Dörte Hamann

Development of the anti–citrullinated protein antibody repertoire prior to the onset of rheumatoid arthritis

OBJECTIVEnTo examine how anti-citrullinated protein antibody (ACPA) epitope spreading takes place prior to the onset of clinical rheumatoid arthritis (RA), and to analyze the pattern of autoantigen reactivity at the beginning of the immune response.nnnMETHODSnMultiple consecutive serum samples from 79 RA patients who had donated blood before disease onset were available for analysis. Fifty-three patients tested positive for ACPAs prior to the onset of clinical RA. For these patients, a median of 6 (interquartile range 4-9) sequential pre-RA serum samples obtained 1-2 years apart were tested. Reactivity to 5 distinct citrullinated peptides was measured by enzyme-linked immunosorbent assay. Two peptides were derived from fibrinogen, 1 from vimentin, 1 from α-enolase, and 1 from filaggrin.nnnRESULTSnIn 25 of 53 ACPA-positive patients, seroconversion from ACPA absence to ACPA presence was observed. In 72% of these patients, the immune response started with reactivity to 1 peptide, without preference for a particular peptide. The number of peptides recognized increased over time, without a dominant epitope-spreading pattern. ACPAs appeared in low levels several years prior to the diagnosis of RA. Antibody titers increased markedly ∼2-4 years before diagnosis.nnnCONCLUSIONnOur findings indicate that ACPA epitope spreading occurs over several years prior to the onset of clinical RA. The initial autoimmune response is mostly directed toward only 1 autoantigen, but this is not always the same antigen. The marked increase in ACPA titers a few years prior to the diagnosis of RA suggests a second stage in disease development, which might be due to a variety of factors.

The extent of the anti-citrullinated protein antibody repertoire is associated with arthritis development in patients with seropositive arthralgia

Objectives To determine the fine specificity of anti-citrullinated protein antibodies (ACPA) in the early phase of arthritis development, the ACPA repertoire in arthralgia patients and the association with arthritis development were studied. Methods A total of 244 patients with arthralgia positive for anti-cyclic citrullinated peptide antibodies (aCCPs) and/or IgM rheumatoid factor (IgM-RF), without arthritis were included. Development of arthritis was defined as presence of one or more swollen joints at clinical examination during follow-up. Sera were tested at baseline for reactivity to five citrullinated peptides derived from fibrinogen (three), vimentin (one) and α-enolase (one) and five corresponding arginine peptides in an ELISA. Results In all, 69 patients (28%) developed arthritis in a median of 3 joints after a median follow-up of 11 (IQR 5–20) months. Reactivity to each peptide was significantly associated with arthritis development (p<0.001). The ACPA repertoire did not differ between patients who did or did not develop arthritis. Among aCCP-positive patients, patients recognising two or more additional citrullinated peptides developed arthritis more often (p=0.04). The number of recognised peptides was positively associated with the aCCP level (p<0.001). Crossreactivity between different peptides was minimal. Conclusions Arthritis development is not associated with recognition of a specific citrullinated peptide once joint complaints are present. The ACPA repertoire in some patients with arthralgia is expanded. High aCCP levels are associated with a qualitatively broad ACPA repertoire. Patients with an extended ACPA repertoire have a higher risk of developing arthritis.

Anti-carbamylated protein (anti-CarP) antibodies precede the onset of rheumatoid arthritis

Objective The presence of anti-citrullinated protein antibodies (ACPA) and IgM-rheumatoid factor (IgM-RF) years before the clinical diagnosis of rheumatoid arthritis (RA) suggests they are possibly involved in the pathogenic process underlying RA. In this study, we analysed whether anti-carbamylated protein (anti-CarP) antibodies, a novel autoantibody system against carbamylated proteins, can also be detected in healthy individuals before they developed RA. Methods Multiple sera from asymptomatic blood donors prior to the onset of their RA symptoms and sera from age-matched and sex-matched controls were tested for the presence of antibodies directed against carbamylated-fetal calf serum (Ca-FCS), carbamylated-fibrinogen (Ca-Fib), cyclic citrullinated-peptide 2 and IgM-RF. Results Anti-Ca-FCS and anti-Ca-Fib antibodies were each present in 27% and 38% of the last serum samples of blood donors prior to the diagnosis of RA. Both anti-Ca-FCS and anti-Ca-Fib antibodies could be detected many years before the onset of RA. Anti-CarP antibodies as well as ACPA are, on average, detected earlier than IgM-RF. Conclusions In addition to ACPA and IgM-RF, also the newly identified anti-CarP antibodies appear many years before the diagnosis of RA.

