RA Patklin H.Sukma.pdf

INTRODUCTION

Total Concept Diagnosis of Rheumatoid Arthritis

PT SALI POLAPA BERSAMA

By : Herlangi Sukma

RHEUMATOID ARTHRITIS

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Manifestation• Joint swelling

(symmetrical)• Pain• Loss of mobility• Fatigue

Consequences• Destruction of cartilage• Erosion of bones• Deformation• Disability• Death


DESTRUCTIVE DISEASE

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Rheumatic Diseases

Rheumatism• „Rheuma“ is derived from the Greek

and describes a flowing pain

• A non-specific term for medical problems affecting the heart, bones, joints, kidney, skin and lung no injury or tumor

• Rheumatism, about 400 diseases, that often differ significantly in cause, symptoms, disease progression, therapy and health consequences

Rheumatoid Arthritis

PT. SALI POLAPA BERSAMA

• Morning stiffness lasting for at least 1 hr.

• Arthritis of 3 or more joint areas

• Arthritis of hand joints

• Symmetric arthritis

• Rheumatoid nodules

• Serum Rheumatoid Factor (RF)

• Typical radiographic changes

Arnett FC et al, Arthritis Rheum 31:315-324,1988

Classification criteria of RA (ACR-1987, rev.)

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What happens ?• Swelling of the synovial lining, causing

pain, stiffness, redness and swelling around the joint

• Rapid division and growth of cells (pannus), which causes the synovium to thicken

• Inflamed cells release enzymes that damage, bone & cartilage. The involved joint looses its shape and alignment

• Pain and loss of movement



RA/RIS/09-07PT. SALI POLAPA BERSAMA

Stages of Rheumatoid Arthritis

RA/RIS/09-07

Early Intermediate Late

RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS

Clinician Treatment :1. Symptoms

2. Causative

RA/RIS/09-07


Anamnesis and Clinical picture

Morning stiffness of jointsSymmetrical joint inflammationRheumatoid nodulesFeverMyalgia

Laboratory Tests :ESRCRPRheumatoid FactorsAnti-CCP

Imaging Technologies

X-RayUltrasoundMRT

- Medication- Fisiotherapy

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Key facts• Rheumatoid arthritis (RA) is a chronic,

progressive and disabling autoimmune disease• RA causes stiffness, pain, loss of mobility,

inflammation, and erosion in the joints• RA affects 1 % of the population• over 40 % of RA patients are disabled within 3 years * RA is an autoimmune disease

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What is an Autoimmune Disease ?

• When your body is attacked ...

• .... by bacteria, viruses or parasites ....

• .... your immune system defends you

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The Loss of Immunological Tolerance

• Normal• Immune system attacks foreign antigens

but tolerizes the own cells

• Pathological• Immune system attacks foreign and self

• antigens and destroys the tissues and organs -

+

Autoimmune Disease ?


This is Autoimmunity

Prevalence of Autoimmune Diseases?

According toRose et al., 1998, The Autoimmune diseases, 3rd Ed.US Census Bureau, Int. Data Base, 2004

Total Prevalence of Autoimmune diseases

• Canada - 1.0 Mio.• Brazil - 5.8 Mio.• Mexico - 3.3 Mio.• Germany - 2.6 Mio.• France - 1.9 Mio.• Russia - 4.5 Mio.

• Iran - 2.1 Mio.• Egypt - 2.4 Mio.• Ethiopia - 2.3 Mio.• India - 33.3 Mio• China - 41.0 Mio.• Thailand - 2 Mio.


Prevalence of Autoimmune Diseases?

Autoimmune Disease (AID) Prevalence• Autoimmune thyroid disease 2.0 % • Rheumatoid arthritis 1.0 %• Systemic Lupus erythematodes 0.5 %• Celiac disease 0.4 %• Pernicious anemia 0.1 %


J. DARMAWAN*,, K. D. MUIRDEN , H. A. VALKENBURG* and R. D. WIGLEY , 1993

0,2 % in 4683 rural and 0,3 % in 1071 urban in Semarang - Indonesia

What is an Autoimmune Disease ?

Organ specific• Hashimoto‘s

Thyroiditis• Celiac disease• Pernicious anemia• Goodpasture‘s

syndrome• AI Liver Diseases

Systemic• Rheumatoid arthritis• Systemic Lupus

Erythematodes (SLE)• Antiphospholipid

syndrome (APS)• Wegeners‘s

granulomatosis


Laboratory investigations• ESR / CRP level

• Rheumatoid Factor (RF)

• Complete Blood Count (CBC)

• Electrolytes

• Creatinin level

• Hepatic panel (AST, ALT and albumin)

• Urinalysis

• Synovial fluid analysis

• Auto-antibodies

(ACR Subcommitee on Rheumatoid Arthritis Guidelines. Arthritis Rheum. 2002)



Laboratory investigations

• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies



HUMASED 40

IMTEC Hs CRP ELISAHs CRP (Fotometri)CRP (turbidimetri)Humatex CRP


• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies



Humatex RF Latex (Rapid Test)RF latex reagent (turbidimetry)IMTEC IgM-RF ELISAIMTEC IgA-RF ELISAIMTEC IgG-RF ELISAIMTEC RF-Sreen IgGAM ELISA

Humatex RF Cat.No. 40052, 40050, 40053 • Latex agglutination qualitative, cut-off 20 IU/ml• Semi quantitative, diluted with Glycine-NaCl Buffer

sensitivity 12 IU/ml standard “International Reference Preparation of Rhematoid Arthritis Serum” (WHO).

