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Kempers AC, Hafkenscheid L, Scherer HU, Toes REM. Variable domain glycosylation of ACPA-IgG: A missing link in the maturation of the ACPA response? Clin Immunol 2017; 186:34-37. [PMID: 28882619 DOI: 10.1016/j.clim.2017.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/03/2017] [Indexed: 12/14/2022]
Abstract
Anti-citrullinated Protein Antibodies (ACPA) are excellent markers for Rheumatoid arthritis (RA) and are postulated to have a pathogenic role in the disease process. A multistep model for the evolution of the ACPA response in RA was proposed in which an initial break of tolerance causes, as "first hit", "silent" production of ACPA without any clinical symptoms. The model further proposes that the ACPA immune response matures upon a certain (unknown) trigger, a "second hit", which leads to epitope spreading, an increase in ACPA titres and extended isotype usage before clinical RA manifestations. These occurrences are indicative of an expansion of the citrulline-specific B cell response, though ACPA remain of low avidity even in established disease. This persistence of low avidity is puzzling, as the typical signs of maturation of the immune response seem to be uncoupled from the classical process of affinity maturation. In fact, it suggests that B cells expressing ACPA could bypass selection mechanisms that otherwise control the expansion of auto-reactive B cells. In the established, chronic phase, we recently found that ACPA-IgG are extensively glycosylated in the variable (Fab) domain. More than 90% of ACPA-IgG molecules carry Fab glycans that are highly sialylated. This molecular feature is striking and may provide a missing link in our understanding of the maturation of the ACPA immune response. This review, therefore, describes the current knowledge about ACPA Fab glycosylation in the pathogenesis of RA.
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Affiliation(s)
- Ayla C Kempers
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, Leiden 2300 RC, The Netherlands.
| | - Lise Hafkenscheid
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, Leiden 2300 RC, The Netherlands.
| | - Hans Ulrich Scherer
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, Leiden 2300 RC, The Netherlands.
| | - René E M Toes
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, Leiden 2300 RC, The Netherlands.
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Tumor necrosis factor-α -308 polymorphism in North Indian rheumatoid arthritis patients and association with mRNA and serum TNF-α. Clin Rheumatol 2017; 36:2209-2216. [DOI: 10.1007/s10067-017-3774-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
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Julià A, Blanco F, Fernández-Gutierrez B, González A, Cañete JD, Maymó J, Alperi-López M, Olivè A, Corominas H, Martínez-Taboada V, González-Álvaro I, Fernandez-Nebro A, Erra A, Sánchez-Fernández S, Alonso A, López-Lasanta M, Tortosa R, Codó L, Lluis Gelpi J, García-Montero AC, Bertranpetit J, Absher D, Myers RM, Tornero J, Marsal S. Identification of IRX1 as a Risk Locus for Rheumatoid Factor Positivity in Rheumatoid Arthritis in a Genome-Wide Association Study. Arthritis Rheumatol 2017; 68:1384-91. [PMID: 26815016 DOI: 10.1002/art.39591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 01/07/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Rheumatoid factor (RF) is a well-established diagnostic and prognostic biomarker in rheumatoid arthritis (RA). However, ∼20% of RA patients are negative for this anti-IgG antibody. To date, only variation at the HLA-DRB1 gene has been associated with the presence of RF. This study was undertaken to identify additional genetic variants associated with RF positivity. METHODS A genome-wide association study (GWAS) for RF positivity was performed using an Illumina Quad610 genotyping platform. A total of 937 RF-positive and 323 RF-negative RA patients were genotyped for >550,000 single-nucleotide polymorphisms (SNPs). Association testing was performed using an allelic chi-square test implemented in Plink software. An independent cohort of 472 RF-positive and 190 RF-negative RA patients was used to validate the most significant findings. RESULTS In the discovery stage, a SNP in the IRX1 locus on chromosome 5p15.3 (SNP rs1502644) showed a genome-wide significant association with RF positivity (P = 4.13 × 10(-8) , odds ratio [OR] 0.37 [95% confidence interval (95% CI) 0.26-0.53]). In the validation stage, the association of IRX1 with RF was replicated in an independent group of RA patients (P = 0.034, OR 0.58 [95% CI 0.35-0.97] and combined P = 1.14 × 10(-8) , OR 0.43 [95% CI 0.32-0.58]). CONCLUSION To our knowledge, this is the first GWAS of RF positivity in RA. Variation at the IRX1 locus on chromosome 5p15.3 is associated with the presence of RF. Our findings indicate that IRX1 and HLA-DRB1 are the strongest genetic factors for RF production in RA.
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Affiliation(s)
- Antonio Julià
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | - Francisco Blanco
- Instituto de Investigación Biomédica de A Coruña-Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Antonio González
- Instituto de Investigación Sanitaria and Hospital Clinico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Joan Maymó
- Hospital del Mar, Barcelona, Barcelona, Spain
| | | | - Alex Olivè
- Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | | | | | | | - Antonio Fernandez-Nebro
- Instituto de Investigación Biomédica de Málaga, Hospital Regional Universitario de Málaga, and Universidad de Málaga, Málaga, Spain
| | - Alba Erra
- Hospital Sant Rafael, Barcelona, Spain
| | | | - Arnald Alonso
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | | | - Raül Tortosa
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | - Laia Codó
- Barcelona Supercomputing Center, Barcelona, Spain
| | | | | | - Jaume Bertranpetit
- National Genotyping Center and Pompeu Fabra University, Barcelona, Spain
| | - Devin Absher
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama
| | - Richard M Myers
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama
| | - Jesús Tornero
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Sara Marsal
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
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Burmester GR, Bijlsma JWJ, Cutolo M, McInnes IB. Managing rheumatic and musculoskeletal diseases — past, present and future. Nat Rev Rheumatol 2017; 13:443-448. [DOI: 10.1038/nrrheum.2017.95] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Identification and Validation of SAA4 as a Rheumatoid Arthritis Prescreening Marker by Liquid Chromatography Tandem-mass Spectrometry. Molecules 2017; 22:molecules22050805. [PMID: 28505104 PMCID: PMC6154608 DOI: 10.3390/molecules22050805] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/08/2017] [Accepted: 05/11/2017] [Indexed: 01/24/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease that progresses into systemic inflammation and joint deformity. RA diagnosis is a complicated procedure, and early diagnostic methods are insufficient. Therefore, in this study, we attempted to identify new markers to improve the accuracy of RA prescreening. e identified differentially expressed proteins (DEPs) by using liquid chromatography tandem-mass spectrometry in health-prescreening sera with high rheumatoid factor (RF) values, and compared the findings with those from sera with normal RF values. We identified 93 DEPs; of these, 36 were upregulated, and 57 were downregulated in high-RF sera. Pathway analysis revealed that these DEPs were related to immune responses. Additionally, four DEPs were statistically analyzed by proteomic analysis; of these, SAA4 was significantly validated in individual enzyme-linked immunosorbent assays. Moreover, SAA4 was significantly upregulated in RA patients (n = 40, 66.43 ± 12.97 ng/mL) compared with normal controls (n = 40, 4.79 ± 0.95 ng/mL) and had a higher area under the curve than C-reactive protein. Thus, we identified SAA4 as a protein that was positively correlated with RF and RA. SAA4 may represent a novel prescreening marker for the diagnosis of RA.
