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IL-2 deficiency and associated regulatory T cell (Treg) defects contribute essentially to SLE pathogenesis. In our previous translational work we proved the efficacy and safety of a low-dose IL-2 therapy in animal models and identified a reversible IL-2 deprivation of Treg also in human SLE patients, together providing the rationales for an IL-2-based immunotherapy of SLE in order to restore Treg activity and thus to re-establish endogenous mechanisms of tolerance that can counteract autoimmunity. Here we report for the first time that a repetitive and cyclic, subcutaneously applied, low-dose IL-2-therapy induced a rapid, strong and sustained reduction of disease activity in parallel to a remarkable and selective expansion of the Treg population in a SLE patient with increased disease activity (SLEDAI 14) refractory to a large variety of approved and experimental therapies. Already after the first therapeutic cycle, signs of arthritis and later also myositis and active skin eruptions disappeared. In addition, levels anti-dsDNA antibodies dramatically declined (ELISA) or even turned negative (Crithidia IFT). During the whole therapeutic regimen, the daily dose of glucocorticosteroids could be reduced from 30 mg/d to 10 mg/d, organ manifestations remained absent and disease activity remained low with a SLEDAI of 4 points. The therapy was very well tolerated and adverse events were minimal suggesting that this therapy is also very safe in SLE patients. In summary, these data provide the first evidence that a subcutaneous low-dose IL-2-therapy is capable to enhance Treg activity and to reduce disease activity in SLE patients, strongly supporting the rationales of this novel and pathophysiologically-driven therapeutic approach.

In our Tissue Engineering group a 3D in vitro model for rheumatoid Arthritis (in vitro pannus) was established with the aim to develop a standardized drug-screening test to analyze the effects of drugs and different biological substances. The advanced model consists of chondrocyte pellet cultures interacting with rheumatoid arthritis (RA) synovial cell cultures. To establish interactive 3D co-cultures defined rheumatoid arthritis synovial cell populations were centrifuged directly on chondrocyte pellet cultures. Histochemical stainings during time of co-culture revealed obvious invasion by RA synovial cell populations into the chondrocyte matrix. Gene expression analysis showed a downregulation of collagen type II expression in chondrocytes within 2 weeks after co-culture with RA synovial cells. Those interactive co-cultures allow the study of single cell populations as well as the cellular interactions in this system under in vitro conditions. Thus, the established co-culture model may be suitable for routine screening tests, which can be useful in supplementing animal experiments in basic research and drug testing.

To determine whether patients with Sjögren's syndrome (SS) have abnormalities in Ig Vlambda and Jlambda gene usage, differences in somatic hypermutation, defects in selection, or indications for perturbations of B cell maturation.Individual peripheral B cells from SS patients were analyzed for their Vlambda gene usage by single-cell polymerase chain reaction amplification of genomic DNA and compared with those from normal controls.Molecular differences from controls in Vlambda-Jlambda recombination were identified that were reflected by findings in the nonproductive Vlambda repertoire of the patients, including enhanced rearrangement of Vlambda10A and Jlambda2/3 gene segments. In addition, a number of abnormalities in the productive repertoire were identified, indicating disordered selection. A greater usage of 4 Vlambda genes (2A2, 2B2, 2C, and 7A), representing 56% of all productive Vlambda rearrangements, was observed, suggesting positive selection of these genes. Overutilization of Jlambda2/3 and underutilization of Jlambda7 in both nonproductive and productive Vlambda rearrangements of SS patients compared with controls suggested decreased receptor editing in SS. The mutational frequency did not differ from that in controls, and positive selection of mutations into the productive V gene repertoire was found, similar to that in controls, although mutational targeting toward RGYW/WRCY motifs, typically found in controls, was not found in SS patients.Disturbed regulation of B cell maturation with abnormal selection, defects in editing Ig receptors, and abnormal mutational targeting may contribute to the emergence of autoimmunity in SS.

The mechanisms of IgG anti-double-stranded DNA (anti-dsDNA) antibody induction are incompletely understood. We recently demonstrated a high prevalence of autoantibodies to the C-terminus of SmD1 in patients with systemic lupus erythematosus (SLE) that was closely associated with anti-dsDNA reactivity. The aim of the present study was to analyze the influence of the SmD1 C-terminus on the generation of pathogenic anti-dsDNA antibodies in a murine model of SLE.Female lupus-prone prenephritic (NZB x NZW)F1 mice (NZB/NZW mice) as well as female control BALB/c, NZW, and (BALB/c x NZW)F, mice (CWF1 mice) were subcutaneously injected with keyhole limpet hemocyanin (KLH)-coupled SmD1(83-119). Controls received injections of recombinant SmD1 (rSmD1), KLH-rSmD1, KLH-coupled randomized peptide of SmD1(83-119), ovalbumin, or saline. Animals were monitored for survival and proteinuria and for levels of plasma creatinine, urea, and autoantibodies. In addition, histologic examinations were performed and T cell responses against SmD1(83-119) peptide and rSmD1 protein were determined in SmD1(83-119)-treated and -untreated NZB/NZW mice.Immunization with KLH-SmD1(83-119), but not with control peptide, significantly accelerated the natural course of lupus in NZB/NZW mice, with premature renal failure and increased development of anti-dsDNA antibodies. Control strains of mice remained healthy, with no relevant anti-SmD1(83-119) antibodies detectable even after immunization. In contrast to findings in control mice, a T cell response against SmD1(83-119) was already present in unmanipulated NZB/NZW mice, and this response was further amplified after immunization.The SmD1(83-119) peptide can influence the pathogenic anti-dsDNA response in the NZB/NZW murine lupus model. The data suggest that an SmD1(83-119)-specific T cell response is critical. Therefore, modulation of these autoantigen-specific T cells by tolerance induction may provide a therapeutic approach to specific immunosuppression in lupus.

In biomedical research and in reconstructive surgery, preservation of intact tissue has been an unsolved problem. In this study, we investigated the viability of cryopreserved artificial cartilage and its synthetic activity of cartilage-specific matrix proteins after thawing for in vitro use. A polymer fleece cylinder (diameter = 3 mm; height = 3 mm) was loaded with a suspension of bovine chondrocytes (25 × 106/ml) and encapsulated with fibrin glue. After a culture period of 1 week, the artificial cartilage units were frozen in a cryoprotection solution containing 10% basal medium (RPMI 1640), 10% DMSO and 80% FCS. The freezing procedure consisted of three steps: a 30-min period at +4°C followed by a 24-hour storage at –80°C. After that, the tissue units were transferred into liquid nitrogen (–196°C) for final storage. Using histochemical staining techniques of cryogenic slices, we investigated the ability of cryopreserved artificial cartilage to produce its specific matrix after thawing. A modified MTT assay was used to determine the viability of frozen tissue units in comparison with unpreserved samples at different moments after thawing. Depending on the chondrocytes used for the formation of artificial cartilage, the viability of cryopreserved tissue varied between 65 and 85%. Both the intensity of alcian blue staining for proteoglycans and the azan staining for collagens increased proportionally with incubation time after thawing. These findings indicate that cryopreservation of small artificial cartilage units is possible with a minor loss of cell viability. Secondly, its synthetic activity of cartilage-specific matrix did not decline after the freezing process.

