free paper session - pro inflammatory cytokines in sle - dr s sriram
TRANSCRIPT
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
ACKNOWLEDGEMENTS
When eating a fruit, think of the person who planted the tree!
Prof. Dr.S.RAJESWARI
Conflict of Interests – nil
Financial disclosures - nil
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.
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.
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
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)
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
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.
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
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
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)
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)
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
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)
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
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
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
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
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
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
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)
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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