Type I interferons and their autoantibodies in the context of systemic lupus erythematosus

PurposeType I IFNs and their autoantibodies are implicated in the pathogenesis of Systemic lupus erythematosus (SLE), but their incidence and importance is still unclear. Neutralizing autoantibodies against IFNα have been previously reported in patients with autoimmune polyendocrinopathy syndrome type I (APS-1), rheumatoid arthritis, thymoma and more recently life-threatening COVID-19 patients. We hypothesized that autoantibodies towards type I IFNs, that develop in some patients with SLE, are neutralizing and may interfere with the course of the disease.MethodsLuciferase immunoprecipitation (LIPS) analysis was used to screen 474 SLE patient and 312 control serum samples for the presence of IFNα binding autoantibodies and determine their subclasses. Type I IFN neutralizing capacity was tested using a reporter cell line. Circulating levels of IFNα were measured with Single Molecule Array (Simoa).Results14% of SLE patients were positive for anti-IFNα and 13% were positive for anti-IFNω. The autoantibodies against IFNα were predominantly of IgG1 subclass and neutralized IFNα bioactivity in approximately one half of the positive cases. Once developed, anti-IFNα autoantibodies were present throughout the disease course. IFNα2 and -α8 were targeted first in two informative follow-up cases. The reactivity broadened to other IFNα subtypes and IFNω within several months. Serum levels of IFNα correlated negatively with anti-IFNα neutralizing titers. Patients with high levels of autoantibodies against IFNα had significantly lower levels of circulating IFNα compared to anti-IFNα negative patients. Interestingly, patients with high IFNα neutralizing capacity displayed significantly lower disease activity than patients without these autoantibodies.ConclusionsBased on our results we suggest that autoantibodies that are able to neutralize the circulating levels of all IFNα subtypes may have a beneficial effect to SLE disease course.

Anti-HLA Antibodies Do Not Increase in Kidney Transplant Recipients During COVID-19 Infection

Purpose: To determine if HLA allo-antibody levels are affected by COVID-19 in renal transplanted patients and to compare the immunoglobulin class and subclass profiles as well as the epitope binding patterns of anti-HLA and anti-SARS-CoV-2 antibodies. Method(s): A cross-sectional study of 46 kidney transplant recipients diagnosed with PCR+ SARS-CoV-2 infection was conducted. Serum samples were collected at the time of infection. For 21 patients, we obtained historical anti-HLA antibody information before COVID-19. Using a single-antigen bead Luminex assay, we determined IgG, IgG1/2/3/4, IgM, and IgA antibodies against Class I and Class II HLA, as well as against five SARS-CoV-2 (Wuhan strain) protein fragments: nucleocapsid, whole spike (S), spike S1, spike S2 and spike receptor binding domain (RBD). Result(s): 26/46 subjects had anti-HLA antibodies of which fourteen had donorspecific anti-HLA antibodies (DSA) compared with 45/46 had anti-SARS-CoV2 antibodies. The majority of DSA were specific to HLA-DQ (10/14), with a dominant IgG/IgG1/IgG3 subclass prevalence. Anti-SARS-CoV-2 antibodies exhibited stronger reactivity towards S and RBD and had increased IgM (38/43, 79%) and IgA (41/42, 85%) prevalence when compared to DSAs (5/14, 35% and 2/14, 14%, p<0.001).Out of 21 patients with pre-COVID-19 data available, calculated panel antibody reactivity (cPRA) levels did not change after COVID-19 in 14 cases (67%);cPRA increased in two cases (10%), both of them with allograft nephrectomy and immunosuppression discontinuation, and decreased in five patients (20%) (from 65.4+/-12.6% before COVID-19, to 29.4+/-33.6% after COVID-19) (Figure 1). Patients with DSA exhibited significantly lower anti-S IgG (9453+/-9945 vs 17975+/-12792;P=0.001), anti-RBD IgM (4464+/-3693 vs 8751+/-6468;P=0.03) and anti-nucleoprotein IgA (998+/-835 vs 5476+/-6895;P=0.001) anti-SARS-CoV2 antibody MFI values than patients without DSA. Conclusion(s): cPRA values did not increase following PCR confirmed COVID-19 diagnosis in renal transplant recipients and those subjects with pre-existing DSA had lower antibody strength directed at SARS-CoV-2 antigens. The lack of increase in alloantibody response is quite remarkable, since over 80% of the patients underwent either significant reduction or withdrawal of mycophenolate mofetil after COVID-19 diagnosis. (Figure Presented).

