Objective:To investigate the key factors of renal damage in patients with primary Sj?gren′s syndrome (pSS), to construct a risk prediction model.Methods:Clinical data of 419 pSS inpatients in the Nanjing Drum Tower Hospital from 2017 to 2020 were retrospectively analyzed. The patients were randomly divided into the model group (315 cases) and the validation group (104 cases) in a 3∶1 ratio by R software randomized package. T test was used in accordance with the normal measurement data, Chi square test was used for counting data, and Kruskal-Wallis H and Mann-Whitney U test were used for non-normal distributed data. A nomogram model was created based on independent factors of renal damage by using LASSO Cox regression analysis, and the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA) were applied to evaluate the sensitivity, accuracy and clinical practicability of the model. Results:Renal impairment occurred in 127 (30.3%)pSS patients, including 89 (70.1%) cases with renal insufficiency, 86 cases with hematuria (67.7%), 107 cases with proteinuria (84.2%) and 49 cases with renal tubular acidosis. Compared with those without renal damage, patients with renal damage had a longer course of disease [3.00 (1.00, 8.00) years vs 1.00 (0.30, 5.00) years; Z=2.33, P=0.005], presence of fatigue [35.1% (33/94) vs 23.5% (52/221), Z=4.49, P=0.038], decreased blood cells count [white blood cell 4.50(3.30, 6.75)×10 9/L vs 5.40(3.70, 8.05)×10 9/L, Z=2.02, P=0.043; hemoglobin 99.00(79.00, 111.00)g/L vs 120.00 (109.00, 128.00)g/L, Z=6.59, P<0.001; platelet 152.00 (89.25, 204.25)×10 9/L vs 188.00 (117.99, 241.00)×10 9/L, Z=2.61, P=0.009], stronger inflammatory reactions [ESR 48.50 (29.75, 86.25)mm/1 h vs 26.00 (11.00, 52.00)mm/1 h, Z=5.83, P<0.001; CRP 5.80 (3.40, 18.45)mg/L vs 4.40 (2.60, 11.40) mg/L, Z=2.33, P=0.020] and higher positive rate for anti-SSA/B antibodies [79.79%(75/94) vs 61.99%(137/221), χ2=9.49, P=0.002; 37.23%(35/94) vs 18.10%(40/221), χ2=13.31, P<0.001], but relatively less pulmonary involvement [20.2%(19/94) vs 33.9%(75/221), χ2=5.93, P=0.016], the differences were statistically significant ( P<0.05). Lasso binary logistics regression analysis showed that EULAR Sj?gren′s syndrome disease activity index score >9[ OR(95% CI)=9.019(3.294, 24.689), P<0.001], dry eye[ OR(95% CI)=2.853(1.502, 5.422), P=0.011], anemia[ OR(95% CI)=3.819(1.913, 7.626), P<0.001], low complement C3 level[ OR(95% CI)=2.453(1.233, 4.879), P=0.011]and hypoalbuminemia [ OR(95% CI) =6.898 (3.007, 15.821), P<0.001] as well as C-reactive protein [ OR (95% CI)=2.168 (1.136, 4.139), P=0.019] were significant related factors of renal impairment. The AUC (95% CI) of the prediction group and the validation group were 0.851 (0.806, 0.896) and 0.832 (0.742, 0.922), respectively, and the model plot and DCA showed that the model had good specificity and clinical efficacy. Conclusion:We propose a new nomogram model with good differentiation and calibration to assist in clinical screening of renal damage in pSS.

Objective:Toanalyze the clinical features of patients with idiopathic inflammatory myopathy (IIM) and interstitial lung disease (ILD) when complicated with pulmonary infection.Methods:Clinical data ofconsecutive IIM patients admitted to our hospital from January 2014 to December 2017 were collected. Patients were divided into two groups: pure IIM-ILD and IIM-ILD with pulmonary infection, and the difference in clinical manifestations and lab test results was compared. The ROC curve was used to evaluate the predictive diagnostic value of T lymphocytes. The data was analyzed by the Chi-square test, Mann-Whitney U test and multiple logistic regression analysis. Results:Totally 153 patients were included, in which 51 cases were complicated with pulmonary infection. The incidence of myalgia, rash, cough/expectoration and fever and the levels of aspartate aminotransferase, lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were increased in the infection group, while the number of lymphocytes was significantly decreased ( P<0.05). Multivariate logistic regression analysis showed that myalgia, cough/expectoration, serum LDH level >350 U/L and peripheral blood lymphocyte count <0.9×10 9/L were independent risk factors for pulmonary infection in IIM-ILD patients (ORvalues 4.31, 3.81, 2.70 and 2.44, respectively, P<0.05) . Meanwhile, the number of natural killer cells as well as CD3 +, CD3 +CD4 +, CD3 +CD8 + T cells in the infection group was significantly lower than that in the pure IIM-ILD group ( Z values -2.28, -3.094, -2.918, and -2.308, respectively, P<0.05). ROC curve showed that CD3 + T cells combined with CRP improved the diagnostic sensitivity of pulmonary infection in IIM-ILD. Conclusion:IIM-ILD patients are more likely to have myalgia,cough/expectoration as well as increased LDH level when complicated with infection. The decrease in peripheral T lymphocyte numbers may indicate an increased risk of pulmonary infection in these patients.

