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Shekarian A, Fakhrolmobasheri M, Mazaheri-Tehrani S, Yousefian A, Heidarpour M. The prevalence of positive thyroid autoantibodies in patients with subacute thyroiditis: a systematic review and meta-analysis. Endocrine 2024; 84:29-41. [PMID: 38147263 DOI: 10.1007/s12020-023-03655-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/09/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE Subacute thyroiditis (SAT) is a transient inflammatory disorder of the thyroid gland with a possible viral etiology. We conducted this study to estimate the pooled prevalence of thyroid autoantibodies in SAT patients. This question arose due to the varying reports on the positivity rates of thyroid autoantibodies among SAT patients. METHODS We searched PubMed, Embase, Scopus, and Web of Science from their inception until March 25th, 2023. Observational studies reporting the positivity rate of thyroid autoantibodies for more than ten patients were included. We used the Joanna Briggs Institute's (JBI) critical appraisal checklist to assess the quality of the included studies. Pooled prevalence estimates with 95% confidence intervals were calculated using the random effects model. Subgroup analyses were performed to find sources of heterogeneity. RESULTS Out of 1373 identified records, 32 studies involving 2348 SAT patients were included in our study. Thyroglobulin antibody (TgAb) and thyroid peroxidase antibody (TPOAb) were positive in 22.8% and 12.2% of patients, respectively. The Study design, mean erythrocyte sedimentation rate and mean thyroid-stimulating hormone of patients were identified as sources of heterogeneity. As our secondary objectives, we found a recurrence rate of 14.7% and permanent hypothyroidism in 11.6% of patients. CONCLUSION The results of our study revealed a low TPOAb positivity rate in SAT patients, consistent with its non-autoimmune etiology. The TgAb positivity rate in SAT patients was higher than that of the general population, possibly explained by the transient release of thyroglobulin into the bloodstream during the thyrotoxic phase, leading to subsequent TgAb production. Furthermore, our findings demonstrate a notable recurrence rate and permanent hypothyroidism among SAT patients, highlighting the importance of ongoing follow-up care.
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Affiliation(s)
- Arman Shekarian
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Fakhrolmobasheri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sadegh Mazaheri-Tehrani
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhossein Yousefian
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Heidarpour
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Wang Y, Fang S, Zhou H. Pathogenic role of Th17 cells in autoimmune thyroid disease and their underlying mechanisms. Best Pract Res Clin Endocrinol Metab 2023; 37:101743. [PMID: 36841747 DOI: 10.1016/j.beem.2023.101743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Autoimmune thyroid disease, encompassing Graves' disease and Hashimoto's thyroiditis, has a very complex etiology. Pathogenesis of the disease involves both genetic susceptibility and environmental triggers. Traditionally, imbalance of T helper cell 1 and 2 was thought to result in the immune disorders in Graves' disease and Hashimoto's thyroiditis. However, increasing evidence recently revealed the important role of T helper 17 cell and its relative cellular and secretory components in the pathogenesis and progression of autoimmune thyroid disease. This review is aimed to summarize the published studies on the involvement of T helper 17 cell in autoimmune thyroid disease and discuss the underlying regulatory mechanisms, which could possibly serve as the foundation of discovering new therapeutic targets.
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Affiliation(s)
- Yi Wang
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai 200011, China; Chinese Consortium for Thyroid Eye Disease (CCTED), China; Department of Immunology and Microbiology, Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, Shanghai 200025, China.
| | - Sijie Fang
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai 200011, China; Chinese Consortium for Thyroid Eye Disease (CCTED), China; Department of Immunology and Microbiology, Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, Shanghai 200025, China.
| | - Huifang Zhou
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai 200011, China; Chinese Consortium for Thyroid Eye Disease (CCTED), China.
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Dwivedi SN, Kalaria T, Buch H. Thyroid autoantibodies. J Clin Pathol 2023; 76:19-28. [PMID: 36270794 DOI: 10.1136/jcp-2022-208290] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 12/26/2022]
Abstract
Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with thyrotoxicosis. A positive test establishes the diagnosis of Graves' disease (GD) while a negative result in conjunction with imaging studies supports other possible aetiologies. In patients with GD, TRAb levels at diagnosis and at the time of withdrawal of antithyroid drugs can identify patients who are unlikely to achieve remission and guide clinical management decisions. We provide an algorithm that incorporates TRAb in the decision-making process for the management of thyrotoxicosis. The utility of TRAb in predicting the risk of fetal and neonatal thyroid dysfunction is established and widely accepted in guidelines. TRAb may also help in the diagnosis of Graves' orbitopathy, especially in euthyroid or hypothyroid patients and its role in guiding its management is evolving as a useful adjunct to the clinical parameters used in making therapeutic decisions.Anti-thyroid peroxidase antibodies (TPOAb) and anti-thyroglobulin antibodies (TgAb) indicate thyroid autoimmunity. The most common use of TPOAb is to identify patients at a higher risk of progression to treatment-requiring hypothyroidism. They also aid the diagnosis of immune thyroiditis and Hashimoto's encephalopathy. Thyroglobulin measurement is used to help guide differentiated thyroid cancer treatment. TgAb is used as an accompanying test with thyroglobulin measurement as its presence can interfere with the thyroglobulin assay. A negative TgAb result reduces the likelihood of, but does not exclude, interference with thyroglobulin assay.
