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Zhang Z, Tanaka I, Nakahashi-Ouchida R, Ernst PB, Kiyono H, Kurashima Y. Glycoprotein 2 as a gut gate keeper for mucosal equilibrium between inflammation and immunity. Semin Immunopathol 2024; 45:493-507. [PMID: 38170255 PMCID: PMC11136868 DOI: 10.1007/s00281-023-00999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
Glycoprotein 2 (GP2) is a widely distributed protein in the digestive tract, contributing to mucosal barrier maintenance, immune homeostasis, and antigen-specific immune response, while also being linked to inflammatory bowel disease (IBD) pathogenesis. This review sheds light on the extensive distribution of GP2 within the gastrointestinal tract and its intricate interplay with the immune system. Furthermore, the significance of GP2 autoantibodies in diagnosing and categorizing IBD is underscored, alongside the promising therapeutic avenues for modulating GP2 to regulate immunity and maintain mucosal balance.
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Affiliation(s)
- Zhongwei Zhang
- Department of Innovative Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Chiba University Futuristic Mucosal Vaccine Research and Development Synergy Institute (cSIMVa), Chiba, Japan
| | - Izumi Tanaka
- Department of Innovative Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Chiba University Futuristic Mucosal Vaccine Research and Development Synergy Institute (cSIMVa), Chiba, Japan
| | - Rika Nakahashi-Ouchida
- Chiba University Futuristic Mucosal Vaccine Research and Development Synergy Institute (cSIMVa), Chiba, Japan
- Division of Mucosal Immunology, IMSUT Distinguished Professor Unit, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Division of Mucosal Vaccines, International Research and Development Center for Mucosal Vaccines, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Human Mucosal Vaccinology, Chiba University Hospital, Chiba, Japan
| | - Peter B Ernst
- Department of Medicine, School of Medicine, Chiba University-University of California San Diego Center for Mucosal Immunology, Allergy and Vaccine (CU-UCSD cMAV), San Diego, CA, USA
- Division of Comparative Pathology and Medicine, Department of Pathology, University of California, San Diego, CA, USA
- Center for Veterinary Sciences and Comparative Medicine, University of California, San Diego, CA, USA
- Future Medicine Education and Research Organization, Chiba University, Chiba, Japan
| | - Hiroshi Kiyono
- Chiba University Futuristic Mucosal Vaccine Research and Development Synergy Institute (cSIMVa), Chiba, Japan
- Division of Mucosal Immunology, IMSUT Distinguished Professor Unit, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Human Mucosal Vaccinology, Chiba University Hospital, Chiba, Japan
- Department of Medicine, School of Medicine, Chiba University-University of California San Diego Center for Mucosal Immunology, Allergy and Vaccine (CU-UCSD cMAV), San Diego, CA, USA
- Future Medicine Education and Research Organization, Chiba University, Chiba, Japan
- HanaVax Inc., Tokyo, Japan
- Mucosal Immunology and Allergy Therapeutics, Institute for Global Prominent Research, Chiba University, Chiba, Japan
| | - Yosuke Kurashima
- Department of Innovative Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Chiba University Futuristic Mucosal Vaccine Research and Development Synergy Institute (cSIMVa), Chiba, Japan.
- Division of Mucosal Immunology, IMSUT Distinguished Professor Unit, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
- Department of Human Mucosal Vaccinology, Chiba University Hospital, Chiba, Japan.
- Department of Medicine, School of Medicine, Chiba University-University of California San Diego Center for Mucosal Immunology, Allergy and Vaccine (CU-UCSD cMAV), San Diego, CA, USA.
- Division of Clinical Vaccinology, International Research and Development Center for Mucosal Vaccines, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
- Institute for Advanced Academic Research, Chiba University, Chiba, Japan.
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Liaskos C, Gkoutzourelas A, Spyrou V, Koutsoumpas A, Athanasiou LV, Amiridis GS, Billinis C, Bogdanos DP. Pancreatic anti-GP2 and anti-Saccharomyces cerevisiae antibodies in ruminants with paratuberculosis: A better understanding of the immunopathogenesis of Crohn's disease. Clin Res Hepatol Gastroenterol 2020; 44:778-785. [PMID: 32035824 DOI: 10.1016/j.clinre.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/12/2019] [Accepted: 12/27/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ruminants (cattle and sheep) with Mycobacterium avium (MAP)-induced paratuberculosis (ptb), the ruminant model of Crohn's disease (CD), exhibit pancreatic specific autoantibodies (PAB) against GP2 but not against CUZD1. Since anti-Saccharomyces cerevisiae antibodies (ASCAs) is a CD marker, we tested MAP-infected ptb ruminants for ASCA, and compared them with ruminants lacking evidence of anti-MAP serology or with ruminants, which were positive for anti-GP2 antibodies. MATERIAL AND METHODS A total of 98 samples from ruminants (48 cattle and 50 sheep) were studied. IgG anti-MAP antibodies, and CD-related ASCA and anti-GP2 antibodies were tested by modified ELISAs. RESULTS Nine cattle (18.75%) and 20 sheep (40%) were suffered from ptb. ASCA antibodies were present in 21/48 (43.7%) cattle and 10/50 (20%) sheep while anti-GP2 antibodies were present in 14/48 (29.2%) cattle, and 8/50 (16%) sheep. ASCA antibodies were more prevalent in anti-MAP antibody positive (14/29, 48.3%) than in anti-MAP negative ruminants (17/69, 24.6%, P=0.022) and also in anti-GP2 antibody positive (13/23, 56.5%) than in anti-GP2 negative ruminants (18/75, 24%, P=0.003). No association between ASCA and anti-MAP antibody concentrations were found (r=0.159, P=0.117). A significant association between ASCA and anti-GP2 antibody concentration were observed (r=0.211 and P=0.037). CONCLUSION ASCA are present in a significant proportion of ruminants with ptb and correlate with anti-GP2 antibody positivity, a finding further supporting the notion that Crohn's disease and ptb share common immunological mechanisms of antigen-driven loss of self-tolerance.