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Oni P, Prehm P. Mutations in the Fc-region of IgG from synovial fluids of patients with rheumatoid arthritis. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1221232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Paul Oni
- Institut für Physiologische Chemie und Pathobiochemie, Muenster University Hospital, Waldeyerstr. 15, D-48129 Münster, Germany
| | - Peter Prehm
- Institut für Physiologische Chemie und Pathobiochemie, Muenster University Hospital, Waldeyerstr. 15, D-48129 Münster, Germany
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Catrina AI, Joshua V, Klareskog L, Malmström V. Mechanisms involved in triggering rheumatoid arthritis. Immunol Rev 2016; 269:162-74. [PMID: 26683152 DOI: 10.1111/imr.12379] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory syndrome with a strong autoimmune component. The autoantigens in RA are neither tissue nor organ-specific, but comprise a broad collection of post-translational modified proteins, such as citrullinated proteins. These modifications are likely to be triggered by innate stimuli. In genetically susceptible hosts, they can lead to a more substantiated secondary autoimmune reaction targeting the joints and precipitating the clinical onset of RA. Both innate and adaptive mechanisms will then closely interplay to promote chronic joint inflammation in the several absence of appropriate treatment. This scenario, is shared with other autoimmune diseases where potentially pathogenic immune responses are present already before disease onset. Better understanding of these processes will allow both earlier diagnosis of RA and identification of those healthy individuals that are at risk of developing disease, opening possibilities for disease prevention. In this review, we discuss the iterative processes of innate and adaptive immunity responsible for the (longitudinal) development of immune reactions that may contribute to the development of RA.
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Affiliation(s)
- Anca I Catrina
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Vijay Joshua
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Vivianne Malmström
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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58
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Lee YH, Bae SC, Song GG. Diagnostic accuracy of anti-MCV and anti-CCP antibodies in rheumatoid arthritis: A meta-analysis. Z Rheumatol 2016; 74:911-8. [PMID: 26111961 DOI: 10.1007/s00393-015-1598-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the diagnostic performance of anti-mutated citrullinated vimentin (anti-MCV) and anti-cyclic citrullinated peptide (anti-CCP) antibodies in rheumatoid arthritis (RA). METHODS We searched the Medline, Embase, and Cochrane library databases and performed two meta-analyses on the diagnostic accuracy of anti-MCV and anti-CCP in patients with RA compared to healthy controls. RESULTS We identified 12 studies that included a total of 2003 RA patients and 831 healthy controls for the meta-analysis. The pooled sensitivity and specificity of anti-MCV were 68.6% [95% confidence interval (CI) 66.6-79.7] and 94.2% (95% CI 92.4-96.7) and those of anti-CCP were 61.7% (95% CI 59.5-63.8) and 97.1% (95% CI 96.7-98.1), respectively. Anti-MCV PLR, NLR, and DOR were 12.99 (95% CI 8.013-21.27), 0.297 (95% CI 0.238-0.369), and 47.78 (95% CI 28.59-79.84), and those for anti-CCP were 16.71 (95% CI 11.42-24.47), 0.378 (95% CI 0.325-0.439), and 54.20 (95% CI 31.65-92.82), respectively. The AUC of anti-MCV was 0.886, and its Q* index was 0.817, indicating modest accuracy, while the AUC of anti-CCP was 0.946, and its Q* index was 0.885. The sensitivity of anti-MCV was significantly higher than that of anti-CCP in the diagnosis of RA (difference 0.069, 95% CI 0.039-0.098, p < 0.0001), but the specificity of anti-MCV was lower than that of anti-CCP (difference -0.029, 95% CI -0.051 to -0.006, p = 0.012). The Q* index of anti-MCV was significantly lower than that of anti-CCP (difference -0.068, 95% CI -0.070 to -0.065, p < 0.0001). CONCLUSION Our meta-analysis demonstrates that anti-MCV is more sensitive but less specific, and has lower diagnostic accuracy than anti-CCP in RA, although anti-MCV and anti-CCP showed comparable high PLRs.
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Affiliation(s)
- Y H Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, 136-705, Seoul, Korea.
| | - S-C Bae
- Division of Rheumatology, Department of Internal Medicine, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - G G Song
- Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbuk-gu, 136-705, Seoul, Korea
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Lagha A, Messadi A, Boussaidi S, Kochbati S, Tazeghdenti A, Ghazouani E, Almawi WY, Yacoubi-Loueslati B. HLA DRB1/DQB1 alleles and DRB1-DQB1 haplotypes and the risk of rheumatoid arthritis in Tunisians: a population-based case-control study. HLA 2016; 88:100-9. [DOI: 10.1111/tan.12855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 07/13/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023]
Affiliation(s)
- A. Lagha
- Laboratory of Micro-Organisms and Active Biomolecules; El Manar University, University of Sciences of Tunis; Tunis Tunisia
- Department of Immunology; Military Hospital of Tunis; Tunis Tunisia
| | - A. Messadi
- Laboratory of Micro-Organisms and Active Biomolecules; El Manar University, University of Sciences of Tunis; Tunis Tunisia
- Department of Immunology; Military Hospital of Tunis; Tunis Tunisia
| | - S. Boussaidi
- Department of Rheumatology; Habib Thameur Hospital; Tunis Tunisia
| | - S. Kochbati
- Department of Rheumatology; Habib Thameur Hospital; Tunis Tunisia
| | - A. Tazeghdenti
- Laboratory of Micro-Organisms and Active Biomolecules; El Manar University, University of Sciences of Tunis; Tunis Tunisia
| | - E. Ghazouani
- Department of Immunology; Military Hospital of Tunis; Tunis Tunisia
| | - W. Y. Almawi
- Department of Medical Biochemistry; Arabian Gulf University; Manama Bahrain
| | - B. Yacoubi-Loueslati
- Laboratory of Micro-Organisms and Active Biomolecules; El Manar University, University of Sciences of Tunis; Tunis Tunisia
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Aletaha D, Blüml S. Therapeutic implications of autoantibodies in rheumatoid arthritis. RMD Open 2016; 2:e000009. [PMID: 27252890 PMCID: PMC4879342 DOI: 10.1136/rmdopen-2014-000009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 04/04/2016] [Indexed: 01/24/2023] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterised by the presence of autoantibodies. Their value for diagnostic/prognostic purposes has been well established. In contrast, their role in established disease and their associations with disease activity is less clear. Moreover, as evidence is accumulating that these autoantibodies are causally involved in certain key aspects of the disease, such as the initiation and perpetuation of joint inflammation or join destruction, autoantibodies in RA can no longer be regarded as mere epiphenomena, but are integral elements of the pathophysiology of RA.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine 3 , Medical University Vienna , Vienna , Austria
| | - Stephan Blüml
- Division of Rheumatology, Department of Internal Medicine 3 , Medical University Vienna , Vienna , Austria
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61
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Lim SA, Nam S, Kwok SK, Park SH, Chung SH. Serologic Markers Are Associated With Ocular Staining Score in Primary Sjögren Syndrome. Cornea 2016; 34:1466-70. [PMID: 26356755 DOI: 10.1097/ico.0000000000000612] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the relationship between serologic markers and dry eye severity in subjects with primary Sjögren syndrome (SS). METHODS This study evaluated 64 patients diagnosed with primary SS according to the 2012 Sjögren's International Collaborative Clinical Alliance (SICCA) classification criteria. Serum anti-Ro/SSA, anti-La/SSB, rheumatoid factor (RF), and antinuclear antibody (ANA) levels, Ocular Surface Disease Index (OSDI), Schirmer I test values, tear film breakup time, and SICCA ocular staining score (OSS) were determined. RESULTS The conjunctival staining scores were 3.3 ± 1.9, 3.6 ± 2.0, 3.4 ± 1.9, and 3.5 ± 1.9 in the positive anti-Ro (≥25 EU), positive anti-La (≥25 EU), positive RF (≥20 IU/mL), and positive ANA (≥1:320) group, respectively. Subjects with positive anti-Ro, anti-La, RF, or ANA had significantly higher conjunctival staining scores compared with those with negative levels (P < 0.05). The total OSS in the positive ANA group was 5.5 ± 3.0, which was significantly higher than the total OSS (3.4 ± 2.1) in the negative ANA group (P = 0.005). Serum RF and ANA levels had strong correlations with conjunctival staining scores and the total OSS but not with corneal staining scores (r = 0.53, P < 0.001 and r = 0.382, P = 0.002). Other ocular parameters (OSDI, Schirmer I test values, and tear film breakup time) did not differ by the serologic marker level. Interestingly, the OSDI was positively correlated with the corneal staining score and total OSS (r = 0.646, P < 0.001 and r = 0.476, P < 0.001). CONCLUSIONS Serum RF and ANA levels are associated with conjunctival staining scores and the total OSS according to the SICCA OSS in primary SS.