Objective To investigate the expression of soluble vascular endothelial growth factor receptor 1 (sFlt1) in human umbilical cord-derived mesenchymal stem cells (HUCMSC) under the condition of inflammatory cytokine and co-culture with rheumatoid arthritis fibroblast-like synoviocytes (RA-FLSs).Methods ① HUCMSC were cultured alone or stimulated by Tumour necrosis factor (TNF)-αt,interferon (IFN)-γor the combination of TNF-α and IFN-γ.The sFh1 levels of each group were detected by enzyme-linked immunosorbent assay (ELISA) at 24 h,48 h and 72 h respectively.② RA-FLSs and HUCMSC were cocultured in a transwell system with both of them cultured alone as control for 72 hours.ELISA was used to detect sFlt1 levels in each group.T test was used for comparison between two groups,and ANOVA was used to compare multi-group variables.Results ① The sFlt1 levels of TNF-α + IFN-γ group were significantly higher than those of the control group at 24 h and 48 h (24 h (5.4±0.4) ng/ml vs (2.8±1.7) ng/ml,t=0.942,P=0.026;48 h (7.2±0.8) vs (4.3±1.0) ng/ml,t=4.285,P=0.005),while that at 72 h was not significantly different [(9.1±1.7) ng/ml vs (7.0±1.4) ng/ml,t=0.683,P=0.52].And no significant difference in sFlt1 levels between control group and TNF-α group or IFN-γ stimulation group were observed.② Compared with RA-FLSs,the expression of sFlt1 in HUCMSC was significantly higher (8.19±3.64) ng/ml vs (0.19±0.08) ng/ml,t=7.280,P＜0.01].After co-cultured with RA-FLSs and HUCMSC,the sFlt1 concentration of the co-culture group was significantly higher than that of HUCMSC group [(17.26±6.92) ng/ml vs (8.19±3.64) ng/ml,t=3.985,P=0.000 7].Conclusion The sFlt1 expression of HUCMSC is up-regulated by inflammatory cytokine TNF-α combined with IFN-γ.RA FLSs may promote the co-cultured HUCMSC to increase sFlt1 expression by secreting inflammatory factors.

Objective To analyze the clinical profile of primary Sj(o)gren's syndrome (pSS) patientswith central nervous system (CNS) involvement.Methods Thirty-eight pSS-CNS patients at Nanjing Drum Tower Hospital between 2012 and 2016 were enrolled.These patients were divided into high activity group and moderate activity group,according to European League against Rheumatism Sj(o)gren's syndrome Disease Activity Index (ESSDAI).The imaging characteristics,clinical features,laboratory examinations and treatment of 38 cases were retrospectively analyzed.Quantitative differences were analyzed by the student's t-test and qualitative data were analyzed with chi-square or Fisher's exact test.Results The prevalence of central nervous system involvement in pSS patients was 2.93％(38/1 296),while 32％(12/38) as the initial symptom of pSS.Recurrence rate was 39％(15/38).Limb weakness,speech difficulty,sensory disorders,blurred visionwere the most frequent symptoms in pSS-CNS.Multiple lesions in Magnetic resonance imaging (MRI) examination and cerebrospinal fluid abnormality were seen in 94％ (15/16) pSS-CNS patients,among which intra-thecal IgG level increased in 50％ (8/16).In addition,the frequencies of lung involvement,immune associated thrombocytopenia,high-titer antinuclear antibody (ANA) were significantly higher in high activity group of pSS-CNS than those of moderate activity group.The value of above items was 4.7,5.0 and 5.3,respectively,and all the differences were significant (P＜0.05).After high-dose corticosteroids and immunosuppressive therapy,61％ (23/38) patient improved,37％(14/38) were unresponsive to treatment,and 3％(1/38) died because of acute massive cerebral infarction.For those unresponsive patients,mesenchymal stem cell transplantation or immune adsorption treatment might be effective.Conclusion The clinical manifestations of central nervous system are diverse,may be the initial presentations in some pSS patients,with low morbidity and high recurrence rate.Image and lumbar puncture are important for diagnosis.Pulmonary involvement,immune thrombocyto-penia,and high-titer ANA are frequently associated with the activity of pSS-CNS.Most patients have good response to the treatment regimens of high-dose corticosteroids and immunosuppressive therapy,mesenchymal stem cell transplantation or immuno-sorption therapy may be considered in those unresponsive cases.

