Immune complexes in early arthritis. II. Immune complex constituents are synthesized in the synovium before rheumatoid factors.

Synovial fluids and paired sera taken from patients either before, after or at the time of diagnosis of definite rheumatoid arthritis (RA) were compared with samples from patients with unclassified inflammatory arthropathies (IA). Raised levels of immune complexes (IC) were detected in some RA patients by C1q binding activity but in the majority of both RA and IA patients by the platelet aggregation test; levels were usually higher in joint fluids than in sera. IgM rheumatoid factors (RF) and IgA RFs were lower in synovial fluids but IgF RF levels were similar in matched samples. Synovial fluid to serum albumin ratios were used to estimate synovial permeability (inflammation) and then to calculate which patients synthesized macromolecules locally in the synovium. Local synthesis of RFs was detected in a greater proportion of RA than IA patients and only two patients formed RFs locally in the first months of symptoms. Half the patients in both groups however appeared to synthesize or trap IC constituents and in many patients there was evidence of local synthesis within 6 months after their symptoms had started. We conclude that local synthesis of large amounts of RFs is uncommon in the early stages of RA but that IC of unknown composition are synthesized or localized in the affected joints of many patients with RA and inflammatory arthropathies shortly after their symptoms appear.     

Circulating immune complexes and complement in rheumatoid arthritis

Rheumatoid arthritis is characterized immunologically by the detection of rheumatoid factor (RF) and circulating immune complexes (CIC). The pathogenesis role played by these CIC has been discussed a long time. A part of this theoretical question, it could be of interest to know if these technics could help the clinician in the diagnosis or in the follow up of the patients with RA.     

Anti-globulins and circulating complexes in early rheumatoid arthritis

The importance of immunological parameters such as anti-globulins, anti-RANA and circulating immune complexes in rheumatoid arthritis (RA) has been studied by examining patients with early disease who are attending general practitioner clinics with joint pains for the first time. Anti-RANA, and IgG and IgM anti-globulins were detectable in the serum at the earliest time we were able to examine the patients. The anti-globulins had specificity for both rabbit and human IgG from the outset. Immune complexes were similarly raised in early disease. From these patients with early joint pains we were able to predict, by means of multivariant discriminant analysis of the laboratory data obtained from the first serum sample, between those who would develop into patients with classical or definite RA at 1 year and those who would have non-inflammatory joint disease.     

Rheumatoid factors in immune complexes of patients with rheumatoid arthritis

Conclusions Substantial evidence indicates that humoral immunity through antigen-antibody complex formation contributes to the pathogenesis of RA. Several studies have examined the composition of immune complexes present in the synovial fluid of patients with RA. The constituents of these immune complexes have been immunoglobulins and complement components. Only a few polypeptides in these immune complexes have not been identified. These unidentified components account for only a few percent of total proteins present. These results suggest that rheumatoid factors and their antigens are quantitatively the important ingredients of immune complexes in synovial fluid of patients with RA. The immune deposits in the superficial layers of articular cartilage from patients with RA contain RFs and antibodies to type II collagen.IgG RFs are unique autoantibodies in that they can form immune complexes with pathogenic potential by self-association and without the presence of separate antigen molecules. Self-association becomes possible when the antigenic specificity of IgG RFs is directed to antigenic determinants present on the Fc region of the same molecule. Self-association of IgG RFs is enhanced in a milieu of high concentration of these antibodies and in relative paucity of normal IgG — i. e., conditions that exist in the synovial tissue where IgG RFs are synthesized.Relatively little attention has been devoted to antigenic specificity of RFs in relation to disease. The self-associating IgG RFs illustrate how the antibody specificity and presence of antigenic determinants can contribute to formation of unique immune complexes. One of the major antigenic determinants for IgM RFs is in the C2-C3 domain interface and involves some of the same amino acids that constitute the site for binding SPA. The specificity for self-associating IgG RFs is directed to the same antigenic determinant. Fc binding proteins from Streptococci and the Fc binding proteins induced by herpes type 1 virus bind to the same or overlapping areas of human IgG. The reasons for this similarity of binding to IgG between microbial Fc binding proteins and RFs is not apparent. This relationship, however, may stimulate the synthesis of some RFs by an internal image autoantiidiotype mechanism.     

