthritis. Daten zu Baseline (BL), Jahr 1 (W48), Jahr 2 (W108), Jahr 3 (W156) und Jahr 4 (W216). Daten Background. Secukinumab (AIN457) is a new fully human monoclonal antibody (mAb) targeting IL-17A for the treatment of inflammatory diseases. Administration of mAbs can be associated with immunogenicity via the induction of anti-drug antibodies (ADAs). ADAs can lead to unwanted clinical consequences, such as loss of exposure, loss of efficacy due to altered pharmacokinetics and/or functional neutralization and, in the worst case, anaphylactic reaction and immune complex diseases. The assessment of ADA formation is therefore a critical component in the assessment of biotherapeutic safety. Methods. The immunogenicity assessment strategy for secukinumab follows a three-tiered approach. First, samples are analyzed for presence of ADA in a screening assay which takes a 5% false-positive rate into account. In a second step, screening assay positive samples are tested in a confirmatory assay that identifies true positive responses. Finally, true immunogenicity-positive samples are quasi-quantified via titration. A Biacore-based assay was used during the early stages of the secukinumab program, and an MSD-based bridging assay was applied during the later stages of the program. In addition, pharmacokinetics and clinical efficacy as well as safety data are also evaluated. Samples to assess immunogenicity were obtained from 1582 individual subjects encompassing 18 clinical studies in different indications during treatment and during follow-up. Dosing regimens included single doses such as 25 mg subcutaneously in psoriasis patients as well as multiple 7×10 mg/kg doses intravenously in MS patients over a six-month period.Results. None of the subjects tested for immunogenicity developed sustained ADAs. In total, 4 subjects met the definition of treatment-related, transient positive immunogenicity showing low ADA titers. None of these subjects had evidence of loss of efficacy, deviating PK behavior or reported anaphylactic reaction or immune complex disease.Conclusion. Based on the available data, secukinumab appears to carry a low risk of immunogenicity. In the very few transient immunogenicitypositive patients identified so far, there has been no indication of altered pharmacokinetics or loss of efficacy, and no adverse event that could be linked to immunogenicity has been detected. More data from the ongoing phase 3 studies are required to strengthen this encouraging finding in a larger patient population.

Risikofaktoren für eine AA-Amyloidose bei entzündlich-rheumatischen Erkrankungen und bei der idiopathischen AA-Amyloidose Methods. We report a case of an 84-year-old woman suffering from ulceration and signs of infection of the ulnar aspect of the right forearm due to subcutaneous calcification in association with CREST syndrome.Results. This case presents an unusual case of extensive subcutaneous calcification in CREST syndrome requiring surgical excision due to secondary ulceration, inflammation and infection. While a surgical approach has already been described for calcification in different connective tissue diseases, only scant data of massive subcutaneous calcification related to a forearm in CREST syndrome followed by surgical excision exist. Conclusion. In CREST syndrome, extensive subcutaneous calcification related to the forearm can occur. Surgical excision followed by primary wound closure can lead to an excellent postoperative result. Background. The whole blood interferon signature (WBIFNS) is measured in several clinical trials studying inhibitors of interferon alpha (IFN-α) in SLE, but failed repeatedly -in contrast to the less sensitive IFNα -to reflect longitudinal changes in lupus activity and to guide dosage finding of rontalizumab. Therefore, better IFN biomarkers reflecting disease activity over time and individual response to the inhibition of IFNα are needed to optimize the risk-benefit ratio of IFN-inhibitors.