Gold was first used 90 years ago by Robert Koch for the treatment of tuberculosis based on the assumption that rheumatoid arthritis was caused by microbacteria. It soon became clear that this would not explain the action of gold in rheumatoid arthritis, and since then scientists have been struggling to elucidate the mechanisms of gold's action in the treatment of rheumatic diseases. In nearly every area of immunology inhibiting actions of gold could be documented; however, it is still unclear if there is a common denominator or if there are parallel modes of actions which are independent of each other. In any case, also based on recent studies the reactivity of gold compounds with thiol groups appears to the predominant factor. Analyzing the actions of gold in the different phases of an immune reaction suggested that gold plays an important role already in the initiation, namely the uptake and presentation of foreign antigens. Thus, gold is taken up by the macrophages and stored in the lysosomes which are called aureosomes where gold inhibits antigen processing. Especially peptide antigens, which contain sulfur such as cysteine and methionine, are important. Moreover, it could be shown that gold suppresses NF-kappa B binding activity as well as the activation of the I-kappa B-kinase. This mechanism results in a subsequently reduced production of pro-inflammatory cytokines, most notably TNF-alpha, interleukin-1 and interleukin-6. On the subsequent T-cell level, gold has been shown to induce an upregulation of IL-4 mRNA, resulting in a shift of the T-cell population to the Th2 phenotype. Moreover, the activation of T-cells is inhibited. On the effector level, gold inhibits proteolytic enzymes and can result in the destruction of synovial fibroblasts. In conclusion, gold remains one of the most fascinating antirheumatic drugs with multiple modes of actions. The future analysis of molecular mechanisms, especially with regard to signal transduction, will lead to new fundamental knowledge of gold action, possible allowing a further understanding of the pathogenesis of rheumatoid arthritis.

Background The distribution of peripheral B cell subpopulations in SLE is unknown, although a variety of humoral abnormalities are known. Objectives The phenotype and Ig heavy chain gene usage of peripheral B cell subpopulations of patients with active systemic lupus erythematosus (SLE) were examined. Methods Peripheral B cells were characterised by FACS analysis and B cell subpopulations of one patient were characterised for V(D) J gene rearrangements. Results In patients with SLE, there was a marked B lymphocytopenia that affected CD19+/CD27- naive B cells more than CD19+/CD27+ memory B cells leading to a relative predominance of CD27 expressing peripheral B cells. In contrast, CD27high/CD38+/CD19dim/surface Iglow/CD20-/syndecan-1+plasma cells were found at an enhanced frequency in active but not inactive SLE patients. Upon immunosuppressive therapy, CD27high plasma cells and naive CD27- B cells were markedly decreased in the peripheral blood. Mutational analysis of V gene rearrangements of individual B cells confirmed that CD27+ B cells coexpressing IgD were memory B cells preferentially using VH3 family members with multiple somatic mutations. CD27high plasma cells showed a similar degree of somatic hypermutation, but preferentially employed VH4 family members. Conclusion These results indicate that there are profound abnormalities in the various B cell compartments in SLE that respond differently to immunosuppressive therapy.

The ubiquitously expressed intracellular protein formerly designated p68 has been identified as autoantigen at both the antibody and the T cell level in rheumatoid arthritis (RA).We used 2 independent approaches, Edman degradation and matrix-assisted laser desorption ionization-time-of-flight mass spectrometry, to characterize p68, and we compared its features with those of the endoplasmic reticulum stress protein BiP.In synovial sections from RA patients, BiP was highly overexpressed as compared with control sections. Under in vitro stress conditions, BiP was found to translocate to the nucleus and the cell surface. BiP-specific autoantibodies were present in 63% of 400 RA patients, in 7% of 200 patients with other rheumatic diseases, and in none of the healthy subjects. Thus, BiP-specific autoantibodies represent a new diagnostic marker in RA. Furthermore, we found that BiP-specific T cell reactivity was altered in RA. In healthy individuals and patients with other rheumatic diseases, BiP-reactive T cells were undetectable. In RA, overt T cell reactivity to BiP was observed or could be induced by specifically blocking antigen presentation to potentially regulatory T cells.Since overexpression of BiP has been shown to decrease the sensitivity of cells to killing by cytotoxic T cells, BiP overexpression and BiP-specific autoimmunity may be involved in the pathogenesis of RA.

Objective—To investigate further the influence of the autonomic nervous system on chronic rheumatic diseases. Methods—The density and aYnity of ‚2 adrenergic receptors (‚2R) on CD19+ lymphocytes in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSc), as well as intracellular cAMP levels in patients with RA and SLE, were determined. Human peripheral blood mononuclear cells were separated from venous blood of patients and healthy controls by Ficoll-Hypaque density centrifugation. CD19+ lymphocytes were purified by magnetic cell sorting, and ‚2R were determined by a radioligand binding assay with [ 125 I]iodocyanopindolol. Intracellular cAMP levels and ‚2R agonist induced cell death were measured by a radioimmunoassay and flow cytometry using annexin-V binding, respectively. Systemic disease activity of the patients was evaluated using multifactorial scoring systems. Results—The density of ‚2R on peripheral CD19+ lymphocytes was significantly decreased in patients with RA, SLE, and SSc compared with healthy controls. In patients with RA and SSc ‚2R density was negatively correlated with systemic disease activity.Furthermore,although basal intracellular cAMP levels were raised in patients with RA and SLE, the increase of cAMP upon stimulation of ‚2R was significantly reduced in these patients compared with control subjects. Preliminary data suggest that ‚2R agonist induced cell death is diminished in patients with RA exhibiting decreased ‚2R densities. Conclusions—The results of this study show a reduction of ‚2R densities on B lymphocytes mirrored by an impaired intracellular cAMP generation in patients with chronic rheumatic diseases, indicating a decreased influence of the autonomic nervous system on B cells in these conditions. (Ann Rheum Dis 2001;60:505‐510)

