Jörn Kekow

Does Tumor Necrosis Factor α Inhibition Promote or Prevent Heart Failure in Patients With Rheumatoid Arthritis

OBJECTIVE To determine the hazard risk of developing or worsening heart failure in rheumatoid arthritis (RA) patients treated with tumor necrosis factor alpha (TNFalpha) inhibitors. METHODS RA patients ages 18-75 years who started treatment with infliximab, etanercept, or adalimumab (n = 2,757), or conventional disease-modifying antirheumatic drugs (controls; n = 1,491) at the time of enrollment in a German biologics register were studied. Cox proportional hazards models were applied to investigate the influence of disease-related and treatment-specific risk factors on the incidence or worsening of heart failure. RESULTS The 3-year incidence rates of heart failure in patients with and patients without cardiovascular disease at the start of treatment were 2.2% and 0.4%, respectively. After adjustment for traditional cardiovascular risk factors, an increased risk of developing heart failure was found in patients who had a higher 28-joint Disease Activity Score at followup (hazard ratio [HR] 1.47 [95% confidence interval 1.07-2.02], P = 0.019). A residual nonsignificant risk related to treatment with TNFalpha inhibitors remained (adjusted HR 1.66 [95% confidence interval 0.67-4.1], P = 0.28). This residual risk was balanced by the efficacy of the anti-TNF treatment. When only baseline characteristics were taken into account, the HR related to TNFalpha inhibitor treatment decreased to 0.70 (95% confidence interval 0.27-1.84). CONCLUSION The findings of this study indicate that TNFalpha inhibitor treatment that effectively reduces the inflammatory activity of RA is more likely to be beneficial than harmful with regard to the risk of heart failure, especially if there is no concomitant therapy with glucocorticoids or cyclooxygenase 2 inhibitors. Furthermore, the data suggest that TNFalpha inhibition does not increase the risk of worsening of prevalent heart failure.

Mass spectrometric proteome analyses of synovial fluids and plasmas from patients suffering from rheumatoid arthritis and comparison to reactive arthritis or osteoarthritis

Differential proteome analysis is used to study body fluids from patients suffering from rheumatoid arthritis (RA), reactive arthritis (reaA) or osteoarthritis (OA). Mass spectrometric structure characterization of gel‐separated proteins provided a detailed view of the protein‐processing events that lead to distinct protein species present in the respective body fluids. (i) Fibrin(ogen) β‐chain degradation products, presumably plasmin‐derived, appeared solely in synovial fluids (SF) from both patient collectives, (ii) calgranulin B (MRP14) was exclusively identified in SF samples derived from 5 out of 6 patients suffering from RA. Calgranulin B was not observed in synovial fluids from OA patients, nor in plasmas from either patient group. In all cases where calgranulin B was detected, calgranulin C was identified as well. (iii) Serum amyloid A protein spots were determined in plasmas and synovial fluids from patients with RA, but not in patients with OA. In addition to disease‐relevant differences, interindividual differences in haptoglobin patterns of the patients under investigation were observed. Hence, in‐depth proteome analysis of body fluids has proven effective for identification of multiple molecular markers and determination of associated protein structure modifications, that are thought to play a role for specifically determining a defined pathological state of diseased joints.

Mortality in rheumatoid arthritis: the impact of disease activity, treatment with glucocorticoids, TNFα inhibitors and rituximab

Objectives To investigate the impact of disease activity, the course of the disease, its treatment over time, comorbidities and traditional risk factors on survival. Methods Data of the German biologics register RABBIT were used. Cox regression was applied to investigate the impact of time-varying covariates (disease activity as measured by the DAS28, functional capacity, treatment with glucocorticoids, biologic or synthetic disease modifying antirheumatic drugs (DMARDs)) on mortality after adjustment for age, sex, comorbid conditions and smoking. Results During 31 378 patient-years of follow-up, 463 of 8908 patients died (standardised mortality ratio: 1.49 (95% CI 1.36 to 1.63)). Patients with persistent, highly active disease (mean DAS28  > 5.1) had a significantly higher mortality risk (adjusted HR (HRadj)=2.43; (95% CI 1.64 to 3.61)) than patients with persistently low disease activity (mean DAS28 < 3.2). Poor function and treatment with glucocorticoids > 5 mg/d was significantly associated with an increased mortality, independent of disease activity. Significantly lower mortality was observed in patients treated with tumour necrosis factor α (TNFα) inhibitors (HRadj=0.64 (95% CI 0.50 to 0.81), rituximab (HRadj=0.57 (95% CI 0.39 to 0.84), or other biologics (HRadj=0.64 (95% CI 0.42 to 0.99), compared to those receiving methotrexate. To account for treatment termination in patients at risk, an HRadj for patients ever exposed to TNFα inhibitors or rituximab was calculated. This resulted in an HRadj of 0.77 (95% CI 0.60 to 0.97). Conclusions Patients with long-standing high disease activity are at substantially increased risk of mortality. Effective control of disease activity decreases mortality. TNFα inhibitors and rituximab seem to be superior to conventional DMARDs in reducing this risk.