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Affiliation(s)
- Sung A Lim
- *Department of Ophthalmology and Visual Science, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea; †Catholic Institute for Visual Science, College of Medicine, The Catholic University of Korea, Seoul, Korea; ‡Department of Ophthalmology, CHA Bundang Medical Center, CHA University, Seongnam, Korea; and §Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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van Schie KA, Wolbink GJ, Rispens T. Cross-reactive and pre-existing antibodies to therapeutic antibodies--Effects on treatment and immunogenicity. MAbs 2016; 7:662-71. [PMID: 25962087 PMCID: PMC4623040 DOI: 10.1080/19420862.2015.1048411] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The potential for immunogenicity is an ever-present concern during the development of biopharmaceuticals. Therapeutic antibodies occasionally elicit an antibody response in patients, which can result in loss of response or adverse effects. However, antibodies that bind a drug are sometimes found in pre-treatment serum samples, with the amount depending on drug, assay, and patient population. This review summarizes published data on pre-existing antibodies to therapeutic antibodies, including rheumatoid factors, anti-allotype antibodies, anti-hinge antibodies, and anti-glycan antibodies. Unlike anti-idiotype antibodies elicited by the drug, pre-formed antibodies in general appear to have little consequences during treatment. In the few cases where (potential) clinical consequences were encountered, antibodies were characterized and found to bind a distinct, unusual epitope of the therapeutic. Immunogenicity testing strategies should therefore always include a proper level of antibody characterization, especially when pre-formed antibodies are present. This minimizes false-positives, particularly due to rheumatoid factors, and helps to judge the potential threat in case a genuine pre-dose antibody reactivity is identified.
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Affiliation(s)
- Karin A van Schie
- a Sanquin Research; Dept. Immunopathology; Amsterdam, The Netherlands; and Landsteiner Laboratory; Academic Medical Centre; University of Amsterdam ; Amsterdam , The Netherlands
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63
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Lee YH. Diagnostic Accuracies of Anti-carbamylated and Anti-citrullinated Fibrinogen Antibodies in Rheumatoid Arthritis: A Meta-analysis. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.6.373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
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64
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Autoantibodies and their Judicious Use in Pediatric Rheumatology Practice. Indian J Pediatr 2016; 83:53-62. [PMID: 26631069 DOI: 10.1007/s12098-015-1936-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
Autoantibody testing forms an important part of diagnostic workup of patients in Pediatric rheumatology practice. However it is important to understand that the mere presence of autoantibodies does not necessarily mean the presence of an underlying autoimmune disease. Autoantibodies may be present decades before the development of clinical manifestations of an autoimmune disease and may be viewed as harbingers of Autoimmune disease. On the other hand, low-affinity autoantibodies may be present in normal healthy individuals; these natural autoantibodies serve an important function in immune regulation and tolerance. Autoantibody testing in pediatric practice mainly includes testing for anti-nuclear antibodies, anti-dsDNA antibodies, anti-neutrophil cytoplasmic autoantibodies and antiphospholipid antibodies. Rheumatoid factor and anti-CCP do not have much significance in the diagnostic schema in pediatric rheumatology, except perhaps for classification of juvenile idiopathic arthritis (JIA) and prognostication in late-onset polyarticular JIA. The positive predictive value (PPV) of any laboratory test depends on the prevalence of the disease in the population being tested. Hence, test ordering practices greatly impact the performance characteristics and positive predictive value of any laboratory test. A restricted test ordering only in patients with clinical signs and symptoms suggestive of autoimmune disease would thus greatly increase the PPV of tests such as antinuclear antibody used for diagnosing autoimmunity.
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66
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Brandt JE, Priori R, Valesini G, Fairweather D. Sex differences in Sjögren's syndrome: a comprehensive review of immune mechanisms. Biol Sex Differ 2015; 6:19. [PMID: 26535108 PMCID: PMC4630965 DOI: 10.1186/s13293-015-0037-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/17/2015] [Indexed: 02/03/2023] Open
Abstract
Autoimmune diseases (ADs) are estimated to affect between 5 and 8 % of the US population, and approximately 80 % of these patients are women. Sjögren’s syndrome (SS) is an AD that occurs predominately in women over men (16:1). The hallmark characteristic of SS is diminished secretory production from the primary exocrine gland and the lacrimal or salivary glands resulting in symptoms of dry eye and mouth. The disease is believed to be mediated by an inflammatory and autoantibody response directed against salivary and lacrimal gland tissues. This review will examine the literature on sex differences in the immune response of patients and animal models of Sjögren’s syndrome in order to gain a better understanding of disease pathogenesis.