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Affiliation(s)
- Christos Liaskos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece.
| | - Athanasios Gkoutzourelas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
| | - Vasiliki Spyrou
- Department of Animal Production, University of Thessaly, 41110 Larissa, Greece
| | - Andreas Koutsoumpas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
| | - Labrini V Athanasiou
- Department of Medicine, Faculty of Veterinary Medicine, University of Thessaly, Karditsa, Greece
| | - Georgios S Amiridis
- Department of Reproduction and Obstetrics, Faculty of Veterinary Medicine, University of Thessaly, Karditsa, Greece
| | - Charalambos Billinis
- Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Thessaly, Karditsa, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
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Gkiouras K, Grammatikopoulou MG, Theodoridis X, Pagkalidou E, Chatzikyriakou E, Apostolidou AG, Rigopoulou EI, Sakkas LI, Bogdanos DP. Diagnostic and clinical significance of antigen-specific pancreatic antibodies in inflammatory bowel diseases: A meta-analysis. World J Gastroenterol 2020; 26:246-265. [PMID: 31988587 PMCID: PMC6962435 DOI: 10.3748/wjg.v26.i2.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/19/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-invasive criteria are needed for Crohn's disease (CD) diagnosis, with several biomarkers being tested. Results of individual diagnostic test accuracy studies assessing the diagnostic value of pancreatic autoantibodies-to-glycoprotein-2 (anti-GP2) tests for the diagnosis of CD appear promising. AIM To systematically review and meta-analyze evidence on the diagnostic accuracy of anti-GP2 tests in patients with suspected/confirmed CD. METHODS An electronic search was conducted on PubMed, Cochrane-CENTRAL and grey literature (CRD42019125947). The structured research question in PICPTR format was "Population" including patients with symptoms akin to CD, the "Index test" being anti-GP2 testing, the "Comparator" involved standard CD diagnosis, the "Purpose of test" being diagnostic, "Target disorder" was CD, and the "Reference standard" included standard clinical, radiological, endoscopical, and histological CD diagnostic criteria. Quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool and hierarchical models were employed to synthesize the data. RESULTS Out of 722 studies retrieved, 15 were meta-analyzed. Thirteen studies had industry-related conflicts-of-interest, and most included healthy donors as controls (spectrum bias). For the combination of IgA and/or IgG anti-GP2 test, the summary sensitivity was 20% (95% confidence interval: 10%-29%) at a median specificity of 97%. If the test was applied in 10000 suspected patients, 9669 would be true negatives and in 26, the diagnosis would be missed. In this hypothetical cohort, the anti-GP2 would fail to produce a diagnosis for 81.3% of the positive cases. Low summary points of sensitivity and high specificity were estimated for the IgG or IgA anti-GP2 test. Analogous results were observed when the analyses were restricted using specific cut-offs, or when ulcerative colitis patients were used as comparators. CONCLUSION Anti-GP2 tests demonstrate low sensitivity and high specificity. These results indicate that caution is required before relying on its diagnostic value. Additionally, the need for improving the methodology of diagnostic test accuracy studies is evident.