Blood Transcriptomes of Covid-19 Infected Kidney Recipients Demonstrate Frequent and Persistent SARS-CoV-2 Virome Gene Expression

Purpose: Kidney transplant recipients (KTRs) have poor outcomes vs non-KTRs with acute COVID-19. To provide insight into management of immunosuppression during acute COVID-19, we studied peripheral blood transcriptomes during and after COVID-19 from a multicenter KTR cohort. Method(s): Clinical data were collected by chart review. Paxgene blood RNA was polyA-selected and sequenced at enrollment. Result(s): A total of 64 KTRs with COVID-19 were enrolled (31 Early cases (<4weeks from a positive SARS-CoV-2 PCR test) and 33 late cases). Out of the 64 patients, eight died and three encountered graft losses during follow-up. Due to presence of mRNA reads in the blood transcriptome unmapped to the human genome, we aligned the mRNA short reads to the SARS-CoV-2 genome. Surprisingly, our strategy detected the SARS-Cov2 mRNA, especially Spike mRNA in 27 (87%) early cases, and 18 (54%) of late cases (Fig 1A and B). We then analyzed the raw reads from a public dataset of non-KTRs with Paxgene RNA (GSE172114). The SARS-CoV-2 Spike mRNA was detected in 2/47 (4.2%) critically ill COVID-19 cases and 0/25 noncritically ill cases in this non-KTR dataset (compared to KTRs, Chi-square P<0.001;Fig 1B). Among our KTRs, the amount of Spike mRNA was associated positively with the COVID-19 severity score (scale of 1 to 7 of increasing severity;Fig 1C) and inversely with time from initial positive PCR (Fig 1D). More interestingly, 7/64 patients had detectable Spike RNA-emia beyond 60 days after COVID-19 diagnosis. Of the 3 graft losses in our cohort, 2 occurred among these 7 patients. Conclusion(s): Blood transcriptome of KTRs with COVID-19 demonstrated a risk for persistent viremia with implications for pathogenesis of COVID-19 disease. This finding also supports using passive immune strategies in COVID-KTRs. (Figure Presented).

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

An aluminum hydroxide:CpG adjuvant enhances protection elicited by a SARS-CoV-2 receptor-binding domain vaccine in aged mice

[Figure: see text].

Quantification of multiple isotypes of anti-SARS-CoV-2 antibodies in kidney transplant recipients

Purpose: Solid organ transplant recipients are at increased risk of severe outcomes with infection by SARS-CoV-2, the etiologic agent of COVID-19. Antibodies directed against the virus are thought to offer protection and monoclonal antibodies directed against the virus have been used therapeutically. However, a thorough characterization of anti-SARS-CoV2 immune globulin isotypes in organ transplant recipients has not been reported. Methods: Using a semi-quantitative Luminex-based multiplex assay, we determined antibody levels from 48 SARS-CoV-2 PCR+ hospitalized kidney transplant recipients. We measured total IgG, IgM, IgA and IgG subtypes of antibodies directed against 5 distinct viral epitopes including the nucleocapsid protein as well as multiple regions of the spike protein including the receptor binding domain. Results: We identified multiple patterns of antibody responses. Specifically, 5 subjects were seronegative and 29 subjects had IgM, IgG and IgA antibodies specific for multiple epitopes of SARS-CoV-2. The 14 remaining subjects displayed a mixture of immunoglobulin isotypes. Of three subjects indeterminant for IgG antibodies, two had developed IgM, suggesting that they were early in the course of their immune response. Longitudinal samples from one subject demonstrated dynamic changes from IgM+IgG+ -> IgM-IgG+. Utilizing the semi-quantitative aspect of the assay, we found that IgG antibodies to the full Spike and Spike S1 domains were present at a statistically reduced level compared to immunocompetent controls while those directed against the Spike S2 domain were statistically higher. Interestingly, 77% of these subjects had detectable IgA directed against combinations of spike and/ or nucleocapsid specificity. IgG subtype analysis and correlation between antibody expression patterns with clinical severity is under investigation. Conclusions: Overall, these studies indicate that solid organ transplant recipients have the capacity to mount a dynamic antibody response to SARS-CoV-2 infection and that this response differs from immunocompetent individuals.

