Erik R. Vossenaar

Rheumatoid arthritis specific anti-Sa antibodies target citrullinated vimentin

Antibodies directed to the Sa antigen are highly specific for rheumatoid arthritis (RA) and can be detected in approximately 40% of RA sera. The antigen, a doublet of protein bands of about 50 kDa, is present in placenta and in RA synovial tissue. Although it has been stated that the Sa antigen is citrullinated vimentin, experimental proof for this claim has never been published. In this study, we investigated the precise nature of the antigen. Peptide sequences that were obtained from highly purified Sa antigen were unique to vimentin. Recombinant vimentin, however, was not recognized by anti-Sa reference sera. In vivo, vimentin is subjected to various post-translational modifications, including citrullination. Since antibodies to citrullinated proteins are known to be highly specific for RA, we investigated whether Sa is citrullinated and found that Sa indeed is citrullinated vimentin. Anti-Sa antibodies thus belong to the family of anticitrullinated protein/peptide antibodies. The presence of the Sa antigen in RA synovial tissue, and the recent observation that vimentin is citrullinated in dying human macrophages, make citrullinated vimentin an interesting candidate autoantigen in RA and may provide new insights into the potential role of citrullinated synovial antigens and the antibodies directed to them in the pathophysiology of RA.

Citrullinated proteins have increased immunogenicity and arthritogenicity and their presence in arthritic joints correlates with disease severity

Autoantibodies directed against citrulline-containing proteins have an impressive specificity of nearly 100% in patients with rheumatoid arthritis and have been suggested to be involved in the disease pathogenesis. The targeted epitopes are generated by a post-translational modification catalysed by the calcium-dependent enzyme peptidyl arginine deiminase (PAD), which converts positively charged arginine to polar but uncharged citrulline. The aim of this study was to explore the effects of citrullination on the immunogenicity of autoantigens as well as on potential arthritogenicity. Thus, immune responses to citrullinated rat serum albumin (Cit-RSA) and to unmodified rat serum albumin (RSA) were examined as well as arthritis development induced by immunisation with citrullinated rat collagen type II (Cit-CII) or unmodified CII. In addition, to correlate the presence of citrullinated proteins and the enzyme PAD4 with different stages of arthritis, synovial tissues obtained at different time points from rats with collagen-induced arthritis were examined immunohistochemically. Our results demonstrate that citrullination of the endogenous antigen RSA broke immunological tolerance, as was evident by the generation of antibodies directed against the modified protein and cross-reacting with the native protein. Furthermore we could demonstrate that Cit-CII induced arthritis with higher incidence and earlier onset than did the native counterpart. Finally, this study reveals that clinical signs of arthritis precede the presence of citrullinated proteins and the enzyme PAD4. As disease progressed into a more severe and chronic state, products of citrullination appeared specifically in the joints. Citrullinated proteins were detected mainly in extracellular deposits but could also be found in infiltrating cells and on the cartilage surface. PAD4 was detected in the cytoplasm of infiltrating mononuclear cells, from day 21 after immunisation and onwards. In conclusion, our data reveal the potency of citrullination to break tolerance against the self antigen RSA and to increase the arthritogenic properties of the cartilage antigen CII. We also show that citrullinated proteins and the enzyme PAD4 are not detectable in healthy joints, and that the appearance and amounts in arthritic joints of experimental animals are correlated with the severity of inflammation.

Citrullinated proteins: sparks that may ignite the fire in rheumatoid arthritis

Antibodies directed to citrullinated proteins (e.g. anti-CCP [cyclic citrullinated peptide] antibodies) are highly specific for rheumatoid arthritis (RA). These antibodies are produced at the site of inflammation in RA, and therefore citrullinated antigens are also expected to be present in the inflamed synovium. We discuss literature showing that the presence of citrullinated proteins in the synovium is not specific for RA. The RA-specific antibodies are therefore most likely the result of an abnormal immune response that specifically occurs in RA patients. It was recently shown that presence of anti-CCP antibodies precedes the onset of clinical symptoms of RA by years. It thus appears that it may take years for initial events that cause the generation of anti-CCP antibodies to develop into full-blown disease.

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-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.

Expression of citrullin-containing antigens in RA synovium

The presence of autoantibodies directed to citrulli-nated antigens in serum is highly specific for RA. The aim of this study was to compare anti-CCP concentrations in paired serum/SF samples of patients with RA and to investigate whether this is associated with the expression of citrullinated antigens in RA synovium and to study the nature of these antigens.

