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Zhang G, Xu J, Du D, Liu Y, Dai L, Zhao Y. Diagnostic values, association with disease activity and possible risk factors of anti-PAD4 in rheumatoid arthritis: a meta-analysis. Rheumatology (Oxford) 2024; 63:914-924. [PMID: 37824204 DOI: 10.1093/rheumatology/kead545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/02/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE Anti-peptidyl arginine deaminase 4 (anti-PAD4) antibody has been a subject of investigation in RA in the last two decades. This meta-analysis investigated the diagnostic values, association with disease activity and possible risk factors of anti-PAD4 antibody in rheumatoid arthritis. METHOD We searched studies from five databases up to 1 December 2022. Bivariate mixed-effect models were used to pool the diagnostic accuracy indexes, and the summary receiver operating characteristics (SROC) curve was plotted. The quality of diagnostic studies was assessed using QUADAS-2. Non-diagnostic meta-analyses were conducted using the random-effects model. Sensitivity analysis, meta-regression, subgroup analyses and Deeks' funnel plot asymmetry test were used to address heterogeneity. RESULT Finally, 24 journal articles and one letter were included. Anti-PAD4 antibody had a good diagnostic value between RA and healthy individuals, but it might be lower between RA and other rheumatic diseases. Moreover, anti-PAD4 could slightly enhance RA diagnostic sensitivity with a combination of ACPA or ACPA/RF. Anti-PAD4 antibody was positively correlated with HLA-SE and negatively correlated with ever or current smoking in patients with RA. RA patients with anti-PAD4 antibody had higher DAS28, ESR, swollen joint count (SJC) and the possibility of having interstitial lung disease (ILD) and pulmonary fibrosis compared with those without. CONCLUSION Our study suggests that anti-PAD4 antibody is a potentially useful diagnostic biomarker and clinical indicator for RA. Further mechanistic studies are required to understand the impact of HLA-SE and smoking on the production of anti-PAD4 antibody.
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Affiliation(s)
- Guangyue Zhang
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiayi Xu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Dongru Du
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Lunzhi Dai
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zhao
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Cappelli LC, Hines D, Wang H, Bingham CO, Darrah E. Anti-Peptidylarginine Deiminase 4 Autoantibodies and Disease Duration as Predictors of Treatment Response in Rheumatoid Arthritis. ACR Open Rheumatol 2024; 6:81-90. [PMID: 38058274 PMCID: PMC10867292 DOI: 10.1002/acr2.11630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Given that autoantibodies to peptidylarginine deiminase 4 (PAD4) are associated with erosive disease in established rheumatoid arthritis (RA), this study was conducted to compare the clinical and prognostic use of anti-PAD4 antibodies in patients with early and established RA. METHODS Sera from patients with early (duration <2 years; n = 422) or established (duration ≥2 years; n = 359) RA from two randomized clinical trials of tofacitinib ± methotrexate compared with adalimumab + MTX or MTX alone were evaluated for the presence of anti-PAD4 and anti-PAD3/4 antibodies at baseline and posttreatment time points. Summary statistics were calculated for demographic, clinical, and serological characteristics, and generalized estimating equations were used to model clinical outcomes by disease duration according to anti-PAD4 status. RESULTS Anti-PAD4 antibodies were present in 22% and 40% of patients with early and established RA, respectively, stable following treatment, and associated with baseline joint damage only in established RA. In early RA, baseline anti-PAD4 antibodies were associated with a greater improvement in disease activity score 28-joint count using C-reactive protein levels after treatment compared with individuals with negative anti-PAD4 (P = 0.049). Tofacitinib ± MTX was more broadly efficacious than MTX alone at improving clinical outcomes in early and established RA, irrespective of anti-PAD4 status (P < 0.05 for all), whereas adalimumab + MTX exhibited differential benefits in achieving disease activity score remission in early RA (P = 0.036) and American College of Rheumatology 20 responses in established RA (P = 0.002). CONCLUSION Differences in prevalence, clinical associations, and treatment-response outcomes according to anti-PAD4 antibody status in early and established RA suggests the existence of a therapeutic window to prevent the accumulation of irreversible joint damage in early patients with RA with anti-PAD4 antibodies.
