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Jiménez-Martínez M, Dankers W, van Baarsen LGM. The key role of the lymph node niche in the development of rheumatoid arthritis. Joint Bone Spine 2024; 91:105661. [PMID: 37977526 DOI: 10.1016/j.jbspin.2023.105661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Marina Jiménez-Martínez
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, The Netherlands; Lab of Experimental Immunology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Infection and Immunity, Inflammatory Diseases, Amsterdam, The Netherlands; Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wendy Dankers
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, The Netherlands; Lab of Experimental Immunology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Infection and Immunity, Inflammatory Diseases, Amsterdam, The Netherlands
| | - Lisa G M van Baarsen
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, The Netherlands; Lab of Experimental Immunology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Infection and Immunity, Inflammatory Diseases, Amsterdam, The Netherlands; Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
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2
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Pascu LS, Sârbu N, Brădeanu AV, Jicman (Stan) D, Matei MN, Sârbu MI, Voinescu DC, Nechita A, Tatu AL. MRI Findings in Axial Psoriatic Spondylarthritis. Diagnostics (Basel) 2023; 13:diagnostics13071342. [PMID: 37046559 PMCID: PMC10093281 DOI: 10.3390/diagnostics13071342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Abstract
Psoriatic arthritis is a significant medical condition with a high prevalence, a wide variety of non-specific symptoms, and a high degree of overlap with other spondylarthritis disorders, particularly ankylosing spondylitis. Hence, knowledge of the magnetic resonance imaging (MRI) manifestations and a multidisciplinary strategy are required for the better management of these patients. We searched publications from the last 10 years and focused on the most relevant ones which discussed the classification criteria, the MRI characteristics of axial psoriatic arthritis, the importance of MRI for follow up, and the reliability of skin and synovial biopsy. Axial spondylarthritis can be diagnosed and followed up on using the well-established MRI technique and, additionally, a biopsy. The analysis and concordance between them can provide new directions for future studies.
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Affiliation(s)
| | - Nicolae Sârbu
- “Sf. Ioan” Clinical Emergency Children Hospital, 800487 Galati, Romania
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Andrei Vlad Brădeanu
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
- “Sf. Andrei” Emergency County Clinical Hospital, 177 Brailei st, 800578 Galati, Romania
| | - Daniela Jicman (Stan)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Madalina Nicoleta Matei
- “Sf. Ioan” Clinical Emergency Children Hospital, 800487 Galati, Romania
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Mihaela Ionela Sârbu
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Doina Carina Voinescu
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
- “Sf. Andrei” Emergency County Clinical Hospital, 177 Brailei st, 800578 Galati, Romania
| | - Aurel Nechita
- “Sf. Ioan” Clinical Emergency Children Hospital, 800487 Galati, Romania
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Alin Laurențiu Tatu
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
- Infectious Diseases Dermatology Department, “Sf. Parascheva” Infectious Diseases Clinical Hospital, 800179 Galati, Romania
- Multidisciplinary Integrated Center of Dermatological Interface Research MIC-DIR, 800008 Galati, Romania
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Anang DC, Ramwadhdoebe TH, Hähnlein JS, van Kuijk B, Smits N, van Lienden KP, Maas M, Gerlag DM, Tak PP, de Vries N, van Baarsen LGM. Increased Frequency of CD4+ Follicular Helper T and CD8+ Follicular T Cells in Human Lymph Node Biopsies during the Earliest Stages of Rheumatoid Arthritis. Cells 2022; 11:cells11071104. [PMID: 35406668 PMCID: PMC8997933 DOI: 10.3390/cells11071104] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/27/2023] Open
Abstract
Follicular T helper cells (Tfh cells) provide key B-cell help and are essential in germinal center formation and (auto) antibody generation. To gain more insight into their role during the earliest phase of rheumatoid arthritis (RA), we analyzed their frequencies, phenotypes, and cytokine profiles in peripheral blood and lymph node biopsies of healthy controls (HCs), autoantibody-positive individuals at risk for developing RA (RA-risk individuals), and early RA patients. Subsequently, we confirmed their presence in lymph nodes and synovial tissue of RA patients using immunofluorescence microscopy. In the blood, the frequency of Tfh cells did not differ between study groups. In lymphoid and synovial tissues, Tfh cells were localized in B-cell areas, and their frequency correlated with the frequency of CD19+ B cells. Compared to lymphoid tissues of healthy controls, those of RA patients and RA-risk individuals showed more CD19+ B cells, CD4+CXCR5+ follicular helper T cells, and CD8+CXCR5+ follicular T cells. These Tfh cells produced less IL-21 upon ex vivo stimulation. These findings suggest that Tfh cells may present a novel rationale for therapeutic targeting during the preclinical stage of RA to prevent further disease progression.
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Affiliation(s)
- Dornatien Chuo Anang
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Tamara H. Ramwadhdoebe
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Janine S. Hähnlein
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Bo van Kuijk
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Noortje Smits
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Krijn P. van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands; (K.P.v.L.); (M.M.)
| | - Mario Maas
- Department of Radiology, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands; (K.P.v.L.); (M.M.)
| | - Daniëlle M. Gerlag
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- UCB Pharma, Slough SL1 3XE, UK
| | - Paul P. Tak
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Candel Therapeutics, Needham, MA 02494, USA
- Department of Internal Medicine, Cambridge University, Cambridge CB2 0QQ, UK
| | - Niek de Vries
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Lisa G. M. van Baarsen
- Amsterdam Rheumatology & Immunology Center (ARC), Department of Rheumatology & Clinical Immunology, 1007 MB Amsterdam, The Netherlands; (D.C.A.); (T.H.R.); (J.S.H.); (B.v.K.); (N.S.); (D.M.G.); (P.P.T.); (N.d.V.)