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Affiliation(s)
- Konstantinos Gkiouras
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa GR41110, Greece
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
| | - Maria G Grammatikopoulou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa GR41110, Greece
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Sindos Campus, Thessaloniki GR57400, Greece
| | - Xenophon Theodoridis
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa GR41110, Greece
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
| | - Eirini Pagkalidou
- Laboratory of Hygiene, Social and Preventive Medicine and Medical Statistics, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
| | - Evangelia Chatzikyriakou
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, Faculty of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki GR54124, Greece
| | - Anna G Apostolidou
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Sindos Campus, Thessaloniki GR57400, Greece
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Biopolis, Larissa GR41110, Greece
| | - Lazaros I Sakkas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa GR41110, Greece
| | - Dimitrios Petrou Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa GR41110, Greece
- Division of Transplantation, Immunology and Mucosal Biology, MRC Centre for Transplantation, King's College London Medical School, London GR41110, United Kingdom
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Duman AE, Hülagü S, Çelebi A, Korkmaz U, Musul MM, Şentürk Ö, Şirin G, Yılmaz H, Koç DÖ, Dindar G, Öztürkler M, Bozkurt N, Kır HM. Differential diagnosis of Crohn's disease using antibodies to glycoprotein 2 and Saccharomyces cerevisiae. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 30:21-27. [PMID: 30465525 DOI: 10.5152/tjg.2018.18135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Glycoprotein 2 (GP2), the major autoantigen of Crohn's disease (CD)-specific pancreatic autoantibodies, is reportedly correlated with several characteristics of CD. We investigated this serological marker in Turkish patients with CD and assessed its utility in combination with anti-Saccharomyces cerevisiae antibodies (ASCAs) for differential diagnosis of CD. MATERIALS AND METHODS A total of 60 patients with CD, 62 patients with ulcerative colitis (UC), and 46 healthy controls with a definite diagnosis who were similar in age and sex were enrolled in the study conducted from November 2011 to October 2012. ASCA and anti-GP2 levels were measured using commercially available kits. RESULTS Anti-GP2 IgA and IgG levels were higher in patients with CD (25%) than in those with UC (5%) and controls (2%). The seroprevalence of anti-GP2 IgA was markedly higher than that of IgG in patients with CD in contrast to previous studies. The specificity and positive predictive value of seropositivity for both ASCA and anti-GP2 were 100%. ASCA IgA seropositivity was correlated with a complicated disease course and a history of surgery. There was no correlation between anti-GP2 seropositivity and disease location, disease behavior, or a history of surgery. CONCLUSION The combination of ASCA and anti-GP2 may enable differentiation of CD from UC. As ASCA seropositivity is associated with a more complicated disease course, patients seropositive for ASCA at the initial diagnosis should undergo more intense therapy.
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Affiliation(s)
- Ali Erkan Duman
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Sadettin Hülagü
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Altay Çelebi
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Uğur Korkmaz
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Mahmut Mert Musul
- Department of Biochemistry, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Ömer Şentürk
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Göktuğ Şirin
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Hasan Yılmaz
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Deniz Öğütmen Koç
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Gökhan Dindar
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Murat Öztürkler
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Neslihan Bozkurt
- Department of Gastroenterology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Hale Maral Kır
- Department of Biochemistry, Kocaeli University School of Medicine, Kocaeli, Turkey
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Schlör A, Holzlöhner P, Listek M, Grieß C, Butze M, Micheel B, Hentschel C, Sowa M, Roggenbuck D, Schierack P, Füner J, Schliebs E, Goihl A, Reinhold D, Hanack K. Generation and validation of murine monoclonal and camelid recombinant single domain antibodies specific for human pancreatic glycoprotein 2. N Biotechnol 2018; 45:60-68. [DOI: 10.1016/j.nbt.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 02/28/2018] [Accepted: 03/29/2018] [Indexed: 12/24/2022]
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Antibodies against glycoprotein 2 display diagnostic advantages over ASCA in distinguishing CD from intestinal tuberculosis and intestinal Behçet's disease. Clin Transl Gastroenterol 2018; 9:e133. [PMID: 29446764 PMCID: PMC5830545 DOI: 10.1038/ctg.2018.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023] Open
Abstract
Objectives: There is an increasing need to identify reliable biomarkers for distinguishing Crohn’s disease (CD) from other gastrointestinal disorders sharing similar clinical and pathological features. This study aimed at evaluating the diagnostic potential of antibodies to zymogen granule glycoprotein GP2 (aGP2) in a large, well-defined Chinese cohort with a special focus on their role in discriminating CD from intestinal Behçet's disease (BD) and intestinal tubercolosis (ITB). Methods: A total of 577 subjects were prospectively enrolled, including 171 patients with CD, 208 patients with ulcerative colitis (UC), 71 with BD, 57 with ITB and 70 healthy controls (HC). aGP2 and anti-Saccharomyces cerevisiae antibodies (ASCA) were determined by ELISA. Perinuclear antineutrophil cytoplasmic antibodies were tested by indirect immunofluorescent assay. Results: aGP2 IgG and IgA levels were significantly elevated in patients with CD compared with those in patients with UC, intestinal BD, and ITB and HC. Conversely, ASCA IgG levels were not different between CD and intestinal BD patients, whereas ASCA IgA levels did not discriminate CD from intestinal BD and ITB patients. aGP2 IgA and IgG displayed a better assay performance (larger areas under the curve) over ASCA IgA and IgG in differentiating CD from disease controls (P<0.05). ASCA IgA did not discriminate CD from disease controls. aGP2 IgA and/or IgG was significantly associated with penetrating disease (B3) and ileal CD (L1) (P<0.05), whereas ASCA IgA and/or IgG was not. Conclusions: In comparison with ASCA, aGP2 distinguishes CD from intestinal BD or ITB as disease controls more efficiently, aiding in the differential diagnosis of IBD.
