FREE PAPER SESSION - Pro inflammatory cytokines in SLE - Dr S Sriram

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(IL6, TNFΑLPHA AND INTERFERON GAMMA) IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND THEIR CLINICAL CORRELATION Dr.S.SRIRAM MD DM PG FROM IOR, MMC&RGGGH ASSISTANT PROFESSOR DEPARTMENT OF RHEUMATOLOGY SREE BALAJI MEDICAL COLLEGE,CHENNAI

Transcript of FREE PAPER SESSION - Pro inflammatory cytokines in SLE - Dr S Sriram

Page 1: FREE PAPER SESSION - Pro inflammatory cytokines in SLE -  Dr S Sriram

PROINFLAMMATORY CYTOKINES

(IL6, TNFΑLPHA AND INTERFERON

GAMMA) IN

PATIENTS WITH SYSTEMIC LUPUS

ERYTHEMATOSUS AND THEIR CLINICAL

CORRELATION

Dr.S.SRIRAM MD DMPG FROM IOR, MMC&RGGGHASSISTANT PROFESSORDEPARTMENT OF RHEUMATOLOGYSREE BALAJI MEDICAL COLLEGE,CHENNAI

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ACKNOWLEDGEMENTS

When eating a fruit, think of the person who planted the tree!

Prof. Dr.S.RAJESWARI

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Conflict of Interests – nil

Financial disclosures - nil

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BACKGROUND Systemic lupus erythematosus (SLE) is characterised by imbalance

between the production of pro and anti inflammatory cytokines, which

contributes to

Immune dysfunction

Inflammation of the tissues and organ damage

B-cell and T-cell hyperactivity

No data exists about role of proinflammatory cytokines in our south

Indian SLE patients till date.

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AIM AND OBJECTIVES

PRIMARY OBJECTIVE

To study the levels of proinflammatory cytokines (IL6, TNFα, IFN-γ) in

systemic lupus erythematosus(SLE) patients as compared to healthy control

volunteers

SECONDARY OBJECTIVES

To correlate the levels of cytokines with clinical features

To correlate the cytokine levels with ESR, SLEDAI and other lab

parameters.

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All adult patients with SLE who

satisfied SLICC 2012

ACR/EULAR criteria

Patients with

× Childhood lupus

× Overlap syndromes

× Mixed connective tissue disorder

× Secondary Sjogrens syndrome

× Lupus flare due to infections and offending

drugs

× Pregnancy, lactation

× Associated antiphospholipid antibody

syndrome

INCLUSION CRITERIA EXCLUSION CRITERIA

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MATERIALS AND METHODS

88 newly diagnosed SLE patients (F-82; M- 6)

60 age and sex matched healthy individuals (F-44; M- 16)

Institutional ethical committee approval was obtained

Written and informed consent was taken from all patients and controls

Cross sectional study

Done at Institute of Rheumatology, MMC&RGGGH

Study period : September 2015 to Feb 2016 (6months)

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MATERIALS AND METHODS

Baseline investigations were done for all patients

Serum levels of IFNγ, IL6, and TNFα were done by solid phase sandwich

ELISA

Sensitivity of the TNFα kit was < 8pg/ml

Sensitivity of the IL6 kit was < 2pg/ml

Sensitivity of the IFNγ kit was < 5pg/ml

Calibrated recombinant protein was used to generate a standard curve

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STATISTICAL ANALYSIS(SPSS 21)

For continuous variables - Mean ± standard deviation (SD) Means between two groups – Unpaired Student -test𝑡

Association between cytokines, laboratory investigations and clinical

manifestations - Fischer’s exact test

Correlations between various cytokines, laboratory measures and

SLEDAI - Pearson correlation

A p value ≤0.05 was considered statistically significant.

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RESULTS

Mean age of SLE patients - 29.49 ± 10.34years; controls 31.05±11.12years.

