AUTOANTIBODIES PRECEDING AUTOIMMUNE DISEASES STUDY GROUP - - PowerPoint PPT Presentation

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

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

Autoantibodies precede clinical manifestations of autoimmune diseases Time frame Detectable autoantibody 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)

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

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

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

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

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 Clinical onset detection

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

Facts about Primary Biliary Cirrhosis  Autoimmune liver disease with inflammation and injury to epithelial cells of intra- hepatic 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.

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

How 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

The bait....

AMA  individuals with normal serum alkaline X PBC patients phosphatase n = 130 n = 82  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

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

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

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

PBC had higher anti-PDC-E2 avidity than AMA  BN p <0.001 Relative avidity GROUPS Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

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

PBC (triple and double isotype AMA) & BN (mono-isotype AMA) PBC had higher anti-PDC-E2 avidity than AMA  BN 60 p =0.006 50 40 PBC CBP 30 BN BN 20 10 0 1 isotype 2 isotypes 3 isotypes Number of Ig Classes (IgA, IgG, IgM) in Rat Tissue IIF

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

PBC serum recognized more cell domains than BN 60 p =0.002 50 40 PBC CBP 30 BN BN 20 10 0 1 domain 2 domains 3 domains 4 domains Number of Cell Domains Targeted in HEp-2 IIF

AMA  - BN individuals with normal liver enzymes Established PBC High titer anti-PDC-E2 Low titer anti-PDC-E2 High affinity anti-PDC-E2 IgG Low affinity anti-PDC-E2 IgG High titer anti-gp210 Low titer anti-gp210 Triple and double AMA isotype Mono AMA isotype ≥2 cell domains targeted Only 1 cell domain targeted

Progression in humoral autoimmune response? Low titer anti-PDC-E2 ? Low affinity anti-PDC-E2 IgG Low titer anti-gp210 Mono AMA isotype High titer anti-PDC-E2 Only 1 cell domain targeted High affinity anti-PDC-E2 IgG High titer anti-gp210 Triple and double AMA isotype ≥2 cell domains targeted Horizon of events timeline Autoantibody Clinical onset detection Dellavance A, Cançado E, Andrade LEC et al, Hepatol Int, in press

Preliminary evaluation of longitudinal follow-up AMA  BN Serial samples available for 13 of 82 cases (16%) Auto-antibody 2003 2008 2009 parameter IIF-AMA 1/40 Non-reactive 1/640 Anti-PDC-E2 IgG Non-reactive Non-reactive 5.7 Anti-PDC-E2 IgG Non-reactive Non-reactive 65 avidity (%) WB-AMA bands (kDa) 52 74, 52 74, 52

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

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

Per-cutaneous liver biopsy in an asymptomatic individual?

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

Enhanced Liver fibrosis (ELF) SCORE

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

Changing paradigm “Clinical stage” “Immunological stage” Time frame Detectable autoantibody Tissue injury

Which one is easier to fight?

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

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 61:1769 – 1778, 2012)

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 .

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

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

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