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Autoantibodies Against Glycoprotein 2 Isoforms in Pediatric Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:1624-1636. [PMID: 28691939 DOI: 10.1097/mib.0000000000001159] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-Glycoprotein 2 (GP2) antibodies are associated with a more complicated course of Crohn's disease (CD) in adults. Four different GP2 isoforms with different length and antibody-binding sites have been identified so far but not been explored in serological studies. We aimed to investigate the diagnostic utility of autoantibodies against all 4 isoforms of GP2 in an exclusively pediatric population for the first time. METHODS We included 278 children and adolescents with inflammatory bowel disease: 164 with CD, 114 with ulcerative colitis, 83 disease controls (acute gastrointestinal infection, nonspecific gastrointestinal functional disorders), and 219 healthy controls. Sera were tested for anti-GP2 antibodies using 4 different isoforms of GP2 for anti-Saccharomyces cerevisiae antibodies, antineutrophil cytoplasmic antibodies, and pancreatic antibodies. RESULTS Anti-GP2 antibodies were significantly more prevalent in patients with CD than in ulcerative colitis and controls. We found a sensitivity of 38% (with a specificity of 95%) for anti-GP2 IgG against isoform 4 in CD. Anti-GP2 IgA against isoform 1 and anti-GP2 IgG against isoform 4 possessed the best diagnostic values for identification of CD. For the differentiation of CD from ulcerative colitis anti-GP2 IgG against isoforms 3 and 4 proved to be most accurate markers. Anti-GP2 antibodies were associated with a more complicated disease behavior and bowel surgery in CD. In a subgroup of patients with CD, anti-GP2 IgG against isoform 4 proved to be a relatively stable marker over time independent of disease activity. CONCLUSIONS Anti-GP2 antibodies against different isoforms are specific markers for CD and for different phenotypes in pediatric inflammatory bowel disease.
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Deng C, Li W, Li J, Zhang S, Li Y. Diagnostic value of the antiglycoprotein-2 antibody for Crohn's disease: a PRISMA-compliant systematic review and meta-analysis. BMJ Open 2017; 7:e014843. [PMID: 28601823 PMCID: PMC5734552 DOI: 10.1136/bmjopen-2016-014843] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To perform a meta-analysis to evaluate the diagnostic performance of the antiglycoprotein-2 (GP2) antibody for Crohn's disease (CD). METHODS Three databases (EMBASE, ISI Web of Knowledge and PubMed) were systematically searched. There were 17 eligible studies included in the meta-analysis. A total of 2439 patients with CD and 3184 controls were involved in these studies. STATA V.11.2 and Meta-DiSc V.1.4 were used to perform the meta-analysis. RESULTS The area under the summary receiver operating characteristic curve was 0.68-0.72. The pooled diagnostic sensitivity of the anti-GP2 antibody ranged from 14% to 24%, and the specificity was 96%-98%. CONCLUSIONS The anti-GP2 antibody is a specific biomarker for CD, and further exploration of its prevalence among different clinical phenotypes of CD will provide a better understanding of its diagnostic performance.
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Affiliation(s)
- Chuiwen Deng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wenli Li
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Jing Li
- Clinical Laboratory, Peking University International Hospital, Beijing, China
| | - Shulan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yongzhe Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Abstract
Inflammation in inflammatory bowel diseases (IBD) has been linked to a loss of tolerance to self-antigens suggesting the existence of autoantibodies in specific disease phenotypes. However, the lack of clearly defined autoantigenic targets has slowed down research. Genome-wide association studies have identified an impressive number of immune-related susceptibility loci for IBD with no clearly discernible pattern among them. Growing evidence supports the hypothesis that innate immune responses to a low-diversity and impaired gut microbiota may be of key importance in initiating and perpetuating chronic inflammation in IBD. Increasing evidence suggests that reduced microbial diversity and microbial-mucosal epithelium interaction (including adhesion and clearance) are critically involved in IBD pathogenesis. Along these lines the discovery of autoantigenic targets in Crohn's disease (CD) has refocused research in IBD on the possible role of autoimmune responses. The identification of the major zymogen granule membrane glycoprotein 2 (GP2) as an autoantigen in CD patients and its proposed role in the sensing of the microbiota lends credence to this trend. Loss of tolerance to GP2 occurs in up to 40% of patients with CD. Corresponding autoantibodies appear to be associated with distinct disease courses (types or phenotypes) in CD. Here, we critically review autoantibodies in CD for their impact on clinical practice and future IBD research. The immunomodulatory role of GP2 in innate and adaptive intestinal immunity is also discussed.
