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Autoantibodies to Protein-Arginine Deiminase (PAD) 4 in Rheumatoid Arthritis: Immunological and Clinical Significance, and Potential for Precision Medicine

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Autoantibodies to Protein-Arginine Deiminase (PAD) 4 in Rheumatoid Arthritis: Immunological and Clinical Significance, and Potential for Precision Medicine Expert Review of Clinical Immunology ISSN: 1744-666X (Print) 1744-8409 (Online) Journal homepage: https://www.tandfonline.com/loi/ierm20 Autoantibodies to protein-arginine deiminase (PAD) 4 in rheumatoid arthritis: immunological and clinical significance, and potential for precision medicine Laura Martinez-Prat, Boaz Palterer, Gianfranco Vitiello, Paola Parronchi, William H. Robinson & Michael Mahler To cite this article: Laura Martinez-Prat, Boaz Palterer, Gianfranco Vitiello, Paola Parronchi, William H. Robinson & Michael Mahler (2019) Autoantibodies to protein-arginine deiminase (PAD) 4 in rheumatoid arthritis: immunological and clinical significance, and potential for precision medicine, Expert Review of Clinical Immunology, 15:10, 1073-1087, DOI: 10.1080/1744666X.2020.1668778 To link to this article: https://doi.org/10.1080/1744666X.2020.1668778 Accepted author version posted online: 14 Sep 2019. Published online: 13 Oct 2019. Submit your article to this journal Article views: 48 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ierm20 EXPERT REVIEW OF CLINICAL IMMUNOLOGY 2019, VOL. 15, NO. 10, 1073–1087 https://doi.org/10.1080/1744666X.2020.1668778 REVIEW Autoantibodies to protein-arginine deiminase (PAD) 4 in rheumatoid arthritis: immunological and clinical significance, and potential for precision medicine Anti-PAD4 antibodies in RA Laura Martinez-Prata,b, Boaz Paltererc, Gianfranco Vitiellod, Paola Parronchie, William H. Robinsonf,g and Michael Mahlera aResearch and Development, Inova Diagnostics, San Diego, CA, USA; bDepartment of Experimental Science, Francisco de Vitoria University, Madrid, Spain; cspecialist in Allergy and Clinical Immunology, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy; dresident in Allergy and Clinical Immunology, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy; e(Allergy and Clinical Immunology), Laboratory Head, Experimental and Clinical Medicine Department, University of Florence, Florence, Italy; f(Immunology and Rheumatology), Division of Immunology and Rheumatology, Stanford University, Stanford, CA, USA; gGeriatric Research Education and Clinical [GRECC] Division, VA Palo Alto Health Care System, Palo Alto, CA, USA ABSTRACT ARTICLE HISTORY Introduction: The protein-arginine deiminase (PAD) 4 enzyme plays an important role in the patho- Received 1 May 2019 genesis of rheumatoid arthritis (RA) and also represents an antigenic target. Anti-PAD4 antibodies can Accepted 13 September 2019 be present in RA and are associated with specific clinical features. KEYWORDS Areas covered: This review aims to analyze the current knowledge and recent findings on anti-PAD4 Rheumatoid arthritis; RA; antibodies in RA and their clinical and immunological significance. autoantibodies; Expert opinion: Anti-PAD4 antibodies are not currently used in clinical practice for the management of protein-arginine deiminase; RA. Nevertheless, there is growing evidence of their relevance in RA, and of their potential utility to anti-PAD; PAD4; anti-PAD4; improve diagnosis, patient stratification, and prognosis. precision medicine; citrullination 1. Introduction enzymes that catalyze the conversion of peptidyl-arginine into peptidyl-citrulline, a post-translational modification (PTM) Rheumatoid Arthritis (RA) is a chronic, inflammatory disease known as citrullination or deimination, which is an important that affects 0.5–1% of the population [1]. It is a complex part in the pathogenesis of RA. In addition to their role in heterogeneous condition with variable clinical manifestations, citrullination, three members of the PAD family of enzymes characterized by chronic synovial inflammation, and articular have been recently identified as autoantigens in RA, including cartilage and bone damage. Several risk factors have been PAD2, PAD3, and PAD4 [11–13], and among them, antibodies to identified [2], including genetic and environmental factors, as PAD4 are the most characterized. In the last few years, PAD well as lifestyle. Nevertheless, the underlying pathogenic enzymes captured growing attention due to the cumulative mechanisms are still not fully understood. understanding of their role in the pathogenesis of RA and the The presence of autoreactive T- and B-cells and the produc- potential to block PAD activity as a novel treatment strategy tion of autoantibodies are key features of RA, with Rheumatoid [14–16]. The objective of this review is to provide an overview of Factor (RF) and anti-citrullinated protein antibodies (ACPA) the current understanding on anti-PAD4 antibodies in RA, being the main two biomarkers. Yet, up to 60% of the early including their role in pathogenesis, their clinical significance RA patients do not present these antibodies, often referred to and their potential for precision medicine (PM) approaches. as the serological gap [3]. Although the combination of ACPA and RF can increase the diagnostic efficiency [3], seronegative patients persist. Consequently, numerous studies aimed to 2. The PAD enzymes and citrullination identify novel biomarkers to further improve the diagnosis of Citrullination is an important PTM in normal physiological RA [4]. In addition, biomarkers that aid in establishing prog- conditions of key cellular processes such as apoptosis, organi- nosis, in patient stratification, in disease activity monitoring and zation of structural proteins [14,17] and gene regulation, espe- in predicting response to treatment are desired. In this context, cially during early embryonic development [18,19]. The activity several novel autoantibodies have been described in RA of the PAD enzymes is stringently regulated in normal condi- patients over the past few years [4], including antibodies target- tions; however, dysregulation of the citrullination pathway can ing carbamylated proteins (CarP) [5–8] and the protein-arginine occur in association with several diseases, including several deiminase (PAD) enzymes [9–12]. The PAD proteins are types of cancer [20], neurodegenerative diseases [21], and CONTACT Michael Mahler [email protected] 9900 Old Grove Road, San Diego, CA 92131, United States © 2019 Informa UK Limited, trading as Taylor & Francis Group 1074 L. MARTINEZ-PRAT ET AL. Table 1. Protein sequence homology between the protein-arginine deiminase (PAD) 2, 3, and 4 enzymes. Data were generated by BLASTp analysis [38] using Article highlights the FASTA sequences from UniProt (The UniProt Consortium). The UniProt IDs of ● Five members of the PAD family have been described in humans, and each isoform can be found in Table 2. three of them, PAD2, 3 and 4, have been identified as autoantigens in RA. Proteins compared PAD2 vs. PAD3 PAD2 vs. PAD4 PAD3 vs. PAD4 – ● Anti-PAD4 antibodies are found in 30 40% of the RA patients with Identities 345/667 (52%) 337/668 (50%) 374/669 (56%) specificity of >95%, and in 2-18% of the RF and ACPA seronegative Positives 452/667 (67%) 440/668 (65%) 461/669 (68%) individuals. Gaps 5/667 (0%) 8/668 (1%) 11/669 (1%) ● Anti-PAD4 antibodies are associated with joint erosions and a more E value 0.0 0.0 0.0 severe disease phenotype. ● Testing for anti-PAD4 antibodies might provide diagnostic and prog- PAD, protein-arginine deiminase. nostic value. PAD3, and PAD4 have been identified as antigenic targets in RA. As expected by the similar cellular function, there is autoimmune diseases [22]. Particularly relevant is the case of a significant protein sequence homology between these RA, characterized by hypercitrullination and accumulation of three enzymes (Table 1). The members of the PAD family differ citrullinated products and antibodies to the modified antigens in their substrate specificities and tissue-specific expression present in the joints. Thus, citrullination can promote genera- and studies suggest that the PAD enzymes have the capacity tion of neo-(auto) antigens and help trigger the autoimmune to select unique protein targets and that this capability may response [23]. play a role in autoantigen selection in RA [26]. Citrullination and the PAD enzymes also play an important PAD2 is the most broadly expressed isoform. Many proteins role during apoptosis, autophagy and the formation of neu- have been identified as substrates of PAD2, with the main being trophil extracellular traps (NETs) [24], processes well known for myelin basic protein (MBP) in the central nervous system, and their involvement in autoimmunity. During infection or inflam- vimentin in skeletal muscle and macrophages [26,27,35,36]. mation, PAD4 becomes activated in neutrophils resulting in Studies suggest a tissue-specific hormonal regulation of PAD2 the citrullinating of multiple autoantigens [25–27] and the expression [64,65]. Although PAD2 is mainly localized in the ejection of chromatin from the cell, generating the NETs, cytoplasm, data suggest that a fraction of PAD2 can also be important tools in the protection against infection [28]. found in the nucleus despite lacking a nuclear translocation Citrullination of histones represents an important step in this signal, and that this nuclear PAD2 may citrullinate histones H3 process [29]. Little is known about the role of PAD2 in NETs and H4 and play a role in gene regulation [66]. formation; limited data seems to indicate that PAD2 is On the other hand, PAD3 is expressed in hair follicles and required for tumor necrosis factor alpha (TNFα)-induced
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