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Previous issue date: 2016-03-28 / Introduction: Rheumatoid Arthritis (RA) is an autoimmune, inflammatory and chronic disease. Muskuloskeletal ultrasound (MSUS) has been increasingly used for diagnostic evaluation and monitoring of patients. Regulatory T cells (Tregs) and lymphocytes producers of IL 17 (Th17) imbalance and disfuntion, as well as pro inflammatory cytokines, have been implicated in the pathogenesis of RA. There are few studies on the association of circulating lymphocites subtypes and cytokines with MSUS findings in RA. Methods: One hundred and one RA patients (1987 American College of Rheumatology criteria) treated with disease-modifying antirheumatic drugs (DMARDs) were included in this cross sectional study. A blood sample was taken just before clinical and ultrasonographic evaluation, which were all performed on the same day, consecutively and in a blinded fashion. Lymphocytes were isolated and immunophenotyped by flow cytometry to investigate regulatory FoxP3+ T cells and IL-17+ cells. Plasma Th1-Th2-Th17 cytokines (IL-2, IL-4, IL-6, IL-10, IL-17, TNF e IFN-?) and VEGF were searched using a Cytometric Bead Array (CBA; BD biosciences) kit by flow cytometry. Disease acitivity and disability were measured using Disease Activity Score in 28 joints (DAS28) and Health Assessment Questionnaire (HAQ). MSUS (MyLab 60, Esaote, Genova, Italy, 18 MHz linear probe) was performed consecutively by two ultrassound-trained rheumatologists on the wrists, 2th and 3th metacarpophalangeal and 2th and 3th proximal interphalangeal joints of both hands. Gray-scale synovial hypertrophy (PS) and power Doppler signal (pD) were searched using a semi-quantitative scale (0-3). Erosions were classified as present or absent. The sum of the individual joint scores for PS and pD (10-joint PS and pD scores) was calculated and used to correlate with clinical and laboratory data. Mann-Whitney test, Kruskal-Wallis test and Spearman correlation coefficient (rS) were used for statistical analysis, as well as liner multivariate regression. Interater agreement was tested using kappa statistics and intraclass correlation. Results: Among 101 patients, we were able to measure Treg/Th-17 in 90 individuals. Plasma cytokines were searched in 64 patients. Clinical and demographic features were: mean age, 55.8 ? 11 years; female gender, 80%; Caucasians, 85%; median (interquartile range) disease duration 6 (2-13) years; mean ? SD DAS28, 4.28 ? 1.64; mean ? SD HAQ score, 1.11 ? 0.85. Interobserver agreement (kappa) for US features varied from 0.53 to 1.0. Intraclass correlation for 10-joint PS score was 0.964 (95% CI 0.899-0.986, P <0.000) and for 10-joint pD score was 0,859 (95% CI 0.646-0.941, P <0.001). There was no significant correlation of 10-joint PS and pD scores with DAS28 and HAQ score. The presence of bone erosions was associated with 10-joint PS and pD scores (p=0.002), but not with DAS 28 (p=0.079) or HAQ (0.057). Swollen joint count, but not tender joint count, was correlated with 10-joint PS and pD scores (rS=0.54, P<0.001 and rS=0.39, P<0.001; respectively), as well as associated with bone erosions (P<0.001). There was no significant correlation of with 10-joint PS and pD scores with peripheral Tregs (rS=0.122, P=0.254 and rS=0,056, P=0.602) and Th17 cells (rS=-0.083, P=0.438 and rS=-0.060, P=0,575). Tregs and Th17 cells were not associated with erosions (p= 0,831 and p=0,632, respectively). Among all tested cytokines, IL-6 was correlated with DAS28 (rs 0.31 IC95% 0.07 to 0.52), eritrocyte sedimentation rate (rs 0.43 IC95% 0.19 to 