Determination of Immune Markers in Renal Disorders Throughout Biological Therapy of Rheumatoid Arthritis

Manal Azzet Aziz,Abdul Kareem Shehab Diab,Neama Yassir Habil
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Keywords : Rheumatoid Arthritis, renal disorder, cytokines, CRP, ESR
Medical Journal of Babylon  14:2 , 2017 doi:1812-156X-14-2
Published :22 October 2017


This study was conducted to investigate the serum level of C-reactive protein, erythrocyte sedimentation rate, creatinine, glomular filtration rate, tumor necrosis factor-? (TNF-?) and interlukin-6 (IL6) in rheumatoid arthritis patients associated with renal impairment treated with antiTNF-?. This study included "two groups; 54 patients with rheumatoid arthritis treated with Etanercept (Enbrel) 50mg and 58 patients with rheumatoid arthritis on treatment other than Anti TNF-? as a comparative"group. The results showed that renal function tests of rheumatoid arthritis patients who received Anti TNF-? were different, before and"after treatment. A "significant decrease in the value of creatinine and in the level of GFR after 6 months of treatment was observed"(P? 0.0001). The erythrocyte sedimentation rate, C-reactive protein, interlukin-6 and TNF-? increased in rheumatoid arthritis patients with renal disorders before biologic therapy compared with the comparison group who were on treatment other than Anti TNF-?. Following the administration of Anti TNF-?"therapy. These inflammatory parameters were significantly diminished in the rheumatoid arthritis patients after the therapy. The treatment with Anti TNF-? seems to be a factor in restoring the levels of the inflammatory immune markers.


Rheumatoid arthritis (RA) is a chronic autoimmune disease that targets "articular and extra-articular" organs, which may leads to "substantial morbidity" and mortality [1]."In addition, uncontrolled RA can cause progressive renal disorders, high medical and social costs, and decreases life expectancy [2]. Reports revealed that in industrialized country the "incidence of RA disease affects 0.5-1% of older adults population" and higher in women than" men [2-3]. "Few studies "have specifically examined the association of renal diseases in patients with RA treated with biological" therapy (Anti TNF"-?). A significant rate of renal damage in RA was found in some researches, that can be expressed by both a reduced glomerular filtration rate (GFR) and tubular function. This complication may range from"5% to" 50%.[4-5] "The complications in RA patients are clinically common, because it is not only limits the management of primary disease per see, but also increases the rate of death.[1]"In fact, end stage renal diseases are the common cause of death in RA"patients [6]. "Over the last decades, a close association between inflammation and renal disease has been recognized in several"studies [7-9]."It is not easy to define the main cause of impaired renal function in patients"with long standing"RA because of the coexistence of multiple possible"causes." Diseases "modifying anti-rheumatic drugs (DMARD) such as"D-penicillamine, cyclosporin and "methotrexate that are"currently used to treat rheumatic diseases have an impact on renal function due to their side effects, inflammatory mediators, and renal paranchymal"toxicity [5,10]. "The treatment of autoimmune rheumatic diseases has gradually developed by the introduction of biological therapy that is targeting inflammatory mediators to treat autoimmune disease"such as"RA."This type of"treatment, the biological therapy, is a tumor necrosis factor alpha inhibitor"(anti"TNF-?). These medications act by"inhibiting the proinflammatory cytokine TNF-?" such as "infliximab and the IL-6 receptor inhibitor (tocilizumab)" in which it"targets a protein called IL"-6.[5] It is prescribed for"RA and other groups of inflammatory arthritis to reduce inflammation, decrease joint damage, and may extract effects on"renal function.[5,11,12]"Etanercept (Enbrel), another anti TNF-? is also indicated and prescribed for Iraqi patients with RA"to control disease"progression, inhibiting large number of clinical responses; decreases joint damage, and enhancing"physical function, therefore," improves QoL in patients with active RA. Etanercept can be started with or without other DMARD such as "methotrexate [13]. "TNF? is a significant pro-inflammatory cytokine which can cause renal damage and shows various effects on different cell types, and plays an important role in the pathogenesis of chronic inflammatory diseases such as RA [14,15]. According to the "Dutch Rheumatoid Arthritis Monitoring register (DREAM), anti-TNF "agents are commonly utilized in 60% of the RA patients for the last five years.[16] "Interleukin-6 cytokine is produced by several types of immune cells generally in response to physiologic stimuli,"such as TNF-?".[14] In "RA patients the IL-6 is the most abundantly expressed" cytokine [17]. "In patients"with RA, a precise estimation of renal diseases is particularly important. The incidence of renal diseases in patients with RA is not clearly"identified, though patients with"RA often show markers of renal function" disorders [10] "such as blood urea and serum creatinine, erythrocyte sedimentation rate (ESR) and C-reactive" protein"(CRP), in addition to the general inflammatory markers such as the erythrocyte sedimentation rate (ESR) and"C-reactive protein (CRP). To "date, according to new National Kidney Foundation classification, there are no data in the literature on the prevalence of renal diseases in"RA"patients [18-19]. The purpose of this study is to evaluate the incidence of certain abnormal laboratory and inflammatory markers associated with renal impairment"in RA"patients. The "study appraise the renal function during treatment with anti TNF-? agents, one of the"biological DMARD medications that are recently introduced in Iraq for"treating RA.