Here, we show that the highly sensitive monocyte restricted IFNα response protein SIGLEC-1, also known as sialoadhesin or CD169, is a useful biomarker to monitor longitudinal changes in disease activity of SLE patients. Methods. IFN-α and SIGLEC-1 were measured by DELFIA and flow cytometry, respectively, in 24 accurately characterized lupus patients over a period of up to 12 months (overall 112 visits). Changes of biomarker and changes of disease activity (BILAG2004) were correlated using spearman rank test (SRT). Disease courses of selected SLE patients were plotted to demonstrate in detail the relations of IFN-biomarkers with disease activity, SLE medication and clinical manifestations. Background. A 74-year-old woman was admitted because of sudden attack of convulsion and somnolence situation with positive cANCA and myeloperoxidase antibodies. Cerebral magnetic resonance imaging (MRI) showed thickening and marked progression of the dura-meningeal enhancement and edematous changes at pre and post central gyrus left side. Based on these findings, it was diagnosed as hypertrophic cranial pachymeningitis related to ANCA-associated vascultis as unusual presentation. There was only temporarily und partial responce to a 7-month therapy with cyclophosphamide 1000 mg i.v and oral glucocorticosteroids . Taking into consideration the severe, life-threatening course of the disease in the case of our patient, the decision was made to use rituximab, a chimeric, monoclonal IgG1 antibody directed against CD20, leads to destruction of B cells via complement mediated lysis and antibody dependent cellular cytotoxicity. The first administration of the medication was performed according to the pattern for rheumatoid arthritis patients treated with rituximab, i.e. 2 infusions for 1000 mg in 14-day intervals in combined therapy with glucocorticosteroids. A follow-up MRI at 6 months after start with rituximab showed significant regression of the meningeal pathology at temporo-occipatel aspects (Pachymeningitis) and completely resolution of edematous changes at pre and post central gyres. The complete clinical remission was achieved by introducing rituximab. Conclusion. Rituximab seems to be successful therapie for the induction and maintenance of remission in patients with ANCA-associated vasculitis (AAV) with CNS involvement (hypertrophic cranial pachymeningitis ) , who had previously failed to respond to standard treatment with cyclophosphamide and steroids and a range of alternative treatments [1, 2] . Antikörperdiagnostik. Mit Prednisolon-Therapie (1 mg/kgKG, 40 mg/ Tag) und zusätzlich Methotrexat 15 mg wöchentlich war keine anhaltende Normalisierung der Entzündungsserologie zu erzielen. Infliximab (5 mg/kg) 6-wöchentlich i.v. erbrachte nur kurzzeitig eine Normalisierung der Entzündungswerte, dann trotz weiterer Infusionen einen erneuten Anstieg der BSG bis auf 91 mm, CRP 58 mg/l. Nach Umstieg auf Tocilizumab (400 mg /8 mg/kgKG) alle 4 Wochen konnte nach 6 Wochen eine bislang anhaltende Normalisierung der Entzündungsserologie erzielt werden (CRP 1,1 mg/l, BSG 9 mm 1. Std.). Der Allgemeinzustand der Patientin besserte sich deutlich, der Hb-Wert normalisierte sich auf 7,9 mmol/l. In der kontrastverstärkten Sonographie fand sich ein Abfall in der Kontrastmittelaufnahme der A. carotis communis. Die maximale Intima-media-Dicke reduzierte sich bislang auf 1,7 mm. Schlussfolgerung. Die bisherige Standardtherapie der Takayasu-Arteriitis mit Prednisolon und MTX führte auch im vorliegenden Fall nicht zur Remission. Für Infliximab fanden wir ein frühzeitiges Therapieversagen des sonst erfolgreich beschriebenen Ansatzes einer TNF-α-Blockade bei Riesenzellarteriitis. Dennoch gelang mit Tocilizumab eine bislang über 12 Monate andauernde klinische, sonomorphologische und serologische Remissionsinduktion bei monatlicher Fortführung der IL-6-blockierenden Therapie. 4 