- Department of Experimental Immunology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, 1007 MB Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-56-64969; Fax: +31-20-69-19658
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4
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Fiechter RH, Bolt JW, van de Sande MGH, Aalbers CJ, Landewé RBM, Maas M, Tas SW, van Baarsen LGM. Ultrasound-guided lymph node biopsy sampling to study the immunopathogenesis of rheumatoid arthritis: a well-tolerated valuable research tool. Arthritis Res Ther 2022; 24:36. [PMID: 35115042 PMCID: PMC8812012 DOI: 10.1186/s13075-022-02728-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Analyses of lymphoid organs are required to further elucidate the pathogenesis of inflammatory diseases like rheumatoid arthritis (RA). Yet, invasive tissue collection methods are scarcely applied, because they are often considered burdensome, although patients do not always consider invasive methods as a high burden. We aimed to investigate the perspectives of study participants undergoing ultrasound-guided inguinal lymph node (LN) needle biopsy sampling and determine the molecular and cellular quantity and quality of LN biopsies. Methods Together with patient research partners, questionnaires were developed to evaluate the motives, expectations, and experiences of participants undergoing a LN biopsy. Healthy controls and RA(-risk) patients were asked to complete these questionnaires before and after the procedure. RNA and lymphocyte yields from obtained LN biopsies were also calculated. Results We included 50 individuals, of which 43 (86%) reported their pre- and post-procedure experiences. The median reported pain on a 5-point Likert scale (1 not to 5 very painful) was 1. Interestingly, almost all (n = 32; 74%) study participants would undergo a second procedure and more than half (n = 23; 54%) would encourage others to take part in the LN biopsy study. Motives for current and future participation were mostly altruistic. Inguinal hematoma occurred frequently, but no other significant or unexpected complications ensued. The LN biopsies yielded sufficient and high-quality RNA and lymphocyte numbers. Conclusions Ultrasound-guided inguinal LN biopsy sampling is well-tolerated, safe, and provides sufficient material for further molecular and cellular analyses. Our participants’ positive experiences endorse the application of this research tool to further elucidate the pathogenesis of RA and other inflammatory diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02728-7.
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Affiliation(s)
- Renée H Fiechter
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Janne W Bolt
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marleen G H van de Sande
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Caroline J Aalbers
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robert B M Landewé
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Lisa G M van Baarsen
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Amsterdam Rheumatology and Immunology Center (ARC), EULAR & FOCIS Center of Excellence, Amsterdam UMC, Location Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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5
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O'Byrne AM, de Jong TA, van Baarsen LGM. Bridging Insights From Lymph Node and Synovium Studies in Early Rheumatoid Arthritis. Front Med (Lausanne) 2022; 8:820232. [PMID: 35096912 PMCID: PMC8795611 DOI: 10.3389/fmed.2021.820232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease of unknown etiology characterized by inflammation of the peripheral synovial joints leading to pannus formation and bone destruction. Rheumatoid Factor (RF) and anti-citrullinated protein antibodies (ACPA) are present years before clinical manifestations and are indicative of a break in tolerance that precedes chronic inflammation. The majority of studies investigating disease pathogenesis focus on the synovial joint as target site of inflammation while few studies explore the initial break in peripheral tolerance which occurs within secondary lymphoid organs such as lymph nodes. If explored during the earliest phases of RA, lymph node research may provide innovative drug targets for disease modulation or prevention. RA research largely centers on the role and origin of lymphocytes, such as pro-inflammatory T cells and macrophages that infiltrate the joint, as well as growing efforts to determine the role of stromal cells within the synovium. It is therefore important to explore these cell types also within the lymph node as a number of mouse studies suggest a prominent immunomodulatory role for lymph node stromal cells. Synovium and proximal peripheral lymph nodes should be investigated in conjunction with one another to gain understanding of the immunological processes driving RA progression from systemic autoimmunity toward synovial inflammation. This perspective seeks to provide an overview of current literature concerning the immunological changes present within lymph nodes and synovium during early RA. It will also propose areas that warrant further exploration with the aim to uncover novel targets to prevent disease progression.
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Affiliation(s)
- Aoife M. O'Byrne
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, Netherlands
| | - Tineke A. de Jong
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, Netherlands
| | - Lisa G. M. van Baarsen
- Department of Rheumatology and Clinical Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, Netherlands
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Bolt JW, van Ansenwoude CMJ, Hammoura I, van de Sande MG, van Baarsen LGM. Translational Research Studies Unraveling the Origins of Psoriatic Arthritis: Moving Beyond Skin and Joints. Front Med (Lausanne) 2021; 8:711823. [PMID: 34485340 PMCID: PMC8415974 DOI: 10.3389/fmed.2021.711823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with psoriatic arthritis (PsA) are suffering from a decreased quality of life despite currently available treatments. In the latest years, novel therapies targeting the IL-17/IL-23 and TNF pathways improved clinical outcome. Despite this, remission of disease is not achieved in a considerable group of patients, continuous treatment is very often required to reach clinical remission, and prevention of PsA in patients with psoriasis (PsO) is currently impossible. A better understanding of PsA pathogenesis is required to develop novel treatment strategies that target inflammation and destruction more effectively and at an early stage of the disease, or even before clinically manifest disease. The skin is considered as one of the sites of onset of immune activation, triggering the inflammatory cascade in PsA. PsO develops into PsA in 30% of the PsO patients. Influenced by environmental and genetic factors, the inflammatory process in the skin, entheses, and/or gut may evolve into synovial tissue inflammation, characterized by influx of immune cells. The exact role of the innate and adaptive immune cells in disease pathogenesis is not completely known. The involvement of activated IL-17A+ T cells could implicate early immunomodulatory events generated in lymphoid organs thereby shaping the pathogenic inflammatory response leading to disease. In this perspective article, we provide the reader with an overview of the current literature regarding the immunological changes observed during the earliest stages of PsA. Moreover, we will postulate future areas of translational research aimed at increasing our knowledge on the molecular mechanisms driving disease development, which will aid the identification of novel potential therapeutic targets to limit the progression of PsA.
