[Comparative assessment of sensitivity and specificity of three variants of classification criteria for systemic lupus erythematosus in a cohort of Russian patients].

BACKGROUND: The clinical and serologic heterogeneity of systemic lupus erythematosus (SLE) presents challenges for diagnosis, particularly in the earliest stages of the disease when there are insufficient signs to make a reliable diagnosis. AIM: To make a comparative assessment of sensitivity and specificity of various classification criteria of SLE on a cohort of patients of Nasonova Research Institute of Rheumatology. MATERIALS AND METHODS: A total of 252 patients were included in the study; 152 (60%) of 252 patients had reliable SLE (mean age 36 [29.5-46] years, duration of disease 9 [3.4-19] years). Of 252 patients, 26 (11%) had PAPS (mean age 36.5 [31-42] years, duration of disease 4.6 [1-10.4] years). Systemic sclerosis was diagnosed in 74/252 (29%) patients, (mean age 51.5 [42-59] years, duration of disease 9 [5-16] years). The quality of the classification function of the criteria was assessed by ROC analysis. RESULTS: SLE was diagnosed in 131 (86%) of 152 patients using the American College of Rheumatology - ACR)-1997 criteria, in 145 (95%) using the The Systemic Lupus International Collaborating Clinics (SLICC) 2012 criteria, and in 144 (94.7%) using the European League Against Rheumatism (EULAR)/ACR 2019 criteria. ANF positivity was the least statistically significant of all signs in relation to the diagnosis of SLE. The area under the curve (AUC) for ANF≥1/160 titers was AUC 0.654 for the ACR-97 criteria, AUC 0.616 for the SLICC-12 SLE criteria, and AUC 0.609 for the 2019 EULAR/ACR criteria. ROC analysis of the relationship between the number of criteria/points and a reliable diagnosis of SLE revealed a high diagnostic accuracy - the AUC for all SLE criteria was greater than 0.940. In the ROC analysis of patients with SLE and PAFS, indicating the number of diagnostic criteria, sensitivity was 86% for ACR-1997, 95% for SLICC-2012, 95% for EULAR/ACR 2019, and specificity was 100, 62 and 62%, respectively. CONCLUSION: The classification criteria SLICC-2012 and EULAR/ACR 2019 are more sensitive for the diagnosis of SLE in the Russian population, and the criteria ACR-1997 are more specific. All three variants of the SLE classification criteria have sufficient sensitivity and specificity for their use in real clinical practice.

[Effectiveness and safety of selective and non - selective factor Xa inhibitors in antiphospholipid syndrome and systemic lupus erythematosus: anti - Xa - activity range].

