Upload
ira-con
View
104
Download
1
Embed Size (px)
Citation preview
Takayasu arteritis (TA) – CMC Vellore Experience
Dr Ruchika GoelAssistant Professor, Department of RheumatologyChristian Medical College, Vellore
2
Outline
• Clinical Profile
• Genetics and Immuno-pathogenesis
• Disease activity assessment
– Biomarkers – blood and radiological
• Management
• Outcome predictors
3
Clinical profile of childhood onset TA in India
N- 40 children
Nearly 40% children were misdiagnosed at secondary level care
The Journal of Rheumatology 2014; 41:6; doi:10.3899/jrheum.131117
4
Brunner etal, Rheumatology 2010 (n= 241)
CMC Vellore, J Rheum 2014(N= 40)
Clinical features of childhood onset TAK
5
• Total patients studied – 503 adult and juvenile onset TA
• Prospectively followed up - N= 168 (72 with follow up ≥ 12 months)
Clinical profile and outcome of Indian patients with TA
Goel R, Danda D, Joseph G, Nair A, Ravindran R, TS Kumar, Jayaseelan L, Jayaseelan V, Paul Bacon. Unpublished data
Age at onset of symptoms - 25.6 ± 11.1 years
Disease duration - 12 (6-48) months
Features of arterial ischemia- 53-57%
DEI.Tak – 9 (extensive disease)
Active disease at baseline – 73%
Baseline TADS (384 patients)- 6 (4-9, max-22)
6
• 100 juvenile onset TA
• Comparison of juvenile and adult onset TA:
– Raised creatinine (OR-4.07)
– Cardiomyopathy (OR-2.5)
– ITAS 2010 score (OR=1.08)
– Lesser frequency of claudication at presentation (OR= 0.528)
– lower ESR values at presentation (p=0.022)
– Outcome was similar
Goel R, Danda D, Joseph G, Nair A, Ravindran R, TS Kumar, Jayaseelan L, Jayaseelan V, Paul Bacon. Unpublished data
Clinical profile and outcome of Indian patients with TA
7
Region India (Jain, 1996) n= 106
India (Present study, 2016) n= 503
Design a R P/RPeriod NR 2004-2016Females 61% 77.9%Age at onset (years) 27* 25.6 ± 11.1 Age at onset ≥40 years 17.3% 11.5% Diagnostic delay (months) NR 6 (3-24)Type 5 ds 55.7% 50.5%C+ disease NR 60/269* (22.3%)P+ disease 49.% (n=4) 39/243# (16%)Renal Artery 53% 39.2%History of Tuberculosis 7.5% 8.3%Claudication NR 54.8%Pulse loss NR 53.3%Fever 16% 21.4%Raised ESR/CRP 60% 50%/ 72.6%
Disease activity criteria ND ITAS-2010
Indian Scenario- no change b/w 1996 - 2016
American & Japanese (> 90%)
(40% in multi-ethnic French series )
Similar Mayo Clinic and Italian cohorts
8
GENETICS AND IMMUNOPATHOGENESIS
9
Genotype / allele Cases (n=218)
Controls (n=220)
p
IL17F rs763780 (His 161 Arg)AlleleAG
41620
39743 0.003
(pc 0.006)GenotypeAAAGGG
198200
178411
0.004 (pc 0.048)
IL17F 161 G allele (rs763780): protective against TA susceptibility (OR = 0.35 (0.17-0.72)
*Odds ratio adjusted for age and gender for AG genotype was 0.4 (0.19-0.85)# Odds ratio adjusted for age and gender for G allele was 0.35 (0.17-0.72)
Danda D, Ruchika Goel, Hindhumathi M, Kabeerdoss J, L Jayaseelan, Jayaseelan V, Joseph G, Danda S. IRACON 2014
SNP in IL-6 (1), IL17 F (3), IL10 (3), TGFβ (3)
10
rs763780 in IL-17 (both phases combined)
An=416
Gn=20
p AA n=198
AGn= 20
p
No. of patients (%) No. of patients (%)
Fever as presentation 95 (22.8) 9 (45) 0.023 43 (21.7) 9 (45) 0.02
Syncope 43 (10.3) 5 (25) 0.057 19 (9.5) 5 (25) 0.036
Stroke 17 (4) 3 (15) 0.058 7 (3.5) 3 (15) 0.052
