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Hensvold A, Klareskog L. Towards prevention of autoimmune diseases: The example of rheumatoid arthritis. Eur J Immunol 2021; 51:1921-1933. [PMID: 34110013 DOI: 10.1002/eji.202048952] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/18/2021] [Indexed: 12/16/2022]
Abstract
Prevention is the ultimate aim for clinicians and scientists concerned with severe diseases, like many immune-mediated conditions. Here, we describe recent progress in the understanding of etiology and molecular pathogenesis of rheumatoid arthritis (RA), which make this disease a potential prototype for prevention that may include both public health measures and targeted and personalized approaches that we call "personalized prevention." Critical components of this knowledge are (i) better understanding of the dynamics of the RA-associated autoimmunity that may begin many years before onset of joint inflammation; (ii) insights into how this immunity may be triggered at mucosal surfaces after distinct environmental challenges; (iii) better understanding of which features of the pre-existing immunity may cause symptoms that precede joint inflammation and predict a high risk for imminent arthritis development; and (iv) how molecular events occurring before onset of inflammation might be targeted by existing or future therapies, ultimately by specific targeting of Major histocompatibility complex (MHC) class II restricted and RA-specific immunity. Our main conclusion is that studies and interventions in the phase of autoimmunity preceding RA offer new opportunities to prevent the disease and thereby also understand the molecular pathogenesis of its different variants.
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Affiliation(s)
- Aase Hensvold
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital (Solna), Stockholm, Sweden.,Center for Rheumatology, Academic Specialist Center, Stockholm, Sweden
| | - Lars Klareskog
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital (Solna), Stockholm, Sweden.,Center for Rheumatology, Academic Specialist Center, Stockholm, Sweden.,Rheumatology Section, Theme inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Adaptive immunity plays central roles in the pathogenesis of rheumatoid arthritis (RA), as it is regarded as an autoimmune disease. Clinical investigations revealed infiltrations of B cells in the synovium, especially those with ectopic lymphoid neogenesis, associate with disease severity. While some B cells in the synovium differentiate into plasma cells producing autoantibodies such as anti-citrullinated protein antibody, others differentiate into effector B cells producing proinflammatory cytokines and expressing RANKL. Synovial B cells might also be important as antigen-presenting cells. Synovial T cells are implicated in the induction of antibody production as well as local inflammation. In the former, a recently identified CD4 T cell subset, peripheral helper T (Tph), which is characterized by the expression of PD-1 and production of CXCL13 and IL-21, is implicated, while the latter might be mediated by Th1-like CD4 T cell subsets that can produce multiple proinflammatory cytokines, including IFN-γ, TNF-α, and GM-CSF, and express cytotoxic molecules, such as perforin, granzymes and granulysin. CD8 T cells in the synovium are able to produce large amount of IFN-γ. However, the involvement of those lymphocytes in the pathogenesis of RA still awaits verification. Their antigen-specificity also needs to be clarified.
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Affiliation(s)
- Hisakata Yamada
- Department of Arthritis and Immunology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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Baker KF, Sim JPX, Isaacs JD. Biomarkers of tolerance in immune-mediated inflammatory diseases: a new era in clinical management? THE LANCET. RHEUMATOLOGY 2021; 3:e371-e382. [PMID: 38279392 DOI: 10.1016/s2665-9913(21)00069-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 11/23/2022]
Abstract
Modern therapeutic agents and treatment regimens have made sustained remission an attainable target for many patients across a spectrum of immune-mediated inflammatory diseases, albeit at the risk of adverse events and the expense of drug prescription and safety monitoring. Clinicians and patients are thus increasingly faced with a novel treatment dilemma: whether and how best to stop immunomodulatory treatment in patients who achieve remission. In this final paper in a Series on therapeutic tolerance induction, we summarise our current knowledge of biomarkers of immune homeostasis in immune-mediated inflammatory diseases and their application to the prediction and attainment of sustained drug-free remission. We summarise evidence from prospective studies of immunomodulatory drug cessation across a range of immune-mediated inflammatory diseases, including rheumatoid arthritis, juvenile idiopathic arthritis, and inflammatory bowel disease. We also consider current evidence for clinical, serological, proteomic, metabolomic, cellular, and microbiomic biomarkers of immune homeostasis. Finally, we discuss the steps necessary for clinical translation of these biomarkers, as well as the potential transformative effect of these biomarkers on management of patients with immune-mediated inflammatory diseases if clinical translation is successfully achieved.