Materials and methods

This "study included 54 RA patients (16 female, 38 male, median age 60 years, range 34-82 years) who attended the outpatients clinic of the Department of Rheumatology, Al-"Yarmook Teaching Hospital and private clinics in"Baghdad" City. RA "was diagnosed according to the"classification criteria of the American College of" Rheumatology"[19]. All "patients used different types of non-steroidal anti-inflammatory drugs (NSAID)"and pain killers. They "received" Anti TNF-? in particular Etanercept (Enbrel) 50mg subcutaneously every 2"weeks for 6 months. A comparison group consisted of 58 of RA subjects (19 female, 39 male, median age 51 years, range 39-72 years) on treatment other than Anti"TNF-? was enrolled.
The study "included"participants with normal blood picture and liver" function" tests.
"Demographic parameters were registered for each patient which included age, gender and body mass"index (BMI) which was calculated from" the"equation: BMI= weight (kg)/height2 "(m).
An "exclusion criteria was set for patients with Diabetes Mellitus, patients with long standing urinary tract infections and any other disease that may have effects on the expected results, hence decrease the presence of "confounders.
"The study procedure was approved by the Ethics Committees of the"local hospital. All participants had given written informed consent prior to starting" the study.
Biochemical Analyses
 Blood was sampled in the morning after overnight fasting. After clotting and separation by centrifuge; the serum was immediately frozen at –20 ?C until analyzed.
Serum concentrations of "CRP, TNF-? (BioSystem, Costa Brava, Barcelona," Spain), and"IL-6"(R&D® Systems, Minneapolis," MN) levels were measured via "enzymatic immune-sorbent assay" (ELISA)." Serum" creatinine was estimated by a colorimetric coupled enzymatic reaction at"570 nm. Blood ESR was determined by a modified Westergren "method.[20]


