Achados inflamatórios e dano estrutural vistos por ultrassonografia em pacientes com artrite reumatoide : correlação com dados clínicos, linfócitos T regulatórios e TH-17 e citocinas inflamatórias no sangue periférico

• Ano de defesa: 2016
• Autor(a) principal: Prado, Aline Defaveri do
• Orientador(a): Staub, Henrique Luiz
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Pontifícia Universidade Católica do Rio Grande do Sul
• Programa de Pós-Graduação: Programa de Pós-Graduação em Medicina e Ciências da Saúde
• Departamento: Faculdade de Medicina
• País: Brasil
• Palavras-chave em Português: ARTRITE REUMATOIDE; LINFÓCITOS T; INFLAMAÇÃO; CITOCINAS; ULTRASSONOGRAFIA; MEDICINA
• Área do conhecimento CNPq: CIENCIAS DA SAUDE::MEDICINA
• Link de acesso: http://tede2.pucrs.br/tede2/handle/tede/6773

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-Ɣ) 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.