1 : 2 24 IU/ml

1 : 4 48 IU/ml1 : 8 96 IU/ml1 : 16 192 IU/ml1 : 32 384 IU/ml

• Sensitivity : ≥ 12 IU/ml



RF HUMAN• Cat.No. 11261P • Photometric-Turbidimetry, with standard concentration

on the label. • Sensitivity : 20 – 100 IU/ml, no prozone up to 1,000 IU/

ml• Diluent, Latex, • Std. (conc. on label), calib. Curve 1 - 5



IMTEC RF IgG, IgA, IgM• ELISA Quantitative determination of Rheumatoid

Factors

• RF Ig G, Cat.no. ITC60007

• RF Ig A, Cat.no. ITC60010

• RF Ig M, Cat.no. ITC60003

Rheumatology


Consisting of :

- CAL 1 – 5 = 12,5 – 25 – 50 – 100 - 200 U/ml

- CTRL +, CTRL - , BUFF WASH, BUFF DIL, CONJ., SUBS, STOP.Sol.

IMTEC RF Screen IgGAM• ELISA Quantitative determination of Rheumatoid

Factors

• Cat.no. ITC60000

Rheumatology


Consisting of :

- CAL 1 – 5 = 12,5 – 25 – 50 – 100 - 200 U/ml IgGAM

- CTRL +, CTRL - , BUFF WASH, BUFF DIL, CONJ., SUBS, STOP.Sol.


• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies


RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS. HUMACOUNT INSTRUMENT


• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies




• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies




• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies




• ESR / CRP level



• Electrolytes

• Creatinin level


• Urinalysis


• Auto-antibodies : Anti CCP, Anti RA33



Bezugslinie / Reference Line /Linea di rifertimento

Nukleosom / Nucleosomes

Histon / HistonesSmD1

U1-snRNPSS-A / Ro 60 kD

SS-B / LaScl 70Zentromer / CentromereJo-1

SS-A / Ro 52 kD

cut-off-Kontrolle / ControlFunktionskontrolle / Functional Control

ELISA

HUMAN-IMTEC - Key Notes

HUMAN-IMTEC - Quality

• Certified under DIN EN ISO 13485:2001 and DIN EN ISO 9001

• First manufacturer of IVD in Germany to meet the requirements of the European IVD directive

• Proven quality for over 15 years


Human - IMTEC - Key Notes

Inovation – IMTEC

IMTEC products has protected and patented in 20 countries Germany and International.

It shows inovation and profesional competency


Human - IMTEC-Product Line

The IMTEC product

range includes ...






SS-A / Ro 52 kD


ELISA LIALine Immuno Assay

IFAImmunofluorescence


12.07.09

Human - IMTEC-Productline

ELISA - Principle•Antigens immobilized on a polystyrene microplate

•Sample incubation / Wash

•Secondary Ab / Wash

•Conjugate catalyzed color change of Substrate

•Stop solution will stop the reaction

•Optical density read-out with Microplate Reader (450/620 nm)


LIA - Principle• Antigens immobilized in a line on

a synthetic membrane

• Sample incubation / Wash

• Secondary Ab / Wash

• Precipitating Substrate - Visualization

• Visual comparison to Cut-Off Control line






SS-A / Ro 52 kD




Immunofluorescence - Principle

• Cells or tissues immobilized on a glass slide

• Incubations of serial sample dilutions

• Secondary Ab - Marked with fluorescent-dye

• Microscopy


Rheumatoid ArthritisELISA

• IMTEC-ANA SCREEN

- IMTEC ds DNA Ab

- IMTEC NUCLEOSOME

- -IMTEC ENA SCREEN

- -IMTEC ENA PROFILE

- -IMTEC ANTI CCP

- -IMTEC ANTI RA33

- -IMTEC RF Screen

- -IMTEC RF IG G

- -IMTEC RF IG M

- -IMTEC RF IG A- -IMTEC PR3 AB

- -IMTEC MPO-ANCA

LINE IMMUNOASSAY (LIA)

• -IMTEC ANA (LIA)

• -IMTEC ANA / dsDNA-LIA

IMTEC TESTSFor RA


Nukleosom / NucleosomesHiston / HistonesSmD1



SS-A / Ro 52 kD



UpdatedDiagnosis of

RA

Sensitivity and specificity of auto antibodies in RA

Marker Sensitivity (%) Specificity (%)

RF 50-90 Low*

APF 33 73-99

AKA 26-33 88-99

Anti Sa 22-40 98

Anti-CCP 50-76 95-98

* CCP = Cyclic Citrunillated Peptides

Anti-RA 33 36 98

RA-33 = hnRNP-A2

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• Antibodies directed against human γ-globulin Fc (mainly IgM, less often IgG or IgA)

• IgM RF calibrated against WHO reference preparation

• Sensitivity 80% in patients with RA• Specificity ranges from 80-90%• High titer predicts adverse outcome

erosive arthritis, vasculitis

• ELISA detects all isotypes


RHEUMATOID FACTORS

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Why testing RF on ELISA ?