"Demographic characteristics for the 54 RA patients under treatment with biological therapy and 58 RA patients as a comparison group are listed in Table1."There were no significant differences between the two groups with regard to parameters such as age, gender, or body weight. The results of renal function tests were different in the patients before and after treatment. Even more, in the" biologically treated patients receiving Anti TNF"-? presented a significant decrease in the value of creatinine and significant increase in the level of"GFR after 6 months of treatment compared to the comparison group (P?0.0001)" (Table 2). "Figure 1"shows the levels of"CRP, ESR, TNF-? IL-6, GFR and serum creatinine of RA patients before and after" biologic therapy compared to the" comparison"group. The "levels of ESR and IL-6 were significantly higher in RA patients after treatment than in comparison group (P ? 0.0001)."RA patients before treatment showed a significant elevation in"ESR, IL-6 and CRP concentration compared to the comparison group (P ? 0.0001 and P ? 0.01"respectively). The concentrations of ESR, IL-6 and CRP were lower in RA patients after treatment than that before treatment. As"can be seen from" Figure 1, Etanercept significantly suppressed TNF-? level in the treated RA" patients compared to the comparison s group"(P ? 0.0001). Pearson’s correlation analysis showed a positive correlation between serum creatinine of RA patients before biologic therapy and with each of the following parameters, CRP"(r = 0.812, P ? 0.0001), "TNF-? (r = 0.387, P = 0.006), ESR (r = 0.462, P ? 0.001), and IL-6 (r = 0.297, P = 0.040) (data not shown). While after treatment, the parameters were CRP (r = 0.327, P = 0.022), TNF-? (r = 0.291, P = 0.044), ESR (r = 0.128, P = 0.399), and IL-6 (r = 0.183, P = 0.212) (Figure"2)."On the other hand, GFR levels before treatment were negatively correlated with CRP (r= -0.895, P ? 0.0001), TNF- ? (r = - 0.637, P ? 0.0001), ESR (r = -0.426, P = 0.003) and IL-6 (r =-0.775, P ? 0.0001) (data not shown)." While after treatment, the parameters were CRP (r = - 0.874, P = 0.0001), TNF- ? (r = - 0.314, P = 0.035), ESR (r = -0.667, P = 0.0001) and IL-6 (r = -0.899, P = 0.0001) (Figure"3).


