AUTOANTIBODIES PRECEDING AUTOIMMUNE DISEASES

Transcription

1 AUTOANTIBODIES PRECEDING AUTOIMMUNE DISEASES STUDY GROUP - AUTOANTIBODY STANDARDIZING COMMITTEE Washington, November 12th 2012 Luis Eduardo Coelho Andrade, M.D, Ph.D. Associate Professor Rheumatology Division UNIFESP luis.andrade@unifesp.br Consultant in Immunology Fleury Medicine & Health luis.andrade@fleury.com.br

2 Conflict of interest Immunology consultant to Fleury Medicine & Health Laboratories (private clinical laboratory )

3 Autoantibodies precede clinical manifestations of autoimmune diseases Detectable autoantibody Time frame Tissue injury Autoantibodies precede the clinical onset of various autoimmune diseases Anti-perinuclear factor (APF) & RA (Aho et al, 1985) Anti-insulin & type I diabetes (Dean et al, 1986) Anti-thyroid peroxidase & Hashimoto`s disease (Watanabe et al, 1995) Anti-dsDNA & SLE (Arbuckle et al, 2003) Anti-CCP e RA (Rantapää-Dahlqvist et al, 2003) AMA & PBC (Crosignani et al, 2008)

4 Clinical-immunological temporal dissociation Horizon of events timeline Autoantibody detection Clinical onset

5 Clinical-immunological temporal dissociation Clinical stage Horizon of events timeline Autoantibody detection Clinical onset

6 Clinical-immunological temporal dissociation Immunological stage Horizon of events timeline Autoantibody detection Clinical onset

7 Clinical-immunological temporal dissociation What is going on here? Is an evolving process going on? Horizon of events timeline Autoantibody detection Clinical onset

8 Clinical-immunological temporal dissociation Progression on the underlying immunological disorder? - Titer increase? Avidity increase? Ig isotype? - Spreading of targets? - epitope? molecules? Horizon of events timeline Autoantibody detection Clinical onset

9 Autoantibodies precede Primary Biliary Cirrhosis for decades AMA AMA + Sp-100 Ascitis Portal hypertension Ictericia Biliary tract lymphocyte accumulation gp-210 Centromere

10 Facts about Primary Biliary Cirrhosis Autoimmune liver disease with inflammation and injury to epithelial cells of intrahepatic biliary ducts; Th17 cells and Treg cells; Female preponderance; Peak of incidence fifth decade; Prevalence women above 40 years old (1:1000); Heterogeneous disease evolution; Anti-mitochondria antibodies precede the disease for years or decades.

11 Concept of pre-biochemical stage of PBC Earliest PBC-specific manifestation ==> increase in serum alkalyne phosphatase AMA & normal liver enzymes Biochemically normal - BN - PBC Primary biliary cirrhosis

12 ow different is the humoral autoimmune response before and after PBC ecclosion? Biochemically normal - BN Primary biliary cirrhosis - PBC Horizon of events timeline Autoantibody detection Clinical onset

13 The bait...

14 AMA individuals with normal serum alkaline phosphatase n = 82 X PBC patients n = 130 Serum concentration of autoantibodies; Avidity of anti-pdc-e2 antibodies ( fraction M2 ); Isotype class of AMA (IgG, IgM, IGA); Number of targeted autoantigens. Dellavance A, Andrade LEC et al, Hepatol Int, in press

15 Other autoantibodies associated with PBC anti-gp-210 Anti-Sp-100 Anti-centromere

16 Autoantibodies in pre-biochemical stage of PBC Methods for evaluation of autoantibodies a. Indirect immunofluorescence on rodent tissue b. ELISA for antibodies to PDC-E2 antibodies ( M2 fraction ), gp210, Sp-100, CENP-B c. Relative avidity of anti-pdc-e2 IgG urea 8M Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

17 Anti-PDC-E2 (arbitrary units) PBC had higher anti-pdc-e2 serum levels than AMA BN p <0.001 GROUPS Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

18 Relative avidity PBC had higher anti-pdc-e2 avidity than AMA BN p <0.001 GROUPS Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

19 Anti-gp210 (arbitrary units) PBC had higher anti-gp210 serum levels than AMA BN p =0.011 GROUPS Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

20 PBC (triple and double isotype AMA) & BN (mono-isotype AMA) PBC had higher anti-pdc-e2 avidity than AMA BN 60 p = CBP BN PBC BN isotype 2 isotypes 3 isotypes Number of Ig Classes (IgA, IgG, IgM) in Rat Tissue IIF

21 Cell domains targeted by autoantibodies Mitochondria Nuclear envelope PML Centromere Tissue - IFI ELISA ELISA & ANA-HEp-2 Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

22 PBC serum recognized more cell domains than BN 60 p = CBP BN PBC BN domain 2 domains 3 domains 4 domains Number of Cell Domains Targeted in HEp-2 IIF

