A.J.W. Zendman

Synovial fluid is a site of citrullination of autoantigens in inflammatory arthritis.

OBJECTIVE To examine synovial fluid as a site for generating citrullinated antigens, including the candidate autoantigen citrullinated alpha-enolase, in rheumatoid arthritis (RA). METHODS Synovial fluid was obtained from 20 patients with RA, 20 patients with spondylarthritides (SpA), and 20 patients with osteoarthritis (OA). Samples were resolved using sodium dodecyl sulfate-polyacrylamide gel electrophoresis, followed by staining with Coomassie blue and immunoblotting for citrullinated proteins, alpha-enolase, and the deiminating enzymes peptidylarginine deiminase type 2 (PAD-2) and PAD-4. Proteins from an RA synovial fluid sample were separated by 2-dimensional electrophoresis, and each protein was identified by immunoblotting and mass spectrometry. Antibodies to citrullinated alpha-enolase peptide 1 (CEP-1) and cyclic citrullinated peptide 2 were measured by enzyme-linked immunosorbent assay. RESULTS Citrullinated polypeptides were detected in the synovial fluid from patients with RA and patients with SpA, but not in OA samples. Alpha-enolase was detected in all of the samples, with mean levels of 6.4 ng/microl in RA samples, 4.3 ng/microl in SpA samples, and <0.9 ng/microl in OA samples. Two-dimensional electrophoresis provided evidence that the alpha-enolase was citrullinated in RA synovial fluid. The citrullinating enzyme PAD-4 was detected in samples from all 3 disease groups. PAD-2 was detected in 18 of the RA samples, in 16 of the SpA samples, and in none of the OA samples. Antibodies to CEP-1 were found in 12 of the RA samples (60%), in none of the SpA samples, and in 1 OA sample. CONCLUSION These results highlight the importance of synovial fluid for the expression of citrullinated autoantigens in inflammatory arthritis. Whereas the expression of citrullinated proteins is a product of inflammation, the antibody response remains specific for RA.

Autoantibodies to citrullinated (poly)peptides: a key diagnostic and prognostic marker for rheumatoid arthritis.

Rheumatoid arthritis (RA), is a common systemic autoimmune disease with a prevalence of about 1% worldwide. RA is marked by a chronic inflammation of the synovial joints, which leads to joint swelling, progressive joint erosions and eventually disability. Current therapies for RA are mainly anti-inflammatory strategies and so far unable to cure the disease. Nevertheless, these therapies can slow down the extent of swelling and erosive damage (reviewed by Smolen and Steiner). Insights gained over the last years suggest that aggressive therapy given early in the disease has the greatest therapeutic potential. It is therefore, crucial to identify the RA patients prior to the occurrence of joint damage. The American College of Rheumatology (ACR) criteria for classification of RA are mainly based on clinical observations and are therefore, not well suited to diagnose RA at an early stage of the disease. The only serological marker included in the ACR criteria is the rheumatoid factor (RF). RF antibodies can be detected in the majority of RA patients (up to 80%), but are not very specific (less than 90%) for RA. For this reason, more specific and sensitive serological markers would be beneficial. The serological marker that meets these requirements is the anti-citrullinated protein antibody. This review will discuss the potential of this autoantibody system for the diagnosis and prognosis of RA.

Citrullination, a possible functional link between susceptibility genes and rheumatoid arthritis.

Antibodies directed to citrullinated proteins (anti-cyclic citrullinated peptide) are highly specific for rheumatoid arthritis (RA). Recent data suggest that the antibodies may be involved in the disease process of RA and that several RA-associated genetic factors might be functionally linked to RA via modulation of the production of anti-cyclic citrullinated peptide antibodies or citrullinated antigens.

Anti-cyclic citrullinated peptide positivity in non-rheumatoid arthritis disease samples: citrulline-dependent or not?

Background: Antibodies directed against citrullinated proteins (eg anti-cyclic citrullinated peptide (CCP)) have excellent diagnostic and good prognostic potential for rheumatoid arthritis. Type 1 autoimmune hepatitis (AIH-1) is a chronic liver disease characterised by a variety of serum autoantibodies. Recently, in a large group of patients with AIH-1 without clear rheumatoid arthritis overlap, a relatively high percentage (9%) of anti-CCP2 positivity was scored. Objectives: To characterise the citrulline-dependence of the observed anti-CCP2 positivity in AIH-1 sera as well as in other groups of patients without rheumatoid arthritis (mainly rheumatic diseases). Methods: Serum samples of 57 patients with AIH-1 and 66 patients without rheumatoid arthritis, most of them reported as anti-CCP positive, were tested for citrulline-specific reactivity with a second generation anti-CCP kit, with the citrullinated and the corresponding non-citrullinated (arginine-containing) antigen. A subset of AIH-1 sera was also tested with a CCP1 ELISA (and arginine control). Results: The anti-CCP2 reactivity of most non-rheumatoid arthritis rheumatic diseases samples (87–93%) was citrulline-specific, whereas a relatively high percentage of AIH-1 samples (42–50%) turned out to be reactive in a citrulline-independent manner. The use of citrullinated and non-citrullinated CCP1 peptides confirmed a high occurrence of citrulline-independent reactivity in AIH-1 samples. Conclusions: In rheumatoid arthritis and most non-rheumatoid arthritis rheumatologic disease sera, anti-CCP positivity is citrulline-dependent. However in some patients, particularly patients with AIH-1, citrulline-independent reactivity in the anti-CCP2 test can occur. A positive CCP test in a non-rheumatic disease (eg liver disease) should therefore be interpreted with care, and preferably followed by a control ELISA with a non-citrullinated antigen.

Anti-CCP Antibody Detection Facilitates Early Diagnosis and Prognosis of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a common systemic autoimmune disease with a prevalence of about 1% worldwide [1]. The American College of Rheumatology (ACR) criteria for the classification of RA [2] are not very well suited to diagnose RA at an early stage of the disease [3, 4], because these criteria rely heavily on the expression of clinical symptoms of RA. In early RA these clinical parameters are often not (yet) manifest. Therefore, a specific and sensitive (serological) marker, which is present very early in the disease, is needed. A good marker should ideally not only indicate the development of the disease, but also be able to predict its erosive or non-erosive progression. The serological parameter that meets these requirements for a good and useful marker for early RA is the anti-citrullinated protein antibody. The sensitivity of this antibody is comparable to that of the rheumatoid factor (RF) (approximately 80%), but its specificity is much higher, about 98%. Several assays have been developed to detect this class of autoantibodies, which are termed anti-CCP because the most sensitive test is based upon cyclic citrullinated peptides. This review will discuss the potential of this autoantibody system for the diagnosis and prognosis of RA.