Balance between survivin, a key member of the apoptosis inhibitor family, and its specific antibodies determines erosivity in rheumatoid arthritis

Rheumatoid arthritis (RA) is a highly heterogeneous disease with respect to its joint destructivity. The reasons underlying this heterogeneity are unknown. Deficient apoptosis in rheumatoid synovial tissue has been recently demonstrated. We have therefore decided to study the synovial expression of survivin, a key member of the apoptosis inhibitor family. The levels of survivin and antibodies against survivin were assessed by an ELISA in matched blood and synovial fluid samples collected from 131 RA patients. Results were related to joint erosivity at the time of sampling. Monocytes were transfected with survivin anti-sense oligonucleotides and were assessed for their ability to produce inflammatory cytokines. Survivin levels were significantly higher in patients with destructive disease as compared with in RA patients displaying a non-erosive disease. High survivin levels were an independent prognostic parameter for erosive RA. In contrast, high levels of antibodies against survivin were found in patients with non-erosive RA, and were negatively related to erosivity. Survivin levels in RA patients were influenced by treatment, being significantly lower among patients treated with disease-modifying anti-rheumatic drugs. Specific suppression of survivin mRNA resulted in downregulation of IL-6 production. We conclude that survivin determines the erosive course of RA, whereas survivin antibodies lead to a less aggressive course of the disease. These findings together with decreased survivin levels upon disease-modifying anti-rheumatic drug treatment, and the downregulation of inflammatory response using survivin anti-sense oligonucleotides, suggest that extracellular survivin expression mediates the erosive course of joint disease whereas autoimmune responses to the same molecule, manifested as survivin targeting antibodies, mediate protection

Decreased levels of soluble receptor for advanced glycation end products in patients with rheumatoid arthritis indicating deficient inflammatory control

The receptor for advanced glycation end products (RAGE) is a member of the immunoglobulin superfamily being expressed as a cell surface molecule and binding a variety of ligands. One of these ligands is high-mobility group box chromosomal protein 1, a potent proinflammatory cytokine, expression of which is increased in synovial tissue and in synovial fluid of rheumatoid arthritis (RA) patients. The interaction of high-mobility group box chromosomal protein 1 with cell-surface RAGE leads to an inflammatory response. In contrast, the presence of soluble RAGE (sRAGE) may abrogate cellular activation since the ligand is bound prior to interaction with the surface receptor. Our aim was to analyse to what extent sRAGE is present in patients with chronic joint inflammation (RA) as compared with patients with non-inflammatory joint disease and with healthy subjects, and to assess whether there is an association between sRAGE levels and disease characteristics. Matching samples of blood and synovial fluid were collected from 62 patients with RA with acute joint effusion. Blood from 45 healthy individuals, synovial fluid samples from 33 patients with non-inflammatory joint diseases and blood from six patients with non-inflammatory joint diseases were used for comparison. sRAGE levels were analysed using an ELISA. RA patients displayed significantly decreased blood levels of sRAGE (871 ± 66 pg/ml, P < 0.0001) as compared with healthy controls (1290 ± 78 pg/ml) and with patients with non-inflammatory joint disease (1569 ± 168 pg/ml). Importantly, sRAGE levels in the synovial fluid of RA patients (379 ± 36 pg/ml) were lower than in corresponding blood samples and correlated significantly with blood sRAGE. Interestingly, a significantly higher sRAGE level was found in synovial fluid of RA patients treated with methotrexate as compared with patients without disease-modifying anti-rheumatic treatment. We conclude that a decreased level of sRAGE in patients with RA might increase the propensity towards inflammation, whereas treatment with methotrexate counteracts this feature

Short- and long-term effects of anti-CD20 treatment on B cell ontogeny in bone marrow of patients with rheumatoid arthritis