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Affiliation(s)
- Janne W. Bolt
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Chaja M. J. van Ansenwoude
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Ihsan Hammoura
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Marleen G. van de Sande
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Lisa G. M. van Baarsen
- Department of Rheumatology & Clinical Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Experimental Immunology, Amsterdam Institute for Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
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Al Khabouri S, Benson RA, Prendergast CT, Gray JI, Otto TD, Brewer JM, Garside P. TCRβ Sequencing Reveals Spatial and Temporal Evolution of Clonal CD4 T Cell Responses in a Breach of Tolerance Model of Inflammatory Arthritis. Front Immunol 2021; 12:669856. [PMID: 33986757 PMCID: PMC8110912 DOI: 10.3389/fimmu.2021.669856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Effective tolerogenic intervention in Rheumatoid Arthritis (RA) will rely upon understanding the evolution of articular antigen specific CD4 T cell responses. TCR clonality of endogenous CD4 T cell infiltrates in early inflammatory arthritis was assessed to monitor evolution of the TCR repertoire in the inflamed joint and associated lymph node (LN). Mouse models of antigen-induced breach of self-tolerance and chronic polyarthritis were used to recapitulate early and late phases of RA. The infiltrating endogenous, antigen experienced CD4 T cells in inflamed joints and LNs were analysed using flow cytometry and TCRβ sequencing. TCR repertoires from inflamed late phase LNs displayed increased clonality and diversity compared to early phase LNs, while inflamed joints remained similar with time. Repertoires from late phase LNs accumulated clones with a diverse range of TRBV genes, while inflamed joints at both phases contained clones expressing similar TRBV genes. Repertoires from LNs and joints at the late phase displayed reduced CDR3β sequence overlap compared to the early disease phase, however the most abundant clones in LNs accumulate in the joint at the later phase. The results indicate CD4 T cell repertoire clonality and diversity broadens with progression of inflammatory arthritis and is first reflected in LNs before mirroring in the joint. These observations imply that antigen specific tolerogenic therapies could be more effective if targeted at earlier phases of disease when CD4 T cell clonality is least diverse.
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Affiliation(s)
| | | | | | | | | | | | - Paul Garside
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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Steen J, Forsström B, Sahlström P, Odowd V, Israelsson L, Krishnamurthy A, Badreh S, Mathsson Alm L, Compson J, Ramsköld D, Ndlovu W, Rapecki S, Hansson M, Titcombe PJ, Bang H, Mueller DL, Catrina AI, Grönwall C, Skriner K, Nilsson P, Lightwood D, Klareskog L, Malmström V. Recognition of Amino Acid Motifs, Rather Than Specific Proteins, by Human Plasma Cell-Derived Monoclonal Antibodies to Posttranslationally Modified Proteins in Rheumatoid Arthritis. Arthritis Rheumatol 2019; 71:196-209. [PMID: 30152202 PMCID: PMC6563427 DOI: 10.1002/art.40699] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 08/23/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Antibodies against posttranslationally modified proteins are a hallmark of rheumatoid arthritis (RA), but the emergence and pathogenicity of these autoantibodies are still incompletely understood. The aim of this study was to analyze the antigen specificities and mutation patterns of monoclonal antibodies (mAb) derived from RA synovial plasma cells and address the question of antigen cross-reactivity. METHODS IgG-secreting cells were isolated from RA synovial fluid, and the variable regions of the immunoglobulins were sequenced (n = 182) and expressed in full-length mAb (n = 93) and also as germline-reverted versions. The patterns of reactivity with 53,019 citrullinated peptides and 49,211 carbamylated peptides and the potential of the mAb to promote osteoclastogenesis were investigated. RESULTS Four unrelated anti-citrullinated protein autoantibodies (ACPAs), of which one was clonally expanded, were identified and found to be highly somatically mutated in the synovial fluid of a patient with RA. The ACPAs recognized >3,000 unique peptides modified by either citrullination or carbamylation. This highly multireactive autoantibody feature was replicated for Ig sequences derived from B cells from the peripheral blood of other RA patients. The plasma cell-derived mAb were found to target distinct amino acid motifs and partially overlapping protein targets. They also conveyed different effector functions as revealed in an osteoclast activation assay. CONCLUSION These findings suggest that the high level of cross-reactivity among RA autoreactive B cells is the result of different antigen encounters, possibly at different sites and at different time points. This is consistent with the notion that RA is initiated in one context, such as in the mucosal organs, and thereafter targets other sites, such as the joints.
