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Wu X, Wang G, Zhang L, Xu H. Genetics of Ankylosing Spondylitis-Focusing on the Ethnic Difference Between East Asia and Europe. Front Genet 2021; 12:671682. [PMID: 34194471 PMCID: PMC8236852 DOI: 10.3389/fgene.2021.671682] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/04/2021] [Indexed: 01/07/2023] Open
Abstract
Ankylosing spondylitis (AS) is a common, highly heritable inflammatory arthritis affecting the mainly axial joints in both East Asia and Europe. To date, the pathogenesis of AS is still unknown, although we know that genetics play a vital role in it. The HLA-B27 allele is found in over 85% of AS patients. However, strong evidence suggests that other major histocompatibility complex (MHC) and non-MHC genes are also involved in the pathogenesis. In addition, current data showed that there were significant differences in both genomics and metagenomics among the different ethnic populations. The investigation of the key role of the microbiome in AS pathogenesis also highlighted the host–microbiome genetic interactions. Here, we systematically review current AS genetic research data and further compare genetic differences, especially between East Asian and European groups, which may highlight the challenge in future genetic studies.
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Affiliation(s)
- Xin Wu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Geng Wang
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Luding Zhang
- Department of Health Management, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Peking-Tsinghua Center for Life Sciences, Tsinghua University, Beijing, China.,School of Clinical Medicine, Tsinghua University, Beijing, China
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Abstract
PURPOSE OF REVIEW To discuss the disease incidence and prevalence rates of axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS) relative to those of rheumatoid arthritis (RA). RECENT FINDINGS According to the most recently published systematic reviews, pooled prevalence estimates for RA are 0.38% in North America, and 0.21 to 0.25% in European subregions, while that of AS is 0.20% in North America and 0.25% in Europe. The estimated prevalence of axSpA has been reported to be approximately twice as common as AS in a study from the USA. This finding has also been supported by studies from northern Norway, central Italy, western Turkey, northern and southern regions of China, and rural Taiwan. These data suggest that axSpA, that encompasses AS, may be more prevalent than RA, at least in some countries. In general, higher occurrences of RA relative to AS have been noted worldwide, both in terms of incidence and prevalence. But axSpA, that encompasses AS, may be more prevalent than RA, at least in some countries. There is a need for concurrently run studies in the same population for a reliable comparison to establish occurrence of RA, AS, and axSpA. It is hoped that the implementation of the ICD-11 codes for axSpA will be helpful in determining a more accurate estimate of its incidence and prevalence.
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Luo F, Zhao Z, Zhang J, Leng J. Comparison of HLA-B*27 subtypes between Chinese patients with ankylosing spondylitis and non-ankylosing spondylitis carriers. J Int Med Res 2019; 47:3171-3178. [PMID: 31177886 PMCID: PMC6683902 DOI: 10.1177/0300060519853929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective To investigate the distribution of subtypes between HLA-B*27 (+) patients with ankylosing spondylitis (AS) and carriers. Methods This case–control study recruited Chinese Han patients with HLA-B*27 (+) AS from six hospitals in Zhejiang Province, China between 2013 and 2018. Patients who were examined for HLA-B*27 because of back pain or arthralgia but who did not have AS or arthritis were recruited as controls. HLA-B*27 target DNA was amplified by amplification refractory mutation systems and HLA-B*27 subtypes were determined by sequencing. Results The positive rate of HLA-B*27 was significantly higher in the AS group than in the control group. In AS patients, HLA-B*2704 was predominant at 86.4%, followed by HLA-B*2705 at 12.6%; HLA-B*2704 and HLA-B*2705 were found in 70.0% and 10.0% of controls, respectively. HLA-B*2702 and HLA-B*2706 were detected at low frequencies in the control group, while the rare subtype HLA-B*2715 was only observed in two (1.0%) patients with AS. HLA-B*2707 was not detected in AS or control groups. Conclusion HLA-B*2704 is the predominant subtype among patients with AS and carriers in southeast China.