The cases and healthy controls were matched regarding age and sex

Mean disease duration - 1.5 ± 1 years

The mean ± SD of SLEDAI - 14.26 ± 5

Patients were divided into 2 groups based on SLEDAI SLEDAI ≥ 11 – n= 64 SLEDAI ≤ 10 - n= 24

No statistical significance between the two groups regarding age, sex and

disease duration

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ANALYSIS OF SUBGROUPS

S.No Lab parameter SLEDAI ≥ 11 SLEDAI ≤ 10 p value1 Spot urine PCR 1.87 ± 1.10 0.63 ± 0.11 P=0.02

2 Serum creatinine (mg/dL) 1.25 ± 0.9 0.87 ± 0.2 P = 0.04

3 ESR (mm/h) 66.71 ± 22.2 52.81 ± 31.03 P = 0.02

4 Hemoglobin (g/dL) 9.25 ± 1.88 9.37 ± 1.58 P=0.79

5 Complement C3 (mg/dL) 76.4 ± 65.98 97.69± 65.04 P=0.17

6 Complement C4 (mg/dL) 10.02± 7.8 12.3±11.06 P=0.28

7 Serum albumin (g/dL) 3.69 ± 0.84 4.11 ± 0.69 P=0.03

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CYTOKINE LEVELS IN CASES AND CONTROLS

IL6

2.1 times higher in patients (143.01±64.94 pg/ml) than controls (69.33±11.7pg/ml)

(p<0.0001)

TNFα

1.8 times higher in patients (427.13±206.49pg/ml) than controls (236.05±23.53pg/ml)

(p<0.0001)

Higher in patients with SLEDAI ≥11(440±277pg/ml) than in patients with SLEDAI ≤ 10

(20.4±19.6pg/ml) (p<0.0001)

IFN γ

8 times higher in patients (25.65±64.81pg/ml; median 8) than the controls

(mean±SD=2.95±10.28pg/ml, median-0) (p=0.0080)

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CYTOKINES AND CLINICAL FEATURES

IL6 High IL6 values were associated with increased prevalance of oral ulcer

(136.54±66.70) (t = 2.053; p=0.001)

Mean serum IL6 was significantly higher in patients who had neurological

involvement with SLEDAI ≥11(n=8;76.97±52.6) than in patients with

neurological involvement and SLEDAI ≤ 10(n=3;23.6±11.98) (p=0.013)

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CYTOKINES AND CLINICAL FEATURES

TNF-α

Age of patients had a positive correlation with TNF-α (R=0.24, p=0.024)

Higher TNF-α values were significantly associated with increased prevalance of

alopecia (396.18±238.40; t-2.069; p<0.0001)

Mean serum TNFα in patients with renal involvement in patients with SLEDAI

≥11 (n=48; 276.97±152.6) was significantly elevated than in patients with

SLEDAI ≤ 10 (n=10;53.6±31.98) (p<0.013)

0 10 20 30 40 50 60 700

500

1000Age vs TNFα

Age (years)

TNFα(pg/ml)

R=0.24 p=0.024

n=88

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CYTOKINES AND CLINICAL FEATURES

IFN γ

Higher in females than males (F- 26.94 ± 66.93pg/ml; M- 8 ± 10.35pg/ml; p<0.05)

Significantly higher in patients who had lymphadenopathy (n=9,

mean±SD=7.89±7.51pg/ml; t=2.454; p<0.05)

Significant association with class III lupus nephritis (p<0.05)

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CYTOKINES AND ESR IL 6 AND TNF-α CORRELATED POSITIVELY WITH ESR

0 50 100 150 200 250020406080

IL6 vs ESR

IL6(pg/ml)

ESR(mm/hr)

R= 0.62 p= < 0.00001

n=88

0 100 200 300 400 500 600 700 800 900020406080

TNFα  vs ESR

TNFα  (pg/ml)

ESR (mm/hr)

R= 0.33 p=0.001

n=88

IFNγ CORRELATED NEGATIVELY WITH ESR

0 50 100 150 200 250 300 350 400 450010203040506070

IFN vs ESR

IFN (pg/ml)

ESR (mm/hr)

R=-0.21 p=0.04

n=88

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CYTOKINES AND SLEDAI COMPONENTS IL 6 AND TNF-α CORRELATED POSITIVELY WITH anti dsDNA

0 50 100 150 200 2500

50

100

150IL-6 vs anti dsDNA

IL-6 (pg/ml)

dsDNA(IU/ml)

R=0.85 p=<0.00001

n=88

0 100 200 300 400 500 600 700 800 9000

50

100

150TNFα  vs anti dsDNA

TNFα (pg/ml)

dsDNA(IU/ml) R=0.51

p=<0.00001

n=88

IFNγ CORRELATED NEGATIVELY WITH anti dsDNA

0 50 100 150 200 250 300 350 400 450020406080

100120140

IFN vs anti dsDNA

IFN (pg/ml)

dsDNA(IU/ml)