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Affiliation(s)
| | - David Hines
- Johns Hopkins School of MedicineBaltimoreMaryland
| | - Hong Wang
- Johns Hopkins School of MedicineBaltimoreMaryland
| | | | - Erika Darrah
- Johns Hopkins School of MedicineBaltimoreMaryland
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Nava-Quiroz KJ, López-Flores LA, Pérez-Rubio G, Rojas-Serrano J, Falfán-Valencia R. Peptidyl Arginine Deiminases in Chronic Diseases: A Focus on Rheumatoid Arthritis and Interstitial Lung Disease. Cells 2023; 12:2829. [PMID: 38132149 PMCID: PMC10741699 DOI: 10.3390/cells12242829] [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: 10/14/2023] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023] Open
Abstract
Protein citrullination is accomplished by a broad enzyme family named Peptidyl Arginine Deiminases (PADs), which makes this post-translational modification in many proteins that perform physiological and pathologic mechanisms in the body. Due to these modifications, citrullination has become a significant topic in the study of pathological processes. It has been related to some chronic and autoimmune diseases, including rheumatoid arthritis (RA), interstitial lung diseases (ILD), multiple sclerosis (MS), and certain types of cancer, among others. Antibody production against different targets, including filaggrin, vimentin, and collagen, results in an immune response if they are citrullinated, which triggers a continuous inflammatory process characteristic of autoimmune and certain chronic diseases. PAD coding genes (PADI1 to PADI4 and PADI6) harbor variations that can be important in these enzymes' folding, activity, function, and half-life. However, few studies have considered these genetic factors in the context of chronic diseases. Exploring PAD pathways and their role in autoimmune and chronic diseases is a major topic in developing new pharmacological targets and valuable biomarkers to improve diagnosis and prevention. The present review addresses and highlights genetic, molecular, biochemical, and physiopathological factors where PAD enzymes perform a major role in autoimmune and chronic diseases.
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Affiliation(s)
- Karol J. Nava-Quiroz
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City 14080, Mexico; (K.J.N.-Q.); (G.P.-R.)
- Programa de Doctorado en Ciencias Médicas Odontológicas y de la Salud, Universidad Nacional Autónoma de México (UNAM), Mexico City 04510, Mexico
| | - Luis A. López-Flores
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City 14080, Mexico; (K.J.N.-Q.); (G.P.-R.)
- Programa de Doctorado en Ciencias Médicas Odontológicas y de la Salud, Universidad Nacional Autónoma de México (UNAM), Mexico City 04510, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City 14080, Mexico; (K.J.N.-Q.); (G.P.-R.)
| | - Jorge Rojas-Serrano
- Rheumatology Clinic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City 14080, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan, Mexico City 14080, Mexico; (K.J.N.-Q.); (G.P.-R.)
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Palterer B, Vitiello G, Del Carria M, D'Onofrio B, Martinez-Prat L, Mahler M, Cammelli D, Parronchi P. Anti-protein arginine deiminase antibodies are distinctly associated with joint and lung involvement in rheumatoid arthritis. Rheumatology (Oxford) 2023; 62:2410-2417. [PMID: 36440916 DOI: 10.1093/rheumatology/keac667] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/04/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES RA is a chronic inflammatory disease in which possible interstitial lung disease (ILD) is an extra-articular manifestation that carries significant morbidity and mortality. RF and ACPA are included in the RA classification criteria but prognostic and diagnostic biomarkers for disease endotyping and RA-ILD are lacking. Anti-protein arginine deiminase antibodies (anti-PAD) are a novel class of autoantibodies identified in RA. This study aimed to assess clinical features, ACPA and anti-PAD antibodies in RA patients with articular involvement and ILD. METHODS We retrospectively collected joint erosions, space narrowing, clinical features and lung involvement of a cohort of 71 patients fulfilling the 2010 ACR/EULAR RA classification criteria. Serum samples from these patients were tested for ACPA IgG (QUANTA Flash CCP3), and anti-PAD3 and anti-PAD4 IgG, measured with novel assays based on a particle-based multi-analyte technology (PMAT). RESULTS Anti-PAD4 antibodies were significantly associated with radiographic injury (P = 0.027) and erosions (P = 0.02). Similarly, ACPA levels were associated with erosive disease (P = 0.014). Anti-PAD3/4 double-positive patients displayed more joint erosions than patients with anti-PAD4 antibodies only or negative for both (P = 0.014 and P = 0.037, respectively). RA-ILD (15.5%, 11/71 patients) was associated with older age (P < 0.001), shorter disease duration (P = 0.045) and less erosive disease (P = 0.0063). ACPA were elevated in RA-ILD, while anti-PAD4 were negatively associated (P = 0.043). CONCLUSION Anti-PAD4 and anti-PAD3 antibodies identify RA patients with higher radiographic injury and bone erosions. In our cohort, ILD is associated with lower radiographic and erosive damage, as well as low levels of anti-PAD4 antibodies.