The aim of the study was to evaluate the anti - Xa - activity (aXa) of selective and non - selective factor Xa inhibitors in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) patients according to clinical implications and laboratory parameters. MATERIALS AND METHODS: Clinical and laboratory data were analyzed retrospectively in SLE and APS patients who protractedly received low weight molecular heparins (LWMH) and selective factor Xa inhibitors fondaparinux and rivaroxaban. The study included 70 patients in the middle age 39 [31; 43] years: 15/70 (21%) - with SLE, 10/70 (14%) - with APS and 45/70 (65%) - with SLE and APS (SLE+APS). All the patients received anticoagulants: 29 patients - nadroparin (98.3 [67.8; 129.5] IU/kg/day), 29 patients - fondaparinux (5 [5; 7.5] mg/day), 3 patients - enoxaparin (1.2 [0.8; 1.5] mg/day) and 9 patients - rivaroxaban (20 mg/day). All the patients signed informed consents. RESULTS: aXa therapeutic range of 0.1-1.5 IU/ml was found in 43/70 (61%) patients, low aXa - in 14/70 (20%) and high aXa - in 13/70 (19%) patients. Patients with low aXa underwent anticoagulant dose correction. There were not any major bleedings and thrombosis relapses in the study. Increased aXa was more common in patients, who took fondaparinux (31%), than in those, who took nadroparin (7%) and rivaroxaban (23%), p=0.02. Patients with enoxaparin had normal aXa range. In the absence of bleeding in SLE and APS patients, received anticoagulants in standardized therapeutic dose, the next factors influenced the aXa range excess: valvular heart disease (VHD) with the 3rd stage of mitral valve insufficiency as a result of aseptic Libman-Sacks endocarditis (odds ratio - OR 9.02, 95% confidential interval - CI [1.53; 53.12], p=0.015), peripheral artery disease in analogy with arteritis obliterans (AO) (OR 6.86, 95% CI [1.25; 37.71], p=0.027), and also triple - positivity of all types of antiphospholipid antibodies (OR 4.93, 95% CI [1.11; 21.99], p=0.036). According to found logistic regression model, aXa range excess risk can be prognosticated by the next formula: Z = -3.98 + 2.2 × VHD (yes-1/no-0) + 1.9 × AO (yes-1/no-0) + 1.6 × Triple - positivity (yes-1/no-0). Classified function value Z=0.39 defines the patients group with aXa range excess. Thus the value Z>0.39 indicates aXa range excess in the absence of bleeding, herewith sensibility is of 77% and specificity is 86%, positive prognostic value is 84.3%. CONCLUSION: In SLE and APS patients the next clinical and immunologic manifestations influenced the aXa therapeutic range excess: peripheral artery disease in analogy with AO, earlier aseptic Libman-Sacks endocarditis with the 3rd stage of mitral valve insufficiency and triple - positivity of all types of antiphospholipid antibodies, that does not need LWMH and fondaparinux dose correction. In contrast, anticoagulant dose reduction can cause clinical symptoms progression. Therapeutic aXa range in such patients should be extended.

[THE CLINICAL INFORMATIVENESS OF AUTOMATED METHODS OF SCREENING DETECTION OF ANTI-NUCLEAR ANTIBODIES USING INDIRECT REACTION OF IMMUNE FLUORESCENCE, ENZYME-LINKED IMMUNOSORBENT ASSAY AND MULTIPLEX XMAP TECHNOLOGY UNDER SYSTEMIC LUPUS ERYTHEMATOSUS].

Thew antinuclear antibodies (ANA) consist heterogeneous group of auto antibodies reacting with various components of nucleus and cytoplasm. The ANA is a main serological marker of systemic lupus erythematosus (SLE). The implementation in clinical practice of new highly productive techniques of immune analysis using automated systems sets up prerequisites for standardization and amelioration of reproducibility of detection of ANA. The study was carried out to compare diagnostic significance of automated techniques of screening detection of ANA (indirect immunofluorescence test on cells HEp-2 (IIFT-HEp-2)), enzyme-linked immunosorbent assay (ELISA) and multi-complex immune analysis (MIA, using suspension technology xMAP) in serum of patients with SLE. The serums from 94 patients with SLE were analyzed. The comparison group included 70 patients with other rheumatic diseases. The control group consisted of 30 healthy donors. The screening detection of ANA using technique IIFT-HEp-2 was implemented on automated platform AKLIDES, ELISA - on automated analyzer ALEGRIA and MIA on automated analyzer BioPlex 2200. The technique IIFT-HEp-2 demonstrated the most high diagnostic sensitivity as compared with ELISA and MIA- BioPlex 2200 (96.8%; 79.8% and 82.9% correspondingly). The general diagnostic specificity of detection of ANA using technique IIFT-HEp-2 was lower than in case of ELISA and MIO-BioPlex 2200 (40%, 70% and 57% correspondingly). In the group of healthy donors the lowest diagnostic specificity was observed in ANA screening analysis using MIA-BioPlex 2200 (80%) while in case of applying IIFT-HEp-2 and ELISA indices of diagnostic specificity made up 93.3% and 96.7% correspondingly. The ANA analysis of mix of 26 nuclear antigens using ELISA technique was a reliable laboratory test for diagnostic of SLE (likelihood ratio of positive result - 2.66). By the level of likelihood ratio of negative result of the IIFT-HEp-2 technique was more informative test for exclusion of diagnosis of SLE than techniques of ELISA and MIA-BioPlex 2200 (0.08; 0.29 and 0.3 correspondingly). The detection of ANA using technique of is the most preferable primary screening test for diagnostic of SLE. The ELISA of antibodies to mix of nuclear antigens and MIA on the basis of xMAP technology are less preferable screening tests for diagnostic of SLE as compared with IIFT-HEp-2 because of false-negative results in 20% and 17% of cases correspondingly. ELISA and MIA are to applied as confirmatory screening tests permitting to detect antigen-specific ANA in patients with SLE with positive results of IIFT-HEp-2.