• Fully automatable • Detection of all relevant Ig-classes

The simultaneous detection of IgA and IgM class RF is nearly 100 % specific for RA *

• High sensitivity• Standardized method• Information on therapy outcome

Domer et al., Curr Opin Rheumatol 2004;16:246–253.

Bobbio-Pallavicini, F. et al. Ann Rheum Dis 2007;66:302

*


RHEUMATOID FACTORS

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High IgA rheumatoid factor levels are associated with poor clinical response to TNFa inhibitors in RABobbio-Pallavicini, F. et al. Ann Rheum Dis 2007;66:302-307

DETECTION OF RF ISOTYPES

INCREASED RELEVANCE

High IgA rheumatoid factor levels are associated with greater risk of developing RAJonsson & Valdimarsson. Ann Rheum Dis 1993;52:161-164

Strong association between IgA RF and bone erosions – More radical treatment is neededBobbio-Pallavicini, F. et al. Ann Rheum Dis 2007;66:302-307

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Rheumatic DiseasesRheumatoid Arthritis (~70%)Sjögren’s Syndrome (~90%)Lupus (~20%)Kryoglobuline Syndrome (90%)

Lung DiseaseInterstitial Fibrosis

InfektionsHepatitis C VirusAcute viral InfectionEndokarditisTuberkulosis

OtherSarcoidosisInflammationAging

RHEUMATOID FACTORS

NEED FOR SPECIFICITY

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• Autoantibodies directed against cyclic citrullinated peptide (derived from filaggrin)

• Sensitivity 60 - 80 %; Specificity > 95 %

• Prognostic marker positive up to 9 years before clinical manifestations

• approx. 30 % of CCP+ are RF IgM-

A Specific Marker for Rheumatoid Arthritis

DIAGNOSTIC ALGORITHM

ANTI-CCP

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Citrullination

• Deimination (Citrullination) of proteins by the enzyme peptidyl-arginin-deiminase (PAD).

• Posttranslational protein modification, leading to modified biochemical characteristics

• Citrullination mainly occurs for proteins of the cytoskeleton (i.e.. cytokeratin, vimentin, filaggrin)

• Citrullination is involved the regulatory process of apoptosis

DIAGNOSTIC ALGORITHM

ANTI-CCP

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Anti-CCP Prognosis of Disease Outcome

• Presence of CCP antibodies is associated with development of erosive arthritis.

• The presence of anti-CCP in high titer has important prognostic implications

• Anti-CCP helps in predicting which RA patients will have persistent disease, and erosive disease

DIAGNOSTIC IMPORTANCE

ANTI-CCP

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• Increasing sensitivity• Detecting RF / CCP seronegative patients• Specific for anti-nuclear antigen• Anti-RA33 associated with mild disease

heterogeneous nuclear ribonucleoprotein A2

• Single Early RA-Marker in 13 % of RA Patients• Specificity of 90 %

increasing to 96 % if negative for Anti-U1-snRNP

MOST SENSITIVE DIAGNOSIS OF RA

ANTI-RA33 ANTIBODIES


RF < 50 U/ml

Anti CCP -

Anti RA33 * ( + )

One of third RA patients is detectable of Anti RA33 and it shows similar specifity like RF

UPDATED DIAGNOSIS OF RA

* Anti RA33 is patented product HUMAN - IMTEC

Anti CCP +

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12.07.09

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The complexities of Rheumatoid Arthritis

J Clin Invest, 116, 4, 2006

RA/RIS/09-07

- 51 -

Autoimmune market worldwide

Help out of the Jungle

Autoimmune Diagnostics is a complex and continuously changing field

Human is the guide to help and provide

up to date autoimmune diagnostics

- 52 -

Autoimmune market worldwide

Customized DiagnosticsEach laboratory requires customized solutions that fit best to their daily routine based on ...

• Turn-over• Test frequency• Test diversity• Official requirements

HUMAN is the right partner…..

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Our ToolsFlyers, Workshops,Seminars,Congress participation



• ESR / CRP level• Rheumatoid Factor (RF)• Complete Blood Count (CBC)• Electrolytes• Creatinin level• Hepatic panel (AST, ALT and albumin)• Urinalysis• Synovial fluid analysis

• Auto-antibodies


SUMMARY : Total Concept Diagnosis Of RASUMMARY : Total Concept Diagnosis Of RA


UPDATED DIAGNOSIS Of RA

12.07.09

End

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RA Patklin H.Sukma.pdf