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Affiliation(s)
- Fangjun Luo
- 1 Department of Clinical Laboratory, Affiliated Zhuji Hospital of Wenzhou Medical University, Zhuji, China
| | - Zhigang Zhao
- 2 Zhejiang Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jie Zhang
- 3 Shanghai ZJ Bio-Tech Co., Ltd, Shanghai, China
| | - Jianhang Leng
- 4 Central Laboratory of Hangzhou First People's Hospital, Hangzhou, China
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Wen YF, Wei JCC, Hsu YW, Chiou HY, Wong HSC, Wong RH, Ikegawa S, Chang WC. rs10865331 associated with susceptibility and disease severity of ankylosing spondylitis in a Taiwanese population. PLoS One 2014; 9:e104525. [PMID: 25184745 PMCID: PMC4153545 DOI: 10.1371/journal.pone.0104525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/10/2014] [Indexed: 12/17/2022] Open
Abstract
Ankylosing spondylitis (AS) is a highly familial rheumatic disorder and is considered as a chronic inflammatory disease. Genetic factors are involved in the pathogenesis of AS. To identify genes which render people susceptible to AS in a Taiwanese population, we selected six single-nucleotide polymorphisms (SNPs) from previous genome-wide association studies (GWASs) which were associated with AS in European descendants and Han Chinese. To assess whether the six SNPs contributed to AS susceptibility and severity in Taiwanese population, 475 AS patients fulfilling the modified New York Criteria and 527 healthy subjects were recruited. We found that rs10865331 was significantly associated with AS susceptibility and with Bath AS Function Index (BASFI). The AA and AG genotypes of rs10865331 were also significantly associated with a higher erythrocyte sedimentation rate. Our findings provided evidence that rs10865331 is associated AS susceptibility and with disease activity (BASFI) in a Taiwanese population.
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Affiliation(s)
- Ya-Feng Wen
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Wen Hsu
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, Taipei Medical University, Taipei, Taiwan
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Henry Sung-Ching Wong
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Ruey-Hong Wong
- Department of Public Health, Chung Shan Medical University, Taichung, Taiwan
| | - Shiro Ikegawa
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Laboratory for Bone and Joint Diseases, RIKEN Center for Integrative Medical Science, Yokohama, Japan
| | - Wei-Chiao Chang
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Department of Pharmacy, Taipei Medical University-Wanfang Hospital, Taipei, Taiwan
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Keane NM, Pavlos RK, McKinnon E, Lucas A, Rive C, Blyth CC, Dunn D, Lucas M, Mallal S, Phillips E. HLA Class I restricted CD8+ and Class II restricted CD4+ T cells are implicated in the pathogenesis of nevirapine hypersensitivity. AIDS 2014; 28:1891-901. [PMID: 24911354 DOI: 10.1097/qad.0000000000000345] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study sought to examine nevirapine hypersensitivity (NVP HSR) phenotypes and their relationship with differing major histocompatibility complex (MHC) Class I and Class II alleles and the associated CD4 and CD8 T-cell NVP-specific responses and their durability over time. METHODS A retrospective cohort study compared HIV-positive patients with NVP HSR, defined by fever and hepatitis and/or rash, with those tolerant of NVP for more than 3 months. Covariates included class I (HLA-A, B, C) and class II (HLA-DR) alleles. Cellular studies examined NVP-specific CD4 and CD8 T-cell responses by interferon-gamma (IFNγ) ELISpot assay and intracellular cytokine staining (ICS). RESULTS NVP HSR occurred in 19 out of 451 (4%) NVP-exposed individuals between March 1993 and December 2011. HLA associations were phenotype dependent with HLA-DRB1*01 : 01 associated with hepatitis (P = 0.02); HLA-B*35 : 01 and HLA-Cw4 associated with cutaneous NVP HSR (P = 0.001, P = 0.01), and HLA-Cw*08 was associated with NVP HSR with eosinophilia (P = 0.04) and multisystemic NVP HSR (P = 0.02). NVP-specific INFγ responses waned significantly more than 3 months from the original reaction and were diminished or completely abrogated when either CD4 or CD8 T cells were depleted from the peripheral blood mononuclear cells culture. CONCLUSION The association of specific class I and II allele pairings with specific phenotypes of NVP HSR, and cellular studies showing both CD4 and CD8 T-cell NVP-specific responses suggest that specific combinations of NVP reactive class I restricted CD8 and class II restricted CD4 T cells contribute to the immunopathogenesis of NVP HSR.