Autoreactivity plays a major role in the pathogenesis of RA. The rheumatoid factor has been and still is for now more than 50 years the only autoreactivity that is clinically applied in the diagnosis of RA. This well reflects the current way of thinking that a single antigen or a single cause drives an individual into disease. Although by now many other autoantigens and autoreactivities have been described, their discovery was always on the search for the one and only autoreactivity that causes RA. This includes also immune reactivities directed against xenogenic antigens. But, none of the known RA-associated autoreactivities is present in all RA patients and none of them occurs exclusively in RA. Thus, the observed sensitivities and specificities are well below 100%. Therefore, RA has often been postulated to consist of various immunological subentities with similar clinical symptoms. Nevertheless, none of the autoreactivities correlates with a distinct clinical feature or course of disease. It is about time to say good-bye to the idea that a single antigen or immunoreactvity causes and maintains rheumatoid arthritis. In this paper we present RA as the clinical outcome of an immune system that has shifted from a healthy to an autoimmune steady state. This is accomplished by many different reactivities and autoreactivities that occur either in parallel or one after the other. The entirety of the known RA-associated reactivities and (auto)antigens is presented in detail. The major RA-relevant autoantigens comprise BiP, citrulline, the Sa-antigen, hnRNP A2, p205, IgG, calpastatin, calreticulin, collagen and the shared HLA-DR epitope. The accumulation of factor--involving autoreactivities, cytokines, environmental and genetic factors--that challenge the normal regulatory mechanisms of the immune system lead to a regulatory catastrophe. In individuals developing the clinical features of RA the immune system has been regulated to a new--autoimmune--steady state. This attractor "rheumatoid arthritis" has many features of what has originally been described by Irun Cohen as the immunological homunculus: The healthy immune system is configured such as to direct its attention to major self-antigens. Thus it creates an autoreactivity to many autoantigens as a prerequisite for regulatory mechanisms that are sufficient to control them. The shift from the normal to rheumatoid attractor involves the inflammatory cytokines TNF-alpha, IL-1 and IL-6, autoreactive T- and B cells directed at a variety of synovial and systemic antigens, activated dendritic cells and macrophages, tissue destruction and genetic factors such as the association with shared epitope. Environmental factors involved may also, but do not necessarily, include infection. With the appearance of clinical features of RA, naive, potentially autoreactive T cells infiltrate the synovial compartment and become activated by dendritic cells and other APCs. The autoantigenic peptides that are presented to these T cells are derived from inflammatory cell and tissue destruction as well as from tissue repair and remodeling processes. These T cells proliferate and either provide help to B cells with the specificity to the same antigens or cause direct cytopathic tissue damage. Thereby, more and novel antigens are generated, released and presented again to naive or primed autoreactive T cells. These processes involving cytokines, tissue destruction and autoreactive T cells are sufficient to maintain RA even without the permanent presence of a triggering agent. The recursive autoimmune processes are well consistent with the finding of the many different autoreactivities in RA and their respective sensitivities and specificities. The massive influx of T cells into the arthritic joint is accompanied by the anergization of over 90% of T cells in this compartment--which further substantiates the concept of the RA attractor within the self-regulating immune system. Thereby, the RA-attracted immune system is not able to completely downregulate the inflammation and the local tissue damage/repair. Thus, the immune system is permanently stimulated and suddenly by chance shifts to a stable state different from the healthy system--reaching the wide fields of rheumatoid arthritis which in itself is self-sustaining as the healthy state before disease onset.

To develop a novel 3-dimensional (3-D) in vitro model of Lyme arthritis to use in the study of the interactions between Borrelia burgdorferi (Bb) and human synovial host cells with respect to phagocytosis and potential persistence of Bb as well as the induction of proinflammatory cytokines and chemokines.Two distinct culture systems, consisting of synovial membrane explants or interactive synovial cells embedded in 3-D fibrin matrices, were chosen. Both systems were artificially infected with Bb, and the interactions between Bb and synovial tissue/cells were studied by histology, immunohistochemistry, and electron microscopy. Functional analyses included the induction/secretion of cytokines by Bb in the model system.Both culture systems proved to be stable and reproducible. The host cells and spirochetes showed high levels of viability and maintained their physiologic shape for3 weeks. Bb invaded the synovial tissue and the artifical matrix in a time-dependent manner. Host cells were activated by Bb, as indicated by the induction of interleukin-1beta and tumor necrosis factor alpha. Electron microscopic analysis revealed Bb intracellularly within macrophages as well as synovial fibroblasts, suggesting that not only professional phagocytes, but also resident synovial cells are capable of phagocytosing Bb. Most interestingly, the uptake of the spirochetes appeared to cause severe damage of the synovial fibroblasts, since the majority of these cells displayed ultrastructural features of disintegration.A novel 3-D in vitro model has been established that allows the study of distinct aspects of Lyme arthritis under conditions that resemble the pathologic condition in humans. This reproducible, standardized model supplements animal studies and conventional 2-D cultures. The disintegration of synovial fibroblasts containing Bb or Bb fragments challenges the concept of an intracellular persistence of Bb and may instead reflect a mechanism that contributes to the inflammatory processes characteristic of Lyme arthritis.

The p205 autoantigen is the strongest stimulatory antigen for T cells known in rheumatoid arthritis (RA). It contains an 11 aminoacid stretch identical to a sequence (278-288) located in the CH2 domain of immunoglobulin G. This domain contains the major epitopes of rheumatoid factors. This study aimed to analyze if the p205-specific T cell responses are also directed against RF epitopes and to analyze the role of p205 in the production of rheumatoid factors in general. p205 was enriched from synovial fluid as described earlier. p205-derived peptides were chemically synthesized. T cell proliferation assays were performed with cells obtained from RA and control patients and healthy individuals. Sequencing and mass spectrometry by matrix assisted laser desorption-time of flight (MALDI-TOF) of p205 revealed that it containes sequences with similarity and identity to IgG and other members of the immunoglobulin superfamily. p205 was detected in the synovial membrane of RA patients by antisera specific for p205-derived peptides. Cells staining positive for p205 were also positive for the macrophage marker CD68. p205 staining did never occur in B cell clusters staining positive for CD19 or in T cell infiltrates staining positive for CD3. No B and T cells were detected in the highly p205-positive lining and sublining of the synovial membrane. p205 could react with monoclonal rheumatoid factors (RF). Those RF that reacted also with p205 tended to be of a binding specificity characteristic of RA. Those RF that did not react with p205 tended to be of a binding specificity that is also observed in healthy immunized donors or patients with Waldenstrom's macroglobulominia. Synovial fluid (SF), SF-derived p205 and p205-derived peptides were used as antigens in T cell proliferation assays. As control antigens, a mock peptide and PHA were used. SF, p205 and p205-derived peptides stimulated T cells from two thirds of RA patients, but not from patients with other rheumatic diseases or from healthy individuals. SF, p205 and the 11aa p205 peptide with sequence identity to IgG were extremely high stimulators of proliferation in the majority of RA patients and were often in the range of the mitogen PHA. Two other p205-derived peptides were also stimulatory for RA-derived T cells, but to a lesser degree and at a lower frequency of patients. None of these peptides induced T cell proliferation in patients with other rheumatic diseases or healthy individuals. No reactivity was observed with the mock peptide in any of the patients. T cells specific for p205 cocultured in the presence of IgG-specific B cells induced the production of rheumatoid factors upon stimulation with cognate antigen and the 11mer peptide 3. RFs could also be induced upon immunization of rabbits with peptide 3. p205 is a major target of autoreactive T cells in RA and appears to be a novel member of the immunoglobulin superfamily. It contains an IgG-identical stretch and p205 is targeted by RFs. The IgG-identical peptide 3 stimulates T cells such that they can provide cross-help for RF-secreting B cells in vitro and in vivo. p205 may thus likely be the trigger of RF production in RA and may thus be of pathogenic importance.