Tuberculosis (past/present/ follow up)
51 (12.3) 7 (35) 0.003 22 (11.1) 7 (35) 0.003
Aneurysms/ectasias 62 (14.9) 0 0.062 31 (15.6) 0 0.085
Persistent active disease (total patients followed up =162)
287 (85.1) 17 (100) 0.087 24 (14.9) 0 0.133
Association between IL17-F A161G polymorphisms & TA phenotype
11
Th1 and Th17 Cytokines Drive Inflammation inTakayasu Arteritis
D. Saadoun. Arthritis & Rheumatology Vol. 67, No. 5, May 2015, Pp 1353–1360
Increased Circulating Th17 Cells, Serum IL-17A, and IL-23 in Takayasu Arteritis
Misra DP et al. Autoimmune Diseases 2016, Article ID 7841718, 8 pages
12
Association of CRP gene variation in Asian Indian Takayasu arteritis patients
METHODS: SNP genotyping was done with Sequenom iPlexTM Gold Assay and MALDI-TOF platform
N= 54 TA patients and 100 controls (Indian population)
SNPs genotyped:
CRP gene (rs1205, rs1417938, rs3093058 and rs1800947) MCP-1 IL-23RMMP-2 MMP-9 IL-10IL-18 IL-12RB2 CD-24ICAM-1
Statistical analysis was done using the PLINK software
K. Shah, D. Danda, R. Shah, S. Prasanna, P. Chandna, R. Chopra, S. Danda. CMC Vellore (unpublished data)
13
Association of CRP gene SNP (rs1205) in Asian Indian Takayasu arteritis patients (T allele protective OR= 0.632)
TA cases: 104 (84 females)Healthy controls: 185 (166 females)Genotype / allele Cases
(n=104)Controls (n=185)
p
rs1205 in CRP gene
AlleleCT
139 (37.6%)57 (27.4%)
231 (62.4%)151 (73%)
0.013 (pc= 0.026)
GenotypeCC CTTTCT+TT
54.8%37.5%7.7%45.1%
37.3%51.9%10.8%62.7%
CT vs CT+TT= 0.006
Blunted CRP response observed in 14/48 (29.2%) patients with TT homozygous as compared to 8/56 (14.3%) patients with other genotypes (p=0.064).
Nair A, Goel R, Mohan H, Danda S, Jayakanthan K, Danda D. IRACON 2016
14
SNPs significant in GWAS –no association with susceptibility in Indian TA
17 SNPs by SEQUENOM mass array
In collaboration with CCMB, Hyderabad
SNP Geners11810249 5' of IL12RB2rs10919543 near 3' of FCGR3Ars3731865 SLC11A1/intronrs2082412 near 3' of UBLCP1rs3212227 IL12B/UTR-3rs2853694 IL12B/intronrs3213094 IL12B/intronrs3212220 IL12B/intronrs6887695 near IL12Brs6871626 near IL12Brs56167332 near IL12Brs1071583 FCN1/cds-synonrs10120023 FCN1/nearGene-5rs1861494 IFNG/intronrs878329 NLRP1rs8182352 NLRP2rs665268 MLX/missense
117 cases 174 controls
Associated with Tuberculosis in Indians
15
Genotype / allele Cases (n=117)
Controls (n=174)
p
IFN gamma (rs1861494)
AlleleT C
82.9%17.1%
89.1%10.9% 0.032
GenotypeTTTCCC
72%22%6%
80%18%2%
0.043
IFN gamma (rs1861494) in TA
In both TB and IBD, T is the risk allele Functional Changes in both IFNG Methylation and Protein Secretion
Sequenom IPLEX platform
Goel R, Danda D, K Thangaraj, Raj N etal. Unpublished data
16
IMMUNOPATHOGENESIS- INNATE IMMUNITY AND TUBERCULOSIS
17
Humoral Immune response to MTB antigens in TA
A Aggarwal et al. Takayasu's arteritis: role of Mycobacterium tuberculosis and its 65 kDa heat shock protein. International Journal of Cardiology 1996; 55: Pages 49-55
Tuberculosis in TA
T cell reactivity to MTB antigens in TA
Chauhan etal. Cellular and humoral immune responses to mycobacterial heat shock protein-65 and its human homologue in Takayasu's arteritis. Clin Exp Immunol. 2004 Dec; 138(3): 547–553.