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Laass MW, Röber N, Range U, Noß L, Roggenbuck D, Conrad K. Loss and Gain of Tolerance to Pancreatic Glycoprotein 2 in Celiac Disease. PLoS One 2015; 10:e0128104. [PMID: 26047356 PMCID: PMC4457647 DOI: 10.1371/journal.pone.0128104] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 04/23/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Autoantibodies against pancreatic secretory-granule membrane glycoprotein 2 (GP2) have been demonstrated in patients with Crohn's disease but recently also with celiac disease (CD). Both entities are characterized by intestinal barrier impairment with increased gut permeability. Pathophysiological hallmark of CD is a permanent loss of tolerance to alimentary gliadin and a transient loss of tolerance to the autoantigen human tissue transglutaminase (tTG). Therefore, we explored the behavior of loss of tolerance to GP2 reported in CD. METHODS We assessed prevalences and levels of autoantibodies against GP2, CD-specific antibodies to endomysial antigens and tTG as well as Crohn's disease-specific anti-Saccharomyces cerevisiae antibodies in sera of 174 patients with active CD, 84 patients under gluten-free diet (GFD) and 129 controls. Furthermore, we looked for an association between anti-GP2 antibody positivity and degree of mucosal damage in CD. RESULTS We found significantly elevated anti-GP2 IgA positivity in active CD patients (19.5%) compared to CD patients under GFD (0.0%) and controls (5.4%, p < 0.001, respectively). Anti-GP2 IgA levels correlated significantly with CD-specific antibodies (p < 0.001). Anti-GP2 autoantibody positivity disappeared under GFD similarly to CD-specific autoantibodies against tTG and endomysial antigens. For the first time, IgA antibody levels to GP2 are demonstrated to be associated with degree of villous atrophy according to Marsh classification. CONCLUSIONS Anti-GP2 IgA seems to be associated with disease activity in a distinct subgroup of patients with CD. The observed loss of tolerance to GP2 in a subset of patients with CD is transient and disappears under GFD.
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Affiliation(s)
- Martin W. Laass
- Children’s Hospital, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- * E-mail:
| | - Nadja Röber
- Institute of Immunology, Technische Universität Dresden, 01307 Dresden, Germany
| | - Ursula Range
- Institute for Medical Informatics and Biometry, Technische Universität Dresden, 01307 Dresden, Germany
| | - Lydia Noß
- Children’s Hospital, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Dirk Roggenbuck
- GA Generic Assays GmbH, 15827 Dahlewitz/Berlin, Germany
- Faculty of Science, Brandenburg University of Technology Cottbus-Senftenberg, 01968 Senftenberg, Germany
| | - Karsten Conrad
- Institute of Immunology, Technische Universität Dresden, 01307 Dresden, Germany
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Pavlidis P, Shums Z, Koutsoumpas AL, Milo J, Papp M, Umemura T, Lakatos PL, Smyk DS, Bogdanos DP, Forbes A, Norman GL. Diagnostic and clinical significance of Crohn's disease-specific anti-MZGP2 pancreatic antibodies by a novel ELISA. Clin Chim Acta 2014; 441:176-81. [PMID: 25512163 DOI: 10.1016/j.cca.2014.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/01/2014] [Accepted: 12/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND We developed a new IgA and IgG anti-MZGP2 antibody ELISAs based on recombinant isoform-4 of human zymogen granule protein-2 (GP2), which is the major autoantigen of Crohn's disease (CrD)-specific pancreatic autoantibodies and assessed their clinical relevance in the largest inflammatory bowel disease (IBD) cohort tested to date. METHODS 832 sera were studied, including 617 consecutive IBD patients from 323 CrD and 294 ulcerative colitis (UC) follow-up in a tertiary centre, and 112 pathological and 103 normal controls. RESULTS Sensitivity of IgA anti-MZGP2 for CrD in the IBD population was 15% and specificity was 98% (95, 99), while the sensitivity and specificity of IgG anti-MZGP2 were 27% and 97%. IgA and IgG anti-MZGP2 combined testing led to a sensitivity of 31% and a specificity of 96%. Positivity for either ASCA (IgA or IgG) or anti-MZGP2 (IgA or IgG) showed a sensitivity of 75% (70, 80) and a specificity of 84% (79, 89). IgA anti-MZGP2 antibodies were more prevalent in CrD patients with early disease onset (p=0.011). Also, anti-MZGP2 positive patients more frequently had extensive disease with ileal involvement. Patients with longer disease duration were more likely to have IgG anti-MZGP2 antibodies. CONCLUSIONS Our novel ELISA confirms the high specificity of anti-MZGP2 antibodies for CrD and their association with disease severity phenotypes.
