运用ROC曲线方法评价TRAb、TPO-Ab和TGA在Graves'病和HT鉴别诊断中的意义

目的:应用临床诊断性能(ROC)曲线方法评价TSH受体抗体(TRAb)、甲状腺过氧化物酶抗体(TPO-Ab)和甲状腺球蛋白抗体(TGA)在Graves'病(格雷夫斯病)和桥本甲状腺炎鉴别诊断中的意义.方法:以甲状腺细针穿刺细胞学检查结果作为诊断金标准,以采用化学发光法测定63例自身免疫性甲状腺病患者血清的TRAb、TP...     

TSH受体抗体测定的临床意义

目的:探讨血清TRAb的测定变化对G raves甲亢的临床意义。方法:应用放射免疫受体分析法(RRA)对302例甲状腺疾病患者及52例正常健康人的血清TRAb的值进行比较。结果:甲亢组TRAb的测定值阳性率为86.3%;甲亢缓解组TRAb的测定值阳性率为74.5%;甲亢治愈组TRAb的测定值阳性率为32.1%;甲亢复发组TRAb的测定值阳性率为90.3%;单纯性甲状腺肿组TRAb的测定值阳性率为0;甲瘤组TRAb的测定值阳性率为0;甲亢组、甲亢缓解组、甲亢治愈组、甲亢复发组与正常对照组相比有显著性差异(P<0.01);单纯性甲状腺肿组、甲瘤组与正常对照组相比无显著性差异(P>0.05)。结论:TRAb的测定对G raves甲亢的治疗具有重要的参考价值。     

Long-term pathologic changes of alpha1-acid glycoprotein (orosomucoid) glycoforms in autoimmune thyroid disease

OBJECTIVE: We measured alpha1-acid-glycoprotein (AGP) in patients with autoimmune thyroid disease to study a possible relationship between microheterogeneity of the naturally occurring glycoforms of AGP and autoimmune thyroid disease. DESIGN, PATIENTS, MEASUREMENTS: In a group of 12 fasting thyrotoxic patients (11 females, mean age: 43 years) with newly diagnosed Graves' disease (subgroup 1), we measured serum concentrations of total AGP and its 3 glycoforms (micromol/l, crossed affinity immunoelectrophoresis with con A in the first dimension gel) as well as total thyroxine, total triiodothyronine, thyrotropine, thyroid peroxidase antibodies (anti-TPO), antibodies against the TSH receptor (TRAb, TRAK), at baseline and after 12 months of antithyroid drug therapy (ATD). For comparison, 4 subgroups of thyroid patients (patients with Graves' disease and thyroid associated ophthalmopathy (TAO) (subgroup 2, n = 10), radioiodine treated Graves' patients (subgroup 3, n = 7), Graves' patients without TAO (subgroup 4, n = 13), patients with Hashimoto's thyroiditis (subgroup 5, n = 8)) and 25 normal controls (17 females, mean age: 38 years) were studied. RESULTS: In subgroups of TRAb positive Graves patients' serum levels of glycoform 1, 2 or 3 increased significantly (p < 0.005) after 12 months of ATD as compared to both baseline of that person or normal controls. No significant changes were found in the TRAb negative Hashimoto subgroup. CONCLUSION: Patients with autoimmune Graves' disease changed their relationship to AGP, and thus a role of AGP and its 3 glycoforms is suggested in the pathogenesis of Graves' disease.     

Marked increase of CD5 + B cells in hyperthyroid Graves' disease

We examined the proportions of B lymphocytes bearing CD5 cell surface antigen (CD5+ B cells), which are capable of making autoantibodies, in peripheral blood from patients with various thyroid diseases. The level of CD5+ B cells was markedly increased (>9.0%) above the normal range (0.5-7.7%) in untreated, hyperthyroid patients with Graves' disease, although about 10% of the patients had no detectable serum thyroid-stimulating hormone (TSH) receptor antibody (TRAb). However, the levels of CD5+ B cells were normal in untreated patients with destructive thyrotoxicosis due to aggravation of Hashimoto's thyroiditis or subacute thyroiditis. In patients with stimulated hyperthyroid Graves' disease the levels of CD5+ B cells were correlated with those of thyroid hormones and TRAb, all significantly increased. However, once hyperthyroidism was controlled by anti-thyroid drugs, CD5+ B cells were decreased, followed in turn by reduction of TRAb. We conclude that the proportion of CD5+ B cells is useful as a therapeutic index and for diagnosis of Graves' disease and its differentiation from destruction-induced thyrotoxicosis.     

