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Extended report
Low-avidity anticitrullinated protein antibodies (ACPA) are associated with a higher rate of joint destruction in rheumatoid arthritis
  1. Parawee Suwannalai1,2,
  2. Karin Britsemmer3,
  3. Rachel Knevel1,
  4. Hans Ulrich Scherer1,
  5. E W Nivine Levarht1,
  6. Annette H van der Helm-van Mil1,
  7. Dirkjan van Schaardenburg3,
  8. Tom W J Huizinga1,
  9. René E M Toes1,
  10. L A Trouw1
  1. 1Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Ramathibodi hospital, Mahidol University, Bangkok, Thailand
  3. 3Department of Rheumatology, Jan van Breemen Research Institute | Reade, Amsterdam, The Netherlands
  1. Correspondence to Dr LA Trouw, Department of Rheumatology, C1-R, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, The Netherlands; L.A.Trouw{at}


Objectives Anticitrullinated protein antibodies (ACPA) are specific for rheumatoid arthritis (RA) and have been implicated in disease pathogenesis. Previously we have shown that ACPA display a considerably lower avidity as compared with antibodies against recall antigens. Nonetheless, ACPA-avidity did vary between patients. As antibody mediated effects are influenced by antibody-avidity, we now investigated ACPA-avidity in relation to biological activity and clinical outcome.

Methods We determined the avidity of ACPA and related this with severity of joint damage in two Dutch early-RA cohorts containing 199 and 132 patients respectively. Differences in effector functions of low- and high-avidity ACPA were studied.

Results Extensive variation in ACPA-avidity between patients was observed. This allowed the analysis of the relationship between avidity and severity. The presence of low-avidity ACPA is associated with a higher rate of joint destruction. This finding was replicated in an independent cohort. Analysis of the properties of low-versus high-avidity ACPA revealed that low-avidity ACPA are less hampered in their ability to bind ‘new’ citrullinated antigens. Although no differences could be observed regarding cellular activation via Fc-γ receptors, low-avidity ACPA were more potent in activating the complement system.

Conclusions Patients with low-avidity ACPA display a higher rate of joint destruction. Low-avidity ACPA display a higher potency to interact with more citrullinated antigens in time and show that low-avidity ACPA are more potent in complement activation. These data indicate that (low) avidity impacts on the biological activity of ACPA and associates with a worse radiological outcome.

  • Ant-CCP
  • Arthritis
  • Rheumatoid Arthritis

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