Comparative effectiveness of tumour necrosis factor α inhibitors in combination with either methotrexate or leflunomide

Objective: The objective of this study was to compare the effectiveness of a combination of tumour necrosis factor α (TNFα) inhibitors with either methotrexate or leflunomide in the treatment of patients with rheumatoid arthritis in a real-world setting. Methods: Data from 1769 outpatients enrolled in the German biologics register RABBIT who were treated with one of the TNFα inhibitors adalimumab, etanercept, or infliximab in combination with either methotrexate (n  =  1375) or leflunomide (n  =  394) were included in the analysis. Clinical status including disease activity as well as treatment data were documented by the treating rheumatologist at baseline and at 3, 6, 12, 18, 24, 30 and 36 months of follow-up. Results: Patients treated with a combination of biologics with leflunomide had significantly higher baseline disease activity than those treated with methotrexate. The highest disease activity was found for patients treated with the combination infliximab/leflunomide. After 36 months, the discontinuation rates were 46.3%, 51.3% and 61.5% for combinations of etanercept, adalimumab and infliximab with methotrexate and 53.4%, 63.1% and 67.1% for combinations with leflunomide, respectively. European League Against Rheumatism response rates after 24 months ranged from 74% to 81% for combinations with methotrexate and 72% to 81% for combinations with leflunomide. Conclusion: The current clinical practice is to use methotrexate as a first choice for the combination with TNFα antagonists. In a number of patients methotrexate has to be replaced by another disease-modifying antirheumatic drug. Our data support the view that leflunomide is a useful alternative if methotrexate is contraindicated.

Intravenous immunoglobulins and transforming growth factor β

Sir—Jorn Kekow and colleagues (Jan 17, p 184) report substantial but variable amounts of transforming growth factor (TGF) in different intravenous immunoglobulin (IVIg) preparations. They also report increased TGF 2 concentrations in vivo during IVIg infusion. TGF is a powerful inhibitor of proliferation and its administration led to immunosuppression in various animal studies on autoimmune diseases, as reviewed by Jorn Kekow et al. The investigators postulate that TGF contributes to the therapeutic effect of IVIg in autoimmune diseases. We and others have shown in vitro that IVIg inhibits proliferation of antigen-specific and non-antigenspecific stimulated peripheral blood lymphocytes and have speculated that this strong immunosuppressive effect of IVIg contributes to its therapeutic effect. In 1991, we suggested that TGF could be one of the candidate factors in IVIg to mediate this in-vitro effect. To test this hypotheses, we investigated whether addition of antiTGF neutralising antibodies abolished the suppressive effect of IVIg when added to peripheral blood lymphocytes stimulated in a mixed lymphocyte reaction. The anti-TGF neutralising antibody (British Biotechnology Ltd, Abingdon, UK) we used has a high titre for neutralisation of the biological activity of human TGF 1 and TGF 1. Since the antibody has a lower titre for neutralisation of TGF 2,

Capsule impedes adhesion to and invasion of epithelial cells by Klebsiella pneumoniae.

ABSTRACT The adhesion of K21a, K26, K36, and K50 capsulatedKlebsiella strains to ileocecal (HCT-8) and bladder (T24) epithelial cell lines was significantly lower than that of their corresponding spontaneous noncapsulated variants K21a/3, K26/1, K36/3, and K50/3, respectively. Internalization of the bacteria by both epithelial cell lines was also significantly reduced. Similarly, a capsule-switched derivative, K2(K36), that exhibited a morphologically larger K36 capsule and formed more capsular material invaded the ileocecal epithelial cell line poorly compared to the corresponding K2 parent strain. None of the capsulated strains exhibited significant mannose-sensitive type 1 fimbriae, whereas two of the noncapsulated variants K21a/3 and K50/3 exhibited potent mannose-sensitive hemagglutinating activity. Although hemagglutinating activity that could be attributed to mannose-resistantKlebsiella type 3 fimbriae was weak in all strains, in several cases the encapsulated parent strains exhibited lower titers than their corresponding noncapsulated variants. Although the level of adhesion to the ileocecal cells is not different from adhesion to bladder cells, bacterial internalization by bladder cells was significantly lower than internalization by ileocecal cells, suggesting that bladder cells lack components required for the internalization ofKlebsiella.