Overall frequency of TB in our cohort – 8.3% patients
Clinical profile and outcome of TA. CMC Vellore, India (Unpublished)
18
Exposure to mycobacterial cord factor enhances in vitro IL6 production by peripheral blood mononuclear
cells from patients with Takayasu arteritisTDB (Trehalose-6,6-dibehenate) – analogue of Trehalose-6,6-dimycolateType 5 TA, 22 TA and 21 healthy controls
Relative Induction of TNFα and IL6 protein in supernatant of PBMCs after stimulation with TDB (50 μg/ml) (stimulated/ un-stimulated) in TA and controls
Gupta N, Kabeerdoss J, Mohan M, Goel R, Danda D. IRACON 2016 (unpublished)
19
Gene Expression
TDB50/unstimulate
d
HC (n=8) TA (n=9) p Value
IL-6 1.03(0.58-1.45) 2.1(0.77-6.76) 0.1520
CLEC4E 0.43(0.36-0.57) 1.03(0.623-1.346) 0.0111BCL10 0.33(0.28-1.62) 0.97(0.77-1.243) 0.2991
TNF-α 1.21(0.69-2.11) 0.95(0.86-2.023) 0.9182
IFN-γ 0.98(0.8-1.616) 0.96(0.35-2.31) 1.000
IL6 and TNFα
20
TLR-4 and S100 calgranulins expression in Takayasu arteritis
Kabeerdoss J, Goel R, Mohan H, Danda D. IRACON 2016 (27th Nov)
Lumen
Intima
Media
Adventitia
?
VEGF,IL-6,MCP-1
inflam
matio
nTLR4
hsp65HMGB-1
VEGF,IL-6,MCP-1, ???
Weyand C et al. TLR4 and TLR5 induce distinct types of vasculitis Circ Res. 2009 Feb 27; 104(4): 488–495.