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Moon SJ, Oh EJ, Kim Y, Kim KS, Kwok SK, Ju JH, Park KS, Kim HY, Park SH. Diversity of killer cell immunoglobulin-like receptor genes in uveitis associated with autoimmune diseases: ankylosing spondylitis and Behçet disease. Ocul Immunol Inflamm 2013; 21:135-43. [PMID: 23697859 DOI: 10.3109/09273948.2012.754905] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To determine whether the frequencies of specific killer cell immunoglobulin-like receptors (KIR) genotypes are associated with the incidence of uveitis in ankylosing spondylitis (AS) and Behçet disease (BD). METHODS The authors analyzed the frequency of 16 KIR genes in Koreans with either AS (110 patients, all HLA-B27-positive) or BD (86 patients), using polymerase chain reaction sequence-specific oligonucleotide probing. RESULTS The frequency of the inhibitory receptor KIR3DL1 was lower in AS patients affected by uveitis than that in the general population (p < 0.05). The frequency of the KIR3DL1(-)/2DS3(-) was significantly higher in AS patients with uveitis (odds ratio = 9.306, p = 0.007). CONCLUSIONS The study suggests that KIR3DL1 might associate with the resistance to AS-associated uveitis by influencing natural killer cell activity.
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Affiliation(s)
- Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, South Korea
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Díaz-Peña R, López-Vázquez A, López-Larrea C. Old and new HLA associations with ankylosing spondylitis. ACTA ACUST UNITED AC 2012; 80:205-13. [PMID: 22881057 DOI: 10.1111/j.1399-0039.2012.01944.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that primarily involves the axial skeleton and the sacroiliac joint, but may also affect peripheral joints and entheses. AS susceptibility is clearly attributable to genetic factors and the link between human leukocyte antigen (HLA)-B27 and AS is the strongest association between an HLA class I molecule and a disease. However, there is evidence for the involvement of other, non-B27 factors within the major histocompatibility complex (MHC) in AS susceptibility. MHC class I is clearly the most significant genetic region for the disease, although most of the genetic association of this region is driven by HLA-B27. Moreover, several studies have investigated the MHC class II region and its association with AS. This review summarizes the current findings concerning the MHC genetics of the disease, focusing in particular on the associations of HLA with AS found in different ethnic populations throughout the world, and the possible mechanisms underlying them.
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Affiliation(s)
- R Díaz-Peña
- Department of Immunology, Hospital Universitario Central de Asturias, Oviedo, Spain
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Abstract
The human leukocyte antigen (HLA)-B*2706 is a relatively rare subtype of HLA-B27. In contrast to most HLA-B27 subtypes, some studies have reported HLA-B*2706 to be protective against ankylosing spondylitis (AS). A systematic review and a meta-analysis of available studies was performed to investigate the association of HLA-B*2706 with AS. After literature review a random effect meta-analysis was performed. No studies were found comparing the frequency of HLA-B*2706 in AS patients and controls. Meta-analysis of seven studies using HLA-B27-positive AS patients and controls showed a protective effect of HLA-B*2706 on development of AS in HLA-B27 individuals (odds ratio = 0.128, 95% CI = 0.043-0.378, P < 0.001). The results of the meta-analysis of HLA-B*2706 in HLA-B27-positive patients and controls is preliminary evidence of a protective effect of HLA-B*2706 against AS in the population. There is a clear need for additional studies on HLA-B*2706 in AS. Due to the fact that HLA-B*2706 is more or less restricted to Southeast Asia, researchers in this part of the world may have an essential role in performing these studies.