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Affiliation(s)
| | - Tejas Kalaria
- Clinical Biochemistry, New Cross Hospital, Black Country Pathology Services, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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Davies TF, Morshed SA, Mezei M, Latif R. Brief Report - Monoclonal Antibodies Illustrate the Difficulties in Measuring Blocking TSH Receptor Antibodies. Front Endocrinol (Lausanne) 2022; 13:943459. [PMID: 35909553 PMCID: PMC9335193 DOI: 10.3389/fendo.2022.943459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
TSH receptor (TSHR) antibodies are the cause of Graves' disease and may also be found in patients with Hashimoto's thyroiditis. They come in at least three varieties: thyroid stimulating, thyroid blocking and neutral. The measurement of TSH receptor antibodies in Graves' disease and Hashimoto's thyroiditis is a common clinical activity and can be useful in diagnosis and prognosis. We show that it is not possible to detect the blocking variety of TSHR antibody in patients with Graves' disease because the stimulating antibody may overwhelm the measurement of blocking in the bioassays available for their measurement and may blind the valid interpretation of the results. To help explain this in more detail we show a series of studies with monoclonal TSHR antibodies which support this conclusion.
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Zhou Y, Zhou M, Qi Y, Wang W, Chen X, Wang S. The prognostic value of thyroid-stimulating immunoglobulin in the management of Graves' disease. Ther Adv Endocrinol Metab 2021; 12:20420188211044943. [PMID: 34603682 PMCID: PMC8481717 DOI: 10.1177/20420188211044943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The bioassay of thyroid-stimulating immunoglobulin was reported to have a similar performance to the commonly used thyroid-stimulating hormone binding inhibition assay, also known as thyroid receptor antibody assay. The normal reference range of thyroid receptor antibody levels indicates the withdrawal of anti-thyroid drugs in the recent clinical guidelines. METHODS A prospective, longitudinal observational study was conducted to evaluate the prognostic value of thyroid-stimulating immunoglobulin in patients with Graves' disease. RESULTS A total of 77 patients with Graves' disease treated with anti-thyroid drugs were in a continuous follow-up until 1 year after anti-thyroid drugs discontinuation. Commercial kits of thyroid-stimulating immunoglobulin and M22-thyroid-stimulating hormone binding inhibition assay were used and compared. Thyroid-stimulating immunoglobulin was all negative in healthy controls, Hashimoto thyroiditis, and subacute thyroiditis. Thyroid-stimulating immunoglobulin value was highest in untreated patients with Graves' disease (p < 0.001). Under anti-thyroid drugs treatment, thyroid-stimulating immunoglobulin value decreased gradually. A total of 21 patients had positive thyroid-stimulating immunoglobulin at the end of treatment. According to clinical fate of patients with Graves' disease after withdrawal of anti-thyroid drugs, thyroid-stimulating immunoglobulin value and positivity in patients with relapse were significantly higher than that reported in patients with remission (p = 0.001, p < 0.001). After adjustment for age, gender, initial thyroid receptor antibody, initial thyroid-stimulating immunoglobulin, and thyroid receptor antibody at the end of treatment, the odds ratio of positive thyroid-stimulating immunoglobulin for the risk of relapse was 33.271 (95% confidence interval: 4.741-233.458, p < 0.001) and odds ratio of quantitative thyroid-stimulating immunoglobulin was 1.009 (95% confidence interval: 1.002-1.015, p < 0.001). CONCLUSION Thyroid-stimulating immunoglobulin is a good predictor of relapse in patients with Graves' disease treated with anti-thyroid drugs. It might be safer to discontinue anti-thyroid drugs when thyroid-stimulating immunoglobulin and thyroid receptor antibody were both negative.