The stimulation of IgM rheumatoid factor from human B lymphocytes by rheumatoid arthritis complement-activating immune complexes.

Immune complexes from rheumatoid arthritis (RA IC) and Hodgkin's disease (HD IC) sera were separated on an anti-C3g affinity column and their ability to stimulate the production of IgM and IgM RF by normal and RA B lymphocytes tested in a culture system in vitro. RA IC stimulated IgM production of which up to 91.3% had IgM RF activity. HD IC were incapable of stimulating the production of IgM and IgM RF. The stimulation of IgM and IgM RF production by RA IC required de novo protein synthesis. Both RA IC and HD IC were capable of significantly inhibiting (from 47.6 to 72.0%) pokeweed mitogen (PWM)-induced and goat F(ab)2 antihuman mu-induced B lymphocyte proliferation. Thus it is proposed that IC present in human pathological sera may regulate immunoglobulin production by an effect on B lymphocyte proliferation while some may, in addition, be capable of inducing IgM RF production from such cells.     

Detection and partial characterization of immune complexes in patients with rheumatoid arthritis plus Sjogren's syndrome and with Sjogren's syndrome alone.

In order to characterize the immune complexes detected in patients with Sjogren''s syndrome (SS) and with rheumatoid arthritis (RA), the sera of 19 patients with SS alone and 11 with SS plus RA were examined. Elevated quantities of circulating immune complexes (CIC) were detected in 67% by the C1q-binding assay (C1q-BA), 73% by the C1q-solid phase (C1q-SP) assay, 43% by the monoclonal rheumatoid factor solid phase assay (mRF-SP) and 33% by the mRF-inhibition assay (MRF-Inh). Elevated concentrations of IgM RF were detected in 83% and of IgG RF in 73% of the sera by radioimmunoassay. Strong correlations existed between RF of the IgM and IgG classes and both the C1q-BA and the C1q-SP. Three lines of evidence indicated that RF were important components of the immune complexes detected by these radioimmunoassays. These results indicated that in those patients with RA plus SS, as well as those with SS alone, both IgM and IgG RF made substantial contributions to immune complexes detected both by C1q-BA and C1q-SP.     

Correlation of antibody to rheumatoid arthritis associated nuclear antigen and immune complexes to disease activity in patients with rheumatoid arthritis

Twenty-seven patients with rheumatoid arthritis (RA) maintained on drug regimens were studied monthly for 6-10 months. Disease activity was assessed and levels of anti-RA associated nuclear antigen (RANA) and immune complexes were determined. Anti-RANA generally paralleled disease activity in 64% of cases. Immune complex levels paralleled disease activity in 56% of cases and paralleled anti-RANA in 52% of patients. Immune complexes paralleled anti-RANA together with disease activity in only 33% of patients. Anti-RANA and/or immune complex levels paralleled disease activity indices in 82% of cases. Significant fluctuations (greater than or equal to four-fold) in anti-RANA were frequently found (65%) and were associated with concordant changes in immune complex levels 50% of the time and with changes in disease activity indices 59% of the time. The data suggest that levels of anti-RANA and immune complexes may be important in RA and warrant further investigation.     

Interaction of circulating immune complexes with granulocyte function in patients with rheumatoid arthritis

Summary The sera and peripheral blood granulocytes of 10 patients with rheumatoid arthritis and of 10 healthy controls were investigated for the presence of soluble immune complexes and for cellular dysfunction. Using the Rajicell-radioimmunoassay, immune complexes were detected in 7 out of 10 rheumatoid sera. In one patient the presence of immune complexes was demonstrated by immunofluorescence. In all rheumatoid patients with circulating immune complexes decreased chemotactic reactivity and diminished bactericidal capacity of the neutrophils were observed. Incubation of rheumatoid granulocytes with pooled AB-serum or pretreatment of neutrophils of healthy controls with immune complexes containing rheumatoid sera resulted in a reduced number of comparable cellular dysfunctions including increased release of lysosomal enzymes, strongly correlated with the presence of intracellular phagocytosed immune complexes. Phagocytosis and increase of oxidative cell metabolism during phagocytosis were not influenced by circulating immune complexes. Based on our in vitro findings we suggest that the described immune complex-dependent granulocyte dysfunctions are possibly responsible for the high risk of local or systemic bacterial diseases in patients with rheumatoid arthritis.     