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Affiliation(s)
- Johanna Steen
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Peter Sahlström
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden, and Charité Univeristätsmedizin, Berlin, Germany
| | | | - Lena Israelsson
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Sara Badreh
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Daniel Ramsköld
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Monika Hansson
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Philip J Titcombe
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden, and University of Minnesota Medical School, Minneapolis
| | | | | | - Anca I Catrina
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Grönwall
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Peter Nilsson
- KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Lars Klareskog
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vivianne Malmström
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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9
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Yang JHM, Khatri L, Mickunas M, Williams E, Tatovic D, Alhadj Ali M, Young P, Moyle P, Sahni V, Wang R, Kaur R, Tannahill GM, Beaton AR, Gerlag DM, Savage COS, Napolitano Rosen A, Waldron-Lynch F, Dayan CM, Tree TIM. Phenotypic Analysis of Human Lymph Nodes in Subjects With New-Onset Type 1 Diabetes and Healthy Individuals by Flow Cytometry. Front Immunol 2019; 10:2547. [PMID: 31749806 PMCID: PMC6842967 DOI: 10.3389/fimmu.2019.02547] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Ultrasound guided sampling of human lymph node (LN) combined with advanced flow cytometry allows phenotypic analysis of multiple immune cell subsets. These may provide insights into immune processes and responses to immunotherapies not apparent from analysis of the blood. Methods: Ultrasound guided inguinal LN samples were obtained by both fine needle aspiration (FNA) and core needle biopsy in 10 adults within 8 weeks of diagnosis of type 1 diabetes (T1D) and 12 age-matched healthy controls at two study centers. Peripheral blood mononuclear cells (PBMC) were obtained on the same occasion. Samples were transported same day to the central laboratory and analyzed by multicolour flow cytometry. Results: LN sampling was well-tolerated and yielded sufficient cells for analysis in 95% of cases. We confirmed the segregation of CD69+ cells into LN and the predominance of CD8+ Temra cells in blood previously reported. In addition, we demonstrated clear enrichment of CD8+ naïve, FOXP3+ Treg, class-switched B cells, CD56bright NK cells and plasmacytoid dendritic cells (DC) in LNs as well as CD4+ T cells of the Th2 phenotype and those expressing Helios and Ki67. Conventional NK cells were virtually absent from LNs as were Th22 and Th1Th17 cells. Paired correlation analysis of blood and LN in the same individuals indicated that for many cell subsets, especially those associated with activation: such as CD25+ and proliferating (Ki67+) T cells, activated follicular helper T cells and class-switched B cells, levels in the LN compartment could not be predicted by analysis of blood. We also observed an increase in Th1-like Treg and less proliferating (Ki67+) CD4+ T cells in LN from T1D compared to control LNs, changes which were not reflected in the blood. Conclusions: LN sampling in humans is well-tolerated. We provide the first detailed “roadmap” comparing immune subsets in LN vs. blood emphasizing a role for differentiated effector T cells in the blood and T cell regulation, B cell activation and memory in the LN. For many subsets, frequencies in blood, did not correlate with LN, suggesting that LN sampling would be valuable for monitoring immuno-therapies where these subsets may be impacted.
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Affiliation(s)
- Jennie H M Yang
- Department of Immunobiology, School of Immunology & Microbial Sciences (SIMS), King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Leena Khatri
- Department of Immunobiology, School of Immunology & Microbial Sciences (SIMS), King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Marius Mickunas
- Department of Immunobiology, School of Immunology & Microbial Sciences (SIMS), King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Evangelia Williams
- Department of Immunobiology, School of Immunology & Microbial Sciences (SIMS), King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Danijela Tatovic
- Diabetes/Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Mohammad Alhadj Ali
- Diabetes/Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Penelope Moyle
- Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Vishal Sahni
- GlaxoSmithKline Medicines Research Centre, Stevenage, United Kingdom
| | - Ryan Wang
- GlaxoSmithKline Medicines Research Centre, Stevenage, United Kingdom
| | - Rejbinder Kaur
- GlaxoSmithKline Medicines Research Centre, Stevenage, United Kingdom
| | | | - Andrew R Beaton
- GlaxoSmithKline Medicines Research Centre, Stevenage, United Kingdom
| | - Danielle M Gerlag
- GlaxoSmithKline Medicines Research Centre, Stevenage, United Kingdom
| | | | | | - Frank Waldron-Lynch
- Experimental Medicine and Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Colin M Dayan
- Diabetes/Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Timothy I M Tree
- Department of Immunobiology, School of Immunology & Microbial Sciences (SIMS), King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
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10
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Slight-Webb S, Bourn RL, Holers VM, James JA. Shared and unique immune alterations in pre-clinical autoimmunity. Curr Opin Immunol 2019; 61:60-68. [PMID: 31557691 DOI: 10.1016/j.coi.2019.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/01/2019] [Accepted: 08/26/2019] [Indexed: 02/08/2023]
Abstract
Progression from health to a classified autoimmune disease is an evolving process that can happen rapidly in some diseases, but usually takes years to develop. Specific immune alterations predate pathogenic autoimmunity and can be used as disease biomarkers to identify high-risk individuals for prevention studies applied in the pre-clinical state. Here we discuss recent findings that illuminate specific immune pathways that are altered in the earliest phases of pre-clinical autoimmunity as well as those mediators more closely associated with later clinically apparent and classified disease onset.
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Affiliation(s)
- Samantha Slight-Webb
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
| | - Rebecka L Bourn
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
| | - V Michael Holers
- Medicine and Rheumatology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Judith A James
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States; Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, United States.