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Affiliation(s)
- Yulin Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Mengxi Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Yicheng Qi
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | | | | | - Shu Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, 197 Ruijin 2nd Road, Shanghai 200025, P.R. China
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Kahaly GJ, Diana T, Kanitz M, Frommer L, Olivo PD. Prospective Trial of Functional Thyrotropin Receptor Antibodies in Graves Disease. J Clin Endocrinol Metab 2020; 105:5684882. [PMID: 31865369 PMCID: PMC7067543 DOI: 10.1210/clinem/dgz292] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/17/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Scarce data exist regarding the relevance of stimulatory (TSAb) and blocking (TBAb) thyrotropin receptor antibodies in the management of Graves disease (GD). OBJECTIVE To evaluate the clinical utility and predictive value of TSAb/TBAb. DESIGN Prospective 2-year trial. SETTING Academic tertiary referral center. PATIENTS One hundred consecutive, untreated, hyperthyroid GD patients. METHODS TSAb was reported as percentage of specimen-to-reference ratio (SRR) (cutoff SRR < 140%). Blocking activity was defined as percent inhibition of luciferase expression relative to induction with bovine thyrotropin (TSH, thyroid stimulating hormone) alone (cutoff > 40% inhibition). MAIN OUTCOME MEASURES Response versus nonresponse to a 24-week methimazole (MMI) treatment defined as biochemical euthyroidism versus persistent hyperthyroidism at week 24 and/or relapse at weeks 36, 48, and 96. RESULTS Forty-four patients responded to MMI, of whom 43% had Graves orbitopathy (GO), while 56 were nonresponders (66% with GO; P < 0.01). At baseline, undiluted serum TSAb but not thyroid binding inhibitory immunoglobulins (TBII) differentiated between thyroidal GD-only versus GD + GO (P < 0.001). Furthermore, at baseline, responders demonstrated marked differences in diluted TSAb titers compared with nonresponders (P < 0.001). During treatment, serum TSAb levels decreased markedly in responders (P < 0.001) but increased in nonresponders (P < 0.01). In contrast, TBII strongly decreased in nonresponders (P = 0.002). All nonresponders and/or those who relapsed during 72-week follow-up period were TSAb-positive at week 24. A shift from TSAb to TBAb was noted in 8 patients during treatment and/or follow-up and led to remission. CONCLUSIONS Serum TSAb levels mirror severity of GD. Their increase during MMI treatment is a marker for ongoing disease activity. TSAb dilution analysis had additional predictive value.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: Prof. George J Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
| | - Tanja Diana
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Michael Kanitz
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Lara Frommer
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Paul D Olivo
- Department of Molecular Microbiology, Washington University Medical School, St. Louis, Missouri
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Plazinska MT, Sawicka-Gutaj N, Czarnywojtek A, Wolinski K, Kobylecka M, Karlińska M, Prasek K, Zgorzalewicz-Stachowiak M, Borowska M, Gut P, Ruchala M, Krolicki L. Radioiodine therapy and Graves' disease - Myths and reality. PLoS One 2020; 15:e0226495. [PMID: 31929534 PMCID: PMC6957158 DOI: 10.1371/journal.pone.0226495] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022] Open
Abstract
Introduction Autoimmune reactions in Graves’ disease (GD) occur not only in the thyroid gland, but also in the orbital connective tissue, eyelids, extraocular muscles. The occurrence of orbitopathy in the course of GD is influenced by environmental factors, e.g. cigarette smoking. Objectives The aim of the study was to analyze the effect of cigarette smoking on the efficacy of activity of radioiodine(131I) therapy in patients with GD. We also studied the influence of cigarette smoking and the efficacy of prednisone prophylaxis on the risk of thyroid-associated ophthalmopathy (TAO) development after radioiodine therapy (RIT) during two years of follow-up. Patients and methods Medical records of hyperthyroid patients treated with radioiodine had been included. Patients were scheduled to visit outpatient clinics at baseline and 1, 3, 6, 9, 12, 18, and 24 months after RIT. Results The studied group consisted of 336 patients (274 women, 62 men) diagnosed with GD and treated with RIT; 130 patients received second therapeutic dose of 131I due to recurrent hyperthyroidism. Among all studied patients, 220 (65.5%) were smokers and 116 (34.5%) non-smokers. In the group of smokers 115 (52.2%) of patients received single RIT, 105 (47.8%) received second dose of RAI due to recurrent hyperthyroidism. In non-smokers 91 (78.6%) received single activity of RAI, while 25 (21.4%) patients required second RIT due to recurrent hyperthyroidism. The ophthalmic symptoms in the group of smokers after RIT were less frequent, if the patient received preventative treatment in the form of oral prednisone (P = 0.0088). Conclusions The results of our study suggest that cigarette smoking reduces the efficacy of treatment with 131I in patients with GD. The study also confirmed the effectiveness of steroid prophylaxis against TAO development or exacerbation after RIT.
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Affiliation(s)
| | - Nadia Sawicka-Gutaj
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Czarnywojtek
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Kosma Wolinski
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
- * E-mail:
| | | | - Maria Karlińska
- Department of Medical Informatics and Telemedicine, Warsaw Medical University, Warsaw, Poland
| | - Karolina Prasek
- Department of Nuclear Medicine, Warsaw Medical University, Warsaw, Poland
| | | | - Magdalena Borowska
- Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Leszek Krolicki
- Department of Nuclear Medicine, Warsaw Medical University, Warsaw, Poland
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Abstract
Rituximab, a monoclonal antibody targeting the B cell marker CD20, was initially approved in 1997 by the United States Food and Drug Administration (FDA) for the treatment of non-Hodgkin lymphoma. Since that time, rituximab has been FDA-approved for rheumatoid arthritis and vasculitides, such as granulomatosis with polyangiitis and microscopic polyangiitis. Additionally, rituximab has been used off-label in the treatment of numerous other autoimmune diseases, with notable success in pemphigus, an autoantibody-mediated skin blistering disease. The efficacy of rituximab therapy in pemphigus has spurred interest in its potential to treat other autoantibody-mediated diseases. This review summarizes the efficacy of rituximab in pemphigus and examines its off-label use in other select autoantibody-mediated diseases.
