zydus oration - dr ruchika goel

Takayasu arteritis (TA) – CMC Vellore Experience

Dr Ruchika GoelAssistant Professor, Department of RheumatologyChristian Medical College, Vellore

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Outline

• Clinical Profile

• Genetics and Immuno-pathogenesis

• Disease activity assessment

– Biomarkers – blood and radiological

• Management

• Outcome predictors

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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

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Brunner etal, Rheumatology 2010 (n= 241)

CMC Vellore, J Rheum 2014(N= 40)

Clinical features of childhood onset TAK

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• 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 Unpublished data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)

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• 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


Clinical profile and outcome of Indian patients with TA

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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

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GENETICS AND IMMUNOPATHOGENESIS

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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)

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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

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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

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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)

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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

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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

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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

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IMMUNOPATHOGENESIS- INNATE IMMUNITY AND TUBERCULOSIS

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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)

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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)

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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

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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.

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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

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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

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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)

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BIOMARKERS

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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)

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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

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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)

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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)

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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

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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]

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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 ?

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THERAPEUTICS AND OUTCOME

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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

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• 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

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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

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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

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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

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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

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THANK YOU

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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)

zydus oration - dr ruchika goel

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