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Affiliation(s)
- Boaz Palterer
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianfranco Vitiello
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Del Carria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Bernardo D'Onofrio
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | | | | | - Daniele Cammelli
- Dipartimento Medico-Geriatrico, SOD Immunoallergologia, AOU Careggi, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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5
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Wilson TM, Solomon JJ, Humphries SM, Swigris JJ, Ahmed F, Wang H, Darrah E, Demoruelle MK. Serum antibodies to peptidylarginine deiminase-4 in rheumatoid arthritis associated-interstitial lung disease are associated with decreased lung fibrosis and improved survival. Am J Med Sci 2023; 365:480-487. [PMID: 36918112 PMCID: PMC10247162 DOI: 10.1016/j.amjms.2023.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/29/2022] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Interstitial lung disease (ILD) is a leading cause of mortality in rheumatoid arthritis (RA), particularly in those with the usual interstitial pneumonia subtype (RA-UIP). Serum antibodies to peptidylarginine deiminase type 4 (anti-PAD4), particularly a subset that cross-react with PAD3 (PAD3/4XR), have been associated with imaging evidence of ILD. We aimed to determine the specificity of anti-PAD4 antibodies in RA-ILD and to examine associations with markers of ILD severity. METHODS 48 RA-ILD and 31 idiopathic pulmonary fibrosis (IPF) patients were identified from the National Jewish Health Biobank. RA-ILD subtype was defined by imaging pattern on high-resolution chest computed tomography (CT), and serum was tested for anti-PAD4 and anti-PAD3/4XR antibodies. Antibody prevalence, measures of ILD severity (% predicted forced vital capacity, FVC; % predicted diffusion capacity carbon monoxide, DLCO; quantitative CT fibrosis) and mortality were compared between groups. RESULTS Anti-PAD4 antibodies were present in 9/48 (19%) subjects with RA-ILD and no subjects with IPF. Within RA-ILD, anti-PAD4 antibodies were found almost exclusively in RA-UIP (89%). Within RA-UIP subjects, % predicted FVC was higher in anti-PAD4+ subjects, and this finding was most strongly associated with anti-PAD3/4XR antibodies. In addition, quantitative CT fibrosis score was lower in anti-PAD4+ RA-UIP subjects, including those with mono-reactive anti-PAD4 antibodies and anti-PAD3/4XR antibodies. Anti-PAD4+ RA-UIP subjects also exhibited decreased mortality. CONCLUSIONS We demonstrate the presence of serum anti-PAD4 antibodies in a subset of patients with RA-UIP that were notably associated with better lung function, less fibrosis and decreased mortality.
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Affiliation(s)
- Timothy M Wilson
- Division of Rheumatology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joshua J Solomon
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Stephen M Humphries
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Jeffrey J Swigris
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Faduma Ahmed
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Hong Wang
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Erika Darrah
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - M Kristen Demoruelle
- Division of Rheumatology, Department of Medicine, University of Colorado Denver, Aurora, CO, USA
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Aspera-Werz RH, Mück J, Linnemann C, Herbst M, Ihle C, Histing T, Nussler AK, Ehnert S. Nicotine and Cotinine Induce Neutrophil Extracellular Trap Formation-Potential Risk for Impaired Wound Healing in Smokers. Antioxidants (Basel) 2022; 11:antiox11122424. [PMID: 36552632 PMCID: PMC9774423 DOI: 10.3390/antiox11122424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Smoking undoubtedly affects human health. Investigating 2318 representative patients at a level 1 trauma center identified delayed wound healing, tissue infections, and/or sepsis as main complications in smokers following trauma and orthopedic surgery. Therefore, smoking cessation is strongly advised to improve the clinical outcome in these patients, although smoking cessation often fails despite nicotine replacement therapy raising the need for specific interventions that may reduce the complication rate. However, the underlying mechanisms are still unknown. In diabetics, delayed wound healing and infections/sepsis are associated with increased neutrophilic PADI4 expression and formation of neutrophil extracellular traps (NETs). The aim was to investigate if similar mechanisms hold for smokers. Indeed, our results show higher PADI4 expression in active and heavy smokers than non-smokers, which is associated with an increased complication rate. However, in vitro stimulation of neutrophils with cigarette smoke extract (CSE) only moderately induced NET formation despite accumulation of reactive oxygen species (ROS). Physiological levels of nicotine and its main metabolite cotinine more effectively induced NET formation, although they did not actively induce the formation of ROS, but interfered with the activity of enzymes involved in anti-oxidative defense and NET formation. In summary, we propose increased formation of NETs as possible triggers for delayed wound healing, tissue infections, and/or sepsis in smokers after a major trauma and orthopedic surgery. Smoking cessation might reduce this effect. However, our data show that smoking cessation supported by nicotine replacement therapy should be carefully considered as nicotine and its metabolite cotinine effectively induced NET formation in vitro, even without active formation of ROS.