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11
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Karouzakis E, Hähnlein J, Grasso C, Semmelink JF, Tak PP, Gerlag DM, Gay S, Ospelt C, van Baarsen LGM. Molecular Characterization of Human Lymph Node Stromal Cells During the Earliest Phases of Rheumatoid Arthritis. Front Immunol 2019; 10:1863. [PMID: 31481955 PMCID: PMC6711342 DOI: 10.3389/fimmu.2019.01863] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/23/2019] [Indexed: 11/13/2022] Open
Abstract
Rheumatoid arthritis (RA) is a progressive, destructive autoimmune arthritis. Break of tolerance and formation of autoantibodies occur years before arthritis. Adaptive immunity is initiated in lymphoid tissue where lymph node stromal cells (LNSCs) play a crucial role in shaping the immune response and maintaining peripheral tolerance. Here we performed the first epigenomic characterization of LNSCs during health and early RA, by analyzing their transcriptome and DNA methylome in LNSCs isolated from lymph node needle biopsies obtained from healthy controls (HC), autoantibody positive RA-risk individuals and patients with established RA. Of interest, LNSCs from RA-risk individuals and RA patients revealed a common significantly differential expressed gene signature compared with HC LNSCs. Pathway analysis of this common signature showed, among others, significant enrichment of pathways affecting the extracellular matrix (ECM), cholesterol biosynthesis and immune system. In a gel contraction assay LNSCs from RA-risk individuals and RA patients showed impaired collagen contraction compared to healthy LNSCs. In RA LNSCs a significant enrichment was observed for genes involved in cytokine signaling, hemostasis and packaging of telomere ends. In contrast, in RA-risk LNSCs pathways in cancer (cell cycle related genes) were differentially expressed compared with HC, which could be validated in vitro using a proliferation assay, which indicated a slower proliferation rate. DNA methylation analyses revealed common and specific differentially methylated CpG sites (DMS) in LNSC from RA patients and RA-risk individuals compared with HC. Intriguingly, shared DMS were all associated with antigen processing and presentation. This data point toward alterations in cytoskeleton and antigen-processing and presentation in LNSC from RA-risk individuals and RA patients. Further studies are required to investigate the consequence of this LNSC abnormality on LNSC-mediated immunomodulation.
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Affiliation(s)
- Emmanuel Karouzakis
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital of Zurich, Zurich, Switzerland
| | - Janine Hähnlein
- Department of Rheumatology and Clinical Immunology, Department of Experimental Immunology, Amsterdam UMC, Amsterdam Infection and Immunity Institute, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Cristoforo Grasso
- Department of Rheumatology and Clinical Immunology, Department of Experimental Immunology, Amsterdam UMC, Amsterdam Infection and Immunity Institute, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Johanna F Semmelink
- Department of Rheumatology and Clinical Immunology, Department of Experimental Immunology, Amsterdam UMC, Amsterdam Infection and Immunity Institute, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
| | - Paul P Tak
- Department of Rheumatology and Clinical Immunology, Department of Experimental Immunology, Amsterdam UMC, Amsterdam Infection and Immunity Institute, University of Amsterdam, Amsterdam, Netherlands.,Flagship Pioneering, Cambridge, MA, United States.,Ghent University, Ghent, Belgium.,Cambridge University, Cambridge, United Kingdom
| | - Danielle M Gerlag
- Department of Rheumatology and Clinical Immunology, Department of Experimental Immunology, Amsterdam UMC, Amsterdam Infection and Immunity Institute, University of Amsterdam, Amsterdam, Netherlands.,RxCelerate, Cambridge, United Kingdom
| | - Steffen Gay
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital of Zurich, Zurich, Switzerland
| | - Caroline Ospelt
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital of Zurich, Zurich, Switzerland
| | - Lisa G M van Baarsen
- Department of Rheumatology, Center of Experimental Rheumatology, University Hospital of Zurich, Zurich, Switzerland.,Amsterdam Rheumatology & Immunology Center (ARC), Academic Medical Center, Amsterdam, Netherlands
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12
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Lucchino B, Spinelli FR, Iannuccelli C, Guzzo MP, Conti F, Di Franco M. Mucosa-Environment Interactions in the Pathogenesis of Rheumatoid Arthritis. Cells 2019; 8:E700. [PMID: 31295951 PMCID: PMC6678242 DOI: 10.3390/cells8070700] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 12/15/2022] Open
Abstract
Mucosal surfaces play a central role in the pathogenesis of rheumatoid arthritis (RA). Several risk factors, such as cigarette smoking, environmental pollution, and periodontitis interact with the host at the mucosal level, triggering immune system activation. Moreover, the alteration of microbiota homeostasis is gaining increased attention for its involvement in the disease pathogenesis, modulating the immune cell response at a local and subsequently at a systemic level. Currently, the onset of the clinical manifest arthritis is thought to be the last step of a series of pathogenic events lasting years. The positivity for anti-citrullinated protein antibodies (ACPAs) and rheumatoid factor (RF), in absence of symptoms, characterizes a preclinical phase of RA-namely systemic autoimmune phase- which is at high risk for disease progression. Several immune abnormalities, such as local ACPA production, increased T cell polarization towards a pro-inflammatory phenotype, and innate immune cell activation can be documented in at-risk subjects. Many of these abnormalities are direct consequences of the interaction between the environment and the host, which takes place at the mucosal level. The purpose of this review is to describe the humoral and cellular immune abnormalities detected in subjects at risk of RA, highlighting their origin from the mucosa-environment interaction.