0.62) and swollen joint count (rs 0.39 95%CI 0.15 a 0.59). IL-6 was also correlated with 10-joint pD score (rs 0.33 IC95% 0.07 to 0.56), right and left wrists pD (rs 0.34 IC95% 0.11 to 0.54 and rs 0.45 IC95% 0.21 to 0.64), and right and left PS (rs 0.40 IC95% 0.20 to 0.59 and rs 0.35 IC95% 0.08 to 0.57). Using multivariate linear regression model, 10-joint pD score was positively associated with IL-6 independently of DAS28 (P=0.025). There was no association of any of the tested cytokines with bone erosions (P? 0.17 for all tests). Conclusions: In established RA patients, treated with non biological DMARDs, we observed the following: lack of correlation of 10-joint PS and pD scores and DAS28 and HAQ; positive association of 10-joint PS and pD scores with bone erosions; positive association of swollen joint count, but not tender joint count, with MSUS synovitis and erosions; lack of correlation of MSUS features and circulating Treg and Th-17 cells; positive correlation of plasma IL-6 and MSUS synovitis. The association of IL-6 with 10-joint pD score was independent of DAS28. / Introdu??o. A artrite reumatoide (AR) ? uma doen?a autoimune inflamat?ria cr?nica com envolvimento articular proeminente. O ultrassom de alta resolu??o (US) tem sido empregado de maneira crescente na avalia??o diagn?stica e monitoriza??o da doen?a. O desequil?brio entre as fun??es de linf?citos T regulat?rios (Treg) e Th-17, bem como o papel de citocinas pr? inflamat?rias s?o centrais em sua patog?nese. H? escassez de estudos sobre a associa??o entre os achados ultrassonogr?ficos de atividade da AR e dano estrutural com subtipos linfocit?rios e citocinas no sangue perif?rico. M?todos: Neste estudo transversal, foram inclu?dos 101 pacientes com AR de acordo com os crit?rios de 1987 em tratamento com drogas remissivas n?o-biol?gicas. Uma amostra de sangue foi coletada imediatamente antes das avalia??es cl?nica e ultrassonogr?fica, que foram feitas todas no mesmo dia, em sequ?ncia. Os linf?citos foram isolados e imunofenotipados por citometria de fluxo para identificar c?lulas T reg FoxP3+ e linf?citos produtores de IL-17. Citocinas do perfil Th1-Th2-Th17 (IL-2, IL-4, IL-6, IL-10, IL-17, TNF e IFN-?) e VEGF foram quantificadas no plasma por citometria de fluxo utilizando-se o kit Cytometric Bead Array (CBA; BD biosciences). Atividade da doen?a foi quantificada por DAS28 e capacidade funcional, pelo HAQ, ambos realizados por reumatologista treinado, cegado em rela??o aos achados de US. Dois reumatologistas (cegados em rela??o aos dados cl?nicos) com treinamento em ultrassonografia realizaram avalia??o de sinovite e presen?a de eros?es em punhos, 2? e 3? articula??es metacarpofalangeanas e 2? e 3? interfalangeanas proximais bilateralmente utilizando aparelho de alta resolu??o (MyLab 60, Esaote, It?lia, transdutor linear de 18 mHz). Prolifera??o sinovial na escala de cinzas (PS) e capta??o de power Doppler (pD) foram avaliadas utilizando uma escala semi-quantitativa com varia??o de 0 a 3. Eros?es foram classificadas como presentes ou ausentes. A soma dos escores individuais de PS e pD foi calculada (escore 10 PS e escore 10 pD) e utilizada para correlacionar com dados cl?nicos e de laborat?rio. Teste de Mann-Whitney, Kruskal-Wallis e coeficiente de correla??o de Spearman foram usados na an?lise estat?stica, bem como regress?o linear m?ltipla. Correla??o intraclasse e estat?stica kappa foram usados para concord?ncia interobservador. Resultados: Dentre os 101 pacientes inclu?dos, obtivemos quantifica??o de c?lulas Treg e Th-17 em 90 pacientes e dosagem de citocinas em 64 indiv?duos. Em sua maioria, a amostra