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Kim SY, Chang HE, Song SH, Park KU, Song J. Rapid genotyping of HLA-B27 among Korean population by real-time PCR melting curve analysis. Clin Chim Acta 2011; 412:1912-7. [DOI: 10.1016/j.cca.2011.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 05/09/2011] [Accepted: 06/24/2011] [Indexed: 12/20/2022]
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Mou Y, Wu Z, Gu J, Liao Z, Lin Z, Wei Q, Huang J, Li Q. HLA-B27 polymorphism in patients with juvenile and adult-onset ankylosing spondylitis in Southern China. ACTA ACUST UNITED AC 2010; 75:56-60. [DOI: 10.1111/j.1399-0039.2009.01406.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Liu Y, Jiang L, Cai Q, Danoy P, Barnardo MCNM, Brown MA, Xu H. Predominant association of HLA-B*2704 with ankylosing spondylitis in Chinese Han patients. ACTA ACUST UNITED AC 2009; 75:61-4. [PMID: 19804562 DOI: 10.1111/j.1399-0039.2009.01379.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The HLA-B27 subtypes have a varied racial and ethnic prevalence throughout the world. However, the association of B27-subtypes with ankylosing spondylitis (AS) in the mainland China is unknown. To determine the association of B27-subtypes with AS in the Mainland Chinese Han population, a total of unrelated 153 patients with AS were enrolled in a large case-control association study, and 1545 unrelated, healthy, ethnically matched blood donors were included as controls. The genotyping of B27 and its subtypes was performed using the polymerase chain reaction with sequence specific primers (PCR-SSP). A total of 130 (84.97%) AS patients and 61 (3.95%) healthy controls were B27 positive. Three B27-subtypes, B*2704, B*2705 and B*2710, were further identified, of which both B*2704 and B*2705 were strongly AS associated. B*2710 was only detected in one AS patient and two other healthy controls. Considering only B27-positive cases and controls, a statistically different frequency of B27-subtypes was observed, with an over-representation of B*2704 (P = 0.018). B*2704 was clearly more strongly associated than B*2705 with AS [odds ratio (OR ) = 2.4, P = 0.011]. Furthermore, a combined analysis including three previous studies of B27-subtype distributions in Chinese AS cases confirmed the stronger association of B*2704 with AS than B*2705 (OR = 2.5, P = 0.00094).
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Affiliation(s)
- Y Liu
- Department of Rheumatology and Immunology, Changzheng Hospital, The Second Military Medical University, Shanghai, China
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The association of HLA-B*27 subtypes with ankylosing spondylitis in Wuhan population of China. Rheumatol Int 2009; 30:587-90. [PMID: 19536542 DOI: 10.1007/s00296-009-1018-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 06/02/2009] [Indexed: 01/07/2023]
Abstract
The aim of this study was to investigate the association of the B27 subtypes with ankylosing spondylitis (AS) in the Wuhan population of China. We selected 317 HLA-B27-positive individuals (145 controls and 172 patients with ankylosing spondylitis). The B27 subtypes were characterized using a PCR-SSP method. Six B27 subtypes were determined: B*2702, 03, 04, 05, 06 and B*13. HLA-B*2704 and HLA-B*2705 were the two high frequency genotypes in controls and patients. Compared with the controls, the AS patients had high frequency of B*2704 (patients 69.2% vs. controls 53.8%) and low frequency of B*2705 (patients 23.8% vs. controls 33.1%). B*2703 was detected in 10 (5.8%) patients and in 13 (8.9%) controls. B*2702, 06 and B*2713 were relatively rare. Our results show that the allele conferring risk to AS in the Wuhan population of China was B*2704 and B*2705. B*2704 is strongly associated with AS.