R=-0.24 p=0.02

n=88

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CYTOKINES AND SLEDAI COMPONENTS

0 50 100 150 200 2500

1020304050

IL-6 vs C3

IL-6 (pg/ml)

C3 (mg/dl)

R=-0.55 p=<0.00001

n=88

0 50 100 150 200 2500

100200300400

IL-6 vs C4

IL-6 (pg/ml)

C4 (mg/dl)

R=-0.725 p=<0.00001

n=88

0 100 200 300 400 500 600 700 800 9000

100200300400

TNFα  vs C3

TNFα  (pg/ml)

C3 (mg/dl)

R= -0.239 p=0.02

n=88

0 100 200 300 400 500 600 700 800 9000

100200300400

TNFα  vs C4

TNFα  (pg/ml)

C4 (mg/dl)

R=-0.428 p<0.05

n=88

IL 6 AND TNF-α CORRELATED NEGATIVELY WITH C3, C4

IFNγ DID NOT CORRELATE WITH C3, C4

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CYTOKINES AND SLEDAI COMPONENTS

0 50 100 150 200 250 300 350 400 4500

100000200000300000400000500000600000700000800000

IFN vs Platelet count

IFN (pg/ml)

Platelets(lakhs/cu.mm)

R= 0.249 p=0.01

n=88

IFNγ CORRELATED POSITIVELY WITH PLATELET COUNT

IL 6 AND TNF-α DID NOT CORRELATE WITH PLATELET COUNT

NO OTHER HEMATOLOGICAL PARAMETER CORRELATED WITH CYTOKINES

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CYTOKINES WITH SLEDAI

0 100 200 300 400 500 600 700 800 90005

1015202530

R=0.92P<0.0001N=64

TNFα vs SLEDAI SLEDAI COMPONENTS

ALOPECIA

RENAL

ANTI dsDNA

C3,C4

0 50 100 150 200 2500

5

10

15

20

25

30 IL6 vs SLEDAIR=0.42P=0.005n=64

SLEDAI COMPONENTS

ORAL ULCER

CNS LUPUS

ANTI dsDNA

C3,C4

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0 100 200 300 400 500 600 700 800 900050

100150200250

TNFα  vs IL6

TNFα (pg/ml)

IL-6 (pg/ml)

R=0.45p<0.00001

n=88

R=0.24 p=0.024

n=88

0 50 100 150 200 250 300 350 400 4500

50

100

150

200

250IFN vs IL6

IFN (pg/ml)

IL-6 (pg/ml)

R=-0.21 p=0.04

n=88

CORRELATION AMONG CYTOKINES

TNFα  HAD POSITIVE CORRELATION WITH IL6

IFN SHOWED NEGATIVE CORRELATION WITH IL6

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DISCUSSION - APPLIED ASPECTS

Varied results for IFNγ and TNFα in previous studies

Cytokines are inflammatory mediators in active stage of disease

Significant correlation between raised cytokines and SLEDAI

Renal and neurological involvement in active SLE

Knowledge of the role of cytokine in active lupus in our south Indian

population helps us to expand the role of targeted therapies in our

population (IL6 blockers are tried only in renal lupus)

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CONCLUSION

We conclude that IL6 and TNF α are good and reliable markers of

disease activity

Though cytokines do not show a significant association with all the

clinical manifestations, they show good correlation with major organ

systems

Further large scale studies can elucidate the role of biologics in the

management of lupus

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REFERENCES1. Gillian S Dean, Jonathan Tyrrell-Price, Esther Crawley, David A Isenberg. Cytokines and systemic

lupus erythematosus. Ann Rheum Dis 2000;59:243–251

2. Jacob and Stohl. Cytokine disturbances in systemic lupus erythematosus. Arthritis Research &

Therapy 2011, 13:228

3. Elaine V. Lourenco and Antonio La Cava. Cytokines in Systemic Lupus Erythematosus. Curr Mol

Med. 2009; 9(3): 242–254.

4. Grondal G, Gunnarsson I, Ronnelid J, Rogberg S, Klareskog L, Lundberg I: Cytokine production,

serum levels and disease activity in systemic lupus erythematosus. Clin Exp Rheumatol 2000,

18:565-570

5. Linker-Israeli M, Deans RJ, Wallace DJ, Prehn J, Ozeri-Chen T, Klinenberg JR: Elevated levels of

endogenous IL-6 in systemic lupus erythematosus.A putative role in pathogenesis. J Immunol 1991,

147:117-123

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