Alloimmunization to human immunoglobulin genetic markers is frequent in early rheumatoid arthritis.

HLA and Gm allotypes of 99 consecutive Swedish patients with rheumatoid arthritis were determined. Ninety-two of the 198 haplotypes contained DR4, a significant increase. The patients' sera from 3 different occasions were studied for anti-immunoglobulin profile as judged by 6 selected anti-Rh coats, 4 of them being monoclonal anti-Ds restricted as to allotype. Ninety-two of the patients were reactive with a polyclonal anti-Rh Ri as against 10 with the monoclonal carrying the G1m(f) allotype. Antibodies to Ig coats carrying defined allotypes were more frequently observed in patients not carrying the allotype in question than in those individuals possessing it. The difference was significant or highly significant as regards presence/absence of G1m(a), G3m(b) and G3m(g), respectively. Anti-G1m(a) and anti-G3m(g) cooccurred in 17 of the patients. Results consistent with presence/absence of particular anti-immunoglobulins at the 3 examinations were observed in 74 of the patients. Gm allotypes or antiallotypes were not statistically related with DR4 status. In conclusion, alloimmunization to Gm markers frequently occurs in early rheumatoid arthritis.     

Measurement of terminal complement complexes in rheumatoid arthritis.

Though complement activation is recognized as a central event in inflammation in the rheumatoid joint, little attention has been paid to the role of the cytolytic membrane attack complex of complement in the pathogenesis of this disease. The membrane attack complex causes a variety of non-lethal effects in nucleated cells, including stimulation of release of inflammatory mediators, and cell proliferation. Thus in the rheumatoid synovium, non-lethal effects of complement membrane attack may play a major role in disease pathology. In order to investigate this possibility, assays for the detection of terminal complement complexes in biological fluids have been established, and used to demonstrate membrane attack pathway activation in rheumatoid arthritis. Terminal complement complexes were present in increased levels in synovial fluid (mean, 1,334 ng/ml) and plasma (mean, 513 ng/ml) in 20 patients with rheumatoid arthritis when compared with controls (mean, 285 ng/ml and 129 ng/ml respectively). Using an assay specific for the SC5b-9 complex it was demonstrated that the raised levels of terminal complement complexes in rheumatoid synovial fluid consisted of a mixture of inactive SC5b-9 complexes and fluid-phase complement membrane attack complexes.     

An autoantibody targeting glycated IgG is associated with elevated serum immune complexes in rheumatoid arthritis (RA)

Advanced glycation end-products (AGE) play a role in diabetes complications and in RA. An autoantibody to IgG-AGE has been shown to correlate with RA disease activity. Thus we sought to analyse serum immune complexes (IC) and AGE-modified proteins in Caucasians and North American Indians to see if the presence of anti-IgG-AGE influenced their composition. Polyethylene glycol precipitation of IC from the serum of anti-IgG-AGE-positive or -negative RA patients, and healthy and diabetic controls were examined. Concentrations of circulating IC were highest in anti-IgG-AGE+ RA patients, followed by anti-IgG-AGE- RA patients, which were greater than healthy controls. IC amounts in the Ojibwe were consistently higher than in Caucasians. Affinity purification of AGE-modified proteins from IC and immunoblotting with antibodies against Ig gamma and mu heavy chains, kappa and lambda light chains, and AGE Nepsilon(carboxymethyl)lysine and imidazolone yielded similar results: anti-AGE+ RA patients had elevated levels relative to those without the autoantibody. Levels in both RA groups were higher than in controls. Glycated albumin amounts followed a similar distribution, but were not influenced by the presence of anti-AGE antibodies. A heavily glycated kappa-chain was present primarily in IC from anti-IgG-AGE+ patients. These studies indicate that anti-AGE antibodies have a direct impact on the accumulation of IgG-AGE but not glycated albumin, and may block the normal clearance of IgG-AGE through AGE receptors.     

Circulating immune complexes in children suffering from rheumatic fever and juvenile rheumatoid arthritis

The investigation on the occurrence of immunological complexes in 20 children with rheumatic fever (RF) and 15 suffering from juvenile rheumatoid arthritis (JRA) were carried out. A group of 15 healthy children served as control. The presence of circulating immune complexes was found in 10 out of 20 children with acute RF and in 12 out of 15 children with JRA. The investigation of immune complexes in the third and sixth week of treatment showed decreasing concentration of proteins determined by PEG precipitation method.     