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Affiliation(s)
- Nina A Ran
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
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Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part I. Ophthalmic Plast Reconstr Surg 2016; 32:321-8. [DOI: 10.1097/iop.0000000000000697] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Bartalena L, Burch HB, Burman KD, Kahaly GJ. A 2013 European survey of clinical practice patterns in the management of Graves' disease. Clin Endocrinol (Oxf) 2016; 84:115-20. [PMID: 25581877 DOI: 10.1111/cen.12688] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 11/13/2014] [Accepted: 12/02/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Management of Graves' disease (GD) in Europe was published in 1987. Aim of this survey was to provide an update on clinical practice in Europe, and to compare it with a 2011 American survey. DESIGN Members of the European Thyroid Association (ETA) were asked to participate in a survey on management of GD, using the same questionnaire of a recent American survey. RESULTS A total of 147 ETA members participated. In addition to serum TSH and free T4 assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (85·6%) and thyroid ultrasound (70·6%) to confirm aetiology, while isotopic studies were selected by 37·7%. Antithyroid drug (ATD) therapy was the preferred first-line treatment (83·8%). Compared to the previous European survey, Europeans currently more frequently use TRAb measurement and thyroid ultrasound for diagnosis and evaluation, but first-line treatment remains ATDs in a similar percentage of respondents. Current clinical practice patterns differ from those in North America, where isotopic studies are more frequently used, and radioiodine (RAI) still is first-line treatment. When RAI treatment is selected in the presence of mild Graves' orbitopathy and/or associated risk factors for its occurrence/exacerbation, steroid prophylaxis is frequently used. The preferred ATD in pregnancy is propylthiouracil in the first trimester and methimazole in the second and third trimesters, similar to North America. CONCLUSIONS Significant changes in clinical practice patterns in Europe were noted compared to the previous European survey, as well as persisting differences in diagnosis and therapy between Europe and North America.
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Affiliation(s)
- L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - H B Burch
- Endocrinology, Diabetes, and Metabolism Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - K D Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC, USA
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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Giuliani C, Saji M, Bucci I, Napolitano G. Bioassays for TSH Receptor Autoantibodies, from FRTL-5 Cells to TSH Receptor-LH/CG Receptor Chimeras: The Contribution of Leonard D. Kohn. Front Endocrinol (Lausanne) 2016; 7:103. [PMID: 27504107 PMCID: PMC4958915 DOI: 10.3389/fendo.2016.00103] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Since the discovery 60 years ago of the "long-acting thyroid stimulator" by Adams and Purves, great progress has been made in the detection of thyroid-stimulating hormone (TSH) receptor (TSHR) autoantibodies (TRAbs) in Graves' disease. Today, commercial assays are available that can detect TRAbs with high accuracy and provide diagnostic and prognostic evaluation of patients with Graves' disease. The present review focuses on the development of TRAbs bioassays, and particularly on the role that Leonard D. Kohn had in this. Indeed, 30 years ago, the Kohn group developed a bioassay based on the use of FRTL-5 cells that was characterized by high reproducibility, feasibility, and diagnostic accuracy. Using this FRTL-5 bioassay, Kohn and his colleagues were the first to develop monoclonal antibodies (moAbs) against the TSHR. Furthermore, they demonstrated the multifaceted functional nature of TRAbs in patients with Graves' disease, with the identification of stimulating and blocking TRAbs, and even antibodies that activated pathways other than cAMP. After the cloning of the TSHR, the Kohn laboratory constructed human TSHR-rat luteinizing hormone/chorionic gonadotropin receptor chimeras. This paved the way to a new bioassay based on the use of non-thyroid cells transfected with the Mc4 chimera. The new Mc4 bioassay is characterized by high diagnostic and prognostic accuracy, greater than for other assays. The availability of a commercial kit based on the Mc4 chimera is spreading the use of this assay worldwide, indicating its benefits for these patients with Graves' disease. This review also describes the main contributions made by other researchers in TSHR molecular biology and TRAbs assay, especially with the development of highly potent moAbs. A comparison of the diagnostic accuracies of the main TRAbs assays, as both immunoassays and bioassays, is also provided.
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Affiliation(s)
- Cesidio Giuliani
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti–Pescara, Chieti, Italy
- *Correspondence: Cesidio Giuliani,
| | - Motoyasu Saji
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, OH, USA
| | - Ines Bucci
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti–Pescara, Chieti, Italy
| | - Giorgio Napolitano
- Unit of Endocrinology, Department of Medicine and Sciences of Aging, Ce.S.I.-Me.T., University of Chieti–Pescara, Chieti, Italy
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Ponto KA, Diana T, Binder H, Matheis N, Pitz S, Pfeiffer N, Kahaly GJ. Thyroid-stimulating immunoglobulins indicate the onset of dysthyroid optic neuropathy. J Endocrinol Invest 2015; 38:769-77. [PMID: 25736545 DOI: 10.1007/s40618-015-0254-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/05/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE Recognition of dysthyroid optic neuropathy (DON) requires sensitive diagnostic tools. Clinical assessment may fail to reliably evaluate the acuteness of DON especially if signs for inflammation are missing. Aim of this cross-sectional study was to assess the relationship between thyroid-stimulating immunoglobulins (TSI) and onset of DON. METHODS At a multidisciplinary orbital center, serum TSI levels were measured in 180 consecutive patients with thyroid eye disease (TED) and 302 healthy controls with a FDA-cleared cell-based bioassay using a chimeric TSH receptor and a CRE-dependent luciferase. RESULTS Thirty of 180 (16.7 %) patients with TED had DON of recent onset or a past history of DON (post-DON). Optic disk swelling was present and visual-evoked potentials were pathologic in all eyes with DON of recent onset, but in one of 13 (7.7 %) with post-DON, only (p = 0.005). 19/20 (96 %) patients with DON of recent onset were TSI-positive. TSI was associated with DON of recent onset (OR: 20.96; 95 % CI 1.064-412.85, p = 0.045). All controls were TSI negative. TSI correlated with the clinical activity score (R = 0.70, p < 0.001) and higher TSI-levels were noted in active vs. inactive TED (485.1 ± 132.3 vs. 277.7 ± 143.7 %, cut-off < 140 %; p < 0.001). Six of seven (85.7 %) patients with inactive TED with recent onset DON versus one of four (25 %) with active post-DON were TSI-positive (p = 0.006). A discriminatory cut-point of 377 SRR % for TSI was determined based on a ROC analysis (sensitivity: 0.95, specificity: 0.8). CONCLUSIONS Serum TSI levels identify patients with DON of recent onset requiring urgent therapy.