Antibodies to mutated citrullinated vimentin and disease activity score in early arthritis: a cohort study

IntroductionThe aim of our study was to investigate the association between arthritic disease activity and antibodies to mutated citrullinated vimentin (anti-MCV), because such a relation has been suggested.MethodsAnti-MCV levels were measured in 162 patients with early arthritis (123 with rheumatoid arthritis and 39 with undifferentiated arthritis) at baseline and at 1 and 2 years of follow up. Disease activity was measured using the disease activity score (Disease Activity Score based on 28 joints [DAS28]) and serum C-reactive protein. General estimation equation analysis was used to assess the relation between anti-MCV levels and DAS28 over time.ResultsBoth, anti-MCV levels and DAS28 exhibited a significant decrease during the first and second year. However, the association between anti-MCV levels and DAS28, adjusted for dependency on sequential measurements within one individual, was very low (β = 0.00075). In a population of patients with rheumatoid arthritis or undifferentiated arthritis, anti-MCV had a specificity of 92.3% and a sensitivity of 59.3% when using the recommended cut-off of 20 U/ml. Specificity and sensitivity of antibodies against second-generation cyclic citrullinated peptide, using the recommended cut-off value of 25 U/ml, were 92.1% and 55.3%, respectively. Anti-MCV-positive early arthritis patients had significantly higher Sharp-van der Heijde score, erythrocyte sedimentation rate and C-reactive protein levels than did anti-MCV-negative patients at all time points (P < 0.005), but DAS28 was higher in anti-MCV-positive patients at 2 years of follow up only (P < 0.05).ConclusionBecause the correlation between anti-MCV levels and parameters of disease activity was very low, we conclude that it is not useful to monitor disease activity with anti-MCV levels.

Monoclonal anti-citrullinated protein antibodies selected on citrullinated fibrinogen have distinct targets with different cross-reactivity patterns

OBJECTIVEnACPAs are thought to play a pathogenic role in RA. Because of their polyclonal nature it is difficult to study characteristics of ACPAs such as cross-reactivity or affinity. This study aimed to analyse the ACPA response at clonal level.nnnMETHODSnCitrullinated fibrinogen-specific B cells were isolated from blood derived from an RA patient by fluorescent automated cell sorting (FACS). Antigen specificity was verified by ELISA of culture supernatant. RNA of antigen-specific B cells was isolated and VH and VL chains were cloned and subsequently expressed as IgG1 antibodies.nnnRESULTSnTwo human recombinant antibodies were obtained that bind to citrullinated fibrinogen peptide (cFib). Both monoclonal antibodies originate from different naive B cells, undergo extensive somatic hypermutation and bind to cFib (but not to Fib) with moderate avidity. Furthermore, they show distinct cross-reactivity patterns towards other citrullinated peptides, suggesting that both antibodies have different primary targets.nnnCONCLUSIONnTogether these data suggest that ACPAs are formed by antigen-driven maturation, and that multiple citrullinated antigens are involved in activating the B-cell response.

Preferential decrease in IgG4 anti-citrullinated protein antibodies during treatment with tumour necrosis factor blocking agents in patients with rheumatoid arthritis