Rheumatoid arthritis (RA) is characterized by the occurence of autoreactive antibodies and T cells. RA is heterogneous disease also with respect to these autoreactivities, since none of them is present in every RA patient and they are additionally also present - although to a considerably lesser extent - in other autoimmune diseases and even in healthy individuals. It has now been analyzed if there are clusters of autoreactivites that are absolutely specific for RA. Therefore, the RA-associated autoantigens RA33 (hnRNP A2), cit-rulline, rheumatoid factor (RF), the stress protein BiP (heavy chain binding protein), calpastatin (Calp) and calreticulin (Calr) have either been biochemically purified or used as a kit of of recombinant antigen or chemically synthesized peptides. These antigens have been applied to screen sera and PBMCs from RA and control patients for reactivity and the data have subsequently been subjected to cluster analyses. Analyzing the reactivities of 100 RA and 100 control patients, the following patterns of the three combined autoreactivities were determined to be absolutly specific for RA: RF+Cit+BiP+, RF-Cit+BiP+. RA-specific patterns composed of four autoreactivities are RA33+RF+Cit+BiP+, RA33-RF+Cit+BiP+, RA33+RF+Cit+ BiP-, RA33+RF-Cit+BiP+, RA33+RF+Cit-BiP+, RA33-RF+Cit-BiP+. RA-specific patterns composed of five autoreactivites are RA33+RF+Cit+BiP+Calp+, RA33-RF+Cit+BiP+Calp+, RA33+ RF+Cit+BiP-Calp+, RA33+RF-Cit+BiP+Calp+, RA33+RF+ Cit+BiP+Calp-, RA33+RF+Cit+BiP-Calp-. RA-specific autoreactiv-ities composed of six autoreactivities are RA33+RF+ Cit+BiP+Calp+Calr+, RA33-RF+Cit+BiP+Calp+Calr+, RA33+ RF+Cit+BiP-Calp-Calr+, RA33-RF+Cit+BiP-Calp+Calr+, RA33-RF+Cit-BiP-Calp+Calr-. Other patterns also occured exclusively in RA patients, but the differences did not reach statistical significance. Patterns including p205-reactivity have yet to be analyzed and will be presented. Summing up the RA-specific patterns that are complementary to each other, the sensitivity of the analysis for RA is 54%. It appears evident that analyzing other known and unknown RA-associated autoantigens will further increase the sensitivity of the autoreactivity cluster analysis. The diagnostic confidence will markedly improve by testing autoreactivity patterns that clearly distinguish RA from other rheumatic diseases. The composition of the autoreactivity patterns will also improve our understanding of the pathogenesis.

BiP (heavy chain binding protein) is the major chaperone of the endoplasmic reticulum that interacts transiently with most of the proteins of the secretory pathway and assists in their folding. BiP's function under stress conditions is essential for cell viability and constitutively increasing or decreasing the BiP levels is detrimental to cell growth or to survival. Here, we present the RA autoantigen formerly designated "p68" as identical to BiP and that autoreactivity against BiP is a specific feature of RA. p68 was isolated and proven to be identical to BiP by two different approaches (Edman sequencing and MALDI-TOF mass spectrometry). Using tissue sections, BiP has been shown to be overexpressed in the RA as compared to the OA joint. Applying immunoblots, BiP-reactive autoantibodies were present in 63% of 400 RA patients, in 7% of 200 patients with other rheumatic diseases and in 1 of 150 healthy individuals. In patients with early arthritis approximately 50% are positive. An ELISA was established to quantify anti-BiP antibodies and the data of 400 RA and 400 control patients will be presented. The majority of RA sera was found reactive with a posttranlationally modified form of BiP and the major epitope was O-linked N-acetylglucosamine. Furthermore, we present evidence that BiP-specific T cell reactivity is pathogenically altered in RA. Overt BiP-specific T cell reactivity as determined by T cell proliferation assays could be observed in two thirds of patients with RA, but neither in healthy individuals nor in patients with other rheumatic diseases. Blocking anti-HLA-DR antibodies expectedly decreased T cell proliferation indicating the presence of HLA-DR restricted effector T cells. A subset of RA patients exhibited a BiP-specifically suppressed T cell reactivity. Blocking anti-HLA-DR antibodies in these assays overcame the suppressive effect and allowed an increased proliferation. This argues strongly for the presence of BiP-specific regulatory T cells restricted for HLA-DR and BiP-specific effector T cells restricted for HLA-DP and -DQ in this subset of RA patients. These effects could not be mimicked by blocking anti-IL-10 or anti-TGF-b antibodies, implicating that other factors or also direct cell-cell-contact are required. Apparently, the healthy immune system views BiP as a component to which autoreactivity is either avoided or tightly regulated. In RA this general principle appears to have lost control. BiP-reactive may serve as a new diagnostic marker in RA, while regulatory T cells may provide means for a specific therapy.

Systemic sclerosis (SSc) is characterised by skin fibrosis together with a dysfunction of the immune system and vasculopathy. Until now, only a few accepted treatment options have existed for patients with progressive disease.1 A similar skin fibrosis is seen in graft-versus-host disease, an immunologically mediated disease in recipients of haematological stem cells.2 In graft-versus-host disease, targeting of CD25-positive lymphocytes with a monoclonal antibody (basiliximab) has been shown to reduce its syptoms and complications.3 CD25 is the cluster designation for the high-affinity interleukin-2 receptor expressed on T and B lymphocytes after their activation. Activated lymphocytes are also thought to play a role in the pathogenesis of SSc as patients have elevated serum interleukin-2 receptor levels and the levels correlate with mortality and disease duration.4 5 As we had already treated one rapidly progressive SSc patient refractory to other forms of treatment with the monoclonal antibody basiliximab,6 we started a …

New therapeutic strategies are required in the management of adult-onset Still’s disease (AOSD) refractory to glucocorticoids, disease-modifying antirheumatic drugs (DMARDs) or anti-tumour necrosis factor α antagonists (anti-TNFs). It has been suggested that interleukin 1 (IL1) plays a key role in the maintenance of the chronic inflammatory diseases, providing a rationale for an IL1-blocking therapy.1 2 Anakinra, an IL1 receptor antagonist (IL1-RA) approved for the treatment of rheumatoid arthritis,3 has shown promising results in small cohorts of patients with AOSD.4 5 6 7 8 However, it is unclear whether these effects can be sustained over a long treatment period. We report rapid and long-lasting responses to anakinra in eight patients with AOSD refractory to glucocorticoids, DMARDs and/or anti-TNFs. From December 2004, eight consecutive patients with refractory adult-onset …