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Affiliation(s)
- K A Ponto
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - T Diana
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
| | - H Binder
- Department of Biomedical Statistics, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - N Matheis
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
| | - S Pitz
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - N Pfeiffer
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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Meng Z, Zhang G, Sun H, Tan J, Yu C, Tian W, Li W, Yang Z, Zhu M, He Q, Zhang Y, Han S. Differentiation between Graves' disease and painless thyroiditis by diffusion-weighted imaging, thyroid iodine uptake, thyroid scintigraphy and serum parameters. Exp Ther Med 2015; 9:2165-2172. [PMID: 26136954 DOI: 10.3892/etm.2015.2430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 04/13/2015] [Indexed: 12/29/2022] Open
Abstract
The aim of the present study was to assess the apparent diffusion coefficient (ADC) in diffusion-weighted imaging (DWI), thyroid radioactive iodine uptake (RAIU), thyroid scintigraphy and thyrotropin receptor antibody (TRAb) levels in the differential diagnosis between Graves' disease (GD) and painless thyroiditis (PT). A total of 102 patients with GD and 37 patients with PT were enrolled in the study. DWI was obtained with a 3.0-T magnetic resonance scanner, and ADC values were calculated. RAIU and thyroid scintigraphy were performed. Tissue samples were obtained from patients with GD (6 cases) following thyroidectomy, and from patients with PT (2 cases) following biopsy. Receiver operating characteristic (ROC) curves were drawn, optimal cut-off values were selected, and the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were assessed. It was found that the ADC, TRAb and RAIU were significantly higher in GD than in PT (P<0.05). ROC curves showed areas under the curves for RAIU, ADC and TRAb that were >0.900. RAIU was the reference method. Sensitivity, specificity, accuracy, PPV and NPV were 96.078, 91.892, 95.000, 97.059 and 89.474% for ADC, and 88.235, 75.676, 84.892, 90.909 and 70.000% for TRAb, after the optimal thresholds of 1.837×10-3 mm2/sec and 1.350 IU/ml were determined respectively. Histopathology showed that tissue cellularity in PT was much higher than in GD due to massive lymphocytic infiltration. The results of the present study indicate that RAIU, ADC and TRAb are of diagnostic value for differentiating between GD and PT. DWI has great potential for thyroid pathophysiological imaging because it reflects differences in tissue cellularity between GD and PT.
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Affiliation(s)
- Zhaowei Meng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Guizhi Zhang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Haoran Sun
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Jian Tan
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Chunshun Yu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Weijun Tian
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Weidong Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Zhiqiang Yang
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Mei Zhu
- Department of Endocrinology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Qing He
- Department of Endocrinology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Yujie Zhang
- Department of Pathology, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Shugao Han
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China ; Department of Radiology, Second Affiliated Hospital of Zhejiang Medical University, Hangzhou, Zhejiang 310000, P.R. China
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Diana T, Kanitz M, Lehmann M, Li Y, Olivo PD, Kahaly GJ. Standardization of a bioassay for thyrotropin receptor stimulating autoantibodies. Thyroid 2015; 25:169-75. [PMID: 25317659 DOI: 10.1089/thy.2014.0346] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cell-based bioassays for functional thyroid stimulating autoantibodies (TSAb) are sensitive diagnostic tools. However, there is no bioassay available that is standardized with international reference material. We aimed to promote the standardization of the test results among laboratories that perform TSAb bioassays and calibrate TSAb levels against the second international standard (IS) 08/204 from the National Institute for Biological Standards and Control (NIBSC). METHODS Serum TSAb activity was measured with a FDA-cleared bioassay that utilizes CHO cells expressing a chimeric thyrotropin receptor (TSHR) and a c-AMP response-element-dependent luciferase. The IS was applied for calibration. TSAb results were reported as percentage of specimen-to-reference ratio (SRR%) and converted into mIU/L. RESULTS The IS dose-response curve was obtained using concentrations from 0.3125 to 200 mIU/L. Mean TSAb SRR%±standard deviation (SD) values for the IS concentrations 0.3125, 0.625, 1.25, 2.5, 5, 10, 20, 40, 60, 80, 100, 120, 160, and 200 mIU/L were 63±4 (CV 6.3%), 63±4 (6.3), 67±2 (3.0), 76±6 (7.9), 91±8 (8), 134±8 (5.9), 201±13 (6.5), 294±12 (4.1), 336±10 (3.0), 348±8 (2.3), 360±14 (3.8), 371±15 (4.0), 381±9 (2.4), and 389±10 (2.6), respectively. A total of 127 dilution experiments were performed using 12 high TSAb-positive sera from patients with Graves' disease. When diluting TSAb-positive sera, IS concentrations within the linear range 5, 10, 20, 40, and 80 mIU/L were used for the calibration curve. All standard curves had R(2) values >0.95. Low coefficient of variation (CV %) values for the IS calibration curve (4-6%) were obtained. Compared to bovine TSH, no significant differences were noted using either a pool of healthy donors or a normal serum as reference controls. The average IU measured value for the assay cutoff (SRR 140%) corresponded to 9.54±1.68 mIU/L, and clinical application was shown in 60 Graves' patients. CONCLUSIONS The TSAb bioassay demonstrated excellent performance in terms of linear range, limit of quantitation, and imprecision. The dilution experiments showed a high correlation coefficient and excellent reproducibility. Thus, TSAb levels can be reliably converted from SRR% to IU/L. These results offer the perspective of standardizing TSAb levels among laboratories and enable more accurate comparison of TSAb studies.