[Plasminogen activator inhibitor type 1 gene polymorphism and thromboses in patients with antiphospholipid syndrome].

AIM: To estimate the prevalence of plasminogen activator inhibitor type 1 (PAI-1) gene polymorphism in patients with antiphospholipid syndrome (APS) and its implication in vascular disorders. SUBJECTS AND METHODS: The investigation enrolled 138 patients: 103 with APS, including 47 with systemic lupus erythematosus (SLE) + APS and 56 with primary APS (PAPS), 15 with SLE without APS, 20 with idiopathic thrombosis (IT), a control group (30 apparently healthy individuals). Thrombosis at various sites was recorded in 91 (88%) of the 103 patients with APS. The authors analyzed both the presence of thrombotic events in all the groups and the number of cases of thrombosis in each patient. Antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies, and anti-beta2-glycoprotein type 1 antibodies, were studied in all the patients. To diagnose a genotype in patients by the code encoding for PAI-1, DNA isolated from peripheral blood by standard methods was used and further investigated by real-time polymerase chain reaction. RESULTS: Out of 91 patients with APS and thrombosis, 27 (30%) had the 4G/4G genotype, which corresponded to homozygous mutation in the PAI-1 gene, 50 (55%) had the 4G/5G genotype (heterozygous mutation), and 14 (15%) had the 5G/5G (a normal genotype). The PAI-1 4G/5G genotype was present in 22 (70%) of 31 patients with SLE + APS and lower limb deep vein thrombosis versus 17 (470%) of 36 patients with PAPS (odds ratio (OR) 2.73; 95% confidence interval (CI), 0.89 to 8.59; p = 0.08) and in 9 (90%) of 10 patients with SLE + APS and pulmonary artery thromboembolism versus 8 (40%) of 20 patients with PAPS (OR 13,5; 95% CI, 1.23 to 344.98; p = 0.02). The incidence of thrombosis per 100 person-years was higher in the PAI-1 4G/4G and 4G/5G groups: 35.4 and 28.1 cases per 100 person-years, respectively. Thromboses were least often in the group of patients with the PAI-1 5G/5G genotype (18.6). CONCLUSION: The prevalence of the PAI-1 5G/5G genotype in patients with APS and thrombosis was significantly lower than in those with SLE without APS or thrombosis. The 4G/5G polymorphism in APS in the presence of SLE was associated with venous thromboembolisms whereas in PAPS there was no relationship between the PAI-1 genotype, a history of thrombosis, and its localization.

[Subclinical and clinical manifestations of atherosclerosis in antiphospholipid syndrome].