As last year, a consensus group to consider the use of tumour necrosis factor (TNF) blocking agents was formed by an organising committee constituted of rheumatologists from the Universities of Erlangen, Leiden and Vienna in Europe in cooperation with universities in the United States. Pharmaceutical support was obtained from a number of companies, but these institutions had no part in the decisions regarding this specific programme nor with regard to the participants or attendees at this conference. The approximately 100 rheumatologists and bioscientists from 25 countries who attended the consensus conference were chosen from a worldwide group of people felt to have experience or interest in the use of TNF blocking treatment for rheumatoid arthritis (RA). Unfortunately, the number of attendees and participants were limited so that not everyone who might have been appropriate could be invited. During the past year increasing amounts of data on the use of TNF blocking agents in RA have been published. Consequently it was felt appropriate to update the provisional consensus statement published last year (Ann Rheum Dis 1999;58 (suppl 1):I129–30). During this revision it became clear that there are still large areas where knowledge is lacking. In an effort to clarify, for the readers, evidence on which the consensus statement is based, statements with supporting data have been referenced. When a statement is not referenced it will have arisen from the consensus process: small group discussions, large group discussions and repeated drafts of the consensus statement to allow input from all participants. We feel that this statement represents an updated, although still provisional, consensus view of the use of TNF blockade in RA. However, it will …

To improve monitoring of immunological and disease activity, we determined soluble markers of activity of the monocyte/macrophage system (sCD14) and the vascular endothelium (sE-selectin, sICAM-1) in patients with systemic lupus erythematosus (SLE) and primary Sjögren' syndrome (pSS) in comparison to patients with infections or sepsis.Concentrations of sCD14, sICAM-1 and sE-selectin (soluble CD14, ICAM-1 and E-selectin, respectively) were measured in serum samples from patients with SLE and pSS, patients with sepsis, different infectious diseases and healthy controls using ELISA systems.Elevated levels of sE-selectin and sICAM-1 were detected in patients with SLE as well as sepsis, in contrast to patients with a localized infection (SLE and sepsis, respectively, versus infection P < 0.001; Kruskal–Wallis test). Levels of sCD14 were persistently elevated in sera from patients with SLE, whereas these values decreased rapidly after effective therapy in patients with sepsis or infection. A continuous elevation of all of these three parameters was associated with a fatal outcome in patients with sepsis as well as in patients with SLE.Combined elevation of sCD14, sICAM-1 and sE-selectin correlates with the prognosis in patients with active SLE and indicates a remarkable immune activation involving the monocyte/macrophage system and the endothelium comparable to an activation found only in patients with sepsis.

In patients with systemic sclerosis (SSc) treatment-related mortality after autologous stem cell transplantation (ASCT) appears to be increased as compared to patients with hematological malignancies. In our phase I/II study on ASCT in autoimmune diseases a patient with SSc died on day 2 after ASCT. Here we report the results of the autopsy which revealed advanced pulmonary and cardiac fibrosis as the most probable cause of death. In spite of detailed technical examination before enrollment, the cardiopulmonary function tests did not reflect the advanced stage of the disease. We conclude that in selected patients with SSc, biopsies should be performed to reduce mortality after ASCT.

This group of rheumatologists gathered in Vienna out of concern about the absence of a uniform view and guidance on the introduction of tumour necrosis factor (TNF)-blocking therapies in our clinics. With our growing experience, evaluation of drug treatment of rheumatoid arthritis (RA), and previous participation in consensus statements,1 we have had the opportunity of discussing the accrued knowledge as well as personal experiences in the use of TNF-blocking agents and of formulating our jointly shared views on: For the present, TNF blockade should be reserved for patients with RA whose symptoms and signs are resistant to disease modifying antirheumatic drug (DMARD) treatment. It is generally agreed that all patients with active disease should be treated with DMARDs, as such treatment ameliorates symptoms and slows progression of structural damage.2 However, long term efficacy of DMARDs is limited and toxicity accumulates.3 Currently, two TNF-blocking agents, etanercept and infliximab, have received regulatory authority approval for the treatment of RA. Both compounds, alone or in combination with methotrexate, have proved to be successful in significantly reducing inflammatory activity …

The therapeutic success of low doses of glucocorticoids is mediated entirely by classical genomic effects, whereas that of high doses is also mediated to an as yet unknown extent by nongenomic effects. We assessed the relative therapeutic importance of these nongenomic effects in pulse therapy.A [3H]dexamethasone radioligand binding assay was used to measure the number of glucocorticoid receptor sites (R, given as number of sites per cell) and glucocorticoid receptor binding affinity (Kd, given in nM) in peripheral blood mononuclear cells isolated from 26 healthy control blood donors and 27 patients with rheumatic diseases. Patients were divided into 4 groups on the basis of their glucocorticoid dose: 0 mg (Group A),or = 0.25 mg (Group B), 0.25 to 1 mg (Group C), and1 mg (Group D) of prednisolone equivalent per kg per day.Sex independent normal values of 3605 +/- 1136 for R and 5.39 +/- 3.4 for Kd were found. At 5407 +/- 1968, the number of receptor sites in patients not receiving glucocorticoid therapy (Group A) was significantly higher than that of controls (p0.01). In patients receiving glucocorticoid therapy this value was reduced at 3855 +/- 866 (Group B), 3358 +/- 963 (Group C), and 2685 +/- 962 (Group D). The values in Groups C and D were significantly lower than those in untreated patients (p0.02).In pulse therapy doses of glucocorticoids that exceed receptor saturation are administered for several days, but in addition significant receptor downregulation occurs. Therefore, we assume an increase in the relative contribution of the nongenomic effects of glucocorticoids to the therapeutic success under these conditions.

The objective of this study was to assess the feasibility of transplanting embryonic chondrogenic cells within a collagen-fibrin substrate for the reconstitution of full-thickness cartilage defects in chicken knee joints.Full-thickness cartilage defects were created mechanically on the weight-bearing surface of the tibial condyle in 45 adult chickens and subsequently filled with chondrocytes embedded in a chondrocyte-collagen-fibrin gel. The transplants were compared to untreated defects and collagen-fibrin transplants without cells. The results were analyzed using histochemical and morphometrical methods after 3, 12 and 24 weeks. A semiquantitative histological grading system was applied to evaluate the transplant integration and the newly formed cartilage architecture.Chondrocyte-gel grafts developed to hyaline-like cartilage without any granulation tissue in the interface after 3 weeks. After 12 weeks the defects in the experimental group were filled completely with hyaline cartilage. The defects in the control groups in all cases healed with fibrous repair tissue.Fibrin-collagen gel allowed stable graft fixation and provided an adequate microenvironment for embryonic chondrocytes to generate hyaline-like neocartilage in a full-thickness cartilage defect.