Objective: To investigate the dynamics of IgG1 and IgG4 anti-citrullinated protein antibody (ACPA) subclasses during anti-tumour necrosis factor (TNF) treatment in patients with rheumatoid arthritis (RA). Methods: IgG, IgG1 and IgG4 ACPA levels were determined by ELISA on anti-citrullinated fibrinogen (ACF) and IgG1 : IgG4 ACPA ratios were calculated. A pilot study was performed in 28 ACF-positive patients treated with infliximab for one year. Confirmation of the results was obtained using a cohort of 180 consecutive patients treated with adalimumab for 28 weeks. Results: The median reduction in ACF levels was 31% for total IgG, 29% for IgG1, 40% for IgG4 and 22% for the IgG4 : IgG1 ACF ratio in the infliximab cohort. In adalimumab-treated patients, ACF levels declined 14% for total IgG and IgG1, and 36% for IgG4 ACF; the IgG4 : IgG1 ratio was reduced by 24% (all percentage values p<0.05). The decrease in antibody levels was correlated with the clinical response; European League Against Rheumatism good responders had the greatest decline in antibody levels and this effect was most pronounced for IgG4 (48% reduction). The IgG4 : IgG1 ACF ratio preferentially decreased in patients with adequate therapeutic adalimumab levels. Conclusion: ACPA subclass distribution is modulated by effective anti-inflammatory treatment. The preferential decline of IgG4 ACPA, reflected by the decreased IgG4 : IgG1 ratio, suggests a beneficial effect of anti-TNF treatment on chronic antigenic stimulation by citrullinated proteins. This effect may be directly anti-TNF mediated or the result of effective dampening of the inflammation in the rheumatoid joint.

Comparisons of Serum Infliximab and Antibodies-to-Infliximab Tests Used in Inflammatory Bowel Disease Clinical Trials of Remicade®.

ABSTRACTMonitoring infliximab (IFX) concentrations and antibodies-to-IFX (ATI) titers during inflammatory bowel disease treatment may allow more informed decisions in assessing exposure/response and determining appropriate dosing. To aid in interpreting results from different commercial tests in the context of Janssen’s published Remicade® results, the reliability of Janssen’s IFX and ATI assays was compared with commercial assays from KU Leuven, Sanquin, Dynacare, and LabCorp. Test results were independently reported to Janssen. All assays were tested for specificity, selectivity, and precision. ATI assays were evaluated for sensitivity, drug interference, and potential interference of tumor necrosis factor-alpha (TNF-α). IFX assays were specific, accurate, and reproducible. Intra-class correlation of Janssen IFX assay results with those from KU Leuven, Sanquin, Dynacare, and LabCorp were 0.960, 0.895, 0.931, and 0.971, respectively. ATI titers >10 interfered with IFX assessment in all IFX assays, whereas TNF-α (≤50xa0ng/mL) did not interfere with IFX detection in any assay. ATI assays specifically and reproducibly detected ATI. Janssen, Sanquin, and LabCorp ATI methods were more resistant to IFX interference than Dynacare and KU Leuven, which were affected by IFX concentrations at ≥2xa0μg/mL. TNF-α (<5xa0ng/mL) did not interfere with ATI detection. Strong agreement was observed between Janssen’s IFX and ATI assays and the diagnostic service provider assays. Our study results indicate that all four commercially available assays are suitable for therapeutic drug monitoring of IFX. The substantial agreement reported here between the comparator assays and the Janssen drug-tolerant assay provides support to clinicians in their use of these commercial assays, and for understanding their patients’ IFX and ATI results relative to published data from clinical studies of Remicade.

Clinically relevant discrepancies between different rheumatoid factor assays

Abstract Background: Accurate measurements of rheumatoid factors (RFs), autoantibodies binding IgG, are important for diagnosing rheumatoid arthritis (RA) and for predicting disease course. Worldwide, various RF assays are being used that differ in technique and target antigens. We studied whether assay choice leads to clinically important discrepancies in RF status and level. Methods: RF measurements using four commercial RF assays were compared in 32 RF+ samples. Using enzyme-linked immunosorbent assays (ELISAs), the influence of the target antigen source – human IgG (hIgG) versus rabbit IgG (rIgG) – on measured RF levels was investigated in arthralgia patients and RA patients. Results: Substantial discrepancies were found between RF levels measured in the four commercial assays. Six samples (19%) with RF levels below or slightly above the cutoff in the rIgG-based Phadia assay were RF+ in three assays using hIgG as the target antigen, some with very high levels. Direct ELISA comparisons of RF reactivity against hIgG and rIgG estimated that among 173 ACPA+ arthralgia patients, originally RF negative in rIgG-based assays, up to 10% were single positive against hIgG. Monoclonal RFs binding to hIgG and rIgG or hIgG only supported these findings. In a cohort of 69 early RA patients, virtually all RF responses reacted with both targets, although levels were still variable. Conclusions: The use of RF assays that differ in technique and target antigen, together with the different specificities of RF responses, leads to discrepancies in RF status and levels. This has important consequences for patient care if RA diagnosis and disease progression assessments are based on RF test results.