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Anti-Protein-Arginine Deiminase 4 IgG and IgA Delineate Severe Rheumatoid Arthritis. Diagnostics (Basel) 2022; 12:diagnostics12092187. [PMID: 36140588 PMCID: PMC9497810 DOI: 10.3390/diagnostics12092187] [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: 08/09/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022] Open
Abstract
There is a strong need for biomarkers of rheumatoid arthritis (RA) in all phases of the patient’s journey and to enable the implementation of precision medicine strategies to improve patient care. The objective of this study was to evaluate the presence of anti-protein-arginine deiminase (PAD) 4 IgG and IgA in the sera of RA patients and disease controls, and to investigate their association with joint erosion and biological treatment use. Sera from 104 RA and 155 controls were tested for the presence of anti-PAD4 IgG and IgA using a new particle-based multi-analyte technology (PMAT). Information on the erosive disease and biological treatment use was available for 54 of the RA patients, who were also tested for anti-citrullinated protein antibodies (ACPA). An association between the autoantibodies and these clinical features was investigated. Anti-PAD4 showed sensitivity and specificity values of 25.0% and 94.2% for IgG and of 21.2% and 94.8% for IgA for RA, respectively. The levels of these antibodies were also significantly higher in RA patients vs. controls, in erosive RA vs. non-erosive disease, and in patients under biologics vs. patients that were not on this treatment regimen. The anti-PAD4 IgG and IgA levels were correlated (rho = 0.60, p < 0.0001), but individuals that were positive for only one of the two isotypes were also observed. Anti-PAD4 IgG and IgA are associated with severe RA, and they represent valuable biomarkers for prognosis prediction and patient stratification.
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Thirugnanasambandham I, Radhakrishnan A, Kuppusamy G, Kumar Singh S, Dua K. PEPTIDYLARGININE DEIMINASE-4: MEDICO-FORMULATIVE STRATEGY TOWARDS MANAGEMENT OF RHEUMATOID ARTHRITIS. Biochem Pharmacol 2022; 200:115040. [DOI: 10.1016/j.bcp.2022.115040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 12/15/2022]
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Demoruelle MK, Wang H, Davis RL, Visser A, Hoang J, Norris JM, Holers VM, Deane KD, Darrah E. Anti-peptidylarginine deiminase-4 antibodies at mucosal sites can activate peptidylarginine deiminase-4 enzyme activity in rheumatoid arthritis. Arthritis Res Ther 2021; 23:163. [PMID: 34092252 PMCID: PMC8182933 DOI: 10.1186/s13075-021-02528-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/10/2021] [Indexed: 01/23/2023] Open
Abstract
Background Mucosal sites are hypothesized to play a role in the development of rheumatoid arthritis (RA). Since serum anti-peptidylarginine deiminase (PAD)4 antibodies, including a subset that cross-react with PAD3 (PAD3/4), are specific for RA and associate with severe disease, we sought to examine whether anti-PAD4 and anti-PAD3/4 antibodies were present in the lung and oral mucosa of subjects with RA and “at-risk” for RA. Methods We included 37 RA, 25 healthy control, and 46 subjects “at-risk” for RA based on familial RA and/or serum anti-citrullinated protein antibody (ACPA) positivity. Paired serum, sputum, and saliva were evaluated for anti-PAD4 and anti-PAD3/4 using immunoprecipitation and ACPA using ELISA. Immunoglobulins (Ig) were purified from representative samples, and their effect on citrullination of histone H3 by recombinant human PAD4 was measured by anti-citH3 immunoblot. Results Anti-PAD4 antibodies were detected in the serum of 6/37 (16.2%), sputum of 3/37 (8.1%), and saliva of 3/33 (9.1%) RA subjects and in the serum and sputum of 1/46 (2.2%) at-risk subjects. None of the healthy controls had anti-PAD4 antibodies at any site. Serum, sputum, and salivary anti-PAD4 antibodies were more prevalent in RA subjects with RA duration >2 years. Purified antibodies from representative anti-PAD4-positive and anti-PAD3/4-positive sputum were primarily of the IgA isotype and able to increase PAD4 enzymatic activity. Conclusions Anti-PAD4 antibodies are present in the sputum and saliva of a portion of RA patients and are infrequent in at-risk subjects. Importantly, the ability of anti-PAD4, and particularly anti-PAD3/4, antibodies in the sputum to enhance PAD4 enzymatic activity suggests that anti-PAD4 may play an active role in the RA lung.
