The biochemistry of the human synovial lining with special reference to alterations in metabolism in rheumatoid arthritis

The pathobiology of osteoarthritis and the rationale for the use of pentosan polysulfate for its treatment

OBJECTIVES

Structure-modifying osteoarthritis (OA) drugs (SMOADs) may be defined as agents that reverse, retard, or stabilize the underlying pathology of OA, thereby providing symptomatic relief in the long-term. The objective of this review was to evaluate the literature on sodium pentosan polysulfate (NaPPS) and calcium pentosan polysulfate (CaPPS), with respect to the pathobiology of OA to ascertain whether these agents should be classified as SMOADs.

METHODS

Published studies on NaPPS and CaPPS were selected on the basis of their relevance to the known pathobiology of OA, which also was reviewed.

RESULTS

Both NaPPS and CaPPS exhibit a wide range of pharmacological activities. Of significance was the ability of these agents to support chondrocyte anabolic activities and attenuate catabolic events responsible for loss of components of the cartilage extracellular matrix in OA joints. Although some of the anti-catabolic activities may be mediated through direct enzyme inhibition, NaPPS and CaPPS also have been shown to enter chondrocytes and bind to promoter proteins and alter gene expression of matrix metalloproteinases and possibly other mediators. In rat models of arthritis, NaPPS and CaPPS reduced joint swelling and inflammatory mediator levels in pouch fluids. Moreover, synoviocyte biosynthesis of high-molecular-weight hyaluronan, which is diminished in OA, was normalized when these cells were incubated with NaPPS and CaPPS or after intraarticular injection of NaPPS into arthritic joints. In rabbit, canine, and ovine models of OA, NaPPS and CaPPS preserved cartilage integrity, proteoglycan synthesis, and reduced matrix metalloproteinase activity. NaPPS and CaPPS stimulated the release of tissue plasminogen activator (t-PA), superoxide dismutase, and lipases from vascular endothelium while concomitantly decreasing plasma levels of the endogenous plasminogen activator inhibitor PAI-1. The net thrombolytic and lipolytic effects exhibited by NaPPS and CaPPS may serve to improve blood flow through subchondral capillaries of OA joints and improve bone cell nutrition. In geriatric OA dogs, NaPPS and CaPPS reduced symptoms, as well as normalized their thrombolytic status, threshold for platelet activation, and plasma triglyceride levels. These hematologic parameters were shown to be abnormal in OA animals before drug treatment. Similar outcomes were observed in OA patients when CaPPS or NaPPS were given orally or parenterally in both open and double-blind trials.

CONCLUSIONS

The data presented in this review support the contention that NaPPS and CaPPS should be classified as SMOADs. However, additional long-term clinical studies employing methods of assessing joint structural changes will be needed to confirm this view.

Ultrastructural causes of rupture of hand tendons in patients with rheumatoid arthritis. A transmission and scanning electron microscopic study

To identify the cause of rupture of hand tendons in patients with rheumatoid arthritis, we studied the underlying ultrastructural changes of the collagenous fibril systems. Samples of the flexor digitorum superficialis (n = 12) and the extensor digitorum communis (n = 20) were taken during tenosynovectomy. Tendons dissected at necropsy (n = 30) served as controls. Specimens were analysed by transmission and scanning electron microscopy. Interfibrillar dysplastic fibrils, "Luse bodies", and intracellular collagen were found in rheumatoid tissues. The diameters of collagen fibrils were significantly reduced compared with the control group (p < 0.01). The duration of the disease usually correlated well with the ultrastructural collagenous lesions. To provide optimum conditions for restoration of rheumatoid hand tendons, early synovectomy in rheumatoid patients seems warranted from the ultrastructural point of view. The alterations in collagen may explain the inadequate function of the hand tendons in patients with rheumatoid arthritis.

Distribution of type VI collagen expression in synovial tissue and cultured synoviocytes: relation to fibronectin expression

Type VI collagen has recently been shown to be an important component of connective tissue. Double label immunofluorescence procedures were used to immunolocalize type VI collagen in normal and rheumatoid synovium and its distribution was compared with that of fibronectin. In normal synovium type VI collagen is expressed in the synovial membrane but not in the interstitium of the villus. In rheumatoid synovium, however, type VI collagen is extensively deposited in both the interstitial connective tissue and along the lining of the synovial membrane. Cultured rheumatoid and normal synoviocytes produce type VI collagen and fibronectin and incorporate them into their extracellular matrix. These data suggest that type VI collagen may play a part in matrix remodelling of the inflamed joint.