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Affiliation(s)
- Kenneth F Baker
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jasmine P X Sim
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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Slot LM, Vergroesen RD, Kerkman PF, Staudinger E, Reijm S, van Dooren HJ, van der Voort EIH, Huizinga TWJ, Toes REM, Scherer HU. Light chain skewing in autoantibodies and B-cell receptors of the citrullinated antigen-binding B-cell response in rheumatoid arthritis. PLoS One 2021; 16:e0247847. [PMID: 33784344 PMCID: PMC8009422 DOI: 10.1371/journal.pone.0247847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 02/13/2021] [Indexed: 11/18/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting 1% of the world population. RA is associated with the presence of autoantibodies, of which anti-citrullinated protein antibodies (ACPA) are most prominent. ACPA are produced by citrullinated antigen-binding B cells that have presumably survived tolerance checkpoints. So far, it is unclear how and when such autoreactive B cells emerge. Light chain (LC) rearrangement and mutation rates can be informative with regard to selection steps during B-cell development. Therefore, we studied LC characteristics of ACPA-expressing B cells and secreted ACPA with the aim to better understand the development of this disease-specific, autoreactive B-cell response. Paired ACPA-IgG and ACPA-depleted IgG were isolated from serum (n = 87) and synovial fluid (SF, n = 21) of patients with established RA. We determined the LC composition for each fraction by ELISA using kappa(Igκ)- and lambda(Igλ) LC-specific antibodies. Cellular LC expression was determined using flow cytometry. In addition, we used a B-cell receptor (BCR)-specific PCR to obtain LC variable region sequences of citrullinated antigen- and tetanus toxoid (TT)-binding B cells. In serum, we observed an increased frequency of lambda LC in ACPA-IgG (1.64:1) compared to control IgG (2.03:1) and to the κ/λ ratio reported for healthy individuals (2:1). A similar trend towards higher frequencies of lambda LCs was observed for ACPA-IgG in SF (1.84:1). Additionally, the percentage of Igλ-expressing B cells was higher for citrullinated antigen-binding B cells (51%) compared to TT-specific (43%) and total CD19+CD20+ B cells (36%). Moreover, an increased Igλ percentage was observed in BCR-sequences derived from ACPA-expressing (49%) compared to TT-specific B cells (34%). Taken together, we report an enhanced frequency of lambda LCs in the secreted ACPA-IgG repertoire and, on the cellular level, in BCR sequences of ACPA-expressing B cells compared to control. This skewing in the autoreactive B-cell repertoire could reflect a process of active selection.
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Affiliation(s)
- Linda M. Slot
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Priscilla F. Kerkman
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen Staudinger
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sanne Reijm
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hugo J. van Dooren
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Tom W. J. Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - René E. M. Toes
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans U. Scherer
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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Toes RE, Raza K. The autoimmune response as a potential target for tolerance induction before the development of rheumatoid arthritis. THE LANCET. RHEUMATOLOGY 2021; 3:e214-e223. [PMID: 38279384 DOI: 10.1016/s2665-9913(20)30445-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 01/28/2024]
Abstract
Rheumatoid arthritis is a chronic inflammatory disease that affects the synovial joints. Although treatment options and efficacy have increased substantially in the past two decades, the disease cannot be cured or prevented. Therefore, rheumatoid arthritis still has a considerable effect on the quality of life of patients, not only because life-long medication is often required, but also because residual disease activity leads to progressive loss of function in the musculoskeletal system and extra-articular morbidity. Key future goals in the management of rheumatoid arthritis are the ability to induce long-lasting drug-free remission in patients with the disease (ie, to achieve a cure), and to prevent disease before it emerges. To reach these goals, it is pivotal to understand the autoimmune response underlying rheumatoid arthritis pathogenesis and to develop ways to permanently silence it (ie, to induce tolerance). For preventive studies, the identification of markers (clinical, immunological, and biological) predictive of future disease is crucial, as prevention of disease will not be feasible without the ability to identify relevant at-risk target populations. In this Series paper, we review the autoimmune response underlying rheumatoid arthritis, how rheumatoid arthritis-specific autoimmunity develops and evolves during the transition from health to disease, and how tolerance studies could be designed to achieve prevention or cure of the disease.
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Affiliation(s)
- Rene Em Toes
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands.
| | - Karim Raza
- Research into Inflammatory Arthritis Centre Versus Arthritis and MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK; Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
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