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Affiliation(s)
- Bruno Lucchino
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy.
| | - Francesca Romani Spinelli
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy
| | - Cristina Iannuccelli
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Paola Guzzo
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy
| | - Fabrizio Conti
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy
| | - Manuela Di Franco
- Rheumatology Unit, Department of Internal Medicine and Medical Specialities, Sapienza University of Rome, 00161 Rome, Italy
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13
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Cope AP. Considerations for Optimal Trial Design for Rheumatoid Arthritis Prevention Studies. Clin Ther 2019; 41:1299-1311. [PMID: 31196650 DOI: 10.1016/j.clinthera.2019.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/07/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022]
Abstract
The field of rheumatology has made major contributions to medicine through the identification of cellular and molecular targets and with the development of therapies for the treatment of an impressive range of immune-mediated rheumatic diseases. In recent years new milestones have been achieved. These include the recognition of an "at risk" state, defined by distinct clusters of characteristics, including disease-specific autoantibodies in serum and symptom complexes that include inflammatory joint pain. Studies seeking to prevent high-risk individuals from progressing to a state of clinically apparent arthritis have been initiated. Here, exploiting the current evidence base, an experimental framework to inform trial design is described, taking into consideration study patient phenotypes and highlighting the impact of risk stratification and the options available for therapeutic intervention according to the different phases of the preclinical syndrome. Pragmatic primary end points and suggestions for a set of risk-focused trial outcome measures are proposed, including both clinical assessments and patient-reported outcome measures. Rheumatoid arthritis prevention studies provide an important experimental framework for generating deeper insights into risk stratification and for refining trial design in the future. To this end, a research agenda is suggested, together with some considerations for imaging and for biological sampling. This commentary concludes with some of the operational issues that arise from such studies and addresses some of the challenges associated with recruitment and retention of the at-risk trial participant.
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Affiliation(s)
- Andrew P Cope
- Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Guys Campus, London, United Kingdom.
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14
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Kalinkovich A, Gabdulina G, Livshits G. Autoimmunity, inflammation, and dysbiosis mutually govern the transition from the preclinical to the clinical stage of rheumatoid arthritis. Immunol Res 2018; 66:696-709. [DOI: 10.1007/s12026-018-9048-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Coras R, Narasimhan R, Guma M. Liquid biopsies to guide therapeutic decisions in rheumatoid arthritis. Transl Res 2018; 201:1-12. [PMID: 30092207 PMCID: PMC6309446 DOI: 10.1016/j.trsl.2018.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/29/2018] [Accepted: 07/10/2018] [Indexed: 12/18/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic, immune-mediated inflammatory disease that has transitioned from a debilitating disease to a chronic, controllable disease. This has been possible due to the introduction of new treatment strategies like "treat-to-target," in which the clinician treats the patient aggressively enough to reach low disease activity or remission, and the introduction of new therapeutic agents, such as biological therapies, which can lead to the prevention of damage by early diagnosis and initiation of treatment. Attention is now being directed toward identifying the optimal treatment for each patient, one that will be the most efficient and have the least number of side effects. Much work has been done to find serologic and synovial biomarkers of response to various RA treatments. Proteomics, genomics and, in the past few years, metabolomics, have all been used in the quest of identifying these biomarkers. Blood-based liquid biopsies provide a minimally invasive alternative to synovial biopsies to identify cellular and molecular signatures that can be used to longitudinally monitor response and allow for personalized medicine approach. Liquid biopsies are comprised of cell-free DNA, immune circulating cells, and extracellular vesicles, and are being increasingly and successfully used in the field of oncology for diagnosis, progression, prognosis, and prediction of response to treatment. Recently, researchers have also begun investigating the usefulness of liquid biopsies in the field of rheumatology; in this review, we will focus on the potential of liquid biopsy blood samples as biomarkers of response to treatment in patients with RA.
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Affiliation(s)
- Roxana Coras
- Department of Medicine, School of Medicine, La Jolla, California; University of California San Diego, San Diego, California; Department of Medicine, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - Rekha Narasimhan
- Department of Medicine, School of Medicine, La Jolla, California; University of California San Diego, San Diego, California
| | - Monica Guma
- Department of Medicine, School of Medicine, La Jolla, California; University of California San Diego, San Diego, California; Department of Medicine, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain.
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16
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Weyand CM, Shen Y, Goronzy JJ. Redox-sensitive signaling in inflammatory T cells and in autoimmune disease. Free Radic Biol Med 2018; 125:36-43. [PMID: 29524605 PMCID: PMC6128787 DOI: 10.1016/j.freeradbiomed.2018.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/01/2018] [Accepted: 03/04/2018] [Indexed: 12/13/2022]
Abstract
Reactive oxygen species (ROS) are byproducts of oxygen metabolism best known for their damaging potential, but recent evidence has exposed their role as secondary messengers, which regulate cell function through redox-activatable signaling systems. In immune cells, specifically in T cells, redox-sensitive signaling pathways have been implicated in controlling several functional domains; including cell cycle progression, T effector cell differentiation, tissue invasion and inflammatory behavior. T cells from patients with the autoimmune disease rheumatoid arthritis (RA) have emerged as a valuable model system to examine the functional impact of ROS on T cell function. Notably, RA T cells are distinguished from healthy T cells based on reduced ROS production and undergo "reductive stress". Upstream defects leading to the ROSlow status of RA T cells are connected to metabolic reorganization. RA T cells shunt glucose away from pyruvate and ATP production towards the pentose phosphate pathway, where they generate NADPH and consume cellular ROS. Downstream consequences of the ROSlow conditions in RA T cells include insufficient activation of the DNA repair kinase ATM, bypassing of the G2/M cell cycle checkpoint and biased differentiation of T cells into IFN-γ and IL-17-producing inflammatory cells. Also, ROSlow T cells rapidly invade into peripheral tissue due to dysregulated lipogenesis, excessive membrane ruffling, and overexpression of a motility module dominated by the scaffolding protein Tks5. These data place ROS into a pinnacle position in connecting cellular metabolism and protective versus auto-aggressive T cell immunity. Therapeutic interventions for targeted ROS enhancement instead of ROS depletion should be developed as a novel strategy to treat autoimmune tissue inflammation.