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Affiliation(s)
- Polychronis Pavlidis
- Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RJ, UK; Department of Gastroenterology and Clinical Nutrition, University College Hospital, 250 Euston Road, London NW1 2PG, UK.
| | - Zakera Shums
- Inova Diagnostics, Inc., San Diego, CA 92131, USA.
| | - Andreas L Koutsoumpas
- Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RJ, UK; Department of Gastroenterology and Clinical Nutrition, University College Hospital, 250 Euston Road, London NW1 2PG, UK.
| | - Jay Milo
- Inova Diagnostics, Inc., San Diego, CA 92131, USA.
| | - Maria Papp
- 2nd Department of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Takeji Umemura
- Department of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Japan.
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary.
| | - Daniel S Smyk
- Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RJ, UK.
| | - Dimitrios P Bogdanos
- Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RJ, UK; 1st Department of Medicine, Semmelweis University, Budapest, Hungary; Department of Medicine, School of Health Sciences, University of Thessaly, Larissa 40500, Greece.
| | - Alastair Forbes
- Department of Gastroenterology and Clinical Nutrition, University College Hospital, 250 Euston Road, London NW1 2PG, UK.
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Systematic review: new serological markers (anti-glycan, anti-GP2, anti-GM-CSF Ab) in the prediction of IBD patient outcomes. Autoimmun Rev 2014; 14:231-45. [PMID: 25462578 DOI: 10.1016/j.autrev.2014.11.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/08/2014] [Indexed: 12/20/2022]
Abstract
Traditionally, IBD diagnosis is based on clinical, radiological, endoscopic, and histological criteria. Biomarkers are needed in cases of uncertain diagnosis, or to predict disease course and therapeutic response. No guideline recommends the detection of antibodies (including ASCA and ANCA) for diagnosis or prognosis of IBD to date. However, many recent data suggest the potential role of new serological markers (anti-glycan (ACCA, ALCA, AMCA, anti-L and anti-C), anti-GP2 and anti-GM-CSF Ab). This review focuses on clinical utility of these new serological markers in diagnosis, prognosis and therapeutic monitoring of IBD. Literature review of anti-glycan, anti-GP2 and anti-GM-CSF Ab and their impact on diagnosis, prognosis and prediction of therapeutic response was performed in PubMed/MEDLINE up to June 2014. Anti-glycan, anti-GP2 and anti-GM-CSF Ab are especially associated with CD and seem to be correlated with complicated disease phenotypes even if results differ between studies. Although anti-glycan Ab and anti-GP2 Ab have low sensitivity in diagnosis of IBD, they could identify a small number of CD patients not detected by other tests such as ASCA. Anti-glycan Abs are associated with a progression to a more severe disease course and a higher risk for IBD-related surgery. Anti-GP2 Ab could particularly contribute to better stratify cases of pouchitis. Anti-GM-CSF Ab seems to be correlated with disease activity and could help predict relapses. These new promising biomarkers could particularly be useful in stratification of patients according to disease phenotype and risk of complications. They could be a valuable aid in prediction of disease course and therapeutic response but more prospective studies are needed.
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Werner L, Sturm A, Roggenbuck D, Yahav L, Zion T, Meirowithz E, Ofer A, Guzner-Gur H, Tulchinsky H, Dotan I. Antibodies against glycoprotein 2 are novel markers of intestinal inflammation in patients with an ileal pouch. J Crohns Colitis 2013; 7:e522-32. [PMID: 23639628 DOI: 10.1016/j.crohns.2013.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/02/2013] [Accepted: 03/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The Crohn's disease (CD)-specific pancreatic auto-antibodies (PAB), have been recently identified to target glycoprotein 2 (GP2). Pouchitis is an inflammation of the small bowel developing in up to 60% of ulcerative colitis patients undergoing proctocolectomy and ileal pouch anal anastomosis. Occurrence of CD-specific antibodies was reported to be a predictor of pouchitis. We aimed to assess the prevalence of anti-GP2 antibodies (anti-GP2) in the serum and feces of pouch patients and to correlate them with clinical parameters. Furthermore, we examined mucosal expression of the GP2 protein in the pouch. METHODS Pouch patients were prospectively recruited and checked for clinical, endoscopic, and laboratory markers of inflammation. IgG and IgA anti-GP2 levels in serum and fecal samples were determined using ELISA. GP2 protein was assessed by immunohistochemistry. RESULTS Anti-GP2 was elevated in both serum and fecal samples of patients with inflamed compared to those with non-inflamed pouches and patients with familial-adenomatous polyposis after surgery (p<0.05, respectively). Moreover, patients with CD-like complications exhibited significantly higher anti-GP2 titers than those without CD-like complications (p≤0.01). High levels of anti-GP2 correlated with more frequent bowel movements per day and with the presence of at least one anti-glycan antibody (p≤0.05). GP2 itself was more abundant in the mucosa of patients with chronic pouchitis. CONCLUSIONS Anti-GP2 exists in the serum and feces of pouch patients and correlates with pouch inflammation, and presence of other serological markers. Thus, anti-GP2 may contribute to better stratification of pouchitis, more-so when the inflammation exhibits CD-like complications.