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Affiliation(s)
- Tanja Diana
- 1 Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center , Mainz, Germany
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15
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Hwang S, Shin DY, Song MK, Lee EJ. High cut-off value of a chimeric TSH receptor (Mc4)-based bioassay may improve prediction of relapse in Graves' disease for 12 months. Endocrine 2015; 48:89-95. [PMID: 24968734 DOI: 10.1007/s12020-014-0325-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
There are scarce reports regarding a functional prognostic value of thyroid-stimulating autoantibody (TSAb) levels using a thyroid-stimulating hormone receptor chimera (Mc4) in Graves' disease (GD) in iodine sufficient area. The aim of this study was to investigate whether Mc4-TSAb can predict GD remission/relapse after antithyroid drug (ATD) treatment and to compare Mc4-TSAb with a binding assay using M22 monoclonal antibody (M22-TRAb) in GD patients. We retrospectively reviewed the results of M22-TRAb and Mc4-TSAb in GD patients treated with ATD for 12 months. GD patients who underwent ATD treatment for at least 12 months were included. We compared the predictive values of M22-TRAb and Mc4-TSAb for GD remission and relapse. Of the 92 patients, 60 (65.2%) achieved remission and 32 (34.8%) relapsed within 12 months. In receiver operating characteristic analysis, there were no significant differences in the area under the curves (AUCs) between Mc4-TSAb [AUC=0.79 (95% CI 0.69-0.89)] and M22-TRAb [AUC=0.69 (95% CI 0.58-0.81)]. The optimal predictive cut-off values of M22-TRAb and Mc4-TSAb were 2.23 IU/L and 230%, respectively. At a high Mc4-TSAb cut-off, the better specificity of 85.0% and positive predictive value (PPV) of 69.0% were shown compared with those at the best cut-off for M22-TRAb. In conclusion, a high cut-off for an Mc4 assay may improve the predictive value of relapse with superior specificity and PPV compared with M22-TRAb in treated GD.
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Affiliation(s)
- Sena Hwang
- Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, 120-752, Republic of Korea
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16
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Diana T, Brown RS, Bossowski A, Segni M, Niedziela M, König J, Bossowska A, Ziora K, Hale A, Smith J, Pitz S, Kanitz M, Kahaly GJ. Clinical relevance of thyroid-stimulating autoantibodies in pediatric graves' disease-a multicenter study. J Clin Endocrinol Metab 2014; 99:1648-55. [PMID: 24517152 DOI: 10.1210/jc.2013-4026] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE The incidence of TSH receptor (TSHR) stimulating autoantibodies (TSAbs) in pediatric Graves' disease (GD) is controversial. This large, multicenter study evaluated the clinical relevance of TSAbs in children with GD both with Graves' orbitopathy (GO) and without orbital disease. DESIGN We conducted a cross-sectional retrospective study. SETTING Sera were collected in seven American and European academic referral centers and evaluated in a central laboratory. PATIENTS AND SAMPLES: A total of 422 serum samples from 157 children with GD, 101 control individuals with other thyroid and nonthyroid autoimmune diseases, and 50 healthy children were studied. MAIN OUTCOME MEASURES TSAbs were measured using a novel, chimeric TSHR bioassay and a cAMP response element-dependent luciferase. TSH binding-inhibitory Ig (TBII) and parameters of thyroid function were also determined. RESULTS In 82 untreated children with GD, sensitivity, specificity, and positive and negative predictive values for TSAb and TBII were: 100 and 92.68% (P = .031), 100 and 100%, 100 and 100%, and 100 and 96.15%, respectively. TSAb and TBII were present in 147 (94%) and 138 (87.9%) of the 157 children with GD (P < .039), respectively; and in 247 (94%) and 233 (89%) of the 263 samples from this group (P < .0075), respectively. In children with GD and GO, TSAb and TBII were noted in 100 and 96% (P < .001), respectively. Hyperthyroid children with GD and GO showed markedly higher TSAb levels compared to those with thyroidal GD only (P < .0001). No significant differences were noted for TBII between the two groups. After a 3-year (median) medical treatment, the decrease of TSAb levels was 69% in GD vs 20% in GD and GO (P < .001). All 31 samples of euthyroid children with GO were TSAb positive; in contrast, only 24 were TBII positive (P = .016). All children with Hashimoto's thyroiditis, nonautoimmune hyperthyroidism, type 1 diabetes, and juvenile arthritis and the healthy controls were TSAb and TBII negative. CONCLUSIONS Serum TSAb level is a sensitive, specific, and reproducible biomarker for pediatric GD and correlates well with disease severity and extrathyroidal manifestations.