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Affiliation(s)
- Cornelia M Weyand
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Veterans Affairs Palo Alto Health Care System Palo Alto, CA 94306, USA.
| | - Yi Shen
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Veterans Affairs Palo Alto Health Care System Palo Alto, CA 94306, USA
| | - Jorg J Goronzy
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, CA 94305, USA; Department of Medicine, Veterans Affairs Palo Alto Health Care System Palo Alto, CA 94306, USA
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17
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Buckley CD, McGettrick HM. Leukocyte trafficking between stromal compartments: lessons from rheumatoid arthritis. Nat Rev Rheumatol 2018; 14:476-487. [DOI: 10.1038/s41584-018-0042-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Hähnlein JS, Nadafi R, de Jong T, Ramwadhdoebe TH, Semmelink JF, Maijer KI, Zijlstra IJA, Maas M, Gerlag DM, Geijtenbeek TBH, Tak PP, Mebius RE, van Baarsen LGM. Impaired lymph node stromal cell function during the earliest phases of rheumatoid arthritis. Arthritis Res Ther 2018; 20:35. [PMID: 29482663 PMCID: PMC5828373 DOI: 10.1186/s13075-018-1529-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/29/2018] [Indexed: 01/09/2023] Open
Abstract
Background Systemic autoimmunity can be present years before clinical onset of rheumatoid arthritis (RA). Adaptive immunity is initiated in lymphoid tissue where lymph node stromal cells (LNSCs) regulate immune responses through their intimate connection with leucocytes. We postulate that malfunctioning of LNSCs creates a microenvironment in which normal immune responses are not properly controlled, possibly leading to autoimmune disease. In this study we established an experimental model for studying the functional capacities of human LNSCs during RA development. Methods Twenty-four patients with RA, 23 individuals positive for autoantibodies but without clinical disease (RA risk group) and 14 seronegative healthy control subjects underwent ultrasound-guided inguinal lymph node (LN) biopsy. Human LNSCs were isolated and expanded in vitro for functional analyses. In analogous co-cultures consisting of LNSCs and peripheral blood mononuclear cells, αCD3/αCD28-induced T-cell proliferation was measured using carboxyfluorescein diacetate succinimidyl ester dilution. Results Fibroblast-like cells expanded from the LN biopsy comprised of fibroblastic reticular cells (gp38+CD31−) and double-negative (gp38−CD31−) cells. Cultured LNSCs stably expressed characteristic adhesion molecules and cytokines. Basal expression of C-X-C motif chemokine ligand 12 (CXCL12) was lower in LNSCs from RA risk individuals than in those from healthy control subjects. Key LN chemokines C-C motif chemokine ligand (CCL19), CCL21 and CXCL13 were induced in LNSCs upon stimulation with tumour necrosis factor-α and lymphotoxin α1β2, but to a lesser extent in LNSCs from patients with RA. The effect of human LNSCs on T-cell proliferation was ratio-dependent and altered in RA LNSCs. Conclusions Overall, we developed an experimental model to facilitate research on the role of LNSCs during the earliest phases of RA. Using this innovative model, we show, for the first time to our knowledge, that the LN stromal environment is changed during the earliest phases of RA, probably contributing to deregulated immune responses early in disease pathogenesis. Electronic supplementary material The online version of this article (10.1186/s13075-018-1529-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janine S Hähnlein
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Reza Nadafi
- Department of Molecular Cell Biology and Immunology, VU Medical Centre, Amsterdam, the Netherlands
| | - Tineke de Jong
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Tamara H Ramwadhdoebe
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Johanna F Semmelink
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Karen I Maijer
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - IJsbrand A Zijlstra
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Danielle M Gerlag
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Present address: Clinical Unit Cambridge, GlaxoSmithKline, Cambridge, UK
| | - Teunis B H Geijtenbeek
- Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Paul P Tak
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.,Present address: Ghent University, Ghent, Belgium.,Present address: University of Cambridge, Cambridge, UK.,Present address: GlaxoSmithKline, Stevenage, UK
| | - Reina E Mebius
- Department of Molecular Cell Biology and Immunology, VU Medical Centre, Amsterdam, the Netherlands
| | - Lisa G M van Baarsen
- Amsterdam Rheumatology & immunology Centre (ARC), Department of Clinical Immunology and Rheumatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands. .,Department of Experimental Immunology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands.
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19
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Hähnlein JS, Ramwadhdoebe TH, Semmelink JF, Choi IY, Berger FH, Maas M, Gerlag DM, Tak PP, Geijtenbeek TBH, van Baarsen LGM. Distinctive expression of T cell guiding molecules in human autoimmune lymph node stromal cells upon TLR3 triggering. Sci Rep 2018; 8:1736. [PMID: 29379035 PMCID: PMC5789053 DOI: 10.1038/s41598-018-19951-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/09/2018] [Indexed: 12/22/2022] Open
Abstract
Infections are implicated in autoimmunity. Autoantibodies are produced in lymphoid tissue where lymph node stromal cells (LNSCs) regulate lymphocyte function. Infections can alter the interaction between LNSCs and lymphocytes resulting in defective immune responses. In rheumatoid arthritis (RA) autoantibody production precedes clinical disease allowing identification of at risk individuals. We investigated the ability of human LNSCs derived from RA, RA-risk and healthy individuals to sense and respond to pathogens. Human LNSCs cultured directly from freshly collected lymph node biopsies expressed TLR1-9 with exception of TLR7. In all donors TLR3 triggering induced expression of ISGs, IL-6 and adhesion molecules like VCAM-1 and ICAM-1. Strikingly, T cell guiding chemokines CCL19 and IL-8 as well as the antiviral gene MxA were less induced upon TLR3 triggering in autoimmune LNSCs. This observed decrease, found already in LNSCs of RA-risk individuals, may lead to incorrect positioning of lymphocytes and aberrant immune responses during viral infections.