Immune complexes and the pathogenesis of meningococcal arthritis.

Immune complex levels were measured in serum and synovial fluid obtained from 10 patients who developed arthritis 3-8 days after the onset of meningococcal meningitis. Mean serum immune complex levels were lower in these patients than in eight age matched control patients with meningococcal disease who did not develop late complications. This observation suggests that meningococcal arthritis follows local formation of immune complexes in the synovium rather than deposition of circulating immune complexes. Purified meningococcal polysaccharide antigen-induced synovitis when injected into the knee of rabbits previously sensitized by i.v. injection with heat killed meningococci.     

Humoral immune response to citrullinated collagen type II determinants in early rheumatoid arthritis

Collagen type II (CII) is a relevant joint-specific autoantigen in the pathogenesis of rheumatoid arthritis (RA). Whereas the reasons for the breakage of self tolerance to this major cartilage component are still enigmatic, T cell responses to glycosylated CII determinants in RA patients indicate that post-translational modifications play a role. Since the conversion of arginine into citrulline by peptidylarginine deiminases (PAD) in some non-joint-specific antigens such as filaggrin or fibrin has been shown to give rise to RA-specific humoral immune responses, we investigated whether PAD modification of cartilage-specific CII might affect its recognition by circulating autoantibodies in early RA. In vitro treatment with purified PAD led to arginine deimination of native CII or of synthetic CII peptides as evidenced by amino acid analysis. The citrullination resulted in modified recognition of the immunodominant CII epitope C1(III) (amino acid residues 359-369) by murine and human antibodies. In a cohort of early RA patients (n=286), IgG antibodies directed toward a synthetic citrullinated C1(III) peptide (citC1(III)-P) were detectable with a prevalence of 40.4%. The partial autoantibody cross-reactivity between citC1(III)-P and citrullinated peptides mimicking epitopes of the cytoskeletal autoantigen filaggrin suggests that autoimmunity to cartilage-specific modified self might be a critical intermediate bridging recognition of PAD-modified extra-articular autoantigens with the disruption of tolerance to native cartilage constituents.     

Immune complexes in the spleen. Replacement of immune complexes trapped in spleen follicles by new immune complexes from the circulation.

The fate of intravenously injected 125I-BGG-anti-BGG in the spleen of mice was studied using autoradiography. Part of the labelled immune complexes was trapped in the follicles of the spleen as could be expected. In a first experiment it was found that injections with unlabelled immune complexes were followed by a partial release of the labelled immune complexes from the follicles. In a second experiment unlabelled immune complexes retained in spleen follicles appeared to inhibit the trapping of intravenously injected labelled immune complexes to some degree and for some time. The conclusion was drawn from these experiments that immune complexes, which normally remain in part of the lymphoid follicles for a long period, may be replaced by new immune complexes from the circulation. This seems important since trapping in lymphoid follicles of antigen complexed by antibody is the only known mechanism by which small amounts of antigen may be preserved in the body for a long time after the initiation of antibody production. The bulk of antigen and antigen-antibody complexes is removed by phagocytosis followed by destruction. It appeared also that, although all spleen follicles in the mouse spleen is able to retain the complexes for a longer time. Possible explanations for these individual differences between the follicles of one spleen are discussed.     

Autoantigens and immune pathways in rheumatoid arthritis

Rheumatoid arthritis (RA) is a major systemic autoimmune disease. A plethora of putative autoantigens has been described by the reactivity of antibodies present in the sera of patients. Despite this there is little evidence implicating most of them in its pathogenesis. Autoantigens fall into two major groups: first, those that are associated with the joint, such as collagen type II, human chondrocyte glycoprotein 39, and proteoglycans, for which a pathogenic role is easily understood; and second, those proteins not associated with the joint. Of these there are three groups: (1) highly conserved foreign antigens with human homologues, such as heat shock proteins (HSPs), in which the initiating antigenic stimulus may be through infection; (2) post-translationally altered proteins, such as citrullinated filaggrin, to which autoantibodies show high specificity but low sensitivity for RA and immunoglobulin G; and (3) ubiquitous proteins, such as glucose-6-phosphate isomerase, p205, and HSPs secreted during stress, such as BiP. The mechanisms by which such ubiquitous antigens cause pathology predominantly in the joints are difficult to understand. Autoantibodies, such as rheumatoid factors, that form immune complexes resulting in activation of phagocytic cells or the complement system, may cause joint pathology by deposition in the joints. Such an explanation, however, is not available for all of these autoantigens. It is possible that pathology may be the outcome of disturbed immunoregulation.     