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Duangchanchot M, Puapairoj C, Romphruk A, Kongmaroeng C, Leelayuwat C, Romphruk AV. HLA-B*27 subtypes in Northern and Northeastern Thais, Karens, and Bamars determined by a high-resolution PCR-SSP technique. ACTA ACUST UNITED AC 2009; 73:590-4. [DOI: 10.1111/j.1399-0039.2009.01238.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chen MJ, Yang TC, Chu CC, Shyr MH, Lin CL, Lin PY, Yang KL. Detection of a novel HLA-B27 allele, B*2740, in Taiwanese volunteer bone marrow donors by sequence-based typing: curiosity rewarded. Int J Immunogenet 2009; 36:207-11. [PMID: 19476482 DOI: 10.1111/j.1744-313x.2009.00849.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report here a novel HLA-B allele, B*2740, discovered in Taiwanese volunteer marrow donors. The new sequence has nucleotide variation at position 527 (T-->A) as compared to B*2708. The nucleotide change caused an amino acid substitution from valine (V) to glutamic acid (E) at codon 152. Since B*2740 carries sequence confers to HLA-Bw6 public epitope we believe that this novel B*27 allele might have been generated from a gene conversion involving a Bw4-specific allele (probably B*2704) and a Bw6-specific allele.
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Affiliation(s)
- M J Chen
- Laboratory of Immunogenetics and Cord Blood Bank, Buddhist Tzu Chi Marrow Donor Registry and Stem Cells Centre, Buddhist Tzu Chi General Hospital, Buddhist Compassion Relief Tzu Chi Foundation, 707 Section 3 Chung Yang Road, Hualien, Taiwan
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Park KS, Kang SY, Lee WI. HLA-B27 Subtypes in Korean Patients with Ankylosing Spondylitis. Ann Lab Med 2008; 28:46-52. [DOI: 10.3343/kjlm.2008.28.1.46] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Kyung-Sun Park
- Department of Laboratory Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - So-Young Kang
- Department of Laboratory Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Woo-In Lee
- Department of Laboratory Medicine, Kyung Hee University College of Medicine, Seoul, Korea
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Hou TY, Chen HC, Chen CH, Chang DM, Liu FC, Lai JH. Usefulness of human leucocyte antigen-B27 subtypes in predicting ankylosing spondylitis: Taiwan experience. Intern Med J 2007; 37:749-52. [PMID: 17908086 DOI: 10.1111/j.1445-5994.2007.01450.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Genetic factors are clearly attributed to the susceptibility of ankylosing spondylitis (AS). The human leucocyte antigen (HLA)-B27 proved to be the very useful marker for diagnosing AS. The aim of this study was to determine the prevalence of HLA-B27 subtypes in Taiwan and to investigate whether these subtypes may be of help in predicting the diagnosis of AS. METHODS A total of 314 patients with AS and a control group of 71 subjects positive for HLA-B27 detected by flow cytometry analysis were recruited for the study. HLA-B27 subtypes were confirmed by the polymerase chain reaction-sequence-specific primers and sequence-specific oligonucleotide probing. RESULTS Four B27 alleles were identified: B*2704, B*2705, B*2706 and B*2707. HLA-B*2704 was the predominant allele. There were significant differences in the distribution of HLA-B27 subtypes between patients with AS and controls. Five of them who were homozygous for the B*2704 allele were solely found in AS group but not in controls. Statistical analysis showed that B*2704 was positively associated with AS, which suggested an increased possibility of having AS. Other HLA-B27 subtypes showed no strong correlation with AS. CONCLUSION In the Taiwanese population, susceptibility to AS was determined by the presence of HLA-B*2704. Although B*2706 was reported to have a negative association with AS in Taiwanese, Thai and Chinese Singaporean populations, we report, in our study, two AS patients with B*2706 (0.6%). Disease heterogeneity suggests that other than genetic background, many pathogenic factors could be associated with AS. This may need to be investigated with a larger group of patients with AS and controls.
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Affiliation(s)
- T-Y Hou
- Division of Rheumatology/Immunology/Allergy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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