23 Established PBC AMA - BN individuals with normal liver enzymes High titer anti-pdc-e2 High affinity anti-pdc-e2 IgG High titer anti-gp210 Triple and double AMA isotype 2 cell domains targeted Low titer anti-pdc-e2 Low affinity anti-pdc-e2 IgG Low titer anti-gp210 Mono AMA isotype Only 1 cell domain targeted

24 Progression in humoral autoimmune response? Low titer anti-pdc-e2 Low affinity anti-pdc-e2 IgG Low titer anti-gp210? Mono AMA isotype Only 1 cell domain targeted High titer anti-pdc-e2 High affinity anti-pdc-e2 IgG High titer anti-gp210 Triple and double AMA isotype 2 cell domains targeted Horizon of events timeline Autoantibody detection Clinical onset Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

25 Preliminary evaluation of longitudinal follow-up AMA BN Serial samples available for 13 of 82 cases (16%) Auto-antibody parameter IIF-AMA 1/40 Non-reactive 1/640 Anti-PDC-E2 IgG Non-reactive Non-reactive 5.7 Anti-PDC-E2 IgG avidity (%) Non-reactive Non-reactive 65 WB-AMA bands (kda) 52 74, 52 74, 52

26 Preliminary evaluation of longitudinal follow-up BN & BN/AID (n = 13) 1/13 (7.6%) STABLE NO DECLINE 12/13 (92.3%) EXACERBATION PBC & PBC/AID (n = 26) 14/26 12/26 (53.8%) STABLE DECLINE NO Exacerbation (46.2%)

27 Clinical-immunological temporal dissociation Is there any tissue inflammation or injury at this stage? Horizon of events timeline Autoantibody detection Clinical onset Dellavance A, Baldo D, Andrade LEC et al, in submission

28 Per-cutaneous liver biopsy in an asymptomatic individual?

29 Biochemical biomarkers of liver fibrosis & inflammation Type III Procollagen N-terminal Propeptide (PIIINP) Synthesis and degradation of type 3 collagen Tissue inhibitor of metalloproteinase 1 (TIMP-1) Liver tissue remodelling Hyaluronic acid (HA) Structural tissue organization, Water distribution in the extracellular matrix Rosenberg et al, Gastroenterol 127: 1704, 2004

30 Enhanced Liver fibrosis (ELF) SCORE

31 ELF score in PBC and AMA BN PBC (n = 30) BN (n = 45) Dellavance A, Baldo D, Cançado E, Andrade LEC et al, unpublished

32 Changing paradigm Immunological stage Detectable autoantibody Time frame Clinical stage Tissue injury

33 Which one is easier to fight?

34 Is it possible to treat asymptomatic autoimmune diseases or to prevent autoimmune diseases?

35 Preventive treatment of autoimmune diseases? Ursodeoxycholic acid is beneficial when administered early in the natural history of PBC (Ishibashi H et al, Intern Med 50: 1, 2011) Antimalarial treatment is associated with later onset of systemic lupus erythematosus (James JA et al, Lupus. 16:401, 2007) Primary prevention in anti-phospholipid antibody carriers (Bertero MT, Lupus 21: 751, 2012) Hyperbaric oxygen therapy (HOT) in pre-diabetic NOD mice decreases the incidence and severity of type I DM (Faleo et al, Diabetes 61: , 2012)

36 Concluding remarks. Patients with established PBC presented a more vigorous humoral autoimmune response than asymptomatic individuals with normal alkaline phosphatase levels, characterized by: Higher serum levels of anti-mitochondrial and anti-gp210 antibodies Higher relative avidity of anti-mitochondrial antibodies Triple or double isotype autoantibodies Autoantibodies targeting a higher number of cell domains.

37 Concluding remarks. Patients with established PBC presented a more vigorous humoral autoimmune response than asymptomatic individuals with normal alkaline phosphatase levels, characterized by: Higher serum levels of anti-mitochondrial and anti-gp210 antibodies Higher relative avidity of anti-mitochondrial antibodies Triple or double isotype autoantibodies Autoantibodies targeting a higher number of cell domains. Preliminary longitudinal follow-up indicates that asymptomatic individuals with normal alkaline phosphatase tended to present exacerbation of the autoimmune humoral response

38 Concluding remarks. The immunological disorder in pre-clinical stages of autoimmune diseases exhibit a dynamic behavior with progressive intensification and amplification of the humoral autoimmune response

39 Concluding remarks. The immunological disorder in pre-clinical stages of autoimmune diseases exhibit a dynamic behavior with progressive intensification and amplification of the humoral autoimmune response The pre-clinical stages of autoimmune diseases offer a potential opportunity for early intervention and prevention of instatement of full-blown disease

40 ACKNOWLEDGMENTS Alessandra Dellavance. Danielle Baldo & Cristiane Gallindo Research and Development Department, Fleury Medicine and Health Laboratories. Alessandra Danielle Eduardo Luiz Rachid Cançado, Michelle Harriz, & Clarice Abrantes- Lemos Hepatology Division Universidade de São Paulo Eduardo Support: São Paulo State Research Support Agency (FAPESP) & Brazilian National Council for Research (CNPq)