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Affiliation(s)
- M Kristen Demoruelle
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA.
| | - Hong Wang
- Division of Rheumatology, The Johns Hopkins University, 5200 Eastern Ave. Suite 5300, Baltimore, MD, 21224, USA
| | - Ryan L Davis
- Division of Rheumatology, The Johns Hopkins University, 5200 Eastern Ave. Suite 5300, Baltimore, MD, 21224, USA
| | - Ashley Visser
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA
| | - Johnny Hoang
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA
| | | | - V Michael Holers
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA
| | - Kevin D Deane
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA
| | - Erika Darrah
- Division of Rheumatology, The Johns Hopkins University, 5200 Eastern Ave. Suite 5300, Baltimore, MD, 21224, USA.
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Lamacchia C, Courvoisier DS, Jarlborg M, Bas S, Roux-Lombard P, Möller B, Ciurea A, Finckh A, Bentow C, Martinez-Prat L, Mahler M, Gabay C, Nissen MJ. Predictive value of anti-CarP and anti-PAD3 antibodies alone or in combination with RF and ACPA for the severity of rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:4598-4608. [PMID: 33502443 DOI: 10.1093/rheumatology/keab050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this study was to analyse the predictive value of anti-carbamylated protein (anti-CarP) and anti-peptidyl-arginine deiminase type-3 (anti-PAD3) antibodies, alone or in combination with RF and ACPA, to identify patients at high risk of developing severe RA outcomes. METHODS Patients within the Swiss Clinical Quality Management registry with a biobank sample were tested for RF, ACPA, anti-CarP, and anti-PAD3 antibodies. We examined the association of each autoantibody with DAS28, HAQ and radiographic damage (Ratingen) at baseline and longitudinally. RESULTS Analyses included 851 established RA patients and 516 disease controls [axial spondyloarthritis (axSpA = 320) and PsA (196)]. Anti-CarP and anti-PAD3 antibodies were, respectively, present in 22.4% and 10.7% of the whole RA population, and in 13.2% and 3.8% of the RF and ACPA double seronegative patients. At baseline, RA patients with anti-PAD3 had higher DAS28 (4.2 vs 3.7; P= 0.005) and significantly more radiographic damage (14.9 vs 8.8; P= 0.02) than anti-PAD3-negative patients. In the ACPA-negative subgroup, baseline Ratingen scores were significantly higher in anti-PAD3-positive patients (P= 0.01). The combination of anti-PAD3, RF IgM, and ACPA was associated with significantly higher baseline radiographic scores than the double seropositive group (P= 0.04). The presence of any two of the previous autoantibodies was associated with significantly greater radiographic progression over 10 years than if all were absent (P= 0.02). There were no differences in RA outcome measures with regards to anti-CarP. CONCLUSIONS Anti-PAD3 antibodies are associated with higher disease activity and joint damage scores in RA patients.
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Affiliation(s)
| | | | | | | | | | - Burkhard Möller
- Department of Rheumatology, Immunology and Allergy, Bern University Hospital, Bern
| | - Adrian Ciurea
- Department of Rheumatology, Zurich University Hospital, Zurich, Switzerland
| | | | - Chelsea Bentow
- Research and Development, Inova Diagnostics, San Diego, CA, USA
| | | | - Michael Mahler
- Research and Development, Inova Diagnostics, San Diego, CA, USA
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Tiniakou E, Fava A, McMahan ZH, Guhr T, O’Meally RN, Shah AA, Wigley FM, Cole RN, Boin F, Darrah E. Definition of Naturally Processed Peptides Reveals Convergent Presentation of Autoantigenic Topoisomerase I Epitopes in Scleroderma. Arthritis Rheumatol 2020; 72:1375-1384. [PMID: 32162841 PMCID: PMC7486267 DOI: 10.1002/art.41248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Autoimmune responses to DNA topoisomerase I (topo I) are found in a subset of scleroderma patients who are at high risk for interstitial lung disease (ILD) and mortality. Anti-topo I antibodies (ATAs) are associated with specific HLA-DRB1 alleles, and the frequency of HLA-DR-restricted topo I-specific CD4+ T cells is associated with the presence, severity, and progression of ILD. Although this strongly implicates the presentation of topo I peptides by HLA-DR in scleroderma pathogenesis, the processing and presentation of topo I has not been studied. METHODS We developed a natural antigen processing assay (NAPA) to identify putative CD4+ T cell epitopes of topo I presented by monocyte-derived dendritic cells (mo-DCs) from 6 ATA-positive patients with scleroderma. Mo-DCs were pulsed with topo I protein, HLA-DR-peptide complexes were isolated, and eluted peptides were analyzed by mass spectrometry. We then examined the ability of these naturally presented peptides to induce CD4+ T cell activation in 11 ATA-positive and 11 ATA-negative scleroderma patients. RESULTS We found that a common set of 10 topo I epitopes was presented by Mo-DCs from scleroderma patients with diverse HLA-DR variants. Sequence analysis revealed shared peptide-binding motifs within the HLA-DRβ chains of ATA-positive patients and a subset of topo I epitopes with distinct sets of anchor residues capable of binding to multiple different HLA-DR variants. The NAPA-derived epitopes elicited robust CD4+ T cell responses in 73% of ATA-positive patients (8 of 11), and the number of epitopes recognized correlated with ILD severity (P = 0.025). CONCLUSION These findings mechanistically implicate the presentation of a convergent set of topo I epitopes in the development of scleroderma.