The complement fixing ability of putative circulating immune complexes in rheumatoid arthritis and its relationship to extra-articular disease.

The hypothesis that the pathogenicity of putative circulating immune complexes (CIC) in rheumatoid arthritis (RA) is related to their ability to fix complement was investigated. Three assays for CIC were employed; (a) the 125I C1q binding assay (C1q BA), (b) the C1q solid phase assay (C1q SP) and (c) the Raji cell assay (RCA). Evidence for hypercatabolism of complement was obtained by using a highly sensitive quantitative assay for C3d (a breakdown product of C3) by rocket immunoelectrophoresis. One hundred and fifty-two patients with classical or definite RA were studied; 54 had clinical evidence of extra-articular disease including vasculitis, nodules, scleritis, neuropathy and lung disease; 98 patients had clinical evidence of joint disease alone. Plasma levels of C3d were significantly elevated in the RA group as a whole 16.7 +/- 4.4 mg/l (mean +/- 1 s.d.) compared with 13.1 +/- 3.25 mg/l in a group of 55 normal controls (P less than 0.01). Elevated levels of C3d were found in 26% of all patients but occurred significantly more often in the extra-articular disease group (P less than 0.05). Fifty-four percent of patients had at least one positive assay for CIC although no individual assay was positive in more than 36% of the group as a whole. The prevalence of positive CIC was significantly greater in those patients with extra-articular disease than in those with joint disease alone (P less than 0.005). Of the total of 82 patients with putative CIC, 30 (37%) had a raised C3d level. The coincident finding of positive tests for CIC and an elevated C3d level was very significantly correlated with the presence of extra-articular disease (chi 2 = 12.7 P = 10(-3)). Whilst putative CIC are frequent in RA (54%) these findings in contrast to previous work, suggest that the majority are not associated with abnormal complement activation and may account for the relative infrequency of clinically detectable active extra-articular disease.     

Molecular analysis of complement-fixing rheumatoid synovial fluid immune complexes.

The characteristics of the solid-phase conglutinin method for the isolation of C3-containing complexes from the synovial effusions of rheumatoid arthritis patients were assessed. All major proteins in such complexes were identified and shown to be either immunoglobulin or complement components. The high proportion of IgM and the association between complexed IgM and latex agglutination titre suggest that IgM rheumatoid factor, probably binding to self-associated IgG antiglobulins, is of major importance in the formation of complement-fixing complexes. A minority of samples contained unidentified trace components and these differed from one fluid to another. The levels of complexed immunoglobulins were closely correlated to the titres of synovial fluid antiglobulins. The data accords with the view that autosensitization to IgG plays the primary role in the development of immunopathological features of rheumatoid arthritis.     

Antibodies to extractable nuclear antigens in rheumatoid arthritis: relationship to vasculitis and circulating immune complexes

Antibodies to extractable nuclear antigens (ENA) were analysed in the sera of fifty-two patients with severe rheumatoid arthritis (RA) who were divided into two categories: twenty-five with arthritis only and twenty-seven with extra-articular disease. Using haemagglutination, counterimmunoelectropheresis (CIE) and double diffusion, antibodies to ENA were detected in three (12%) of the patients with arthritis only. In the group with extra-articular disease, antibodies were found in sixteen (59%) of the patients. In ten patients the antibodies reacted with an RNase and DNAse resistant, but trypsin sensitive protein component of ENA. These patients all had extraarticular disease with digital vasculitis being a particularly common feature. Their sera also contained circulating immune complexes detected by elevated cryoprecipitate protein levels associated with relatively low complement levels. It is suggested that antibodies to soluble proteins of nuclear origin may be markers of circulating immune complexes in extra-articular RA.