Expression of PAD enzymes and occurrence of citrulline-containing proteins in human blood and synovial fluid cells

Antibodies directed against citrulline-containing antigens are extremely specific for RA. The amino acid citrulline is not incorporated into proteins during protein synthesis. It is generated by posttranslational modification of arginine residues by PAD (peptidylarginine deiminase) enzymes. We investigated the expression of PAD enzymes and the occurrence of citrullinated proteins in peripheral blood (PB) and synovial fluid (SF) cells. PAD types 1 and 3 were absent from the investigated cells, while PAD types 2 and 4 (also known as type 5) were present. In monocyte-derived macrophages PAD type 2 mRNA expression was at a similiar level as in monocytes, while PAD type 2 protein was increased. PAD type 4 mRNA expression was significant in monocytes and almost absent in monocyte-derived macrophages, while PAD type 4 protein levels were similar. In monocytes no citrullinated protein could be detected, while in monocyte-derived macrophages citrullinated vimentin, which is (part of) the Sa-antigen, was present. A similar pattern of mRNA and protein expression was observed in mononuclear cells in paired PB and SF samples of RA patients. These results suggest that PAD type 2 is involved in the citrullination of SF proteins during inflammation.

Citrullinated Proteins in Arthritis; their Presence in Joints and Effects on Immunogenicity

Autoantibodies directed against citrulline‐containing proteins have an impressive specificity of nearly 100% in RA patients and a suggestive involvement in the pathogenesis. The targeted epitopes are generated by a post‐translational modification catalysed by the calcium‐dependent enzyme peptidyl arginine deaminase that converts the positively charged arginine to polar but uncharged citrullin. The aim of this study was to analyse the presence of citrulline in the joints at different time points of collagen‐induced arthritis in DA rats by immunohistochemistry and to investigate how immunogenicity and arthritogenicity was affected by citrullination of rat serum albumin (RSA) and collagen type II (CII). Our results indicate that citrulline could be detected in joints of arthritic animals, first appearance at the onset of disease and increasing as disease progressed into a chronic state. Unimmunized animals or time points before clinical signs of arthritis were negative. By morphology, we state that some infiltrating macrophages as well as the cartilage surface stain positive for citrulline, while the major source of citrullinated proteins appears to be fibrin depositions. A specific Cit‐RSA T‐cell response was observed in animals challenged by citrullinated RSA, no response was recorded when RSA was used as a stimulus. The IgG analysis reveals not only a response towards the modified protein but also cross‐reactivity to native RSA. No T‐cell or B‐cell response was noted in animals injected with unmodified RSA. Cit‐CII induced a disease with higher incidence and earlier onset than did the native counterpart. We conclude that, in contrast to the human disease, citrulline does not seem to appear before clinical signs. As inflammation proceeds, citrulline is detected specifically in the joints. All other organs investigated were negative. We also conclude that citrullination of a protein can break tolerance and increase its arthritogenic properties.

Fibrinogen-specific T cells in rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by the occurence of autoreactive antibodies and T cells. The family of antibodies directed to citrulline-containing antigens (anti-filaggrin, anti-CCP and anti-Sa) have the highest specificity (>98%) for RA. To investigate the presence of citrulline-specific T cells in RA patients, we analyzed T-cell reactivity to unmodified and citrullinated filaggrin and fibrinogen in modified T-cell proliferation assays. No T-cell responses were observed when either unmodified or citrullinated filaggrin was used as the stimulating antigen in serum-free T-cell proliferation assays. With unmodified fibrinogen, however, T-cell proliferation was observed in 8/15 (53%) of RA patients, while only 1/14 control patients (SLE, SSc, PsoA, Sjo) displayed clearly positive T-cell proliferation. The difference was highly significant (P < 0.0001). These findings were even more pronounced when using citrullinated fibrinogen as stimulating antigen: 10/15 (67%) RA patients were positive for T-cell proliferation and again only 1/14 control patients was clearly positive (P < 0.0001). T-cell reactivity in RA patients was significantly (P < 0.05) higher against citrullinated as compared with unmodified fibrinogen. We conclude that fibrinogen (citrullinated or not) can induce proliferation of RA T cells, thereby further substantiating its pathogenic relevance.