Pathogenetic and Clinical Aspects of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitides

Abstract

Anti-neutrophil cytoplasmic autoantibodies (ANCA) targeting proteinase 3 (PR3) and myeloperoxidase expressed by innate immune cells (neutrophils and monocytes) are salient diagnostic and pathogenic features of small vessel vasculitis, comprising granulomatosis with polyangiitis (GPA), microscopic polyangiitis, and eosinophilic GPA. Genetic studies suggest that ANCA-associated vasculitides (AAV) constitute separate diseases, which share common immunological and pathological features, but are otherwise heterogeneous. The successful therapeutic use of anti-CD20 antibodies emphasizes the prominent role of ANCA and possibly other autoantibodies in the pathogenesis of AAV. However, to elucidate causal effects in AAV, a better understanding of the complex interplay leading to the emergence of B lymphocytes that produce pathogenic ANCA remains a challenge. Different scenarios seem possible; e.g., the break of tolerance induced by a shift from non-pathogenic toward pathogenic autoantigen epitopes in inflamed tissue. This review gives a brief overview on current knowledge about genetic and epigenetic factors, barrier dysfunction and chronic non-resolving inflammation, necro-inflammatory auto-amplification of cellular death and inflammation, altered autoantigen presentation, alternative complement pathway activation, alterations within peripheral and inflamed tissue-residing T- and B-cell populations, ectopic lymphoid tissue neoformation, the characterization of PR3-specific T-cells, properties of ANCA, links between autoimmune disease and infection-triggered pathology, and animal models in AAV.

Keywords: anti-neutrophil cytoplasmic autoantibodies; anti-neutrophil cytoplasmic autoantibody vasculitides; eosinophilic granulomatosis with polyangiitis; granulomatosis with polyangiitis; microscopic polyangiitis.

Figure 1

Frequency and phenotype of proteinase 3 (PR3)-specific T-cells determined by flow cytometry. Detection of PR3-specific T-cells within the gated CD3⁺CD8⁺ T-cell population in a GPA-patient (right dot plot). A negative control (left dot plot). Costimulatory CD28 and CD161 expression on gated PR3-specific CD8⁺ T-cells (A) in comparison to PR3-negative CD8⁺ T-cells (B) (4).