Demonstration of endogenous lectins in synovial tissue

We have recently shown that synoviocytes and extracellular matrices exhibit distinct patterns of carbohydrate expression. Their biological relevance is however not known. The purpose of the present study was to find out whether human synovial tissue would also show a specific receptor pattern for complex sugar molecules. Endogenous lectins were displayed by means of biotinylated neoglycoproteins and sulfated polysaccharides in paraffin-embedded material or cryosections. In addition to certain carbohydrate components that are known to be constituents of the carbohydrate part of cellular glycoconjugates, our panel included heparin and fucoidan, a sulfated fucose. Binding sites were shown using the avidin-peroxidase technique for light microscopy. The results were compared with immunohistochemical methods and enzyme histochemistry. Our study demonstrates that human synovial tissue contains a complex pattern of endogenous lectins depending on the different types of synovitis. The staining method we used in the investigation allows for precise localization of saccharide binding receptors and is therefore believed to be a reliable technique for further phenotypic characterization of synovial cells.

Cortisol succinate is slowly hydrolysed in organ cultures of porcine articular tissues and is not equivalent to cortisol

The pro-drug cortisol succinate is frequently used as a substitute for cortisol in organ cultures. We found, however, that in Dulbecco's modified Eagle's medium the time taken for the ester to undergo 50 per cent hydrolysis (t1/2) to cortisol was 75 h. When 15 per cent heat-inactivated normal rabbit serum was present t1/2 decreased to 47 h, but the rate of hydrolysis was not further increased in the presence of porcine articular cartilage or minced synovial tissue. When frozen and thawed synovium was present t1/2 decreased to 33 h, presumably due to the release of carboxyl-esterases from the disrupted cells. The level of tetrahydrocortisol was low in all of the cultures. The slow hydrolysis of cortisol succinate resulted in the exposure of the tissues to undesirable fluctuations in the concentration of active hormone, which decreased to low levels at each medium change. Thus, in co-cultures of porcine synovium and articular cartilage, cortisol had a greater inhibitory effect than cortisol succinate on the breakdown of cartilage matrix caused by synovial tissue.

The application of quantitative cytochemistry to the study of diseases of the connective tissues

The connective tissues are a complex organisation of tissues, cells and intercellular materials spread throughout the body and are subject to a large number of diseases. Such complexity makes the study of the metabolism of the connective tissues in health and more particularly in disease states difficult if one uses conventional biochemical methodology. Fortunately the techniques of quantitative cytochemistry, as developed in recent years, have made it possible to study the metabolism of even such complex and refractory connective tissues as bone. Using properly validated assays of enzyme activity in unfixed sections from various tissues a number of the diseases of the connective tissues have been studied. For example the synovia from patients with rheumatoid arthritis and related conditions have been studied using these techniques and marked alterations in the metabolism of the synovial lining cell population of this tissue have been demonstrated. These alterations in metabolism are believed to be related to the destruction of cartilage and bone found in such diseases. Investigations of the metabolism of the chondrocytes of articular cartilage in a strain of mice which spontaneously develops osteoarthritis has revealed a lack of certain key enzymes of carbohydrate metabolism in precisely those areas where degradation of the matrix of articular cartilage begins suggesting a causal relationship between these events. These same techniques have been used to study the cellular kinetics and metabolism of the dermis and epidermis in the disfiguring disease, psoriasis. The metabolism of healing bone fractures, the diagnosis and treatment of the mucopolysaccharidoses and the metabolic effects of currently used anti-inflammatory and anti-rheumatic drugs have also been examined. Perhaps the most exciting aspect of these studies has been the development and use of the technique of the cytochemical bioassay (CBA) to study hormonally mediated diseases of the connective tissues. Such studies have recently shed new light on the molecular lesion in pseudohypoparathyroidism. Though still in their relative infancy the studies described in this review show the potential inherent in the use of quantitative cytochemistry for the study of diseases of the connective tissues.