Objective To investigate the association of human leucocyte antigen (HLA-DRB1) with anti-melanoma differentiation-associated gene 5 (MDA5) expression in polymyositis/dermatomyositis (PM/DM).Methods Seventy patients with PM,104 patients with DM and 400 healthy controls were included.Genotyping of HLA-DRB1 was performed using the sequencing-based typing method.Levels of anti-MDA5 were measued by enzyme linked immunosorbent assay using recombinant MDA5 antigen.The frequencies of HLA-DRB1 alleles were compared between the patients and controls using a chi-square test or Fisher's exact test.Results Frequencies of DRB1 * 04∶01 [17.0％ vs 1.3％,corrected P-value (Pc)=3.8×10-8;odds ratio (OR)=16.2;95％ confidence interval (CI) (6.6,39.7)] and DRB1 * 12∶02 [(42.6％ vs 19.3％,Pc=0.008;OR=3.1;95％ CI(1.7,5.7)] were significantly higher in anti-MDA5 positive PM/DM patients compared with the controls.The frequencies of DRB1 * 04∶01 [P=5.2×10-6,OR=17.1,95％CI:(5.3,54.9)\ and * 12∶02 [P=3.8×10-4,OR=3.1,95％CI(1.7,5.7)] in anti-MDA5 positive DM-interstitial lung disease (ILD) patients were higher than those in the controls,whereas the frequencies of DRB1 * 04∶01 and * 12∶02 did not differ between the anti-MDA5 negative DM-ILD patients and the controls.No difference in the frequency of DRB1 alleles,other than * 04∶01,carrying the shared epitope (SE),i.e.* 01∶01,* 01∶02,* 04∶05 and * 10∶01,was observed between the controls and DM patients stratified by the presence of anti-MDA5 and ILD.Conclusion DRB1 * 04∶01 and * 12∶02 confer susceptibility to anti-MDA5 antibody production in DM,which cannot be explained by the SE hypothesis.

Objective The aim of this study was to assess the status of protease-activated receptor-2(PAR-2) expression on the peripheral blood immune cells including dendritic cells(DC) of Wegener's granulo matosis(WG) patients.Methods Flow cytometry was used to analyze the expression of PAR-2 protein on peripheral blood immune cells,DC and DC-like monocytes of healthy controls (HC),inactive,active and different medicine-treated WG patients.Two-tail Mann Whitney non-parametric test was used for statistical analysis.Results There was no difference of PAR-2 expression on PMN,monocytes,lymphocytes and DC between WG patients and HC.However,PAR-2 expression on CD14+CD16+ (t=3.823,P=0.004) and CD64+CD16+ (t=2.652,P=0.024) DC-like monocytes was much higher in WG patients compared with HC.In active WG,expression of PAR-2 was up-regulated on the cell surface of PMN (t=2.690,P=0.013 ),monocytes (t=1.688,P=0.047),lymphocytes(t=1.742,P=0.038),BDCA3+DC(t=2.582,P=0.016),CD11c+DC(t=1.828,P=0.044),CD14+CD16+ (t=3.419,P=0.002)and CD64+CD16+ (t=3.494,P=0.005) DC-like monocytes when compared with inactive WG.PAR-2 expression on these cells was similar between cyclophosphamide (Cyc) and Methotrexate (MTX) treated WG patients.Conclusion PAR-2 expression on immune cells,DC and DC-like monocytes correlates with WG occurrence and development.There is no difference in the effects on PAR-2 expression between various medications.

Objective To analyze the prognostic factors and causes of death of patients with systemic lupus erythematosus (SLE).Methods A database with 319 patients were developed.They were newly diagnosed SLE in the Department of Rheumatology and Immunology,Affiliated Drum Tower Hospital of Nanjing University Medical School from 1999 to 2009.Normal distribution of measurement data was presented using mean±standard deviation.The skewed distribution of data was described by median(interquartile range).Using the rate or proportions,the character of classification data was also stated.Survival rate of SLE patients over time was studied by the Kaplan-Meier method,and prognostic factors were analyzed by COX proportional hazards model.Results The 5 year and 10-year survival rates was 96.2%, 88.7%, respectively Prognostic factors affecting survival included duration from onset to diagnosis, anemia, white blood cells in urine, low serum albumin,low C4 level,abnormal ECG and ultrasound echocardiography, pulmonary arterial hypertension (PAH) and systemic lupus erythematosus disease activity index (SLEDAI). However, PAH,duration from onset to diagnosis, low serum albumin were the independent poor prognostic factors and the relative risk and 95% confidence interval were 2.419 (1.052-5.564), 1.162 (1.043-1.294), 0.924 (0.873-0.978), respectively. Renal failure, pulmonary hypertension and infection were the main causes of death,followed by multiple organ failure and lupus encephalopathy. Conclusion PAH, duration from onset to diagnosis, low serum albumin are the important factors predicting poor prognosis. Early diagnosis, timely treatment of SLE organ damages and preventing complications are the key factors to improve the prognosis of patients with SLE.