AIM: To evaluate intima-media complex (IMC) thickness in patients with antiphospholipid syndrome in terms of clinical-laboratory manifestations and thrombosis risk factors. MATERIAL AND METHODS: The trial included 206 patients (57 males and 149 females, age 16-59, mean age 35.9 years). Of them, 58 (28%) patients had primary antiphospholipid syndrome (PAPS) alone, 148 had documented concomitant systemic lupus erythematosus (SLE). Seventy two (48.6%) SLE patients had antiphospholipid syndrome (APS), 29 (19.6%)--anticardiolipin antibodies (aCL) level above 40 IU in two and more measurements without clinical symptoms of APS. In addition to standard tests, APL (lupus anticoagulant), aCL and antibodies to beta-2 glycoprotein, blood lipids were measured. Thrombosis and atherothrombosis risk factors were evaluated. Ultrasound dopplerography estimated thickness of IMC in the carotid and femoral arteries. The control group consisted of 89 donors free of autoimmune diseases. RESULTS: Mean values of IMC thickness did not differ between the groups. Atherosclerotic plaques (ASP) were detected in 25 (12%) of 206 patients: in 5 (9%) from PAPS group, 10 (14%) from SLE+APS, in 4 (14%) and 6 (13%) from SLE groups aPL+ and aPL-, respectively. Mean age of patients with ASP was 46 +/- 6.9 years (32-55 years). ASP occurrence was associated with older age: ASP were detected in 10 (38%) of 26 patients aged over 51 years (24 plaques), in 10 (20%) of 50 patients aged 41-50 years (18 plaques) and in 5 (10%) of 50 patients aged 41-50 years (18 plaques) and in 5 (10%) of 50 patients aged 31-40 years (9 plaques, p = 0.001). IMC thickness and plaques were associated with prior arterial and venous thromboses and occurred significantly more frequently in patients with myocardial infarction and transient ischemic attacks (p < 0.001). Thrombosis and atherothrombosis risk factors were associated with changed IMC thickness. The level of aPL and their type had no effect on IMC thickness and ASP incidence in the groups studied. CONCLUSION: Increased IMC thickness was associated with age irrespective of APS presence. In SLE, ASP appeared at younger age than in PAPS patients. Atherothrombosis risk factors affect IMC thickness irrespective of the level and type of aPL.

[Cardiovascular aspects of antiphospholipid syndrome].

Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia diagnosed based on the presence of a single clinical sign (thrombosis or and obstetric problem) and one serological criterion (anticardiolipin antibodies and/or lupoid anticoagulant and/or antibodies against b2-glycoprotein-1. Clinical feature of the syndrome are diverse and depend on localization and diameter of the affected Bessel. This review focuses on cardiovascular aspects of APS. Cradiovascular system disorders are arbitrarily divided into valvular pathology, coronary and myocardial lesions. The relationship between antiphospholoipid antibodies and atherosclerosis is discussed.

[Polymorphism of the plasminogen activator inhibitor type 1 gene, plasminogen level and thrombosis in patients with antiphospholipid syndrome].

The frequency of venous and arterial thromboses and plasminogen level were investigated in 78 patients with antiphospholipid syndrome (APS), 35 of whom with systemic lupus erythematosus (SLE+APS) and 43 - with primary APS (PAPS). The levels and genotype of plasminogen activator inhibitor type 1 (PAI-1) were determined in 45 patients with APS, of whom 21 patients with SLE + APS and 24 patients with PAPS. A control group included 10 healthy individuals without autoimmune disease signs and thromboses on period of investigation and in past history. It was shown for the first time that for one third of 67 patients with APS and thromboses high positive levels of antiphospholipid antibodies (aPL) are associated with low plasminogen levels. The levels of PAI-1 antigen measured by ELIZA method, which detects active, latent and bound with plasminogen activator PAI-1, were opposed with frequency of thromboses in APS patients. Correlation between the high and increased levels of PAI-1 and high positive aPL levels was found for one third of 43 patients with APS and thrombosis. One of the possible mechanisms of this interconnection was considered. It was shown that arterial and, to a more extent, venous thromboses are associated with the 4G/5G polymorphism of PAI-1 gene and high plasma level of the inhibitor in 79% of APS patients. At the presence of the 4G allele patients with SLE+APS had higher PAI-1 levels than patients with PAPS. The obtained results show that measuring the levels of plasminogen and PAI-1 as well as the 4G/5G polymorphism of PAI-1 gene which is associated with thromboses may have the practical significance for identification of high risk of thrombosis in APS patients.