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Immune response to post-translationally modified proteins in rheumatoid arthritis: what makes it special?
  1. Diane van der Woude,
  2. René E M Toes
  1. Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
  1. Correspondence to Professor René E M Toes, Rheumatology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, Netherlands; r.e.m.toes{at}


Rheumatoid arthritis (RA) exhibits common characteristics with numerous other autoimmune diseases, including the presence of susceptibility genes and the presence of disease-specific autoantibodies. Anti-citrullinated protein antibodies (ACPA) are the hallmarking autoantibodies in RA and the anti-citrullinated protein immune response has been implicated in disease pathogenesis. Insight into the immunological pathways leading to anti-citrullinated protein immunity will not only aid understanding of RA pathogenesis, but may also contribute to elucidation of similar mechanisms in other autoantibody-positive autoimmune diseases. Similarly, lessons learnt in other human autoimmune diseases might be relevant to understand potential drivers of RA. In this review, we will summarise several novel insights into the biology of the anti-citrullinated protein response and their clinical associations that have been obtained in recent years. These insights include the identification of glycans in the variable domain of ACPA, the realisation that ACPA are polyreactive towards other post-translational modifications on proteins, as well as new awareness of the contributing role of mucosal sites to the development of the ACPA response. These findings will be mirrored to emerging concepts obtained in other human (autoimmune) disease characterised by disease-specific autoantibodies. Together with an updated understanding of genetic and environmental risk factors and fresh perspectives on how the microbiome could contribute to antibody formation, these advancements coalesce to a progressively clearer picture of the B cell reaction to modified antigens in the progression of RA.

  • Arthritis, Rheumatoid
  • Anti-Citrullinated Protein Antibodies
  • Autoimmune Diseases

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  • Handling editor Josef S Smolen

  • DvdW and REMT contributed equally.

  • Contributors Both authors contributed equally.

  • Funding DvdW is supported by a Vidi-grant from the Dutch Research Council (grant number: 091501721100053). REMT is supported by a European Research Council advanced grant (AdG2019-884796).

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.