"RA patients are more likely to"develop renal complications than"people without RA. Although the"occurrence for reduced renal function in patients with RA"is described in few"studies,[21] it is clear"that the cause of the renal involvement in RA patients is debatable, and may be due to secondary renal disease caused by glomerulonephritis or amyloidosis, and associated" co-morbidities [5,22,23]. In" addition, a number of studies are underlying the etiologic role of"chronic inflammation in"renal"involvement.[24-25]."Systemic inflammation may contribute to development of renal disorder and anti-inflammatory"biologic drugs, such as anti TNF-?, that possess therapeutic potential"in preventing renal disorder progression in RA" patients [26-28]. In"general, biological agents had been extremely effective in the treatment of"RA."Nevertheless, cases"with serious adverse events have also been" observed [29]. This study show that successful treatment with the biological agents is associated with the control of renal function expressed by lower serum creatinine and higher"GFRs than in the patients before" treatment," although "GFR and creatinine did not return completely to baseline. Earlier studied had utilized serum creatinine to determine renal disorder, while" recently studies have used GFR to estimate renal disorder, although the relationship between serum creatinine and GFRs is" reciprocal [30]. The" higher results of GFR in the biologic" therapy patients, is effectively" underlying suggestion of bring down an ongoing process" of chronic infla-mmation" which may contribute to lowering the developing" renal" failure."Hanzu-Pazara et al. [5] described" a"similar link between the higher GFR in users of Rituximab" (Rituxan), the Anti TNF-?, compared with the non-Anti TNF-? users (100.36 ± 16.76 mL/min/1.73 m2 vs. 63.49 ± 21.60 mL/min/1.73 m2, P < 0.0001). This"may be due to the protective role of Anti TNF-?"treatment in the decreasing the probability of renal"complications. While"Daoussis et al. [22] described a correlation between "cardiovascular manifestations and renal disorders, while no association with"other RA-related"factors. A"number of increased serum levels of"cytokines that associate with the disease activity of RA had been explained. For instance, level of IL-6 was elevated considerably in patients with RA, and it was diminished after administration of anti RA"therapy.[31] These"findings suggest a possible role of IL-6 family cytokines in the pathogenesis of RA." In addition, a favorable clinical response subsequent the administration of anti TNF-? was revealed to be accompanied through the decreased serum levels of these inflammatory"mediators.[32] So"far, much attention has been paid to the inflammatory cytokines role in RA pathogenesis, especially"TNF-? and IL-6 and their importance in clinical"monitoring of the disease"development.[33]"Numerous studies reported that"TNF-? and IL-6 are known to be raised in serum of RA"patients, and can be used as indicators of disease activity and the use of" biologic therapies in RA"" patients [34-35]. Our"study revealed that the serum"TNF-? level is elevated in RA patients prior to biologic therapy"compared to the"comparison group. While the"TNF-? concentration is significantly decreased in the biologic treated patients on the contrary to a previous study by Charles et"al., who"found a dose dependent increase in serum"TNF-?? in RA"patients being treated with biological"agents.[36] The"reason for reduced"TNF-? level after treatment in RA" patients that found in this study and few other studies may be due to that "biologic therapy is a recombinant fusion protein composed of receptors and human IgG1"that binds to"both soluble and cell-bound TNF-?"[29]. "Haworth et al. showed that TNF-? plays an influential role in RA, blocking of TNF-? via antibodies significantly decreased the production of IL-6"[37]. In"the current study we found that IL-6 concentration in serum of RA patients before treatment was nine-fold higher than in comparison group. These"results are in agreement with the findings of Madhok et al., and Leeuwen et al. [38-39]. Following"treatment with the biological therapy, RA patients recorded significant decrease"IL-6 level to be four-fold higher than""control. This result"is concordant with Sato et al and Mori"et al. [29,40] who showed remarkable decrease in IL-6 concentration during the course of" treatment. "In"the "RA patients group, the admini-stration of the biologic therapy led to a reduction of the inflammatory activity as seen by a significant drop of the CRP and ESR"concentration after the reliable period of treatment (?? < 0.001 and ?? < 0.0001 respectively). Several"studies have been analyzed the synthesis and secretion mechanism of CRP during the acute phase" response."Nonetheless, there is little information about a possible role of renal clearance or catabolism in estimating serum CRP."Panichi et al. [41] reported that"CRP is significantly associated to residual renal function"indicating that a decreased clearance of this molecule may partially explain the increased levels reported in renal disorder" patients."Another explanation of elevated"CRP levels may be due to the long standing of hepatic stimuli as a consequence of increased of cytokine IL-6"in renal" patients.[33-42-43] "In"addition to age and sex, infla-mmation can also cause ESR level to be"increased. Whereas"the ESR is not a diagnostic test, it can be utilized as disease activity monitor, response to treatment and the presence of"inflammation. For"instance, in RA patients, the ESR associates well with disease activity, successful treatment can settle inflammatory state and normalize ESR" level. [44,45]. This" study showed a positive correlation between"CRP and ESR with serum"creatinine in RA patients, which proves the link between renal damage in RA and inflammation."Hanzu-Pazara et al. [5]. reported that the effective biologic therapy response can be noticeable by analyzing the infla-mmatory indicators such as"ESR and CRP"which are correlating with a superior renal"function.


"Renal damage in RA patients appears to be more as a consequence of long standing inflammatory"processes. The study found a significant increase in levels of ESR, CRP, IL-6 and TNF in srea of RA patients with renal disorders before biologic therapy. These inflammatory parameters diminished significantly in the RA patients following the administration of Anti TNF-? therapy. After a reliable period of biologic therapy, significant positive and negative correlation was observed in serum creatinine and GFR with ESR, CRP, IL-6 and TNF-? respectively. We conclude that the inhibition of"IL-6 and TNF-? activity may be the main mechanisms of inflammation modula-tion explained for the treatment of RA. Further studies are suggested such as a Randomized Controlled Trials to explore other mechanisms, as well as to generalize the results in the features of renal involvement and rheumatoid arthritis will be necessary.


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