Thyroid function tests

About 80% of thyroid disease consists of thyroid-specific autoimmune diseases, Hashimoto's disease and Grave's disease. To diagnose thyroid diseases, testings for (1) thyroid function and (2) pathogenetic autoantibodies are indispensable. To assess thyroid function, serum hormone concentrations, such as TSH, FT4 and FT3 are measured. Among these hormones, serum TSH concentrations are the most reliable and informative regarding thyroid function, correcting indicating a hyperthyroid, euthyroid or hypothyroid state. Therefore, TSH measurement appears to be the first choice in selecting the hormone determination. Reference intervals for normal healthy subjects of TSH are around 0.4-5.0 microU/ml. The second choice for thyroid function assessment are FT4 which supersedes total T4(TT4). TT4 is affected by changes in serum thyroid hormone binding proteins(TBG, TTR, Albumin). For example, euthyroid pregnant women whose serum TBG are physiologically higher than those of non-pregnant women show augmentation of TT4. However, FT4 depicts within reference intervals, although measurement of FT4 alone is unable to detect any abnormality of thyroid hormone binding proteins. According to its plasma concentration and binding affinity, FT3 measurement deserves no more significance than T3. Another important test for thyroid diseases is to detect serum autoantibodies against thyroid tissues, such as TgAb, TPOAb. Much more important is TSH receptor antibody which differentiates Graves' disease from Hashimoto's thyroiditis. In patients who show hyperthyroidism and some very uncommon hypothyroidism, TSH receptor antibodies should be measured. Three indicators are available as routine tests; TRAb measured by radioreceptor assay; TSAb determined by bioassay using cultured porcine thyroid cells. Usually, TRAb activity clinically correlates well with TSAb. TSBAb was initially discovered in patients with severe hypothyroidism with atrophic thyroid gland. TSBAb blocks thyroid stimulating activity of TSH and consequently causes severe hypothyroidism. TRAb and TSAb are very useful to diagnose and follow patients with Grave's disease.     

TGA、TPO-Ab、TRAb和TSH在自身免疫性甲状腺病中的临床应用

目的：探讨TGA、TPO-Ab、TRAb和TSH在自身免疫性甲状腺病中的诊断和鉴别诊断价值。方法：采用化学发光法检测80例自身免疫性甲状腺病患者（桥本甲状腺炎40例,Graves病40例）、50例甲状腺结节患者和40例正常对照者血清TGA、TPO-Ab、TRAb和TSH水平,通过ROC曲线评估最佳诊断阈值。结果：自身免疫性甲状腺病（桥本甲状腺炎和Graves病）患者与非自身免疫性甲状腺疾病（甲状腺结节）患者血清TGA、TPO-Ab的差异有统计学差异（P〈0.01）,非自身免疫性甲状腺病患者组与正常对照组比较无统计学意义（P〉0.05）。在自身免疫性甲状腺病患者中,Graves病患者TRAb水平高于桥本甲状腺炎患者（P〈0.01）,而TSH水平低于桥本甲状腺炎患者（P〈0.01）。通过ROC曲线分析,当TGA、TPO-Ab分别为70.2U/ml、105.65IU/ml时,对自身免疫性甲状腺病的诊断具有最高的灵敏度和特异性;当TRAb、TSH分别为2.25IU/ml、0.60μlU/ml时,对Graves病和桥本甲状腺炎的鉴别诊断价值最高。实验室建立的参考值与试剂盒提供的参考值比较,具有更高的特异性。结论：TGA和TPO-Ab对自身免疫性甲状腺病的诊断具有重要意义,而TRAb和TSH对鉴别诊断Graves病和桥本甲状腺炎具有重要的临床应用价值。每个实验室有必要建立自己的参考范围,为临床和病人提供更准确、有效的信息。     

The influence of Epstein-Barr virus reactivation in patients with Graves' disease