Background. CD56 is the prototypic NK receptor that is also expressed on a unique population of effector CD4+ cells. These CD56-expressing T cells are expanded in rheumatoid arthritis patients and had features of senescent cells. NKG2D is another NK receptor over expressed on effector CD4+ cells in AAV patients. CD 56+ as well as NKG2D + T cells seem to be involved in tissue injury as they are capable of mediating TCR-independent immune activation. It is hypothesized that IL-15 is able to up regulate the expression of NK cell receptors. Interleukin-15 (IL-15) is a proinflammatory cytokine that is over expressed in AAV and is linked to the expansion of CD4+ effector memory T cells (TEM). In AAV in remission a persistent expansion of these CD4+ effector memory T cells has been observed. In the present study we assessed the expression CD56 on CD4+ T cells of AAV and if expression of these molecules was influenced by IL-15. Methods. The distribution of CD4+ TEM and the proportion of CD56+CD4+ T cells and NKG2D+ CD4+ T cells were analysed in 52 AAV-patients and 30 HCs by FACS. In vitro effects of IL-15 on the expansion of CD4+ TEM and up regulation of cytotoxic markers were assessed in the same way. In addition IL-15 serum levels were measured in patients and HC by ELISA. Results. We observed an increased proportion of circulating CD4+CD56+ T cells in AAV as well as NKG2D+ CD4+ T cells in patients in remission compared to HC (13.6 vs 0.6 p<0.0001 and 14 vs 0.7 p<0.0001). 80% to 90% of these cells were CD4+ effector memory T cells. The percentages of the CD56+CD4+ T cells and NKG2D+ CD4+ T cells were constant over time. We also observed elevated IL-15 serum levels in patients in remission compared to HC (p=0.001). In vitro stimulation of PBMCs with IL-15 increased not only the proportion of CD4+ memory cells (CD45RO+) but also the expression of CD56 and NKG2D on these cells. Conclusion. The driving force behind the persistent expansion of a cytotoxic subset of CD4+ effector memory T cells expressing CD56 and NKG2D+ and being TCR -independent is likely the increased IL-15 expression in AAV patients . Ergebnisse. Unabhängig von Regime der Remissionsinduktion und der primären Erhaltungstherapie lag am Ende der Nachbeobachtungsperiode bei 69% der Patienten eine renale Remission vor (45%; 24% PR). 16% hatten eine persistierende Proteinurie von >0,5 g/Tag bei stabiler Nierenfunktion, 3% eine persistierende Niereninsuffizienz mit erhöhtem Kreatinin bei inaktivem SLE, bei 12% wurden eine persistierende aktive LN und/oder renale Rezidive beobachtet. Vier Patienten verstarben. Patienten mit Langzeit-CR waren gekennzeichnet durch einen niedrigeren tubulointerstitiellen Chronizitätsindex in der initialen Nierenbiopsie (0,37±0,40 vs. 1,47±1,13; p=0,001), eine hochsignifikant geringere Proteinurie nach 6 Cyc-Pulsen (0,36±0,36 vs. 1,97±1,57 g/Tag; p=0,000) und niedrigere dsDNA-AK (61±72 vs. 110±89 U/ml; p<0,05) zum Zeitpunkt des Beginns der Erhaltungstherapie. Eine Proteinurie von <0,35 g/Tag nach 6 Pulsen Cyc zeigte eine Sensitivität von 71% und eine Spezifität von 94% für eine Langzeit-CR. Schlussfolgerung. Eine Proteinurie von <0.35 g/Tag nach Remissionsinduktion mit 6 Pulsen Cyc sowie ein geringer tubulointerstitieller Chronizitätsindex in der Nierenbiopsie sind Prädiktoren einer anhaltenden kompletten renalen Remission bei LN. Background. To evaluate and compare clinical efficacy of three biomarkers for interferon activity (measured directly and indirectly) and six traditional biomarkers to indicate current disease activity in SLE. Methods. IFN-α (DELFIA), IP-10 (ELISA) and SIGLEC-1 (flow cytometry) was measured in 79 accurately characterized lupus patients and compared to serum titres of Anti-dsDNA (ELISA and RIA), Anti-dsDNA-NcX ELISA, Anti-Nuc ELISA, C3 and C4. Disease activity