Lyme arthritis is one of the most common clinical manifestations of Lyme borreliosis. It is caused by an intraarticular infection with Borrelia (B.) burgdorferi. A small number of bacteria are liable to provoke severe arthritis by inducing mechanisms (including the induction of cytokines and chemokines) that amplify the inflammatory response. The cellular immune response against B. burgdorferi is characterised by a predominant T helper cell type 1 (Th1) pattern that appears to be inadequate to overcome the infection. In most cases, Lyme arthritis may be cured by antibiotic therapy. A brief summary of current recommendations for the treatment of Lyme arthritis in adults and children is given in this article. However, about 10% of Lyme arthritis patients do not respond sufficiently to antibiotic treatment. Two not mutually exclusive pathogenetic concepts of these treatment-resistant cases will be discussed in the present study: persistent infection and infection-induced immunopathology.

In reconstruction of cartilage defects, autogenous transplantation is known as a reliable and experienced method. Although a clinical application has not been reported until now, tissue engineering permits in vitro production of autogenous cartilage transplants. Nevertheless, in both methods the cartilage is exposed to individually varying resorptive mechanisms. Among other methods for in vivo tissue protection, the encapsulation with a semipermeable polyelectrolytecomplex membrane could guarantee sufficient protection against resorptive influences. Human septal cartilage was encapsulated (group 1) with polyelectrolytecomplex membranes and subcutaneously implanted on the back of thymusaplastic nude mice. Cartilage implants without encapsulation (group 2) were used as control. Scanning electron microscopy and histochemical investigations were performed 1, 4, 8, 12 and 16 weeks after implantation. Group 1 showed no signs of resorption and chronic inflammation at all. In contrast, group 2 presented, correlating to the time of implanta-tion, increasing signs of cell death and fibrotic transformation, representing an increased activity of resorption. In conclusion, tissue encapsulation with a polyelectrolytecomplex membrane could ensure a sufficient protection of human cartilage transplants from resorptive influences. For the plastic-reconstructive surgeon the desired result becomes more calculable.

Autoimmune diseases that are resistant to conventional treatment cause severe morbidity and even mortality. In the present study we demonstrate that complete remissions can be achieved in refractory polychondritis and systemic lupus erythematosus (SLE), even at advanced stage, with the use of autologous stem-cell transplantation (SCT). Remissions persisted after reconstitution of the immune system. In the treatment of advanced systemic sclerosis (SSc), stable disease may be achieved with autologous SCT., Introduction: Patients with persistently active autoimmune diseases are considered to be candidates for autologous SCT. We performed a phase 1/2 study in a limited number of patients who were refractory to conventional immunosuppressive treatment. Following a period of uncontrolled disease activity for at least 6 months, autologous SCT was performed, after in vivo immunoablation and ex vivo depletion of mononuclear cells. Aims: To investigate feasibility, toxicity and efficacy of the treatment, and the incidence of emergent infections. Methods: Seven patients (aged between 23 and 48 years) were included in the single-centre trial: one had relapsing polychondritis, three had treatment-refractory SLE and three patients had SSc. Stem-cell mobilization was achieved by treatment with moderate-dose cyclophosphamide (2 g/m2; in terms of myelotoxic side effects or myelosuppression) and granulocyte colony-stimulating factor (G-CSF). CD34- cells of the leukapheresis products were removed by high-gradient magnetic cell sorting. After stem-cell collection, immunoablation was performed with high-dose cyclophosphamide (200 mg/kg body weight) and antithymocyte globulin (ATG; 90 mg/kg body weight). Autologous SCT was followed by reconstitution of the immune system, which was monitored by six-parameter flow cytometry and standard serology. The trial fulfilled the European League Against Rheumatism (EULAR) and the European Group for Blood and Marrow Transplantation (EBMT) guidelines for blood and bone marrow stem-cell transplants in autoimmune disease. Results: Among the seven patients studied, the patient with relapsing polychondritis and the patients with SLE were successfully treated and remained in complete remission during a follow up of 10-21 months. Remission persisted despite reconstitution of the immune system, resulting in high numbers of effector-/memory-type T-helper lymphocytes and increasing populations in the naïve T-cell compartment. Before autologous SCT, one of the patients with SLE had a long-lasting secondary antiphospholipid syndrome, with high anticardiolipin antibodies and thromboembolic events. After autologous SCT the antiphospholipid antibodies became negative, and no thrombosis occurred during follow up. Two of the patients with SSc were unaffected by treatment with autologous SCT for 6 or 13 months. The other patient with SSc died 2 days after autologous SCT because of cardiac failure. During stem-cell mobilization with G-CSF, flares of autoimmune disease were seen in the patient with polychondritis and in one patient with SLE. The strategy utilized for depletion of CD34- cells led to a reduction by 4.5-5 log of contaminating CD3+ cells in the transplant. T-cell add-back was required in the patient with polychondritis and in one patient with SLE to provide a dose of 1×104 CD3+ cells/kg body weight for the transplant. Discussion: In vivo immunoablation in combination with autologous SCT after ex vivo depletion of CD34- cells can block the autoimmune process in relapsing polychondritis or SLE without incidence of severe infections. The remissions were achieved in patients with advanced disease that was refractory to previous intensive immunosuppressive therapy. The present results do not indicate that large-scale contamination of the stem-cell transplant with autoreactive cells after selection for CD34+cells occurred. After the preparative regimen, the application of G-CSF was avoided, because induction of flares of the autoimmune disease were noticed during the mobilization of stem cells. In SSc patients, distinct remissions were not observable after autologous SCT; the serological and clinical status did not improve. Follow-up periods of more than 12 months may be required to identify successful treatment with autologous SCT in SSc patients. Among the various autoimmune diseases the efficacy of autologous SCT appears to be dependent on the underlying pathophysiology. The results of the present phase 1/2 study suggest that patients with advanced stage SSc should not be treated with autologous SCT, until the reasons for the lack of response and the possible mortality due to cardiac complications are identified. The observation of flares of autoimmune disease after application of G-CSF emphasizes the need for critical evaluation of the role of G-CSF in immunoablative regimens.