Objective To assess the effects of protease 3(PR3)and protease-activated receptor (PAR)-2-activator on the maturation and functions of peripheral blood dendritic cell(DC)-like monocytes.Methods Density gradient centrifugation was used to isolate peripheral blood mononuclear cells(PBMC)from Wegener's granulomatosis(WG)patients and healthy controls(HC).PBMC were stimulated by LPS,human PR3,trypsin,PAR-2-agonist peptide (PAR-2-AP),LPS+PR3 or LPS+trypsin for 24 h.Flow cytometry was used to analyze the expression of PAR-2,CD80,CD83,HLA-DR on stimulated DC-like monocytes-CD14+CD16high monocytes.ELISA kit was used to test the concentration of IL-6 in the culture supernants.Mann-Whitney non-parameteric test was used fur statistical analysis.Resuits No effect of PR3,trypsin and PAR-2-AP on the expression of PAR-2,CD80,CD83,HLA-DR of DC-like monoeytes was found.LPS could significantly induce PAR-2 expression in HC[from(5.8±1.5)%to(24.5±4.5)%,P=0.002]and the expression of CD80,CD83,HLA-DR in HC and WG;PR3,trypsin,PAR-2-AP and LPS could all stimulate the secretion of IL-6.Conclusion PR3 and PAR-2 pathway-activators can not promote PAR-2expression and maturation of DC-tike monocytes,but they can induce the secretion of IL-6.

ObjectiveTo investigate the role of magnetic resonance imaging (MRI) in treatment efficacy evaluation of polymyositis and dermatomyositis.MethodsFifteen patients with polymyositis and dermatomyositis underwent MRI of thigh were included.Scores of MRI signal intensity of the diseased muscle of every patient were compared before and after treatment and the correlation between serum creatinkinase (CK) level and muscle strength grade were also compared.Correlations between muscle strength grade and MRI score,as well as muscle strength grade and creatinkinase level were analyzed.Comparisons between groups were tested by t test,and the relationship between muscle strength and clinical data was analyzed by Pearson's correlation analysis.ResultsThe signal score of MRI was counted before and after therapy(2.37±0.62,1.30±0.28,respectively,P＜0.05),and CK level[(3841±3175),(549±338) U/L,respectively,P＜0.05] and muscle strength (15.1 ±2.4,18.1 ±0.9,respectively,P＜0.05) were assessed at the same time.Muscle strength grade was associated with signal score of MRI and serum CK level,there was a strong correlation between muscle strength grade and signal score of MRI(r=-0.890,P＜0.05 ).ConclusionMRI may be a useful tool for clinical efficacy evaluation in patients with polymyositis and dermatomyositis.

Objective To explore the clinical efficacy of allogenic mesenchymal stem cells transplantation (MSCT) in patients with refractory polymyositis/dermatomyositis (PM/DM). Methods Bone marrow derived mesenchymal stem cells (BM-MSC) or umbilical cord derived mesenchymal stem cells (UC-MSC)were infused intravenously in 8 PM/DM patients. The clinical manifestations and laboratory parameters,including serum creatin in kinase (CK) and manual muscle test 8 (MMT8) score, were compared before and after MSCT. Staistically andlyzed by paired t-test. Results The eight patients were followed up for six to twelve months after MSCT. The level of serum CK decreased from (1681±430) to (886±248) U/L one week after MSCT (P＜0.05) and further decreased at week 2 (474±61) U/L, 1 month (293±89) U/L, 3 month (202±70) U/L and 6 month (175±46) U/L, respectively (all P＜0.05). MMT8 score increased to 1 month [(67±3) vs (45±14), P＜0.05], 3 month [(64±10) vs (45±14), P＜0.05], 6 month [(64±4) vs (45±14),P＜0.05] after MSCT. The dosage of glucocorticoid steroid were tapered in all patients 2 weeks after MSCT [(18±6) mg vs (34±15) mg, P＜0.05]. Clinical symptoms of interstitial pneumonia of both patients were relieved after MSCT, which was confirmed by the result of high resolution CT (HRCT) of the lung.The skin ulcers tended to be recovered after the transplantation in one DM patient. All patients did not develop transplantation related complications. Conclusion Allogenic MSCT is an effective and safe approach for the treatment of refractory PM/DM. However, extensive follow-up study is needed for long-term benefit evaluation.