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Affiliation(s)
- Jessica E Brandt
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA ; Reumatologia, Dipartimento di Medicina Interna e Specialita Mediche, Sapienza Universita di Roma, 00161 Rome, Italy
| | - Roberta Priori
- Reumatologia, Dipartimento di Medicina Interna e Specialita Mediche, Sapienza Universita di Roma, 00161 Rome, Italy
| | - Guido Valesini
- Reumatologia, Dipartimento di Medicina Interna e Specialita Mediche, Sapienza Universita di Roma, 00161 Rome, Italy
| | - DeLisa Fairweather
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA ; Department of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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Arase N, Arase H. Cellular misfolded proteins rescued from degradation by MHC class II molecules are possible targets for autoimmune diseases. J Biochem 2015; 158:367-72. [DOI: 10.1093/jb/mvv093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 08/26/2015] [Indexed: 01/22/2023] Open
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Dionello CF, Rosa Utiyama SR, Radominski SC, Stahlke E, Stinghen ST, de Messias-Reason IJ. Evaluation of rheumatoid factor and anti-citrullinated peptide antibodies in relation to rheumatological manifestations in patients with leprosy from Southern Brazil. Int J Rheum Dis 2015; 19:1024-1031. [PMID: 26250118 DOI: 10.1111/1756-185x.12668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Leprosy patients may present several osteoarticular complaints, which require further evaluation of inflammatory diseases, such as rheumatoid arthritis (RA). Therefore, an adequate clinical assessment in addition to testing for rheumatoid factors (RF) and anticyclic citrullinated peptide antibodies (anti-CCP), can be useful in order to establish the correct diagnosis. METHOD In this study, the relation of RF and anti-CCP with rheumatological manifestations was evaluated in 97 leprosy patients from Southern Brazil. The results were compared to RA patients and healthy controls from the same geographical area and ethnic background. RESULTS Neuropathy was observed in 71.1% and arthritis in 35.1% of the leprosy patients. A high frequency of RF positivity was observed among the leprosy patients (41.2%, 40/97), with RF immunoglobulin A (IgA) significantly associated with arthritis (OR = 7.9, 95% CI = 1.5-40.6 P = 0.008). Anti-CCP was observed in 9.3% (9/97) of the patients, with anti-CCP2 being the most frequent subtype. Only 4.1% (4/97) of the patients were RF and anti-CCP concomitantly positive. RF IgM showed a significant association with leprosy when compared to healthy controls (P < 0.0001) whereas for anti-CCP2 no significant results were observed (P = 0.0585). However, both biomarkers showed a strong association with RA when compared to leprosy in patients from the same geographical area and ethnic background (anti-CCP2 OR = 38.6; 95% CI = 16.49-90.26; P < 0.0001 and RF IgM OR = 4.51; 95% CI = 2.62-7.77; P < 0.0001). CONCLUSION Due to the similarity of some rheumatological manifestations in leprosy with other inflammatory diseases, such as RA, clinical and laboratorial evaluation of affected patients must be carefully assessed in order to achieve proper diagnosis and treatment.
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Affiliation(s)
- Carla Fontoura Dionello
- Laboratório de Imunopatologia, Departamento de Patologia Médica, Clinical Hospital of Federal University of Parana, Curitiba, Brazil
| | - Shirley Ramos Rosa Utiyama
- Laboratório de Imunopatologia, Departamento de Patologia Médica, Clinical Hospital of Federal University of Parana, Curitiba, Brazil
| | | | - Ewalda Stahlke
- Setor de Dermatologia, Centro Regional de Especialidades Metropolitano de Curitiba, Curitiba, Brazil
| | - Servio Tulio Stinghen
- Laboratório de Imunopatologia, Departamento de Patologia Médica, Clinical Hospital of Federal University of Parana, Curitiba, Brazil
| | - Iara Jose de Messias-Reason
- Laboratório de Imunopatologia, Departamento de Patologia Médica, Clinical Hospital of Federal University of Parana, Curitiba, Brazil.
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Abstract
Laboratory diagnostics play a fundamental role in rheumatology but must always be interpreted in the context of symptoms and clinical signs. Laboratory tests have a variety of purposes, such as confirmation or negation of a diagnosis, differential diagnosis, evaluation of activity and prognosis, involvement of organs and drug side effects. Markers of inflammation and specific autoantibodies are the most important laboratory parameters in rheumatology. Thus, with the suspicion of rheumatoid arthritis the analysis of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), the rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP or ACPA) should be performed as the first line tests. Only a few antibody titers are suitable for monitoring of disease activity. Some autoantibodies exhibit such a high diagnostic value that the antibodies are included in the classification criteria or in the definition of a disease entity.
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70
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Animal models of rheumatoid arthritis: How informative are they? Eur J Pharmacol 2015; 759:278-86. [PMID: 25824900 DOI: 10.1016/j.ejphar.2015.03.047] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/06/2015] [Accepted: 03/12/2015] [Indexed: 12/19/2022]
Abstract
Animal models of arthritis are widely used to de-convolute disease pathways and to identify novel drug targets and therapeutic approaches. However, the high attrition rates of drugs in Phase II/III rates means that a relatively small number of drugs reach the market, despite showing efficacy in pre-clinical models. There is also increasing awareness of the ethical issues surrounding the use of animal models of disease and it is timely, therefore, to review the relevance and translatability of animal models of arthritis. In this paper we review the most commonly used animal models in terms of their pathological similarities to human rheumatoid arthritis as well as their response to drug therapy. In general, the ability of animal models to predict efficacy of biologics in man has been good. However, the predictive power of animal models for small molecules has been variable, probably because of differences in the levels of target knockdown achievable in vivo.
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71
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Åhlin E, Elshafie AI, Nur MAM, Rönnelid J. Anti‐Citrullinated Peptide Antibodies in Sudanese Patients with
L
eishmania donovani
Infection Exhibit Reactivity not Dependent on Citrullination. Scand J Immunol 2015; 81:201-8. [DOI: 10.1111/sji.12265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- E. Åhlin
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
| | - A. I. Elshafie
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
- Department of Pathology and Microbiology Alribat University Hospital Khartoum Sudan
| | - M. A. M. Nur
- Unit of Rheumatology Alribat University Hospital Khartoum Sudan
| | - J. Rönnelid
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
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72
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Hoffmann M, Lundberg K, Steiner G. Autoantibodies in rheumatoid arthritis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00091-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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73
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Holm BE, Sandhu N, Tronstrøm J, Lydolph M, Trier NH, Houen G. Species cross-reactivity of rheumatoid factors and implications for immunoassays. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 75:51-63. [DOI: 10.3109/00365513.2014.965738] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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74
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Ishikawa Y, Usui T, Shiomi A, Shimizu M, Murakami K, Mimori T. Functional engraftment of human peripheral T and B cells and sustained production of autoantibodies in NOD/LtSzscid/IL-2Rγ(-/-) mice. Eur J Immunol 2014; 44:3453-63. [PMID: 25154613 DOI: 10.1002/eji.201444729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/12/2014] [Accepted: 08/13/2014] [Indexed: 11/05/2022]
Abstract
NOD/LtSzscid/IL-2Rγ(-/-) (NSG) mice have advantages in establishing humanized mouse models. However, transferring human PBMCs into these mice often causes lethal GVH disease. In this study, we discovered an improved method for the engraftment of normal or pathological human PBMCs into NSG mice and examined the subsequent induction of specific immune responses. We sequentially transferred human CD4+ memory T (Tm) and B cells obtained from PBMCs of healthy adults or patients with autoimmune diseases into NSG mice. Removing naïve CD4+ T cells from the transferred PBMCs allowed successful engraftment without lethal GVH disease. The transferred Tm cells were found to reside mainly in the spleen and the lymphoid nodules, where they expressed MHC class II molecules and produced cytokines, including IL-21. Surprisingly, the transferred B cells were also well maintained in the lymphoid organs, underwent de novo class-switch recombination, and secreted all isotypes of human Igs at significant levels. Moreover, transferring patient-derived Tm and B cells resulted in sustained production of IgM-rheumatoid factor and antiaminoacyl transfer RNA synthetase Abs in these mice. These results suggest that transfer of Tm and B cells derived from human PBMCs into NSG mice could be a useful method for the study of human autoimmune mechanisms.