Anti-CD4 antibodies have been recently introduced into the therapy of various autoimmune diseases, among them systemic lupus erythematosus (SLE). Their modes of action are not yet fully understood. Interference with cytokine release may be one possible mechanism. Therefore, the effects of anti-CD4 antibodies on the cytokine release of IL-6 (interleukin-6) and TNF-a (tumor necrosis factor alpha) were investigated in a whole blood culture system. Basal and phytohemagglutin/lipopolysaccharide (PHA/LPS)-stimulated cytokine patterns were compared to cytokine release after the addition of anti-CD4 antibodies (MAX. 166H5) or methylprednisolone in short time whole blood cell culture systems from 12 patients with active SLE, 23 patients with inactive SLE and 12 healthy volunteers. TNF-oc and IL-6 concentrations were determined in the supernatants by ELISA. High disease activity correlated with an increased production of proinflammatory cytokines. Cell cultures of patients with inactive SLE showed a diminished capacity to respond to mitogenic stimulation. Anti-CD4 antibodies added in vitro suppressed significantly the unstimulated production of IL-6 (P < 0.02) in the cell cultures of patients with active SLE and in the PHA/LPS-stimulated cell cultures from both groups of SLE patients (both P < 0.001) and healthy volunteers (P < 0.01). However, MAX.16H5 did not affect the release of TNF-a. In control samples methylprednisolone considerably reduced stimulated and unstimulated IL-6 and TNF-ca production in all SLE patients, irrespective of the disease state, and in all healthy controls. These data indicate that the proinflammatory cytokines are involved in the pathogenesis of SLE. It is assumed that anti-CD4 antibodies, which can be effective in the treatment of highly active lupus patients, may act via their influence on cytokine release. The decrease of the proinflammatory cytokines IL-6 under therapy with MAX. 16H5 could explain the observations of clinical trials and animal studies which showed a reduction of inflammatory parameters and diminished production of autoantibodies following treatment with anti-CD4 antibodies.

Rheumatoid arthritis (RA) is a severe disease that leads to joint destruction, loss of quality of life, work disability and premature mortality, as well as significant costs to the patient and to the health care system. Although effective therapeutic regimens are currently available, many patients fail to respond to these treatments, fail to sustain an initial response, or suffer from significant toxicity necessitating withdrawal of treatment. Moreover, remission is rare and curative treatment unknown. It is clear, therefore, that new treatments are needed. Patients and doctors wish the best possible treatment to be prescribed for RA. The highest responsibility of doctors is that towards their patients. However, in an environment of increasing costs for medical care, doctors must also be cognisant of issues related to the costs of newly available treatments. In this context, it is helpful to establish a consensus of worldwide experts for the rational and successful use of such new therapeutic agents, even though such a consensus is provisional and will change as new data become available. The newly developed disease modifying anti-rheumatic treatments seem to be a significant advance in the therapeutic armamentarium for RA. The presently available evidence shows that these …

The research field of tissue engineering combines cells biology, biomaterial science, and surgery. Major long-term goals are tissue and organ replacement therapies using the patients' own cells. Our work is focused on the treatment of severe joint defects and on plastic surgery using in vitro engineered cartilage tissues. The practical approaches in cartilage engineering face problems with three-dimensional cell distribution or cell immobilization raising biocompatibility problems. The tissue engineering of cartilage is based on combining biocompatible cell embedding substances such as fibrin, agarose, alginate, hyaluronic acid and fiber fleece scaffolds of poly alpha-hydroxy acids (PLLA/PGLA). Different technical approaches were established: a) three-dimensional in vitro cultures of chondrocytes for the development of vital tissue transplants and b) interacting three-dimensional cultures consisting of different cell populations, such as BMP-transfected mesenchymal cells. The preshaped artificial tissue constructs were cultured in perfusion chambers to maintain a stable diffusion of nutrients during the in vitro pre-formation step. Subsequently, pre-formed tissues were implanted into nude mice and into 4 mm articular joint defects of rabbits. Transplants were found to produce cartilage typic morphological patterns and matrix. 80% of the transplants remained stable in vivo. However, 20% of the tissues are resorbed or replaced by a fibrous tissue. These results demonstrate that current artificial cartilage transplants are already feasible for plastic reconstruction. The treatment of severe joint defects, however, faces additional problems which are addressed in ongoing studies: (a) the fixation of engineered cartilage in joints, (b) the protection against chronic inflammatory degradation, and (c) the required enormous mechanical stability.

A prospective study was performed comparing conventional radiography, 3-phase bone scintigraphy, ultrasound, and magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examinations in 60 patients with various forms of arthritis including rheumatoid arthritis (RA), spondyl-arthropathy, and arthritis associated with connective tissue disease.A total of 840 finger joints were examined clinically and by all 4 imaging methods. Experienced investigators blinded to the clinical findings and diagnoses analyzed all methods independently of each other. The patients were divided into 2 groups. Group 1 included 32 patients (448 finger joints) without radiologic signs of destructive arthritis (Larsen grades 0-1) of the evaluated hand and wrist and group 2 included 28 patients (392 finger joints) with radiographs revealing erosions (Larsen grade 2) of the evaluated hand and/or wrist.Clinical evaluation, scintigraphy, MRI, and ultrasound were each more sensitive than conventional radiography in detecting inflammatory soft tissue lesions as well as destructive joint processes in arthritis patients in group 1. All differences were statistically significant. We found ultrasound to be even more sensitive than MRI in the detection of synovitis. MRI detected erosions in 92 finger joints (20%; 26 patients) in group 1 that had not been detected by conventional radiography.Our data indicate that MRI and ultrasound are valuable diagnostic methods in patients with arthritis who have normal findings on radiologic evaluation.

The p205 autoantigen and interleukin-2 (IL-2) function synergistically to stimulate T lymphocytes from patients with rheumatoid arthritis (RA), and a p205-derived amino acid sequence is identical to an immunoglobulin sequence located within a domain that is reactive with rheumatoid factors (RF). This study was conducted to analyze in detail the T cell immune response against p205 and to investigate whether immunity to p205 may play a role in T cell-mediated immunopathology in active RA.Cibachron blue, protein A-Sepharose, and gel filtration on Sephacryl were used successively to enrich p205 from synovial fluid (SF). T lymphocytes from RA patients were isolated from the peripheral blood (PB), lymph nodes, and SF, and p205 and peptides derived from known sequences were assessed by T cell proliferation assays in the presence of IL-2.P205-specific proliferation of T cells was observed in PB as well as in SF. When p205 was isolated from RA SF, proliferation of RA T cells peaked on day 3. With p205 purified from SF from trauma patients, there was a significant shift of the maximum T cell proliferation to day 8. T cells were of CD4 or CD8 phenotype, and B cells did not proliferate to a significant degree. The T cell response to p205 was always higher for SF mononuclear cells (SFMC) compared with PBMC (P0.001). In 1 RA patient who underwent repeated leukapheresis, this led to a reproducible decline in p205-specific T cell proliferation to control levels. PB T cells specifically proliferating in response to p205 were detected in 20 of 32 RA patients (63%). Of 26 patients with other inflammatory rheumatic diseases, only 1 showed a minor response to p205, while normal donors did not demonstrate a significant T cell proliferation. A synthetic p205-derived peptide, with an amino acid sequence identical to an immunoglobulin sequence located in the area where RF binds, was reactive with T cells from RA patients.P205 appears to be a major target of autoreactive T cells in RA. P205-specific T cells are primed and more abundant at the site of inflammation. As a T cell target in RA, p205 may well be an antigen involved in the initiation of RF production.