In Graves' disease, the IgG class autoantibody against thyrotropin receptor (TRAb) is produced excessively and induces hyperthyroidism. Epstein-Barr virus (EBV) is one of the human herpesviruses that persists for life, mainly in B lymphocytes, and is occasionally reactivated. Therefore, EBV may affect the antibody production of B lymphocytes that would normally produce TRAb. The purpose of the present study was to evaluate the association of EBV reactivation with the etiology of Graves' disease. Serum levels of EBV antibodies and IgE were determined by ELISA. TRAb levels were determined by radioreceptor assay. We performed in-situ hybridization (ISH) of EBV-encoded small RNA (EBER)1 on the thyroid tissue of one of our patients. In Graves' disease patients with TRAb levels ≥ 10%, EA antibody levels, which indicate EBV reactivation, were moderately but significantly correlated with the levels of TRAb, and weakly but significantly correlated with IgE. EBER1-ISH revealed that one of our patients had EBV-infected lymphocytes infiltrating the thyroid gland. EBV reactivation may stimulate antibody-producing B lymphocytes predisposed to make TRAb, and this may contribute to or exacerbate the disease.     

血清TRAb检测在Graves甲亢治疗中的意义

目的：探讨血清TRAb值在Graves甲亢患者治疗前后的改变及其临床意义。方法：50例正常人和42例Graves甲亢患者在丙基硫氧嘧啶治疗前、后分别用放射免疫分析作了血清TRAb,TSH,FT3,FT4,rT3检测。结果：未经ATD治疗的Graves甲亢患者,血清TRAb阳性率为88％。Graves甲亢患者接受ATD治疗后3个月时,TRAb阳性率为57．14％,其它检测指标除rT3外均与正常组无明显差异（P＞0．05）;6个月时TRAb阳性率为17．50％;12个月时为7．69％;24个月时为5．71％。本组临床缓解停药后有15例复发,该15例中13例（88．66％）血清TRAb原为阳性,显示确有关联。结论：血清TRAb的检测有助于指导Graves甲亢患者的治疗。     

Differential immunosuppressive action of carbimazole and propylthiouracil.

Carbimazole and Propylthiouracil (PTU) are widely used in the treatment of Graves' disease, although controversy still exists as to whether or not they have any direct effect on the immune system. While many previous studies have investigated the possible effects of one or other of these drugs on the immune system only a few have directly compared the effects of equivalent doses of each drug. This study aimed to examine the effects of both drugs, during the initial 8 weeks of treatment, on various biochemical and immunological parameters. The results obtained showed that while thyroid hormone levels fell at similar rates in both treatment groups, TRAb levels and T cell subset abnormalities returned towards normal more rapidly in patients receiving Carbimazole compared to PTU. These results indicate that the effects of Carbimazole on TRAb levels and T cell subset abnormalities are not due solely to its action in controlling the biochemical features of Graves' disease and provide indirect evidence of an action on the immune system in vivo.     

Heterogeneity of thyrotropin binding inhibitor immunoglobulins in serum from untreated patients with hyperthyroid Graves' disease.

We have previously established an assay for the simultaneous assessment of thyrotropin (TSH) binding inhibitor immunoglobulin (TBII) and thyroid stimulating autoantibody activities in cultured rat thyroid cells (FRTL-5 cell), and found a discrepancy in some patients with untreated Graves' disease between the activities of TBII measured in FRTL-5 cells (TBII-rc) and in solubilized thyroid membranes (TBII-pm). In three selected patients with untreated Graves' disease, the different dose-response relationship between TBII-rc and TBII-pm clearly indicated the heterogeneous populations of TBII-pm in patients' sera, with different binding affinities for TSH receptor in intact cells.     

Graves病孕妇丙基硫氧嘧啶治疗后血清TRAb动态检测的临床意义

目的:探讨Graves病孕妇服用丙基硫氧嘧啶治疗后血清TRAb以及甲状腺功能检验值的变化规律及其临床意义.方法:应用放射性受体分析和电化学发光免疫分析动态检测Graves病孕妇服用丙基硫氧嘧啶后的血清TRAb和游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺激素(TSH)水平.结果:孕早期Graves病...     