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Affiliation(s)
- Yuki Ishikawa
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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75
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76
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Lin J, Liu C, Yang B, Ou Q. Age-related diagnostic utility of rheumatoid factor, anticyclic citrullinated peptide and antikeratin antibodies in Chinese patients with rheumatoid arthritis. J Int Med Res 2014; 42:711-7. [PMID: 24764355 DOI: 10.1177/0300060514524734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/29/2014] [Indexed: 11/17/2022] Open
Abstract
Objectives Retrospective study to evaluate the diagnostic utility of rheumatoid factor (RF), anticyclic citrullinated peptide antibodies (ACPA) and antikeratin antibodies (AKA) in a broad age range of patients with rheumatoid arthritis (RA). Methods Clinical and serological data from patients with RA were collected and analysed. Patients were stratified according to age (<16 years [juvenile idiopathic arthritis; JIA], 16–40 years; 41–60 years and >60 years) and sex. Results The study included 3725 patients. There were no significant sex-related differences in rates of RF, ACPA or AKA positivity. RF, ACPA and AKA positivity were significantly less common in patients aged <16 years than those aged ≥16 years. There were no other significant differences between age groups. Conclusions RF, ACPA and AKA have better diagnostic value for RA in adult patients than in patients with JIA. A combination of RF, ACPA and AKA serological testing may be a useful diagnostic tool for RA in Chinese adults.
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Affiliation(s)
- Jinpiao Lin
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Genetic Diagnostic Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Can Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Genetic Diagnostic Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bin Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Genetic Diagnostic Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qishui Ou
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Genetic Diagnostic Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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77
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Performance characteristic of anti-cyclic citrullinated peptide (CCP) assay on Korean rheumatoid arthritis (RA) patients and healthy controls. J Pharm Biomed Anal 2014; 92:69-73. [DOI: 10.1016/j.jpba.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/06/2014] [Accepted: 01/07/2014] [Indexed: 11/18/2022]
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78
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Autoantibodies to IgG/HLA class II complexes are associated with rheumatoid arthritis susceptibility. Proc Natl Acad Sci U S A 2014; 111:3787-92. [PMID: 24567378 DOI: 10.1073/pnas.1401105111] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Specific HLA class II alleles are strongly associated with susceptibility to rheumatoid arthritis (RA); however, how HLA class II regulates susceptibility to RA has remained unclear. Recently, we found a unique function of HLA class II molecules: their ability to aberrantly transport cellular misfolded proteins to the cell surface without processing to peptides. Rheumatoid factor (RF) is an autoantibody that binds to denatured IgG or Fc fragments of IgG and is detected in 70-80% of RA patients but also in patients with other diseases. Here, we report that intact IgG heavy chain (IgGH) is transported to the cell surface by HLA class II via association with the peptide-binding groove and that IgGH/HLA class II complexes are specifically recognized by autoantibodies in RF-positive sera from RA patients. In contrast, autoantibodies in RF-positive sera from non-RA individuals did not bind to IgGH/HLA class II complexes. Of note, a strong correlation between autoantibody binding to IgG complexed with certain HLA-DR alleles and the odds ratio for that allele's association with RA was observed (r = 0.81; P = 4.6 × 10(-5)). Our findings suggest that IgGH complexed with certain HLA class II alleles is a target for autoantibodies in RA, which might explain why these HLA class II alleles confer susceptibility to RA.
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79
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OHMURA K, HIWA R, ARASE H. A new mechanism of autoantibody production: antigen presentation of misfolded protein by MHC class II. ACTA ACUST UNITED AC 2014; 37:462-7. [DOI: 10.2177/jsci.37.462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Koichiro OHMURA
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine
| | - Ryosuke HIWA
- Department of Immunochemistry, Research Institute for Microbial Diseases, Graduate School of Medicine, Osaka University
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, Osaka University
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine
| | - Hisashi ARASE
- Department of Immunochemistry, Research Institute for Microbial Diseases, Graduate School of Medicine, Osaka University
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, Osaka University
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80
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Hamad MB, Marzouk S, Kaddour N, Masmoudi H, Fakhfakh F, Rebai A, Bahloul Z, Maalej A. Anticyclic citrullinated peptide antibody and rheumatoid factor in south Tunisian patients with rheumatoid arthritis: association with disease activity and severity. J Clin Lab Anal 2013; 28:21-6. [PMID: 24375820 DOI: 10.1002/jcla.21638] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 05/15/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To explore relationships between immunological status, clinical features, radiographic damage, disease activity, and functional disability in Tunisian patients with rheumatoid arthritis (RA). MATERIALS AND METHODS The study was carried out in 112 patients with RA. Demographic characteristics, disease duration, disease activity score 28 (DAS28), the Health Assessment Questionnaire (HAQ), and the Sharp/van der Heijde score were collected. Anticyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor (RF) were performed. RESULTS We found that anti-CCP positivity was associated with longer disease duration (P = 0.001), presence of RF (P = 4.89 × 10(-8) ), and night pain positivity (P = 0.025). Patients with positive RF had more night pain and higher anti-CCP positivity (for all P ≤ 0.05). Anti-CCP titer was correlated with disease duration (P = 0.034) and Sharp total score (P = 1.2 × 10(-4) ). Moreover, there was a significant correlation between RF and anti-CCP antibodies titers (P = 0.011). Indeed, DAS28 correlated with HAQ (P = 1.8 × 10(-7) ) and morning stiffness duration (P = 0.045). In multivariate regression analysis, the main factors associated with anti-CCP titers were radiographic damage (P = 1.625 × 10(-4) ) and RF (P = 0.013). For DAS28, only HAQ (P = 2.9 × 10(-4) ) was associated. CONCLUSION These findings suggest that anti-CCP antibodies are associated with RF and more severe joint damage. Moreover, disease activity is associated with functional disability.
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Affiliation(s)
- Mariem Ben Hamad
- Laboratory of Human Molecular Genetics, Faculty of Medicine, University of Sfax, Sfax, Tunisia
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81
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Rheumatoid factors: clinical applications. DISEASE MARKERS 2013; 35:727-34. [PMID: 24324289 PMCID: PMC3845430 DOI: 10.1155/2013/726598] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/10/2013] [Accepted: 10/01/2013] [Indexed: 02/08/2023]
Abstract
Rheumatoid factors are antibodies directed against the Fc region of immunoglobulin G. First detected in patients with rheumatoid arthritis 70 years ago, they can also be found in patients with other autoimmune and nonautoimmune conditions, as well as in healthy subjects. Rheumatoid factors form part of the workup for the differential diagnosis of arthropathies. In clinical practice, it is recommended to measure anti-cyclic citrullinated peptide antibodies and rheumatoid factors together because anti-cyclic citrullinated peptide antibodies alone are only moderately sensitive, and the combination of the two markers improves diagnostic accuracy, especially in the case of early rheumatoid arthritis. Furthermore, different rheumatoid factor isotypes alone or in combination can be helpful when managing rheumatoid arthritis patients, from the time of diagnosis until deciding on the choice of therapeutic strategy.