It has been known for a long time that B cells play a role in rheumatoid arthritis (RA). By production of autoantibodies, presentation of auto-antigens and by producing cytokines B cells may contribute to the pathogenesis of RA. In recent years it has been shown that anti-B cell therapy is a powerful tool in the treatment of RA. The aim of this thesis was to a) investigate the effect on B cell ontogeny following B cell depletion therapy, b) during B cell depletion therapy evaluate serological and humoral immune responses and finally, c) try to establish a connection between Epstein-Barr virus (EBV) infection, CD25+ B cells and outcome of B cell deletion therapy. In paper I we could show that in bone marrow of RA patients following anti-CD20 treatment with rituximab (RTX) IgD expressing naïve cells are depleted whereas immature and memory B cells where still detectable. However, the long-term effects clearly showed a reduction of memory B cells in bone marrow. The examination of rheumatoid factor (RF) production revealed that RFs decline short after treatment but returned to baseline levels concurrently with the IgD expressing B cells when patients where subjected to an additional course. In paper II the cellular and humoral immune responses were evaluated by immunisation of RA patients before or during RTX treatment with a protein vaccine against influenza and a pneumococcal polysaccharide vaccine. The results suggest that both cellular and humoral immune responses are affected in patients receiving RTX treatment and we therefore suggest that immunisation should be performed before RTX treatment. In paper III we investigate the effects of EBV on selected B cell subsets and how infection may affect the clinical response to RTX treatment. The phenotypical study showed that B cells are more mature in EBV infected patients and the CD25+ B cell subset was more mature as compared to the CD25- B cell population. The evaluation of clinical response to RTX treatment with regard to B cell subsets showed that non-responding EBV+ patients had a significantly larger CD25+ plasma cell population. When investigating the effects of EBV stimulation in vitro we found that the CD25+ B cell population developed into antibody-producing cells to a higher extent than did the corresponding CD25- B cell population. The results of our studies indicate that that B cells play an essential role in the pathogenesis of RA. During RTX treatment we suggest that the IgD expressing population may harbour the autoantibody producing B cells. We also claim that that there are subsets of B cells (i.e. CD25+ B cells) that may have significant impact on the pathogenesis of RA, and the clinical outcome following RTX treatment

Decreased levels of the gelsolin plasma isoform in patients with rheumatoid arthritis

Introduction Gelsolin is an intracellular actin-binding protein involved in cell shape changes, cell motility, and apoptosis. An extracellular gelsolin isoform, plasma gelsolin circulates in the blood of healthy individuals at a concentration of $200 \pm 50$ mg/L and has been suggested to be a key component of an extracellular actin-scavenging system during tissue damage. Levels of plasma gelsolin decrease during acute injury and inflammation, and administration of recombinant plasma gelsolin to animals improves outcomes following sepsis or burn injuries. In the present study, we investigated plasma gelsolin in patients with rheumatoid arthritis.Methods Circulating and intra-articular levels of plasma gelsolin were measured in 78 patients with rheumatoid arthritis using a functional (pyrene-actin nucleation) assay and compared with 62 age- and gender-matched healthy controls.Results Circulating plasma gelsolin levels were significantly lower in patients with rheumatoid arthritis compared with healthy controls ($141 \pm 32$ versus $196 \pm 40$ mg/L, P = 0.0002). The patients' intra-articular plasma gelsolin levels were significantly lower than in the paired plasma samples ($94 \pm 24$ versus $141 \pm 32$ mg/L, P = 0.0001). Actin was detected in the synovial fluids of all but four of the patients, and immunoprecipitation experiments identified gelsolin-actin complexes.Conclusions The plasma isoform of gelsolin is decreased in the plasma of patients with rheumatoid arthritis compared with healthy controls. The reduced plasma concentrations in combination with the presence of actin and gelsolin-actin complexes in synovial fluids suggest a local consumption of this potentially anti-inflammatory protein in the inflamed joint

Survivin Measurement improves Clinical Prediction of Transition From Arthralgia to RA—Biomarkers to Improve Clinical Sensitivity of Transition From Arthralgia to RA

Background: Arthralgia often predates development of rheumatoid arthritis (RA). A set of joint symptoms commonly found in patients during their transition from arthralgia to RA, has been recently proposed.Aim: To combine clinical and serological markers and to improve recognition of imminent rheumatoid arthritis (RA) among patients with arthralgia.Methods: The total of 1,743 first-visit patients attending the rheumatology ward in Gothenburg for joint symptoms were identified during 12 consecutive months. Among those, 63 patients were classified as RA, 73 had undifferentiated arthritis and 180 had unexplained arthralgia. New RA cases, which prospectively developed during 48 months, comprised the preclinical (pre) RA group. The joint symptoms of the first-visit were analyzed aiming to distinguish patients with arthralgia and arthritis, and patients with pre-RA, who later developed the disease. The receiver operating characteristics curves were constructed. In the model, symptoms with the odds ratio &gt;2.0 between the arthralgia and pre-RA were combined with information about RA-specific antibodies, C-reactive protein (CRP), and survivin in serum.Results: The proposed set of clinical symptoms distinguished the arthralgia patients from RA and pre-RA. Presence of survivin in serum showed strong association with clinical joint symptoms in arthralgia. A combination of symptoms in several small joint areas, increasing number of joints with symptoms, and patient's experience of swelling in small hand joints at the first visit identified pre-RA cases with 93% specificity. Grouping those symptoms with information about survivin, RA-specific antibodies, and CRP (or gender) in the final algorithm achieved 91% specificity and 55.2% of positive prediction for transition from arthralgia to RA.Conclusion: Clinical and serological parameters in combination aid recognition of imminent RA among arthralgia patients with appropriate sensitivity