Donor-specific anti-hla alloantibody in kidney transplant recipients with COVID-19 exhibit a different immunoglobulin class and subclass profile when compared to anti-SARS-CoV-2 antibodies

Purpose: Both anti-HLA and anti-SARS-CoV-2 antibodies target protein antigens. The aim of the present study was to compare the class and subclass profile of such antibodies in a cohort of kidney transplant patients. Methods: We detected and identified anti-HLA and anti-SARS-CoV-2 antibody in 48 kidney transplant recipients who were hospitalized for SARS-CoV-2 PCR+ infection. Anti-HLA antibodies were detected by single-antigen bead Luminex assay, with IgG class, and IgG1-2-3-4 subclass secondary antibody. Anti-SARSCoV- 2 antibodies were also detected by Luminex assay directed against 5 distinct viral epitopes including the nucleocapsid protein as well as multiple regions of the spike protein. The secondary antibodies addressed total IgG, IgG1-2-3-4, IgM and IgA class/subclasses. Results: The antibody profile (Table 1) included 12/48 cases of donor-specific anti- HLA antibodies, and 43/48 cases with anti-SARS-CoV2 antibodies. The majority of HLA-specific antibodies targeted HLA-DQ, with a dominant IgG class and an IgG1+IgG2+IgG3 subclass prevalence. However, anti-SARS-CoV2 antibody profile was characterized by increased prevalence of IgM (38/43, 79%) and IgA (41/42, 85%), and a lower prevalence of IgG2. Conclusions: Overall, these data suggests that kidney transplant recipients with Covid-19 exhibit a humoral immune response both to donor-HLA and SARS-CoV-2. Although both are protein antigens, the allo-immune response has a high-IgG/low IgA pattern, while the Covid-19 antibody profile includes high IgA. Additional follow-up is needed to determine if the increased IgA is a consistent marker of anti-SARS-CoV-2 antibody response. (Table Presented).

Influence of immunosuppressant management on mortality in kidney transplant recipients hospitalized with covid-19

Purpose: Kidney transplant recipients are thought to be at high risk for mortality from COVID-19 due to the necessity for chronic immunosuppressive therapy to prevent graft rejection. However, the optimal immunosuppressant management strategy for patients with COVID-19 remains unknown. Methods: We conducted a single-center, retrospective review of all kidney or kidneypancreas transplant recipients with a functioning graft who were hospitalized with COVID-19 between 3/15/2020-5/15/2020. Patients were followed from the date of admission, up until 1 month following hospital discharge or study conclusion (6/15/2020). Multivariable logistic regression was used to identify potential patient or immunosuppression characteristics associated with the development of severe COVID-19 and in-hospital mortality. Results: 69 (3.2%) patients followed longitudinally at our center were hospitalized with COVID-19 during the review period, 38 of whom were admitted to the study institution. Patients were ethnically diverse, and the majority were receiving tacrolimus (84.2%), mycophenolate (89.5%), and corticosteroids (81.6%) at baseline. Following COVID-19 diagnosis, median tacrolimus trough levels decreased by-11% (-26%-+17%) during hospitalization and mycophenolate doses were reduced by at least 50% in 33 patients. Adjunctive therapy included hydroxychloroquine (68.4%), convalescent plasma (26.3%), anticoagulation (52.6%), and participation in clinical trials (10.5%). Twenty patients developed severe disease, and 11 (28.9%) died during hospitalization. Admission characteristics associated with increased risk for mortality included age (OR=2.0;1.0-4.0) and history of HIV (OR=22.6;1.1-483.7). No association was found between baseline tacrolimus trough levels, mycophenolate dosing, or the number of immunosuppressants prescribed and COVID-19 mortality. Similarly, the degree of immunosuppression reduction following hospital admission was not associated with survival or severe disease progression. No differences were observed in the prescription of adjunctive therapies, with the exception of a higher daily dose of prednisone equivalents in patients who died (37.0 vs 15.4;p=0.02). Among survivors, death-censored allograft survival was 96.2% at 1-month, and no cases of biopsy proven rejection were observed during the review period. Conclusions: The findings from our study confirm age as a significant risk factor for COVID-19 mortality in kidney transplant recipients, and suggest HIV status as an additional risk factor that may warrant further investigation. Pre-emptive immunosuppression reduction does not appear to be warranted, as baseline immunosuppression intensity and dose modulation following diagnosis of infection were not associated with hospital outcomes. However, no episodes of acute rejection were observed, so providers may wish to consider immunosuppression reduction on a case-by-case basis.

Risk of 30-day mortality and cardiopulmonary complications in patients undergoing emergency surgery with perioperative SARS-CoV-2 infection