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82
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Geng H, Nandakumar KS, Xiong L, Jie R, Dong J, Holmdahl R. Incomplete B Cell Tolerance to Cartilage Oligomeric Matrix Protein in Mice. ACTA ACUST UNITED AC 2013; 65:2301-9. [DOI: 10.1002/art.38046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 05/30/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Hui Geng
- Central China Normal University; Wuhan China
- Karolinska Institute; Stockholm Sweden
| | | | - Li Xiong
- Central China Normal University; Wuhan China
| | - Rui Jie
- Central China Normal University; Wuhan China
| | - Jiahui Dong
- Central China Normal University; Wuhan China
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83
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Patel SS, Shah PV. Evaluation of anti-inflammatory potential of the multidrug herbomineral formulation in male Wistar rats against rheumatoid arthritis. J Ayurveda Integr Med 2013; 4:86-93. [PMID: 23930040 PMCID: PMC3737452 DOI: 10.4103/0975-9476.113869] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/02/2013] [Accepted: 05/20/2013] [Indexed: 12/02/2022] Open
Abstract
Background: Immunological and inflammatory mechanisms, which may play a role in a number of disorders like rheumatoid arthritis (RA). Ancient ayurvedic physicians had developed certain dietary and therapeutic measures to arrest or prevent these disorders. Objective: Rheuma off gold (RG) is a herbomineral formulation recommended by ayurvedic medical practitioners for treatment of RA. This study was carried out to lend scientific evidence to the efficacy claim for RG in the management of RA in folklore medicine. Materials and Methods: Arthritis was induced by complete Freund's adjuvant. Treatment with formulation 100 mg/kg and dexamethasone 2 mg/kg was given to rats intragastrically once a day from day 1 to day 21 and after which estimation of physical, biochemical, and hematological parameters were carried out. Results: Treatment of formulation to adjuvant induced arthritic animal showed statistically significant (P < 0.05) improvement in physical parameters like arthritic index, paw edema, paw thickness as well as reduction of inflammatory markers like C-reactive protein, serum rheumatoid factor, erythrocyte sedimentation rate. The treatment also produced statistically significant (P < 0.05) increase in hemoglobin percent and improvement in splenomegaly and thymus index. In the histopathological examination, ameliorative effect of formulation was observed in hyperplasia of synovium, pannus formation, and destruction of the joint space. Conclusion: The results obtained in experiments indicated that the formulation significantly inhibited the adjuvant-induced arthritis which was comparable to dexamethasone and had preferable anti-inflammatory effect without significant side effect. Thus, the formulation may be a potential preventive or therapeutic candidate for the treatment of chronic inflammation and arthritis.
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Affiliation(s)
- Snehal S Patel
- Department of Pharmacology, Institute of Pharmacy, Nirma University, Ahmedabad, India
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84
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Jafarzadeh A, Nemati M, Rezayati MT, Nabizadeh M, Ebrahimi M. Higher serum levels of rheumatoid factor and anti-nuclear antibodies in helicobacter pylori-infected peptic ulcer patients. Oman Med J 2013; 28:264-9. [PMID: 23904920 DOI: 10.5001/omj.2013.74] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/19/2013] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES H. pylori infection has been associated with some autoimmune disorders. The aim of this study was to evaluate the serum concentrations of rheumatoid factor and anti-nuclear antibodies in H. pylori-infected peptic ulcer patients, H. pylori-infected asymptomatic carriers and a healthy control group. METHODS A Total of 100 H. pylori-infected peptic ulcer patients, 65 asymptomatic carriers and 30 healthy H. pylori-negative subjects (as a control group) were enrolled into study. Serum samples of participants tested for the levels of rheumatoid factor and anti-nuclear antibodies by use of ELISA. RESULTS The mean serum levels of rheumatoid factor and anti-nuclear antibodies in peptic ulcer group was significantly higher in comparison to the control group (p<0.05). Although, the mean serum levels of rheumatoid factor and anti-nuclear antibodies in the asymptomatic carriers group was higher than those in the control group, the difference was not statistically significant. No significant differences were observed between peptic ulcer patients and asymptomatic carriers groups regarding the mean serum levels of rheumatoid factor and anti-nuclear antibodies. The mean serum levels of rheumatoid factor in men with peptic ulcer was significantly higher compared to the group of healthy men (p<0.05). Although in female of peptic ulcer patients or asymptomatic carriers groups, the mean serum levels of rheumatoid factor was higher than that in healthy women, but the differences were not statistically significant. Also, no significant differences were observed between men and women with peptic ulcer, asymptomatic carriers control groups based on the serum levels of anti-nuclear antibodies. CONCLUSION The results showed higher serum levels of rheumatoid factor and anti-nuclear antibodies in H. pylori-infected patients with peptic ulcer disease which represent the H. pylori-related immune disturbance in these patients. Additional follow-up studies are necessary to clarify the clinical significance of these autoantibodies in patients with H. pylori infection.
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Affiliation(s)
- Abdollah Jafarzadeh
- Department of Microbiology and Immunology, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Molecular Medicine Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Department of Microbiology and Immunology, Medical School, Kerman University of Medical Sciences, Kerman, Iran
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85
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Abstract
Immune complexes (ICs) are produced during an immune response and may reflect some aspects of an ongoing immune response. Therefore, the identity of antigens incorporated into ICs provides the information that in the future may aid in the development of diagnosis and treatment strategies for autoimmune diseases, infection, cancer, and transplantation therapy, and this information might be more relevant than the information on free antigens. Because ICs may contain many antigens, comprehensive identification and profiling of such antigens are more effective than immunoblotting detection. Here, we introduced mass spectrometry (MS)-based two approaches (immunoproteomics and immune complexome analysis) to comprehensively identify the antigens. Immunoproteomics is a concept to identify disease-associated antigens that elicit immune responses by combining protein separation (two-dimensional electrophoresis, gel-free separation), immunological detection (Western blotting), and MS or by combining immunocapture and MS. Immune complexome analysis is designed for identifying antigens in circulating ICs and consists of ICs separation from serum and direct tryptic digestion followed by nano-liquid chromatography-tandem MS.
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Affiliation(s)
- Kaname Ohyama
- Course of Pharmaceutical Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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86
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Clinical features and independent predictors in the further development of rheumatoid arthritis in undifferentiated arthritis. Rheumatol Int 2013; 33:2827-32. [DOI: 10.1007/s00296-013-2799-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/06/2013] [Indexed: 11/26/2022]
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87
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Scherer HU, Burmester GR. Adaptive immunity in rheumatic diseases: bystander or pathogenic player? Best Pract Res Clin Rheumatol 2013; 25:785-800. [PMID: 22265261 DOI: 10.1016/j.berh.2011.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 11/14/2011] [Indexed: 12/24/2022]
Abstract
Rheumatic diseases comprise a wide spectrum of different conditions. Some are caused by disturbances of the adaptive immune system, while defects in innate immune responses have been identified for others. In between are a variety of multifactorial diseases for which the evidence for a causative involvement of the adaptive immune system is still controversial. In these cases, availability of novel drugs that target key players of the adaptive immune system have improved our understanding of the relevance of adaptive immunity to the disease process, but it has also generated unprecedented findings. Rheumatoid arthritis (RA) is a prototypic example of a disease in which the relative contribution of adaptive immunity to disease pathogenesis is incompletely understood. Although numerous markers have been identified that reflect an activated adaptive immune system, several caveats render interpretation of these findings difficult. For one, the very early immune responses initiating disease are likely to take place before an individual is identified as a patient, and are thus difficult to study in the human. Furthermore, increasing evidence points to pathogenetically distinct subgroups within the clinical diagnosis RA, offering the possibility that adaptive immune responses might be relevant to one subgroup but not the other. In addition, many indications for an adaptive immune system involvement are based on associations for which the underlying mechanism is often unknown. Finally, therapeutic interventions targeting the adaptive immune system have generated heterogeneous results. The present review addresses these issues by placing adaptive immune responses in the context of rheumatic diseases, and by reviewing the evidence for a contribution of adaptive immunity to RA.