was evaluated using BILAG-2004 and a modified SLEDAI-2000 (mSLE-DAI-2K). Additionally, 31 clinically quiescent patients were monitored for flares over the course of 180 days. Results. Increased levels of IFN-α, IP-10 and SIGLEC-1 were found in 32%, 50% and 86% of 66 active SLE patients. IFNα (r=0.45; p<0.0001) and SIGLEC-1 (r=0.54; p<0.0001) correlated better with BILAG-2004 than IP-10 (r=0.38; p=0.0002), Farr assay (r=0.40; p=0.0001), Anti-dsDNA-NcX ELISA (r=0.28; p=0.0061), Anti-dsDNA ELISA (r=0.31; p=0.0025), Anti-Nuc ELISA (r=0.25; p=0.0121), C3 (r=-0.43; p<0.0001) and C4 (r=−0.33; p=0.0013). Predictors of SLE flares were disease duration ≤92 months, mild clinical activity (in contrast to no activity), complement C3≤89 mg/dl and IFN-α ≥20 pg/ml, while only lymphocyte count and age were independent predictors in multivariate analysis. Conclusion. IFN-α, IP-10 and SIGLEC-1 emerged as beneficial biomarkers for disease activity in lupus patients. Therefore, implementation of IFN biomarkers in standard lupus diagnostics should be reappraised, especially in view of emerging anti-IFN-directed therapies. .0001) and carried significantly more often other antibodies (71.1%; p<0.0001), which were separated into U1RNP-(22.7%), Ro-(16.8%), PmScl-(11.5%) antibodies, followed by 10.8% with rheumatoid factors, 7.5% with La-, 5.8% with dsDNA-and 2.8% with Jo-1-and 2.6% with Ku-antibodies. The Kaplan-Meier analysis of the onset of organ involvement revealed a clear inclined position of overlap patients between patients suffering from lcSSc and dcSSc, especially regarding lung fibrosis and heart involvement. Patients suffering from PAH, oesophagus involvement and kidney involvement, overlap and lcSSc patients showed nearly similar curve progression (log rank <0.0001). Furthermore musculoskeletal involvement was significantly more frequent and more progressive in patients with overlap disease, followed by patients with dcSSc and lcSSc (log rank <0.0001). Conclusion. These data support the current concept, that SSc-overlap syndromes should be regarded as a separate SSc subset, distinct from lcSSc and dcSSc, due to a different course of the disease, different proportional distribution of specific autoantibodies and skin/organ involvement. Methoden. 18 Patienten mit GPA (11 mit aktiver und 7 mit in Remission befindlicher GPA) wurden durchflusszytometrisch analysiert und mit 17 Gesunden verglichen. Eine Färbung für CD27, Cd20, CD19, IgD, IgA, CD95, MHCII, wurde mittels Flowjo-Software analysiert. Die statistische Auswertung erfolgte mit "graph pad prism" und p-Werte<0,05 wurden als signifikant angesehen. Die Studie wurde von der Ethik-Kommission der Charité genehmigt. Ergebnisse. Deutliche Unterschiede (p=0,0018) wurden sowohl für die absolute Zahl als auch die Frequenz der Plasmazellen im peripheren Blut der Patienten mit GPA mit Krankheitsaktivität (6,4±5,06/µl) im Vergleich zu denen mit einem BVAS von 0 (2,52±1,6/µl) oder Gesunden (2,27±1,15/µl) gefunden, ähnlich wie bei SLE. Bei Patienten mit GPA ist außerdem eine signifikante erhöhte Anzahl der Plasmazellen IgApositiv (p=0,0028). Die Anzahl der Plasmazellen sowie die Frequenz der Plasmazellen an den B-Zellen im Blut korrelieren mit dem BVAS (r=0,9135; p<0,0001). Interessanterweise zeigte sich keine Expansion der doppelt negativen Memory-Zellen, die zum Beispiel beim SLE beschrieben ist. Für die naiven B-Zellen fand sich ebenfalls ein signifikanter Unterschied zwischen Patienten mit aktiver Erkrankung im Vergleich zu Gesunden. Bei den T-Zellen fanden sich nur diskrete Veränderungen. Schlussfolgerung. Die Anzahl der Plasmazellen ist bei Patienten mit aktiver GPA deutlich erhöht, was eine Rolle von Plasmazell-vermittelten Mechanismen in der Pathogenese nahelegt. Ein Großteil dieser Plasmazellen ist IgA-positiv, diese könnten eine Rolle bei der HNO-Beteiligung spielen.