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Affiliation(s)
- T Diana
- Thyroid Laboratory (T.D., M.K., G.J.K.), Department of Medicine I, Johannes Gutenberg University Medical Center, 55101 Mainz, Germany; Division of Endocrinology (R.S.B., A.H., J.S.), Department of Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115; Department of Pediatrics, Endocrinology, Diabetology, with the Cardiology Division (A. Bossowski), Medical University in Bialystok, 15-089 Bialystok, Poland; Department of Pediatrics (M.S.), University La Sapienza, 00185 Rome, Italy; Department of Pediatric Endocrinology and Rheumatology (M.N.), University of Medical Sciences, 61-701 Poznan, Poland; Institute of Medical Statistics, Biometry, and Epidemiology (J.K.), Johannes Gutenberg University Medical Center, 55101 Mainz, Germany; Department of Cardiology (A. Bossowska), Internal Affair and Administration, Ministry Hospital, 15-089 Bialystok, Poland; Department of Pediatrics (K.Z.), Silesia Medical University, 40-055 Katowice, Poland; and Department of Ophthalmology (S.P.), Johannes Gutenberg University Medical Center, 55101 Mainz, Germany
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17
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Jang SY, Shin DY, Lee EJ, Yoon JS. Clinical characteristics of Graves' orbitopathy in patients showing discrepancy between levels from TBII assays and TSI bioassay. Clin Endocrinol (Oxf) 2014; 80:591-7. [PMID: 24033537 DOI: 10.1111/cen.12318] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 06/23/2013] [Accepted: 08/27/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate clinical characteristics of patients with Graves' orbitopathy (GO) who showed discrepancies between levels of thyroid-stimulating immunoglobulin (TSI) and thyrotropin-binding inhibitory immunoglobulin (TBII). DESIGN Comparative case series. PATIENTS A total of 317 patients with GO in whom Mc4-TSI and M22-TRAb (third-generation TBII) were measured simultaneously. Patients were divided into four groups according to TRAb levels as followings: Group 1, TBII and TSI < median value; Group 2, TBII ≥ median, TSI < median; Group 3, TBII < median, TSI ≥ median; Group 4, both TBII and TSI ≥ median. MEASUREMENT Endocrine and ophthalmic clinical manifestations in each group. RESULTS The median value of M22-TRAb was 6·11 IU/l and that of Mc4-TSI was 415·1 (SRR%). One hundred seventeen patients were classified as Group 1, 41 patients as Group 2, 41 patients as group 3 and 118 patients as group 4. Mean CAS was significantly higher in Groups 3 (2·2) and 4 (2·2) than in Groups 1 (1·6) and 2 (1·4; P = 0·001, ANOVA). Mean modified NOSPECS scores were significantly higher (P < 0·001, ANOVA) in Groups 3 (4·1) and 4 (4·1) than in Groups 1 (3·1) and 2 (2·3). The proportion of patients with hyperthyroidism was larger in Group 2 (85·4% [35/41 patients]) than in Group 3 (48·8% [20/41 patients]; P = 0·002). CONCLUSIONS GO is more active and severe in patients with predominant Mc4-TSI than in patients with predominant M22-TRAb. Patients with hyperthyroidism were more likely to be included with patients with predominant M22-TRAb than with predominant Mc4-TSI.