Graves病患者TRAb与抗TSHAb抗体关系的初步研究

根据自身免疫性甲状腺疾病发病机制的独特型－抗独特型免疫免疫学说，用兔抗人ＴＳＨＡｂ检测ＴＳＨ抗独特型抗体（ＴＳＨＡｂ２）。以正常人为对照，以其结合率＾－ｘ＋２ｓ为正常值上限，大于此值为阳性。６０例ＴＲＡｂ阳性病人，６５％病人ＴＳＨＡｂ２阳性，而４０例ＴＲＡｂ阳性病人中，只有５％病人ＴＳＨＡｂ２阳性。两组差异显著（Ｐ〈０．０５）。ＴＲＡｂ和ＴＳＨＡｂ２呈正相关（ｒ＝０．６４５，Ｐ〈０．０１）。同时用     

Autoantibodies highly increased in patients with thyroid dysfunction

To evaluate the significance of antithyroid antibodie levels, five hundred and twenty-six patients with thyroid diseases and 292 health subjects from Yuci district, Shanxi province, China, were studied. Serum levels were determined for thyroid hormone receptor antibody （TRAb）, microsomal antibody （TMAb） and thyroglobulin antibody （TGAb）. Among patients, the percentages for nodular goiter and thyroid adenoma, Graves＇ disease, and Hashimoto＇s thyroiditis are 44.1%, 19.6% and 17.7%, respectively. The ratios of female to male were 2.0 to 15.6. Antibody-positive patients for TMAb, TGAb and TRAb were detectable as 94.6%, 76.3% and 20.4% for Hashimoto＇s thyroiditis, and 40.0%, 30.0% and 90.3% for Graves＇s disease. In conclusion, the high levels of the TRAb in Graves＇ disease, and those of the TGAbFFMAb in Hashimoto＇s thyroiditis and idiopathic hypothyroidism are meaningful for characterizing the epidemiological basis of the diseases and for using as prognostic indicators for the relapse in individual patients. Cellular ＆ Molecular Immunology.     

Immunoblotting for the detection of TSH receptor autoantibodies.

Immunoblotting was optimized to detect autoantibodies to TSH receptors from human and porcine thyroid tissue and to determine their epitope specificity. Autoantibodies to putative TSH receptor proteins in thyroid particulate membranes were detected in approximately 35% of sera from patients with Graves' disease. However, despite modifications to increase immunoblotting sensitivity and specificity, only a minority (less than 15%) of Graves' disease sera contained autoantibodies that identified epitopes within TSH affinity-purified human or porcine receptor proteins. In these sera there was no correlation between the TSH receptor antibody titre, determined by radioreceptor assay, and receptor epitope reactivity. The sensitivity of immunoblotting was limited by reduced transfer of purified receptor from the gel. However, in addition, the inability to immunoblot the purified receptor with a majority of Graves' sera, under conditions designed to enhance receptor renaturation, appears to reflect a strict conformational requirement for immunoreactivity. Immunoblotting of purified receptors therefore has a limited application in detecting, and defining the epitope reactivity of, TSH receptor autoantibodies.     

Thyroid-stimulating antibodies in patients with long-term remission of Graves' hyperthyroidism

Summary The persistence of TSH receptor antibodies in Graves' disease despite the remission of hyperthyroidism has been described. Our study was designed to evaluate whether this extends to functionally active stimulators of the thyroid, since the occurrence of thyroid-stimulating antibodies (TSAb) in a euthyroid patient could well have important implications on our understanding of the pathogenetic role of such autoantibodies. Forty-four patients with a previous history of Graves' hyperthyroidism were reexamined after having been in long-lasting remission for 3 to 35 years (mean 8 years). Of the patients 16 had been treated by radioiodine, 17 by surgery, and 11 exclusively by antithyroid drugs. The determination of TSAb was based on T3 release from thyroid tissue in vitro to document the final response to these immunoglobulins. TSH-binding inhibiting immunoglobulins (TBII) were evaluated by a radioreceptor assay.TSAb were highly elevated in three of the 44 patients. These three patients showed a normal TSH response to i.v. TRH, suffered from endocrine ophthalmopathy, and had been treated by radioiodine for hyperthyroidism. TBII were found positive in seven patients including the three patients mentioned. The majority of patients positive for TSAb or TBII had been treated by radioiodine and none exclusively by antithyroid drugs.In conclusion, not only TBII but also T3 release-stimulating antibodies may occur in a minority of patients with long-term remission of Graves' hyperthyroidism. However, an absence of hyperthyroidism in these patients despite the presence of such thyroid stimulators seems to be only possible in association with a lack of functional responsiveness of the target organ due to previous administration of destructive therapies. Moreover, a major role of TBII in the absence of TSAb representing stimulatory inactive autoantibodies to the maintenance of remission was not apparent.Abbreviations cAMP cyclic adenosine monophosphate - T3 triiodothyronine - T4 tetraiodothyronine - TBII TSH-binding inhibiting immunoglobulins - TRH TSH-releasing hormone - TSAb thyroid-stimulating antibodies - TSH thyroidstimulating hormone     