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Affiliation(s)
- Eleni Tiniakou
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Andrea Fava
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Zsuzsanna H. McMahan
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Tara Guhr
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Robert N. O’Meally
- Mass Spectrometry and Proteomics Facility, Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ami A. Shah
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Fredrick M. Wigley
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
| | - Robert N. Cole
- Mass Spectrometry and Proteomics Facility, Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA 94122, USA
| | - Erika Darrah
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA
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12
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Curran AM, Naik P, Giles JT, Darrah E. PAD enzymes in rheumatoid arthritis: pathogenic effectors and autoimmune targets. Nat Rev Rheumatol 2020; 16:301-315. [PMID: 32341463 DOI: 10.1038/s41584-020-0409-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
Peptidylarginine deiminases (PADs) have an important role in the pathogenesis of rheumatoid arthritis (RA) owing to their ability to generate citrullinated proteins - the hallmark autoantigens of RA. Of the five PAD enzyme isoforms, PAD2 and PAD4 are the most strongly implicated in RA at both genetic and cellular levels, and PAD inhibitors have shown therapeutic efficacy in mouse models of inflammatory arthritis. PAD2 and PAD4 are additionally targeted by autoantibodies in distinct clinical subsets of patients with RA, suggesting anti-PAD antibodies as possible biomarkers for RA diagnosis and prognosis. This Review weighs the evidence that supports a pathogenic role for PAD enzymes in RA as both promoters and targets of the autoimmune response, as well as discussing the mechanistic and therapeutic implications of these findings in the wider context of RA pathogenesis. Understanding the origin and consequences of dysregulated PAD enzyme activity and immune responses against PAD enzymes will be important to fully comprehend the pathogenic mechanisms involved in this disease and for the development of novel strategies to treat and prevent RA.
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Affiliation(s)
- Ashley M Curran
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pooja Naik
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon T Giles
- Division of Rheumatology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Erika Darrah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Amigues I, Ramadurai D, Swigris JJ. Current Perspectives On Emerging Biomarkers For Rheumatoid Arthritis-Associated Interstitial Lung Disease. Open Access Rheumatol 2019; 11:229-235. [PMID: 31686925 PMCID: PMC6800546 DOI: 10.2147/oarrr.s166070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 09/24/2019] [Indexed: 12/12/2022] Open
Abstract
Rheumatoid arthritis (RA) is a common systemic autoimmune disease whose fibro-inflammatory manifestations may affect a number of tissues and organs, including the lungs. In fact, interstitial lung disease (ILD) is a leading cause of mortality among patients with RA. RA-related interstitial lung disease (RA-ILD) most often presents in an injury pattern called usual interstitial pneumonia (UIP), which portends a relatively worse prognosis than other less commonly occurring patterns of RA-ILD, like non-specific interstitial pneumonia (NSIP). Biomarkers from serum or bronchoalveolar lavage fluid could aid in the identification of patients at risk for RA-ILD, the detection of patients most likely to develop the UIP pattern of RA-ILD, and the prediction of disease behaviour over time. Notably, the use of highly sensitive serologic biomarkers, including rheumatoid factor (RF) and antibodies targeting cyclic citrullinated peptides, while somewhat specific for RA joint disease, have only limited utility as biomarkers for RA-ILD. Candidate biomarkers for RA-ILD include these and other autoantibodies as well as certain genes and molecules that hold promise as biomarkers in other forms of ILD. In this manuscript, we summarize the state of knowledge on biomarkers for the development and progression of RA-ILD.