INTRODUCTION AND OBJECTIVE: Continued vigilance of operative outcomes of COVID-19 patients is important given the relative novelty of the SARS-CoV-2 infection. We here sought to evaluate the 30-day mortality and cardiopulmonary adverse event rates in patients undergoing emergency surgery with perioperative COVID-19 infection, in comparison to a control group of medically managed COVID-19 patients that did not require surgical intervention. METHODS: A retrospective review of electronic medical data from a single tertiary-care center in Michigan was undertaken. Patients who had tested positive for SARS-CoV-2 infection either 7 days before or within 30 days after surgery during March-May 2020 were included in the study (n=52). Propensity score matched (1:6) patients who had been positive for SARS-CoV-2 infection during this time-period but did not undergo surgery were used as controls (n=314, Figure 1). The primary endpoint was 30-day mortality. Secondary endpoints included cardiac and pulmonary complications. Multivariable logistic regression analyses were utilized to account for baseline differences. A pvalue <0.05 was considered significant. RESULTS: The 30-day mortality (17.3% vs 13.1%, p=0.408) and cardiac (28.9% vs 19.1%, p=0.107) and pulmonary complication (55.8% vs 49.4%, p=0.392) rates were similar in patients in the surgical versus non-surgical group, respectively. Multivariable analyses confirmed that an emergency surgical intervention was not associated with increased odds for any of the studied adverse events (p >0.10 for all 3 endpoints). CONCLUSIONS: Patients undergoing emergency surgery with a co-diagnosis of SARS-CoV-2 infection in the perioperative period do not have an increased risk for short-term mortality or cardiopulmonary complications compared to the medically treated COVID-19 patients.

Persistence of neutrophil abnormalities inCOVID-19 convalescence

Background/AimsPatients infected with severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) may develop acute respiratory inflammation, due toan exaggerated immune response and some develop chroniccomplications. Neutrophils play a major role in the pathology ofinflammatory diseases and have been shown to contribute to lung andvascular damage in COVID-19. Our aim was to establish a relationshipbetween neutrophil phenotype and disease severity and to determinewhether neutrophil abnormalities persist in convalescent patients.MethodsPeripheral blood samples were obtained from acute COVID-19patients (n = 74), follow-up (FU) patients discharged following inpatientadmission (n = 56), a median of 87 days after discharge, and healthycontrols (HCs, n = 22). Patients were stratified by disease severitybased on inspired oxygen (FiO2) and admission to intensive care (ICU).Neutrophils were isolated from whole blood by negative selection forphenotyping and functional analysis. PBMC Isolation Tubes were usedto quantify and phenotype low density neutrophils (LDNs) within thePBMC fraction. For quantification of reactive oxygen species (ROS)production, isolated neutrophils were incubated with a ROS reactivedye, DHR-123 and stimulated with PMA. All samples were stained andfixed prior to analysis by flow cytometry.ResultsThere was a marked increase in neutrophils expressing the activationand degranulation markers, CD64 (P < 0.0001) and CD63 (P < 0.0001)and a reduction in neutrophils expressing the maturity markers, CD10(P < 0.0005) and CD101 (P < 0.0005) in patients with acute COVID-19compared to HCs. Increased frequency of neutrophils expressingCD64 (P < 0.005), CD63 (P < 0.01) and expressing decreased CD101(P < 0.0001) were also detected in FU patients compared to HCs.Notably, 42.3 4.4% of neutrophils were CD101lo in FU patients, compared to 29.0 3.7% in acute patients and 9.6 4.1% in HCs.These changes were most apparent in FU patients recovering fromsevere COVID-19 compared to mild or moderate disease. Thefrequency of LDNs in PBMCs from acute patients was significantlyhigher than HCs (P < 0.0001), and correlated with disease severity.Similarly, the frequency of LDNs in FU patients was significantly higherthan in HCs (P < 0.0005). We found a trend towards higher basal ROSproduction in acute and FU patients, but a blunted response to PMAstimulated ROS production in neutrophils from acute patients versusHCs (P < 0.0001). Impaired ROS production persisted in FU patientscompared to HCs (P < 0.01).ConclusionCirculating neutrophils in acute COVID-19 have an altered phenotypeand comprise immature and activated cells. This altered phenotypepersisted in convalescence and may contribute to the persistence ofsymptoms and an increased susceptibility to subsequent infections.Future work will aim to investigate the functional implications of thesefindings.

Digital Transformation to Build Smart Cities

This Chapter provides insights into the smart and sustainable city concept in the international arena. Acknowledging the reality that the establishment of smart and sustainable cities is a journey and cannot be created overnight, the chapter underscores key definitions and frameworks relevant for the topic, while highlighting the important work conducted by international standards developing organizations in this domain. With the emergence of new and emerging technologies (AI, IoT, blockchain, machine learning) urban stakeholders are increasingly attempting to integrate them into their smart city plans. However, when implementing these diverse technologies within one ecosystem, it is important to be aware of the holistic interaction between them in relation to urban operations. This Chapter further delves into the interlinking of these technologies, while looking into key processes for data management. The Chapter concludes with three cases on upcoming smart cities in Asia, which have endorsed and implemented ICT-centric initiatives in various urban sectors to support their respective smart city ventures. One of the key take-aways from the cases examined in this chapter, is the moulding of the smart city plans in light of the COVID-19 pandemic by adopting AI-based applications for the monitoring of COVID-19. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.