foi composta por mulheres (80%) da ra?a branca (85%), com m?dia de idade de 55,8 anos (?11.1anos), tempo de dura??o de doen?a de 6 (2-13) anos (mediana e IIQ). A m?dia do DAS 28 (VSG) foi de 4.28 (?1.64) e do HAQ 1.11 (?0.85). Valores de kappa para a concord?ncia interobservador para o exame ultrassonogr?fico variaram de 0.53 a 1; a correla??o intraclasse para o escore 10 PS foi de 0.964 (IC95% 0.899-0.986, P <0.001) e, para o escore 10 pD, 0.859 (IC95% 0.646-0.941, P <0.001). N?o houve correla??o entre escore 10 PS e escore 10 pD com DAS28 e HAQ. Eros?es ?sseas foram associadas ao escores 10 PS e pD (p=0.002), mas n?o com DAS 28 (P=0,079) e HAQ (P =0,057). Observamos correla??o entre contagem de articula??es edemaciadas com escore 10 PS e escore 10 pD (rS=0.54, P<0.001 e rS=0.39, P<0.001; respectivamente), bem como associa??o com a presen?a de eros?es (P<0.001). N?o observamos correla??o entre contagem de articula??es dolorosas com escore 10 GS (rS = -0.071 P = 0.524), escore 10 pD (rS = -0.196 P = 0.078) ou associa??o com presen?a de eros?es (P=0.248). N?o houve correla??o significativa de escore 10 PS e pD com Treg (rS=0.122, P=0.254 e rS=0,056, P=0.602, respectivamente) e Th-17 perif?ricas (rS=-0.083, P=0.438 e rS=-0.060, P=0,575, respectivamente). N?o se observou associa??o entre percentual de c?lulas Treg e Th-17 e presen?a de eros?es (P=0.831 e P=0.632, respectivamente). A concentra??o de IL-6, mas n?o de outras citocinas, se correlacionou ao DAS28 (rs 0.31 IC95% 0.07 a 0.52), VSG (rs 0.43 IC95% 0.19 a 0.62) e contagem de articula??es edemaciadas (rs 0.39 95%CI 0.15 a 0.59), bem como com escore 10 pD (rs 0.33 IC95% 0.07 a 0.56), capta??o de pD em punhos direito e esquerdo (rs 0.34 IC95% 0.11 a 0.54 e rs 0.45 IC95% 0.21 a 0.64, respectivamente) e PS em punhos direito e esquerdo (rs 0.40 IC95% 0.20 a 0.59 e rs 0.35 IC95% 0.08 a 0.57, respectivamente). Utilizando-se modelo de regress?o linear m?ltipla, observou-se que o escore 10 pD foi positivamente associado a IL-6 independente de DAS28 (P=0.025). N?o houve associa??o entre nenhuma das citocinas testadas e a presen?a de eros?es ?sseas (P? 0.17 para todos os testes). Conclus?es: Em pacientes com AR estabelecida sob uso de remissivos sint?ticos, observamos: aus?ncia de associa??o de escore 10 PS e pD com DAS28 e HAQ; associa??o entre escore 10 PS e pD e eros?es ?sseas; associa??o de contagem de articula??es edemaciadas, mas n?o de articula??es dolorosas, com sinovite e eros?es no US; aus?ncia de associa??o entre achados de US e linf?citos Treg e Th-17 no sangue perif?rico; associa??o entre IL-6 plasm?tica e achados de sinovite no US. A associa??o entre IL-6 e escore pD ocorreu independente do DAS28.
| Identifer | oai:union.ndltd.org:IBICT/oai:tede2.pucrs.br:tede/6773 |
| Date | 28 March 2016 |
| Creators | Prado, Aline Defaveri do |
| Contributors | Staub, Henrique Luiz, Mendon?a, Jos? Alexandre |
| Publisher | Pontif?cia Universidade Cat?lica do Rio Grande do Sul, Programa de P?s-Gradua??o em Medicina e Ci?ncias da Sa?de, PUCRS, Brasil, Faculdade de Medicina |
| Source Sets | IBICT Brazilian ETDs |
| Language | Portuguese |
| Detected Language | English |
| Type | info:eu-repo/semantics/publishedVersion, info:eu-repo/semantics/doctoralThesis |
| Format | application/pdf |
| Source | reponame:Biblioteca Digital de Teses e Dissertações da PUC_RS, instname:Pontifícia Universidade Católica do Rio Grande do Sul, instacron:PUC_RS |
| Rights | info:eu-repo/semantics/openAccess |
| Relation | 7620745074616285884, 600, 600, 600, -8624664729441623247, -969369452308786627 |
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