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Affiliation(s)
- Isabelle Amigues
- Division of Rheumatology, National Jewish Health, Denver, CO, USA
| | - Deepa Ramadurai
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey J Swigris
- Division of Pulmonary, Critical Care and Sleep Medicine, Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
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14
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Martinez-Prat L, Palterer B, Vitiello G, Parronchi P, Robinson WH, Mahler M. Autoantibodies to protein-arginine deiminase (PAD) 4 in rheumatoid arthritis: immunological and clinical significance, and potential for precision medicine. Expert Rev Clin Immunol 2019; 15:1073-1087. [DOI: 10.1080/1744666x.2020.1668778] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Laura Martinez-Prat
- Research and Development, Inova Diagnostics, San Diego, CA, USA
- Department of Experimental Science, Francisco de Vitoria University, Madrid, Spain
| | - Boaz Palterer
- specialist in Allergy and Clinical Immunology, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy
| | - Gianfranco Vitiello
- resident in Allergy and Clinical Immunology, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy
| | - Paola Parronchi
- (Allergy and Clinical Immunology), Laboratory Head, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy
| | - William H. Robinson
- (Immunology and Rheumatology), Division of Immunology and Rheumatology, Stanford University, Stanford, CA, USA
- Geriatric Research Education and Clinical [GRECC] Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Michael Mahler
- Research and Development, Inova Diagnostics, San Diego, CA, USA
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15
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Yadav R, Yoo DG, Kahlenberg JM, Bridges SL, Oni O, Huang H, Stecenko A, Rada B. Systemic levels of anti-PAD4 autoantibodies correlate with airway obstruction in cystic fibrosis. J Cyst Fibros 2019; 18:636-645. [PMID: 30638826 PMCID: PMC6620172 DOI: 10.1016/j.jcf.2018.12.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis (CF) airway disease is characterized by the long-term presence of neutrophil granulocytes. Formation of neutrophil extracellular traps (NETs) and/or autoantibodies directed against extracellular components of NETs are possible contributors to neutrophil-mediated lung damage in CF. The goal of this study was to measure their levels in CF adults compared to healthy controls and subjects with rheumatologic diseases known to develop NET-related autoantibodies and pathologies, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Sera were analyzed from the following number of subjects: 37 CF, 23 healthy controls (HC), 20 RA, and 21 SLE. CF had elevated serum myeloperoxidase (MPO) concentrations (347.5±56.1 ng/ml, mean+/-S.E.M., p = .0132) compared to HC (144.5±14.6 ng/ml) but not of neutrophil elastase (NE) complexed with alpha-1-antitrypsin, cell-free DNA or NE-DNA complexes. The peptidylarginine deiminase 4 (PAD4) enzyme is required for NET formation and associated DNA release in neutrophils. Serum levels of anti-PAD4 antibodies (Ab) were elevated in CF (p = .0147) compared to HC and showed an inverse correlation with a measure of lung function, FEV1% predicted (r = -0.5020, p = .015), as did MPO levels (r = -0.4801, p = .0026). Anti-PAD4 Ab levels in CF sera associated with lung infection by P. aeruginosa, but not that by S. aureus, age, sex, CF-related diabetes or the presence of musculoskeletal pain. Serum levels of anti-citrullinated protein Abs (ACPAs) and anti-nucleosome Abs were not elevated in CF compared to HC (p = .7498, p = .0678). In summary, adult CF subjects develop an autoimmune response against NET components that correlates with worsening lung disease.
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Affiliation(s)
- Ruchi Yadav
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA
| | - Dae-Goon Yoo
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA
| | - J Michelle Kahlenberg
- Division of Rheumatology, University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - S Louis Bridges
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | - Oluwadamilola Oni
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA
| | - Hanwen Huang
- Department of Epidemiology & Biostatistics, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Arlene Stecenko
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Balázs Rada
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA.
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16
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Soluble Markers of Antibody Secreting Cell Function as Predictors of Infection Risk in Rheumatoid Arthritis. J Immunol Res 2019; 2019:3658215. [PMID: 31183387 PMCID: PMC6512050 DOI: 10.1155/2019/3658215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 03/25/2019] [Indexed: 12/03/2022] Open
Abstract
Background Rheumatoid arthritis (RA) is a systemic autoimmune disease associated with immune dysregulation and increased risk of infections. The presence of autoantibodies and immunoglobulin abnormalities indicates B-cell and antibody-secreting cell (ASC) dysfunction. We hypothesize that soluble factors associated with B-cell and ASC activity are decreased in RA patients and that this is linked to higher susceptibility to infections. Methods Using the Johns Hopkins Arthritis Cohort and Biorepository, we contrasted serum protein levels of soluble factors involved in B-cell activation (CD40, CD40L) and B-cell/ASC homing (CXCL10, CXCL11, and CXCL13) or survival (BAFF, APRIL, TACI, and BCMA) in 10 healthy subjects and 23 adult RA patients (aged 24-65 years). We subdivided RA patients into those with (n = 17) and those without infections (n = 6) within a 2-year period. In order to reduce the effect of RA treatment, we only included patients receiving methotrexate monotherapy or no RA treatments at baseline. Soluble serum protein levels of B-cell/ASC factors were quantified by multiplex immunoassays. Results We identified that (1) serum levels of soluble BCMA, APRIL, CD40, and CD40L were significantly decreased in RA patients relative to healthy individuals; (2) serum soluble BCMA, predominantly released by ASC, correlated with serum concentrations of class-switched immunoglobulins, IgG and IgA; and (3) RA patients with a history of infections had significantly lower soluble BCMA levels compared with healthy donors and with RA patients without infections. Conclusions Our study using soluble factors linked to B-cell/ASC activation and survival suggests that there is a paucity of ASC in a subset of RA patients and that this may be linked to altered antibody production and increased risk of infections. Further delineating the link between ASC and infection susceptibility in RA may optimize disease management and provide novel insights into disease pathogenesis that are susceptible to intervention.