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Affiliation(s)
- Lael Werner
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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14
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Komorowski L, Teegen B, Probst C, Aulinger-Stöcker K, Sina C, Fellermann K, Stöcker W. Autoantibodies against exocrine pancreas in Crohn's disease are directed against two antigens: the glycoproteins CUZD1 and GP2. J Crohns Colitis 2013; 7:780-90. [PMID: 23140841 DOI: 10.1016/j.crohns.2012.10.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/15/2012] [Accepted: 10/17/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Autoantibodies against exocrine pancreas (PAb) have been reported to be pathognomonic markers of Crohn's disease (CD). Recently, the glycoprotein GP2 has been proposed as the exclusive target for PAb but two equally prevalent binding patterns can be observed in the indirect immunofluorescence test (IIFT) using cryosections of human pancreas: a reticulogranular and a droplet pattern. AIM To identify autoantigens corresponding to the staining patterns. METHODS Different lectins were screened for their ability to immobilize PAb-reactive glycoproteins from cell free human pancreas. The glycoproteins were then purified via UEA-I affinity chromatography and identified by mass spectrometry. The two candidate autoantigens were separately expressed in HEK293 cells, and the recombinant cells applied as substrates in IIFT to analyze sera from 96 patients with CD, 89 controls and hybridoma supernatants during the generation of murine monoclonal antibodies. RESULTS The UEA-I eluate was able to neutralize PAb reactivity of both patterns in IIFT. It contained two major constituents which were identified as the glycoproteins CUZD1 and GP2. With the recombinant cells, 35.4% of the CD patients exhibited positive reactions (CUZD1 alone 19.8%, GP2 alone 9.4%, and both antigens 6.2%). The reaction with the CUZD1 expressing cells was strictly correlated to the reticulogranular pattern, whereas the antibodies causing the droplet pattern stained the GP2 expressing cells. Antigen-capture ELISA using the newly generated monoclonal antibodies against CUZD1 and GP2 verified this relationship. CONCLUSIONS The concordant reactivities of the different platforms can be regarded as a proof for the authenticity of the two identified autoantigens.
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Affiliation(s)
- Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Luebeck, Germany.
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15
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Roggenbuck D, Reinhold D, Werner L, Schierack P, Bogdanos DP, Conrad K. Glycoprotein 2 antibodies in Crohn's disease. Adv Clin Chem 2013; 60:187-208. [PMID: 23724745 DOI: 10.1016/b978-0-12-407681-5.00006-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pathogenesis of Crohn's disease (CrD) and ulcerative colitis (UC), the two major inflammatory bowel diseases (IBD), remains poorly understood. Autoimmunity is considered to be involved in the triggering and perpetuation of inflammatory processes leading to overt disease. Approximately 30% of CrD patients and less than 8% of UC patients show evidence of humoral autoimmunity to exocrine pancreas, detected by indirect immunofluorescence. Pancreatic autoantibodies (PAB) were described for the first time in 1984, but the autoantigenic target(s) of PABs were identified only in 2009. Utilizing immunoblotting and matrix-assisted laser desorption ionization time-of-flight mass spectrometry, the major zymogen granule membrane glycoprotein 2 (GP2) has been discovered as the main PAB autoantigen. The expression of GP2 has been demonstrated at the site of intestinal inflammation, explaining the previously unaddressed contradiction of pancreatic autoimmunity and intestinal inflammation. Recent data demonstrate GP2 to be a specific receptor on microfold (M) cells of intestinal Peyer's patches, which are considered to be the original site of inflammation in CrD. Novel ELISAs, employing recombinant GP2 as the solid phase antigen, have confirmed the presence of IgA and IgG anti-GP2 PABs in CrD patients and revealed an association of anti-GP2 IgA as well as IgG levels with a specific clinical phenotype in CrD. Also, GP2 plays an important role in modulating innate and acquired intestinal immunity. Its urinary homologue, Tamm-Horsfall protein or uromodulin, has a similar effect in the urinary tract, further indicating that GP2 is not just an epiphenomenon of intestinal destruction. This review discusses the role of anti-GP2 autoantibodies as novel CrD-specific markers, the quantification of which provides the basis for further stratification of IBD patients. Given the association with a disease phenotype and the immunomodulating properties of GP2 itself, an important role for GP2 in the immunopathogenesis of IBD cannot be excluded.
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Affiliation(s)
- Dirk Roggenbuck
- Faculty of Natural Sciences, Lausitz University of Applied Sciences, Senftenberg, Germany.