Complex genetic predisposition in adult and juvenile rheumatoid arthritis

BackgroundRheumatoid arthritis (RA) and juvenile rheumatoid arthritis (JRA) are complex multifactorial diseases caused by environmental influences and an unknown number of predisposing genes. The present study was undertaken in order to investigate association of polymorphisms in candidate genes with RA and JRA in German subjects.ResultsUp to 200 unrelated German RA and JRA patients each and 300–400 healthy controls have been genotyped for HLA-DRB1, TNFa, TNFA -238a/g, TNFA -308a/g, TNFA -857c/t, TNFR1 -609g/t, TNFR1 P12P, TNFR2 del 15bp, IKBL -332a/g, IKBL -132t/a, IKBL C224R, CTLA4 -318c/t, CTLA4 T17A, PTPRC P57P, MIF -173g/c, the MIF and IFNG microsatellites as well as for D17S795, D17S807, D17S1821 by polyacrylamide gel electrophoresis, single-strand conformation polymorphism analysis, restriction fragment length polymorphism analysis or allele specific hybridization. None of the investigated genetic markers is associated with both, RA and JRA, but there are some statistically significant differences between patients and controls that have to be discussed sensibly.ConclusionsThe difficulty in investigating the genetics of complex disorders like RA and JRA may arise from genetic heterogeneity in the clinically defined disease cohorts (and generally limited power of such studies). In addition, several to many genes appear to be involved in the genetic predisposition, each of which exerting only small effects. The number of investigated patients has to be increased to establish the possibility of subdivison of the patients according their clinical symptoms, severity of disease, HLA status and other genetic characteristics.

A detailed protocol for the measurement of TGF-β1 in human blood samples

Quantification of the multifunctional cytokine Transforming Growth Factor-beta1 (TGF-beta1) in blood samples has aroused increasing interest in recent years, since an abnormal regulation of this cytokine appears to play a key role in the pathogenesis of different diseases, such as autoimmundiseases or malignant tumors. The measurement of TGF-beta1 is complicated by a lot of problems concerning the collection, preparation and handling of blood samples, the platelet contamination, and the TGF-beta1 activation procedure. Here, we recommend detailed instructions for measurement of TGF-beta1 in blood plasma samples which should be followed to exclude the determination of false positive or negative results.

Soluble tumour necrosis factor receptor treatment does not affect raised transforming growth factor beta levels in rheumatoid arthritis.

Objective: To further elucidate the immunomodulating effects of anti-tumour necrosis factor α treatment in rheumatoid arthritis (RA) by studying changes in plasma levels of transforming growth factor β (TGFβ) in patients with RA undergoing etanercept treatment. Methods: Plasma levels of TGFβ1 and TGFβ2 were determined in 26 patients with RA during six months of etanercept treatment and compared with disease activity and laboratory parameters, including matrix metalloproteinase-3 (MMP-3) and interleukin 6 (IL6). Results: Before treatment all patients had raised TGFβ1, IL6, and MMP-3 levels. In the course of treatment IL6 and MMP-3 levels decreased significantly, accompanied by a drop in serological markers (C reactive protein and erythrocyte sedimentation rate) and clinical disease activity (visual analogue scale and Thompson joint score). By contrast, high levels of latent TGFβ1 were present in all specimens over the entire six months. TGFβ2 levels did not change during treatment. Conclusions: Etanercept treatment induces subtle changes in the cytokine network. Although the proinflammatory cytokine IL6 is down regulated, the persistence of high TGFβ plasma levels indicates the existence of as yet unknown mechanisms for TGFβ overexpression in RA. This may predispose to severe infections and can cause an altered tumour defence.

Determination of transforming growth factor β2 in human blood samples by ELISA

Abstract Transforming growth factors β (TGFβs) show pleotrophic functions in vitro and in vivo. Biological effects depend on the cell type, the TGFβ isoform, and the availability of active TGFβ. Bioassays for TGFβ have not proven to be reliable tools in the measurement of TGFβ in human blood samples. Previously described sandwich ELISAs for measuring TGFβ are limited to single TGFβ isoforms and have not been evaluated for use in human sera or plasma. We describe a simple procedure to quantitate not only TGFβ1 but also TGFβ2 in human blood samples using commercially available antibodies. The sensitivity of the TGFβ2 ELISA was 11 pg/ml. There was no crossreactivity between the TGFβ1 and TGFβ3 isoforms. High concentrations of TGFβ1 and TGFβ3 in spiked samples did not interfere with TGFβ2 determination. TGFβ2 recovery was highest in EDTA plasma (> 88%), and the intra-and interassay variance was 6% and 8.5% respectively. Applying the ELISA to human plasma specimens a significant percentage of TGFβ2 (3.7 ± 0.8 ng/ml) was found (about 50% of the TGFβ1 content).