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Affiliation(s)
- Hans Ulrich Scherer
- Department of Rheumatology, Leiden University Medical Center, RC Leiden, The Netherlands.
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88
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Abstract
The adaptive immune system augments host defenses against diverse infectious threats, yet also carries intertwined risks for the development of autoimmune disease. The immune system incorporates homeostatic pathways for essential housekeeping functions that involve recognition of oxidation-modified endogenous molecules. Now, the properties of a physiological class of natural autoantibodies, which seem to modulate the severity or even prevent the onset of autoimmune disease, are beginning to be defined. Whereas disease-associated IgG autoantibodies to nuclear antigens and citrulline-modified self-proteins have been shown to activate innate pattern recognition receptors leading to increased cell death and tissue injury, a class of IgM autoantibodies to oxidation-associated neo-antigens can oppose these pathogenic effects. These naturally arising regulatory IgM autoantibodies enhance the capacity for the phagocytic clearance of host cells affected by programmed death pathways. These antibodies can also suppress key signalling pathways in the innate immune system involved in the control and resolution of inflammatory responses to Toll-like receptor agonists and disease-associated IgG autoantibodies.
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89
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Sweet RA, Cullen JL, Shlomchik MJ. Rheumatoid factor B cell memory leads to rapid, switched antibody-forming cell responses. THE JOURNAL OF IMMUNOLOGY 2013; 190:1974-81. [PMID: 23365079 DOI: 10.4049/jimmunol.1202816] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
B cells are critical in the initiation and maintenance of lupus. Autoreactive B cells clonally expand, isotype switch, and mutate--properties associated with memory B cells (MBCs), which are typically generated via germinal centers. The development and functions of autoreactive MBCs in lupus are poorly understood. Moreover, mounting evidence implicates the extrafollicular (EF) response in the generation of switched and mutated autoantibodies that are driven by BCR and TLR corecognition, raising the question of whether MBCs are generated in this context. In this study, we investigated autoreactive MBC generation associated with this type of response. We transferred B cells from AM14 site-directed BCR transgenic mice into nontransgenic normal recipients and elicited an EF response with anti-chromatin Ab, as in prior studies. By following the fate of the stimulated cells at late time points, we found that AM14 B cells persisted at increased frequency for up to 7 wk. Furthermore, these cells had divided in response to Ag but were subsequently quiescent, with a subset expressing the memory marker CD73. These cells engendered rapid, isotype-switched secondary plasmablast responses upon restimulation. Both memory and rapid secondary responses required T cell help to develop, emphasizing the need for T-B collaboration for long-term self-reactivity. Thus, using this model system, we show that the EF response generated persistent and functional MBCs that share some, but not all, of the characteristics of traditional MBCs. Such cells could play a role in chronic or flaring autoimmune disease.
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Affiliation(s)
- Rebecca A Sweet
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
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90
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Fairweather D, Petri MA, Coronado MJ, Cooper LT. Autoimmune heart disease: role of sex hormones and autoantibodies in disease pathogenesis. Expert Rev Clin Immunol 2012; 8:269-84. [PMID: 22390491 DOI: 10.1586/eci.12.10] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiovascular disease (CVD) and autoimmune diseases (ADs) are the first and third highest causes of death in the USA, respectively. Men have an increased incidence of the majority of CVDs, including atherosclerosis, myocarditis, dilated cardiomyopathy and heart failure. By contrast, nearly 80% of all ADs occur in women. However, in one category of ADs, rheumatic diseases, CVD is the main cause of death. Factors that link rheumatic ADs to CVD are inflammation and the presence of autoantibodies. In this review we will examine recent findings regarding sex differences in the immunopathogenesis of CVD and ADs, explore possible reasons for the increased occurrence of CVD within rheumatic ADs and discuss whether autoantibodies, including rheumatoid factor, could be involved in disease pathogenesis.
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Affiliation(s)
- DeLisa Fairweather
- Johns Hopkins University Bloomberg School of Public Health, Department of Environmental Health Sciences, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
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91
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Wright C, Sibani S, Trudgian D, Fischer R, Kessler B, LaBaer J, Bowness P. Detection of multiple autoantibodies in patients with ankylosing spondylitis using nucleic acid programmable protein arrays. Mol Cell Proteomics 2012; 11:M9.00384. [PMID: 22311593 DOI: 10.1074/mcp.m9.00384] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Ankylosing spondylitis (AS) is a common, inflammatory rheumatic disease that primarily affects the axial skeleton and is associated with sacroiliitis, uveitis, and enthesitis. Unlike other autoimmune rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus, autoantibodies have not yet been reported to be a feature of AS. We therefore wished to determine whether plasma from patients with AS contained autoantibodies and, if so, characterize and quantify this response in comparison to patients with rheumatoid arthritis (RA) and healthy controls. Two high density nucleic acid programmable protein arrays expressing a total of 3498 proteins were screened with plasma from 25 patients with AS, 17 with RA, and 25 healthy controls. Autoantigens identified were subjected to Ingenuity Pathway Analysis to determine the patterns of signaling cascades or tissue origin. 44% of patients with ankylosing spondylitis demonstrated a broad autoantibody response, as compared with 33% of patients with RA and only 8% of healthy controls. Individuals with AS demonstrated autoantibody responses to shared autoantigens, and 60% of autoantigens identified in the AS cohort were restricted to that group. The autoantibody responses in the AS patients were targeted toward connective, skeletal, and muscular tissue, unlike those of RA patients or healthy controls. Thus, patients with AS show evidence of systemic humoral autoimmunity and multispecific autoantibody production. Nucleic acid programmable protein arrays constitute a powerful tool to study autoimmune diseases.
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Affiliation(s)
- Cynthia Wright
- Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, United Kingdom.
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92
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Association of anti-CCP positivity with serum ferritin and DAS-28. Rheumatol Int 2011; 30:223-7. [PMID: 19444453 DOI: 10.1007/s00296-009-0941-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Accepted: 04/28/2009] [Indexed: 10/20/2022]
Abstract
Antibodies to cyclic citrullinated peptides (anti-CCP) are highly specific for the diagnosis of rheumatoid arthritis (RA) with a marginal increased prediction of the disease. In this study, we aimed to investigate the relation of the presence of anti-CCP with clinical manifestations and disease activity in a cohort of RA patients. A total of 61 RA patients were included in this study. Data of disease-related parameters such as duration of disease, medications, degree of pain (visual analog scale, VAS), disease activity score 28 (DAS-28) and health assessment questionnaire (HAQ) were recorded. Laboratory workup included erythrocyte sedimentation rate (ESR), plasma C-reactive protein (CRP), rheumatoid factor (RF), anti-CCP, complete blood count and anemia parameters. Anti-CCP positivity was associated with higher scores of DAS-28, longer duration of morning stiffness, serum RF positivity and low levels of serum ferritin, while it was not associated with disease duration, VAS, HAQ, ESR, CRP and hemoglobin.