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Darrah E, Yu F, Cappelli LC, Rosen A, O'Dell JR, Mikuls TR. Association of Baseline Peptidylarginine Deiminase 4 Autoantibodies With Favorable Response to Treatment Escalation in Rheumatoid Arthritis. Arthritis Rheumatol 2019; 71:696-702. [PMID: 30507066 DOI: 10.1002/art.40791] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/27/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine if the baseline presence of autoantibodies to peptidylarginine deiminase 4 (PAD4) predicts therapeutic response to biologic and conventional disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) in whom methotrexate (MTX) monotherapy was unsuccessful. METHODS Baseline serum from 282 RA patients in whom MTX monotherapy was unsuccessful was screened for the presence of anti-PAD4 antibodies by immunoprecipitation. Clinical response to either triple DMARD (MTX, sulfasalazine, and hydroxychloroquine) or MTX/etanercept combination therapy was determined at 24 and 48 weeks post-treatment initiation. Disease activity was measured using the Disease Activity Score 28-joint assessment (DAS28), and erosive disease was quantified using the Sharp/van der Heijde scoring method. Generalized estimating equations (GEEs) were used to model the clinical responses to treatment in patients with and those without baseline anti-PAD4 antibodies. RESULTS Anti-PAD4 antibody positivity was associated with male sex, a history of never smoking, and anti-citrullinated protein antibodies. At baseline, patients with anti-PAD4 antibodies had longer disease duration and significantly more radiographic joint damage than anti-PAD4-negative patients, but did not differ in disease activity according to the DAS28. In unadjusted analyses and multivariable GEE models, patients with anti-PAD4 antibodies exhibited greater improvements in DAS28 (adjusted P = 0.02 and P = 0.008, respectively) and less radiographic progression (adjusted P = 0.01 and P = 0.002, respectively) compared to anti-PAD antibody-negative patients, independent of treatment received. CONCLUSION Although anti-PAD4 antibodies were associated with worse baseline radiographic joint damage, suggesting a history of active or undiagnosed disease, treatment escalation therapy was more effective in reducing disease activity and slowing the progression of joint damage in this patient subset.
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Affiliation(s)
- Erika Darrah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fang Yu
- University of Nebraska Medical Center, Omaha
| | - Laura C Cappelli
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antony Rosen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James R O'Dell
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
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Yu C, Jin S, Wang Y, Jiang N, Wu C, Wang Q, Tian X, Li M, Zeng X. Remission rate and predictors of remission in patients with rheumatoid arthritis under treat-to-target strategy in real-world studies: a systematic review and meta-analysis. Clin Rheumatol 2018; 38:727-738. [PMID: 30341703 DOI: 10.1007/s10067-018-4340-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 01/14/2023]
Abstract
This systematic review and meta-analysis aim to evaluate the remission rate of patients with rheumatoid arthritis (RA) in real-world studies and to summarize potential predictors of remission in RA. Studies reporting remission rate in patients with RA were searched from MEDLINE, EMBASE, and Scopus databases. Two reviewers independently assessed all studies according to eligibility criteria and extracted data. Generally, observational studies reporting remission rate in adult (≥ 18 years) patients with RA were included. Quality assessments were performed using the Newcastle-Ottawa Scale. Pooled analyses of remission rate were conducted using a random-effects model and data were analyzed in subgroups to identify potential source of heterogeneity. Sensitivity analyses were performed by serially excluding each study. Potential predictors of remission were summarized. Thirty-one studies with ~ 82,450 RA patients in total were included. Using the DAS28 remission criteria, the pooled 3-, 6-, 12-, and 24-month remission rates were 17.2%, 16.3%, 21.5%, and 23.5%, respectively. Subgroup analyses showed that 11.7% and 13.8% of TNFi inadequate responders reached remission after 6- and 12-month use of non-TNFi biologics. Predictors of remission included male, higher education level, and lower baseline disease activity, while initial use of corticosteroids was negative predictors of remission. Sustained remission was rare regardless of different criteria used. Remission was a reachable target in real-world studies, while attention should also be paid to achieve sustained remission.
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Affiliation(s)
- Chen Yu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Shangyi Jin
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Nan Jiang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Chanyuan Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China. .,Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China.
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China. .,Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave., Beijing, 100730, China.
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