21
mRNA expression of TLR4 & RAGE in PBMCs
0.0001
0.001
0.01
0.1 HCTA
TLR4 RAGE
Rel
ativ
e ex
pres
sion
Expressions of mRNA values are shown in the box plot are median (central line), interquartile range (limit of the box) and range (whiskers)
HC (n=19); TA (n=24)
Number of denotes strength of significance; =p<0.05,=p<0.01
Results
22
Endogenous TLR4 ligands in PBMCs
Expressions of mRNA values are shown in the box plot are median (central line), interquartile range (limit of the box) and range (whiskers)
Both left and right y-axes are used, expression levels of S100A9 & S100A12 are depicted using the right y-axis
Number of denotes strength of significance; =p<0.05,=p<0.01
0.1
1
10
100
1000
0.01
0.1
1
10
100
HC
TA
S100A8 S100A9 S100A12
Rel
ativ
e ex
pres
sion
Relative expression
23
Serum S100 calgranulin levels
MRP8/14
HC TA0
2000
4000
6000
8000
10000
MR
P8/1
4 (n
g/m
l)Healthy controls (HC) (n=16) and Takayasu arteritis (TA) (n=19) commercial ELISA kits from BiolegendHealthy controls (HC) (n=19) and patients with Takayasu
arteritis (TA) (n=24)
24
BIOMARKERS
25
Baseline
IFNG_A
IFNG_SIL6_
AIL6_
S
IL23_A
IL23_S
IL17_A
IL17_S
0
25
50
75
100
125
Pro-inflammatory cytokine
conc
entr
atio
n (p
g/m
l)
Goel R, Kabeerdoss J, Babu R, Prakash JA, Babji S, Balaji V, Nair A, Mathew J, Jayaseelan V, Danda D Abstract : IRACON 2010
Serum Cytokine Profile In Asian Indian Patients With Takayasu Arteritis And Its Association With Disease Activity
Levels of IFNy correlated with disease duration
IFN-γ**
IL-6*
IL-23*
IL-17*
IL-10
TGF-β
• N= 32 consecutive Indian patients satisfying ACR criteria (active-15, stable-17) ; 91% on steroids at sample collection
• Follow up (active-4, Stable- 28)
26
HLA-E in TA
Coupel S etal. Expression and release of soluble HLA-E is an immunoregulatory feature of endothelial cell activation. Blood 2007; 109(7): 2806-2814
TA surgical specimens have revealed γδT-cells, NK cells, cytotoxic T-cells, T-helper cells, and macrophages to be the main infiltrating cells in aortic tissue*
*Seko Y et al/ J Vasc Res 2004;41(1):84– 90
27
Soluble-HLA-E: a follow up biomarker in Takayasu arteritis, independent of HLA-E genotype
Serum sHLA-E levels in patients classified by disease activity and healthy controls (n= 51 TA patients and 27 age and sex matched healthy controls)
n=23 n=17 n=9 n=27
Goel R, Kabeerdoss J, Mohan H, Jude J, TS Kumar, Jayaseelan V, Bacon P, Danda D. accepted for publication IJRD
AUC of 0.81 (95% CI: 0.66- 0.95)
28
sHLA-E levels showed a rising trend in patients with non responders (p=0.25) while it showed
a trend to decrease during follow up in responders (p=0.38)
T0 T1 T20
10
20
30
40
50
60
70
80
90
100
sHLA-E concentration in relapsing / per-sistently active disease
Baseline visit <-----Follow up visits------->
sHL
A-E
con
cent
ratio
ns (p
g/m
l)
1
2
3
4
5
6
7
T0 T1 T20
10
20
30
40
50
60
70
80
90
100
sHLA-E concentration in patients with stable disease course
Baseline visit <-----Follow up visits-->
sHL
A-E
con
cent
ratio
n (p
g/m
l)
29
Serum Amyloid A As A Marker of Disease Activity And Treatment Response In Takayasu Arteritis
• 197 TA patients screened b/w June 2014- Feb 2016• 99 TA patients (26 index visit) and 40 healthy controls • Active disease = 43 patients • Grumbling disease = 8• Stable disease= 48
0
100
200
300
400
500
Disease activity at baseline
Seru
m A
myl
oid
A (n
g/m
l)
Nair A, Goel R, Mohan H, Kabeerdoss J, Jayaseelan V, Danda D. Under review
30
Follow up SAA levels were measured for 9 responders and 12 non-responders
• SAA levels decreased only in responders
[189.9 ng/ml to 119.0 ng/ml, p= 0.008]
• Levels did not change significantly in non- responders
[146.9 ng/ml to 148.5 ng/ml at follow up, p=0.695]
31
Pathogenesis of TA
TDM? (mTB)TDB
Increased endogenous TLR-4 ligandsS100 A8,9,12 TLR-4
IL17 polymorphism ++
SAA ↑ ↑ CRP ↑ ↑
Normal in upto 40%
rs1205 CRP SNP
sHLA-E
Sawalha A. ACR AHRP Annual meeting, 2016Washington DC.