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Affiliation(s)
- Janine S Hähnlein
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tamara H Ramwadhdoebe
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna F Semmelink
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ivy Y Choi
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ferco H Berger
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Danielle M Gerlag
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Clinical Unit Cambridge, GlaxoSmithKline, Cambridge, UK
| | - Paul P Tak
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Ghent University, Ghent, Belgium
- University of Cambridge, Cambridge, UK
- GlaxoSmithKline, Stevenage, UK
| | - Teunis B H Geijtenbeek
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lisa G M van Baarsen
- Amsterdam Rheumatology & immunology Center (ARC), Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Molendijk M, Hazes JM, Lubberts E. From patients with arthralgia, pre-RA and recently diagnosed RA: what is the current status of understanding RA pathogenesis? RMD Open 2018; 4:e000256. [PMID: 29480896 PMCID: PMC5822638 DOI: 10.1136/rmdopen-2016-000256] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/15/2017] [Accepted: 11/24/2017] [Indexed: 01/01/2023] Open
Abstract
It is believed that therapy for rheumatoid arthritis (RA) is the most effective and beneficial within a short time frame around RA diagnosis. This insight has caused a shift from research in patients with established RA to patients at risk of developing RA and recently diagnosed patients. It is important for improvement of RA therapy to understand when and what changes occur in patients developing RA. This is true for both seropositive and seronegative patients. Activation of the immune system as presented by autoantibodies, increased cytokine and chemokine production, and alterations within several immune cells occur during RA development. In this review we describe RA pathogenesis with a focus on knowledge obtained from patients with arthralgia, pre-RA and recently diagnosed RA. Connections are proposed between altered immune cells, cytokines and chemokines, and events like synovial hyperplasia, pain and bone damage.
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Affiliation(s)
- Marlieke Molendijk
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johanna Mw Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Erik Lubberts
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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21
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Pre-symptomatic autoimmunity in rheumatoid arthritis: when does the disease start? Semin Immunopathol 2017; 39:423-435. [PMID: 28337522 PMCID: PMC5486797 DOI: 10.1007/s00281-017-0620-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/21/2022]
Abstract
It is well recognised that a state of autoimmunity, in which immunological tolerance is broken, precedes the development of symptoms in the majority of patients with rheumatoid arthritis (RA). For individuals who will later develop seropositive disease, this manifests as autoantibodies directed against proteins that have undergone specific post-translational modifications. There is evidence that the induction of this autoantibody response occurs at peripheral extra-articular mucosal sites, such as the periodontium and lung. In addition to their utility as diagnostic markers, these autoantibodies may have a pathogenic role that helps localise disease to the synovium. Alongside the development of autoantibodies, other factors contributing to pre-symptomatic autoimmunity may include dysbiosis of the gastrointestinal tract, abnormal development of lymphoid tissue, and dysregulated autonomic and lipid-mediated anti-inflammatory signalling. These factors combine to skew the balance between pro-inflammatory and anti-inflammatory signalling in a manner that is permissive for the development of clinical arthritis. We present data to support the concept that the transitions from at-risk states to systemic autoimmunity and then to classifiable RA depend on multiple “switches”. However, further prospective studies are necessary to define the molecular basis of these switches and the specific features of pre-symptomatic autoimmunity, so that preventative treatments can be targeted to individuals at high risk for RA. In this review, we analyse mechanisms that may contribute to the development of autoimmunity in at-risk individuals and discuss the relationship between this pre-symptomatic state and subsequent development of RA.
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22
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Tuncel J, Haag S, Holmdahl R. MHC class II alleles associated with Th1 rather than Th17 type immunity drive the onset of early arthritis in a rat model of rheumatoid arthritis. Eur J Immunol 2017; 47:563-574. [PMID: 28012172 PMCID: PMC7163699 DOI: 10.1002/eji.201646760] [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: 10/12/2016] [Revised: 12/06/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
Polymorphisms in the MHC class II (MHCII) genes are strongly associated with rheumatoid arthritis, supporting the importance of autoreactive T helper (Th) cells for the development of this disease. Here, we used pristane-induced arthritis (PIA), induced by the non-antigenic hydrocarbon pristane, to study the impact of different MHCII alleles on T-cell activation and differentiation. In MHCII-congenic rats with disease-promoting MHCII alleles, pristane primarily induced activation of Th1 cells, whereas activated T cells were Th17 biased in rats with protective MHCII alleles. Neutralization of IFN-γ during T-cell activation abrogated the development of disease, suggesting that Th1 immunity is important for disease induction. Neutralization of IL-17, by contrast, suppressed arthritis only when performed in rats with established disease. Adoptive T-cell transfers showed that T cells acquired arthritogenic capacity earlier in strains with a prevailing Th1 response. Moreover, upon pristane injection, these strains exhibited more Ag-primed OX40+ and proliferating T cells of polyclonal origin. These data show that T cells are polarized upon the first encounter with peptide-MHCII complexes in an allele-dependent fashion. In PIA, the polyclonal expansion of autoreactive Th1 cells was necessary for the onset of arthritis, while IL-17 mediated immunity contributed to the progression to chronic disease.
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Affiliation(s)
- Jonatan Tuncel
- Division of Medical Inflammation Research, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA, USA
| | - Sabrina Haag
- Division of Medical Inflammation Research, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rikard Holmdahl
- Division of Medical Inflammation Research, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
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23
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Emerging therapies for pre-RA. Best Pract Res Clin Rheumatol 2017; 31:99-111. [DOI: 10.1016/j.berh.2017.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/07/2017] [Indexed: 01/20/2023]
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