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93
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Ohyama K, Ueki Y, Kawakami A, Kishikawa N, Tamai M, Osaki M, Kamihira S, Nakashima K, Kuroda N. Immune complexome analysis of serum and its application in screening for immune complex antigens in rheumatoid arthritis. Clin Chem 2011; 57:905-9. [PMID: 21482748 DOI: 10.1373/clinchem.2010.157776] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Analysis of circulating immune complexes (CICs) produced during an immune response may be useful in elucidating some aspects of this process. Identification of antigens incorporated into CICs provides information that may be helpful in developing diagnostic and treatment strategies for autoimmune diseases, infection, cancer, and transplantation therapy, and such information might be more relevant than information on free antigens. Because CICs may contain many antigens, comprehensive identification and profiling of such antigens is more effective than immunoblotting detection. METHODS We developed a novel proteomic strategy (immune complexome analysis) in which immune complexes (ICs) are separated from serum, digested directly with trypsin, and then subjected to nano-liquid chromatography-tandem mass spectrometry for identifying and profiling antigens in CICs. We applied this strategy to the analysis of CICs in 21 rheumatoid arthritis (RA) patients. Serum samples from 13 healthy donors and 8 osteoarthritis patients were used as controls. RESULTS CICs containing thrombospondin-1 (TSP-1) and platelet factor 4 (PF4) were found in the serum of 81% and 52% of RA patients, respectively, and in none of the controls. CONCLUSIONS The ICs in the serum of a majority of the RA patients contained TSP-1 or PF4, and these ICs may have potential as alternative biomarkers. Our technique for immune complexome analysis uses routine clinical samples, simple protocols, and widely available equipment. This method may be generally applicable to the study of the relationship between CICs and certain diseases associated with the immune response in animals and humans.
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Affiliation(s)
- Kaname Ohyama
- Department of Environmental and Pharmaceutical Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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94
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Kouris I, Tsirmpas C, Mougiakakou SG, Iliopoulou D, Koutsouris D. E-Health towards ecumenical framework for personalized medicine via Decision Support System. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2010:2881-5. [PMID: 21095976 DOI: 10.1109/iembs.2010.5626308] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The purpose of the present manuscript is to present the advances performed in medicine using a Personalized Decision Support System (PDSS). The models used in Decision Support Systems (DSS) are examined in combination with Genome Information and Biomarkers to produce personalized result for each individual. The concept of personalize medicine is described in depth and application of PDSS for Cardiovascular Diseases (CVD) and Type-1 Diabetes Mellitus (T1DM) are analyzed. Parameters extracted from genes, biomarkers, nutrition habits, lifestyle and biological measurements feed DSSs, incorporating Artificial Intelligence Modules (AIM), to provide personalized advice, medication and treatment.
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Affiliation(s)
- Ioannis Kouris
- School of Electrical and Computer Engineering, National Technical University of Athens, 9 Heroon Polytechneiou Str., 15780 Zografou, Greece.
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95
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Ho RCM, Fu EHY, Chua ANC, Cheak AAC, Mak A. Clinical and psychosocial factors associated with depression and anxiety in Singaporean patients with rheumatoid arthritis. Int J Rheum Dis 2011; 14:37-47. [PMID: 21303480 DOI: 10.1111/j.1756-185x.2010.01591.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To assess the frequency of, and factors associated with, depression and anxiety in Singaporean patients with rheumatoid arthritis (RA). METHOD One hundred RA patients were recruited in a cross-sectional study. Socio-demographics, severity of anxiety and depression, disease activity, levels of serological markers and health-related quality of life were analyzed. RESULTS Twenty-six percent presented with anxiety, 15% with depression and 11% with both. Univariate regression showed that age (P = 0.039), Disease Activity Scale (DAS-28) (P < 0.001), number of medications (P < 0.001) and rheumatoid factor (RF) (P < 0.001) were positively associated with severity of depression, while income (P = 0.001), education (P = 0.029), self-perceived social support (P = 0.007), Short form 12 (SF-12) physical health (P < 0.001) and SF-12 mental health (P < 0.001) were negatively associated with severity of depression. After adjustment for confounding factors in multivariate regression, income (β = -0.347, P = 0.018), RF (β = 0.304, P = 0.043) and SF-12 mental health (β = -0.501 P = 0.001) remained significantly associated with depression. Univariate regression showed that DAS-28 (P = 0.009), number of medications (P = 0.004) and RF (P = 0.043) were positively associated with anxiety, while income (P = 0.022), self-perceived social support (P = 0.04), SF-12 physical health (P < 0.001) and SF-12 mental health (P < 0.001) were negatively associated with anxiety. After adjustment for confounding factors, no factors remained significantly associated with anxiety. CONCLUSION Low income, high levels of RF and poor mental health were associated with depression in RA. Our findings may help to formulate depression screening strategies. Further research is required to identify the role of RF in depression.
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Affiliation(s)
- Roger C M Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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96
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Methotrexate-associated lymphoplasmacytic lymphoma complicated with type 2 cryoglobulinemia. Int J Hematol 2011; 93:253-256. [PMID: 21210259 DOI: 10.1007/s12185-010-0749-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 12/01/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
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97
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Anticyclic-Citrullinated Protein Antibodies in the Diagnosis of Ophthalmic Inflammatory Disease. Ophthalmic Plast Reconstr Surg 2011; 27:e1-2. [DOI: 10.1097/iop.0b013e3181c70c2e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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98
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Steiner G, Hoffmann M. Autoantibodies in rheumatoid arthritis. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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99
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Prokopec KE, Rhodiner M, Matt P, Lindqvist U, Kleinau S. Down regulation of Fc and complement receptors on B cells in rheumatoid arthritis. Clin Immunol 2010; 137:322-9. [PMID: 20850384 DOI: 10.1016/j.clim.2010.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 07/22/2010] [Accepted: 08/09/2010] [Indexed: 01/08/2023]
Abstract
B cell tolerance is regulated by receptors that modulate B cell receptor signaling, such as Fc gamma receptor IIb (FcγRIIb; CD32b) and complement receptors (CR) 1 and 2. Deficiency in these receptors may contribute to autoimmunity. To address this we have investigated the receptor expression in healthy individuals in comparison with rheumatoid arthritis (RA) patients. In healthy subjects we found that women had overall lower FcγRIIb expression on B cells than men that significantly decreased with age. RA patients had fewer FcγRIIb, CR1 and CR2 positive B cells and decreased receptor expressions compared to healthy subjects. Further, the RA B cells displayed a significantly increased proliferative response when cultured with interleukin-2 in vitro. In summary, the dysregulated B cells in RA are associated with lower FcγRIIb, CR1 and CR2 levels. The reduced FcγRIIb expression on B cells in women may influence the increased frequency of autoimmunity in women.
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Affiliation(s)
- Kajsa E Prokopec
- Department of Cell and Molecular Biology, Uppsala University, Uppsala, Sweden
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100
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Preclinical rheumatoid arthritis: identification, evaluation, and future directions for investigation. Rheum Dis Clin North Am 2010; 36:213-41. [PMID: 20510231 DOI: 10.1016/j.rdc.2010.02.001] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Rheumatoid arthritis (RA) likely develops in several phases, beginning with genetic risk, followed by asymptomatic autoimmunity, then finally, clinically apparent disease. Investigating the phases of disease that exist prior to the onset of symptoms (ie, the preclinical period of RA) will lead to understanding of the important relationships between genetic and environmental factors that may lead to disease, as well as allow for the development of predictive models for disease, and ultimately preventive strategies for RA.
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