The proteasome subunit HC9 (alpha3) has recently been identified as a major target of the humoral autoimmune response in patients with autoimmune myositis and systemic lupus erythematosus. Since B cell hyperreactivity is a common feature of systemic autoimmune diseases, patients with primary Sjögren's syndrome (SS) and other control groups were investigated to evaluate the significance of autoantibodies against the proteasome.Analyses of autoantibodies directed against the 20S proteasome were performed using enzyme-linked immunosorbent assay, immunoblot, and 2-dimensional electrophoresis. Forty-three patients with primary SS, 47 patients with rheumatoid arthritis including 9 with secondary SS, 19 patients with gastrointestinal tumors, and 80 healthy controls were tested for antiproteasome antibodies.Antiproteasome antibodies were detected in 39% of patients (17 of 43) with primary SS. In contrast, only 1 of 47 patients with rheumatoid arthritis showed positive reactivity (P0.001). Serum samples from 19 tumor patients (P0.003) and 80 healthy controls (P0.001) were serologically negative. Moreover, immunoblotting and 2-dimensional analysis of the antiproteasome response revealed a polyspecific recognition pattern in 7 patients with primary SS. Different proteasomal subunits of the alpha and beta type, including subunits that carried the proteolytic active sites, were recognized by the patients' sera.The humoral antiproteasome response in primary SS, in contrast to its secondary form, is characterized by an extensive recognition pattern of several subunits, indicating a polyspecific B cell activation against the 20S proteasome. Moreover, proteolytically active beta-type subunits, which are important for the generation of major histocompatibility complex class I-restricted antigens, appear to be targets of the autoimmune response. The data indicate that the proteasome itself may stand on a cross point of pathways that links mechanisms of the immune defense with features of systemic autoimmunity.

To investigate whether plasma levels of matrix metalloproteinases 3 (MMP-3, stromelysin), MMP-1 (collagenase), tissue inhibitor of metalloproteinases 1 (TIMP-1), and MMP1/TIMP-1 complex (MT complex) are specifically elevated in erosive joint diseases compared to nonerosive rheumatic diseases, and to assess how these markers reflect the clinical activity of rheumatoid arthritis (RA) compared to circulating cytokines and markers of connective tissue turnover as well as established variables [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor titer].Plasma levels of MMP-3, MMP-1, TIMP- 1, and MT complex were determined by ELISA. One hundred fifteen patients with RA, 20 with osteoarthritis (OA), 28 with psoriasis arthritis (PsA), 24 with ankylosing spondylitis (AS), 3 groups with systemic autoimmune diseases, and 30 healthy controls were analyzed. In patients with RA routine laboratory variables, circulating inflammatory cytokines [interleukin 1 (IL-1), tumor necrosis factor-alpha (TNF-alpha), and IL-6], collagen degradation products, and markers of bone formation were determined in parallel and were correlated to 4 variables of clinical activity.MMP-3 levels were markedly elevated in RA compared to controls and OA, but also in all other groups, including 26 patients with systemic lupus erythematosus (SLE). MMP-1 levels were significantly elevated in RA, but also in OA, PsA, SLE, and mixed connective tissue disease. In contrast, MT complex was elevated in RA only. TIMP-1 was not different from controls. CRP levels, MMP-3, and ESR correlated best with clinical activity of RA. In contrast, there was no correlation of IL-1 and TNF-alpha and only a weak correlation of IL-6 with clinical measures. Among variables of connective tissue turnover, only pyridinoline and deoxypyridinoline crosslinks were weakly correlated with disease activity.Elevated MMP-3 and MMP-1 levels are not specific for RA or for erosive joint diseases in general. In contrast, elevated MT complex levels were observed in patients with RA. However, the correlation of MT-1 with clinical data was weaker than that of MMP-3. Elevated MMP-3 levels reflected disease activity of RA better than cytokine levels or markers of connective tissue turnover. However, MMP-3 levels do not exceed the association of CRP with clinical activity.

Due to the public discussion on the drug "Orthokin", the Commission for Pharmacotherapy of the German Society for Rheumatology (Deutschen Gesellschaft fur Rheumatologie, DGRh) has summarized the relevant data. An unpublished study with 400 patients shows an advantage for Orthokin compared to either hyaluronic acid or a placebo for the treatment of osteoarthritis related chronic knee pain. Until these data have been published in an appropriate specialist journal, it is not possible for the DGRh to give a recommendation.

The hypothesis of rheumatoid arthritis (RA) as a T cell mediated disease has led to the development of numerous therapeutic approaches that target the function of T cells. The development of monoclonal antibodies against the T cell surface molecule CD4 has raised hopes to achieve a major progress in the treatment of RA. However, after encouraging results in early open studies, double blind trials were unable to demonstrate the efficacy of anti-CD4-therapy in RA. There are numerous reasons to explain the failure of this treatment approach. Besides the fact that the T cell hypothesis of RA has repeatedly been challenged, pharmacological problems or an inappropriate selection of outcome criteria have to be considered. The final evaluation of anti-CD4 therapy in RA will be possible only after the testing of newly developed non-depleting anti-CD4 antibodies.

The SmD1 protein is a specific target for the autoantibody response in SLE. To further analyze this reactivity epitope, mapping was performed with cellulose-bound 13-mer peptides overlapping 10 amino acids (aa). In this initial approach, 4 out of 15 SLE sera recognized more than five overlapping peptides of the SmD1 C-terminus. Therefore, longer oligopeptides of up to 37 aa of this region were generated and probed for as antigens by ELISA. For the SmD1 aa 83-119 polypeptide, there was a striking increase of reactivity with 70.0% positive reactions out of 167 SLE sera. In contrast, 105 healthy control sera were negative, and only 8.3% of sera from patients with other inflammatory diseases (n = 267) exhibited a response, which was of low level only. The anti-SmD183-119 reactivity was significantly higher in anti-dsDNA antibody positive vs. negative sera (P < 0.001) and correlated with disease activity. Four of five human monoclonal anti-dsDNA antibodies also reacted with SmD183-119. The specificity for SmD1 was demonstrated by inhibition experiments and immunization of rabbits with SmD183-119 inducing SmD1-specific antibodies. In conclusion, the SmD183-119 peptide was demonstrated to be an important and highly specific target of the autoimmune response in SLE. The high sensitivity of this ELISA probably depends on a conformational epitope, which appears not to be accessible in the full-size SmD1 protein.