IFNg SNP ?
32
THERAPEUTICS AND OUTCOME
33
Treatment of TA
Mycophenolate mofetil in Takayasu’s arteritis
Tocilizumab in TA
Goel R, Danda D,Mathew J, Edwin N. Clin Rheumatol (2010) 29:329–332
Goel R, Danda D, Kumar TS, Joseph G. IJRD 2013; 16: 754–761
34
Goel R, Danda D, Joseph G, Nair A, Ravindran R, TS Kumar, Jayaseelan L, Jayaseelan V, Paul Bacon. Unpublished data
• Immunosuppression ≈ 95% (MMF was the commonest 2nd line agent in 62%)
• Vascular interventions – 70%
• Follow up ≥ 1 year – 251 patients (42 (IQR: 24-81) months, 24 months for 76%)
o Initial response to IS – 90%
o Relapse – 22.3%
o Damage progression arrested (∆TADS score)- 67.1%
o Increment in damage - directly
associated with active disease course
o Fatalities- 7
Outcome in Indian patients with TA
35
Goel R, Danda D, Joseph G, Nair A, Ravindran R, TS Kumar, Jayaseelan L, Jayaseelan V, Paul Bacon. Unpublished data
N= 503/ follow up >=1 year- 251
Sustained inactive disease - - 34.6% patients
(ITAS A CRP <3 &steroid ≤ 5mg/day thru entire follow up)
Predictors of sustained inactive disease:
– Low ESR values at baseline visit,
– Low CRP values at baseline visit
– Low DEI.Tak scores
– Type 4 disease
• Prediction model: Sensitivity -70% ; Specificity - 61%
• Relapses and sustained inactive disease: 0.5mg/kg/day of initial steroid dose equal
to 1mg/kg/day
Predictors of outcome in Indian patients with TA
36
Determining disease activity
NIH criteria
• Systemic features
• Elevated ESR or CRP
• Symptoms of vascular ischemia
• Typical angiographic features
New onset or worsening of any two of
the above criteria reflects disease
activity
ITAS 2010
Misra R etal, Rheumatology 2010
37
Agreement between angiography and various methods of disease activity assessment
Various scores with new areas Kappa value
ITAS-CRP > 4 & new areas 0.441
ITAS-A ESR >4 & new areas 0.36
ESR > 20mm/1st hr & new areas 0.28
CRP > 6mg/L & new areas 0.34
Angiography data along with concomitant ITAS 2010, ITAS-A [ESR] and ITAS- A
[CRP] was available for 60, 56 and 57 occasions
Goel R, Kumar TS, Danda D, Joseph G, Bacon P, Jayaseelan V [unpublished data]
ITAS –A CRP : best for new areas involvement in angiography ITAS 2010 : best for In-stent re-stenosis
38
Acknowledgement
Prof. Debashish DandaIRAVAS group
Prof R N Misra
Prof Paul Bacon
Christian Medical College, Research Office
Council for Scientific and Industrial Research , Delhi
SERB – Dept of Science and Technology, Delhi
Prof George Joseph
Prof Sathish Kumar
Prof Jayaseelan
Dr Jayakanthan K
Ms Hindumathi
Dr Raheesh Ravindran
DrAshwin Nair
Dr Santhosh Mandal
Dr Nikhil Gupta
39
THANK YOU
40
41
Outcome
Study Patients studied N follow up/ duration (yrs) Mtx/Aza/MMf
Kerr etal, NIH 60 45/5.5 Not specified/ very few
CCF, USA 75 30/3 43%/7%/7%
Mayo Clinic, USA 126 79/ 5.5 58% / 19% /18%
Japanese 106 35/ 0.5-5 50% , 35% CSA (very few)
CMC Vellore 503 251/ 3.5 9%/19%/62%
Sustained remission (lasting for 6 months)- 71% (Mayo clinic)