三种促甲状腺素受体抗体检测试剂的比较

目的：评价某国产促甲状腺素受体抗体（TRAb）检测试剂的临床诊断性能,为临床应用提供指导。方法：应用国产TRAb试剂与两种进口同种试剂（德国Roche和英国RSR）同时检测77份临床样本,对比分析三种试剂检测结果的相关性、符合率,并结合历史资料回顾,计算国产试剂对Graves’病的诊断敏感性。结果：两种进口试剂所测TRAb在Graves’病的阳性比例均为13/15,对本文样本阴、阳性分类符合率为89.6%,总体相关系数为0.767（P〈0.001）。国产TRAb试剂在本文Graves’病阳性比例为2/15,在历史回顾病例的阳性比例为5/31;与两种进口试剂比较符合率〈60%、检测浓度相关系数〈0.2（P〉0.1）。结论：两种进口TRAb试剂对Graves’病具有较高的临床诊断性能并相互吻合,某国产TRAb试剂缺乏临床应用价值,建议摒弃。     

Immunology of the thyrotropin receptor.

Antibodies to the thyrotropin receptor appear to be responsible for hyperthyroidism in Graves' disease. The antibodies, described as thyroid-stimulating antibodies (TSAb) mimic the effects of thyrotropin (TSH) by binding to the TSH receptor and activating adenylate cyclase. TSAb consist of an electrophoretically heterogeneous population of IgG and the thyroid-stimulating site is formed by combination of heavy and light chains in the Fab part of the molecule. Binding studies indicate that the TSAb molecule interacts monovalently with membrane bound TSH receptors and that TSAb consists of an antibody population which shows a restricted heterogeneity with regard to TSH receptor affinity. Studies in patients with Graves' disease and hyperthyroidism indicate that the levels of TSAb correlate well with thyroidal iodine uptake and the absence of pituitary control of thyroid function. However in some patients with ophthalmic Graves' disease or autoimmune thyroiditis there is evidence of serum antibodies which interact with the TSH receptor but are unable to stimulate thyroid function.     

TSH receptor autoantibody immunoassay in patients with Graves' disease: Improvement of diagnostic accuracy over different generations of methods. Systematic review and meta-analysis