A1.49 Anti-carbamylated protein antibodies (ANTI-CARP) precede the onset of rheumatoid arthritis

Background and Objective Anti-citrullinated protein antibodies (ACPA) and IgM-rheumatoid factor (IgM-RF) are auto-antibodies that can be detected many years before the clinical diagnosis of rheumatoid arthritis (RA). In recent studies we discovered a novel family of autoantibodies, anti-carbamylated protein (anti-CarP) antibodies. Carbamylation, like citrullination, is a post-translational modification of proteins. We observed that in RA, next to an antibody response against citrullinated proteins, also an immune response against carbamylated proteins exists. These anti-CarP antibodies are of prognostic value in RA as they associate with severe joint destruction in ACPA negative RA. In addition anti-CarP antibodies associate with future development of RA in patients suffering from arthralgia. Here we analysed whether anti-CarP antibodies are already present prior to symptom onset of RA and which auto-antibody appears first over time. Materials and Methods Sera of 79 RA patients prior to diagnosis and 141 age and sex matched controls that were regular blood donors of the Amsterdam Bloodbank (Amsterdam, The Netherlands) were tested for the presence of anti-CarP antibodies, anti-CCP2 antibodies and RF-IgM using sequential pre-RA sera, obtained at 1-2 year intervals. Results Anti-CarP antibodies were present in 39% of the serum samples that were drawn just prior to the diagnosis of RA of blood donors compared to 4% of the matched control samples. Anti-CarP antibodies were present in both ACPA positive and in ACPA negative patients. Of the 79 individuals that developed RA, 42% were positive for anti-CCP2 antibodies and 24% for IgM RF. Analysis of the longitudinal samples revealed a gradual increase in the number of samples positive for anti-CarP antibodies and in the levels of anti-CarP antibodies towards the diagnosis of RA. We observed that anti-CarP antibodies could be detected many years before the onset of symptoms with a median of 8 years and a maximum of 14 years. Comparing the first appearance of the three autoantibody families revealed that both ACPA and anti-CarP antibodies appear earlier than IgM-RF. Conclusions Next to ACPA and IgM-RF also the newly identified anti-CarP antibodies appear many years before the onset of clinical symptoms of RA.

Development of the Anti-Citrullinated Protein Antibody Repertoire Prior to the Onset of Rheumatoid Arthritis

Background Anticitrullinated protein antibodies (ACPA) probably play a pathogenic role in rheumatoid arthritis (RA). The ACPA response is already expanded before the first symptoms of RA and hardly changes thereafter. Objectives To explore the degree of ACPA epitope spreading prior to onset of clinical RA and the pattern of auto-antigen reactivity at the beginning of the immune response. Methods Multiple serial serum samples of 79 RA patients who had donated blood before disease onset were available for analysis. 47 patients tested ACPA (anti-CCP2) positive prior to the onset of clinical RA. Of these patients a median of 6 (IQR 4–9) sequential pre-RA sera spaced 1–2 years apart were tested for reactivity to five distinct citrullinated peptides in an ELISA. Two fibrinogen peptides, 1 vimentin, 1 α-enolase and 1 cyclic citrullinated peptide (CCP1) were tested. Results Four out of 47 ACPA positive patients (9%) did not show reactivity to any peptide. In 23 ACPA positive patients seroconversion from ACPA absence to ACPA presence was observed. In 16 (70%) of these patients, the immune response started with reactivity towards one peptide, without preference for a particular peptide. In two patients (9%) it started with two peptides, in three (13%) it started with three peptides and in two (9%) it started with four peptides. The number of recognised peptides increased over time, without a dominant epitope spreading pattern. Median titres of all measured ACPA increased over time in a biphasic manner. Conclusion ACPA epitope spreading occurs over several years prior to onset of clinical RA. None of the tested auto-antigens is solely responsible for the initial auto-immune response. ACPA epitope spreading is a random process. ACPA titers increase in a biphasic way, suggesting a ‘second event’ a few years before diagnosis of RA.