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16
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Kuehnel F, Mietsch M, Buettner T, Vervuert I, Ababneh R, Einspanier A. The influence of gluten on clinical and immunological status of common marmosets (Callithrix jacchus
). J Med Primatol 2013; 42:300-9. [DOI: 10.1111/jmp.12055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2013] [Indexed: 01/06/2023]
Affiliation(s)
- Friederike Kuehnel
- Faculty of Veterinary Medicine; Institute of Physiological Chemistry, University of Leipzig; Leipzig Germany
| | - Matthias Mietsch
- Faculty of Veterinary Medicine; Institute of Physiological Chemistry, University of Leipzig; Leipzig Germany
| | | | - Ingrid Vervuert
- Faculty of Veterinary Medicine; Institute of Animal Nutrition, Nutrition Diseases and Dietetics, University of Leipzig; Leipzig Germany
| | - Rayan Ababneh
- Faculty of Veterinary Medicine; Institute of Physiological Chemistry, University of Leipzig; Leipzig Germany
| | - Almuth Einspanier
- Faculty of Veterinary Medicine; Institute of Physiological Chemistry, University of Leipzig; Leipzig Germany
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Liaskos C, Spyrou V, Roggenbuck D, Athanasiou LV, Orfanidou T, Mavropoulos A, Reinhold D, Rigopoulou EI, Amiridis GS, Billinis C, Bogdanos DP. Crohn's disease-specific pancreatic autoantibodies are specifically present in ruminants with paratuberculosis: implications for the pathogenesis of the human disease. Autoimmunity 2013; 46:388-94. [PMID: 23638886 DOI: 10.3109/08916934.2013.786047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mycobacterium avium subspecies paratuberculosis (MAP) induces paratuberculosis (ptb) in ruminants and has clinical and histological features resebling Crohn's disease (CD). Pancreatic autoantibodies (PAB) targeting glycoprotein 2 (GP2) are specifically found in CD, but it is currently unknown whether these autoantibodies can be found in ruminants with ptb. IgG anti-MAP and anti-GP2 antibodies were tested by ELISA in 286 ruminants (212 sheep and 74 cattle). PAB testing was performed by indirect immunofluorescence (IIF) using anti-sheep or anti-cattle specific antisera. PCR analysis confirmed the presence of MAP in anti-MAP positive samples. Anti-GP2 antibodies were more prevalent in anti-MAP antibody positive (26.9%) than in anti-MAP negative ruminants (8.7%, p < 0.001). Anti-GP2 antibodies were found in 16/70 (22.9%) anti-MAP positive sheep compared to 10/142 (7%, p = 0.001) anti-MAP antibody negative and in anti-MAP positive cattle than in negative counterparts (5/8 versus 8/66, p = 0.003). Absorbance values for anti-GP2 antibodies were higher in cattle than in sheep (mean 21 AU/mL ± 25.4SD versus 12.2 AU/mL ± 23 SD, p < 0.001). There was no correlation between anti-GP2 and anti-MAP antibody concentrations. Anti-GP2 antibodies persisted up to 1/1000 and showed the characteristic IIF pancreatic pattern seen by anti-GP2 antibody positive CD samples. This is the first study to demonstrate the presence of CD-specific GP2-reactive pancreatic autoantibodies in MAP-infected ruminants. Our data suggest that CD and ptb are characterised by an antigen-driven loss of immunological tolerance to GP2, implying commonalities in the immunopathogenesis of the human and ruminant inflammatory bowel disorder.
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Affiliation(s)
- Christos Liaskos
- Cellular Immunotherapy and Molecular Immunodiagnostics, Institute of Research and Technology Thessaly, Larissa, Greece
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Ileal inflammation may trigger the development of GP2-specific pancreatic autoantibodies in patients with Crohn's disease. Clin Dev Immunol 2012; 2012:640835. [PMID: 23118780 PMCID: PMC3483735 DOI: 10.1155/2012/640835] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 09/07/2012] [Indexed: 12/11/2022]
Abstract
Why zymogen glycoprotein 2 (GP2), the Crohn's disease (CD)-specific pancreatic autoantigen, is the major target of humoral autoimmunity in inflammatory bowel diseases (IBD) is uknown. Recent evidence demonstrates that GP2 is also present on the apical surface of microfold (M) intestinal cells. As the colon lacks GP2-rich M cells, we assumed that patients with colonic CD are seronegative for anti-GP2. Anti-GP2 antibodies were tested in 225 CDs, including 45 patients with colonic location (L2), 45 with terminal ileum (L1) and 135 with ileocolonic involvement; 225 patients with ulcerative colitis (UC) were also tested. Anti-GP2 reactivity was detected in 59 (26.2%) CDs and 15 (6.7%) UCs (P < 0.001). Only 5 CDs with L2 had anti-GP2 antibodies, compared to 54/180 (30.0%, P = 0.0128) of the CDs with L1 and L3. Anti-GP2 antibody positive CD patients had higher ASCA titres compared to seronegative cases. Amongst the 128 CD patients with previous surgical intervention, 45 (35.0%) were anti-GP2 antibody positive compared to 14/97 (14.0%) without surgical (P < 0.001). Our data support the assumption that ileal inflammation is required for the development of anti-GP2 antibodies in CD, and suggest that the intestine rather than the pancreatic juice is the antigenic source required for the initiation of anti-GP2 antibodies.
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