BackgroundTSH receptor antibodies (TRAb) are the diagnostic hallmark of Graves' disease (GD) and immunoassays for their detection have been available for more than 30 years over three generations of laboratory methods. Despite a growing body of data produced by clinical and laboratory research which demonstrates its elevated sensitivity and specificity, TRAb testing is poorly used for diagnosing GD.The aim of our systematic review and meta-analysis is to verify the diagnostic performance of TRAb detected with 2nd and 3rd generation immunoassay methods.MethodsWe searched for English articles using MEDLINE with the search terms “TSH receptor antibody assay”, “TSH Receptor antibody tests” and “Graves' disease”. We analyzed studies reporting on TSH receptor antibody tests performed by quantitative immunoassays, on untreated patients with GD as the index disease (sensitivity) and on a control group of either healthy subjects or patients affected by other thyroid diseases (specificity).A total of 681 titles were initially identified with the search strategy described. 560 publications were excluded based on abstract and title. Full-text review was undertaken as the next step on 111 publications providing data on TRAb testing; 58 articles were subsequently excluded because they did not include untreated GD patients, or used either bioassays or 1st generation immunoassays. 32 were also excluded because they included data only on sensitivity or only on specificity of the assay, or were duplicates. Finally, 21 articles were selected for meta-analysis.Extraction of data from selected articles was performed by two authors independently, using predefined criteria: the number of patients with GD and the number of healthy or diseased controls; specification of the analytical method used to detect TRAb; sensitivity and specificity of the assay.ResultsThe meta-analysis showed that the overall pooled sensitivity and specificity of the 2nd and 3rd generation TRAb assays are 97.1% and 97.4%, and 98.3% and 99.2%, respectively, with little difference between the types of immunoassay methods employed (human or porcine receptor, manual or automated procedure). The likelihood of a TRAb-positive individual to have GD is 1367- to 3420-fold greater (depending upon the type of assay) compared to a TRAb-negative person.ConclusionsData from the meta-analysis showed that TRAb measured with 2nd and 3rd generation immunoassay methods have very high sensitivity and specificity in the diagnosis of GD. The difference between 2nd and 3rd generation methods is small and is equally useful. In contrast with recommendations made by clinical endocrinologists who are not familiar with the state of the art in diagnostic technologies of autoimmunology laboratories, we propose a wide application of these tests in clinical practice to screen all hyperthyroid patients.     

Determination and clinical significance of anti-idiotypic antibody--in model experiments of thyroglobulin and TSH]

Anti-idiotypic (anti-ID) antibody in test serum was determined by the direct binding assay using 125I-anti-human thyroglobulin (hTg). Several positive cases were found in Graves' disease and thyroiditis chronica. Positive anti-ID antibodies could be classified into two types. Type 1 showed the positive anti-hTg antibody and high Tg levels by RIA using double antibody method. Type 2 showed the positive anti-hTg antibody but low Tg levels by RIA. The binding of 125I-hTg to anti-hTg antibody was displaced by anti-ID antibody in type 1, but was not anti-ID antibody in type 2. A case of coexistence of autoantibody to hTSH and auto-anti-ID antibody to anti-hTSH antibody was found. She showed normal thyroid function (T4, T3), but TSH level showed discrepancy by different assay methods. Both autoantibodies for hTSH and for anti-hTSH antibody were demonstrated by the reaction of patient's antibody with both 125I-hTSH and 125I-anti-hTSH (MoAb). These two autoantibodies belong to the polyclonal IgG. The autoantibody for hTSH recognized only the beta-subunit of hTSH. Neither stimulating type of TSH receptor antibody (TRAb) nor blocking type of TRAb interfered with the binding of patient's anti-ID to 125I-anti-hTSH. This binding reaction could be inhibited by the unlabeled hTSH. This anti-ID might represent the internal image of the non-biological active site of TSH molecule, because of absence of thyroid stimulating activity. These anti-ID antibodies may provide evidence supporting a network theory of the immune system.     

Human lymphocyte antigens (HLA) and Graves' disease in Turkey

To evaluate the association of HLA types with Turkish patients with Graves' disease, HLA typing, clinical findings, and thyroid antibodies were correlated. The HLA types, clinical findings (ophthalmopathy and age at onset), and thyroid stimulating hormone (TSH) receptor (TRAb) and antithyroid microsomal antibodies (MAb) were analyzed. Seventy Turkish patients with Graves' disease and 306 control subjects were assessed. Serological HLA typing was performed in HLA A, B, C, DR, and DQ loci. There was a significantly increased prevalence of HLA B8, B49, DR3, DR4, and DR10 in Graves' disease. The association of Graves' disease with HLA DR3 was found to be less strong than previously described. The HLA DR4 antigen may contribute to the predisposition of Graves' disease in Turkey. The results suggest that HLA B7, B13, DR7, DQw2, and DQw3 may confer a protective effect for Graves' disease in Turkey. Patients carrying HLA B12, B18, and B44 haplotypes had a tendency to develop the disease at a later age. The difference from the other studies may be the result of the selection of the controls; in part, of the variability in serological typing reagents; and, also, of the rather weak HLA associations with the disease.This study was presented in part at the Annual Meeting of the National Endocrinology and Diabetes Association, Bursa, Turkey, May 25–28, 1992.