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Affiliation(s)
- Sun Young Jang
- Department of Ophthalmology, Soonchunhyang Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea; Yonsei University Graduate School of Medicine, Seoul, Korea
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18
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Abstract
Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy
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19
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Li Y, Kim J, Diana T, Klasen R, Olivo PD, Kahaly GJ. A novel bioassay for anti-thyrotrophin receptor autoantibodies detects both thyroid-blocking and stimulating activity. Clin Exp Immunol 2013; 173:390-7. [PMID: 23647395 PMCID: PMC3949626 DOI: 10.1111/cei.12129] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 12/23/2022] Open
Abstract
Autoantibodies to the thyrotrophin (TSH) receptor (anti-TSHR) are unique, in that they are involved directly in the pathophysiology of certain autoimmune thyroid diseases (AITD). Thyroid-stimulating antibodies (TSAb) act as agonists that activate the thyroid gland and cause Graves' disease. Other anti-TSHR antibodies block TSH and can cause hypothyroidism. Thyroid-blocking antibodies (TBAb) have not been studied as extensively as TSAb. We developed a TBAb bioassay based on a cell line that expresses a chimeric TSHR. The 50% inhibitory concentration of the chimeric Chinese hamster ovary (CHO)-Luc cells was more than five-fold lower compared with the wild-type CHO-Luc cells. We tested the performance of this bioassay using a thyroid-blocking monoclonal antibody K1-70, established an assay cut-off and detected TBAb in 15 of 50 (30%) patients with AITD. Interestingly, the assay detects both TSAb and TBAb and measures the net activity of a mixture of both types of antibodies. There was a high correlation (R(2) 0·9, P < 0·0001) between the results of the TSAb assay and the negative percentage inhibition of the TBAb assay. The TBAb bioassay was approximately 20-fold more sensitive than a commercially available TSHR binding assay (TRAb). In contrast to TRAb, sera with high levels of TBAb activity were able to be diluted several hundred-fold and still exhibit blocking activity above the cut-off level. Thus, this TBAb bioassay provides a useful tool for measuring the activity of anti-TSHR antibodies and may help clinicians to characterize the diverse clinical presentations of patients with AITD.
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Affiliation(s)
- Y Li
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - J Kim
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - T Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Gutenberg University Medical CenterMainz, Germany
| | - R Klasen
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - P D Olivo
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Gutenberg University Medical CenterMainz, Germany
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Jang SY, Shin DY, Lee EJ, Choi YJ, Lee SY, Yoon JS. Correlation between TSH receptor antibody assays and clinical manifestations of Graves' orbitopathy. Yonsei Med J 2013; 54:1033-9. [PMID: 23709442 PMCID: PMC3663223 DOI: 10.3349/ymj.2013.54.4.1033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To investigate an association between the levels of serum thyroid-stimulating hormone (TSH)-receptor autoantibodies (TRAbs) and Graves' orbitopathy (GO) activity/severity scores, and compare the performance of three different TRAb assays in assessing the clinical manifestations of GO. MATERIALS AND METHODS Cross-sectional study. Medical records of 155 patients diagnosed with GO between January 2008 and December 2010 were reviewed. GO activity was assessed by clinical activity score (CAS) and severity graded with the modified NOSPECS score by a single observer. Serum TRAb was measured by three different methods: 1st generation thyrotropin-binding inhibitor immunoglobulin (TBII) assay (TRAb1st); 3rd generation TBII assay (TRAb3rd); and biological quantitative assay of thyroid-stimulating immunoglobulin (TSI) using Mc4-CHO cells (Mc4-CHO TSI assay). Results were correlated with scores of activity/severity of thyroid eye disease. RESULTS All three assays (TRAb1st, TRAb3rd, and Mc4-CHO TSI) yielded results that were significantly positively correlated with CAS (β=0.21, 0.21, and 0.46, respectively; p<0.05) and proptosis (β=0.38, 0.34, and 0.33, respectively; p<0.05). Mc4-CHO TSI bioassay results were significantly positively correlated with all GO severity indices (soft tissue involvement, proptosis, extraocular muscle involvement, and total eye score; β=0.31, 0.33, 0.25, and 0.39, respectively; p<0.05). CONCLUSION Mc4-CHO TSI bioassay was superior over the two TBIIs in assessing active inflammation and muscle restriction due to GO, whereas TBII assay would be sufficient for evaluation of patients with proptosis.
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Affiliation(s)
- Sun Young Jang
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Yeob Shin
- The Institute of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jig Lee
- The Institute of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Joon Choi
- The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Yeul Lee
- The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sook Yoon
- The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
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Relevance of TSH-receptor antibody levels in predicting disease course in Graves' orbitopathy: comparison of the third-generation TBII assay and Mc4-TSI bioassay. Eye (Lond) 2013; 27:964-71. [PMID: 23743527 DOI: 10.1038/eye.2013.120] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/30/2013] [Indexed: 12/12/2022] Open
Abstract
AIMS To investigate if TSH-receptor antibody (TRAb) levels measured in early Graves' orbitopathy (GO) stages are predictive of clinical disease course beyond 1 year after initial GO diagnosis and to compare performance of two newly developed TRAb assays (third-generation thyrotropin-binding inhibitor immunoglobulin (TBII) assay vs Mc4-thyroid-stimulating immunoglobulin (TSI) bioassay) in predicting disease course. METHODS Newly diagnosed, untreated GO patients whose duration of ocular symptoms was less than 6 months were included. One year after initial diagnosis, all patients were classified as presenting either a mild (Group 1) or severe course (Group 2) according to their clinical manifestations. The measurements of two TRAb assays at initial GO diagnosis were used for analysis. RESULTS Data from 112 patients were available for analysis. Seventy-three patients (65.2%) were designated as Group 1, and 39 patients (34.8%) as Group 2. Patients with higher initial TRAb levels demonstrated a higher risk of severe disease course upon multiple regression analysis (P<0.01). The cutoff values for the prediction of severe course of the third-generation TBII and Mc4-TSI assays were 10.67 IU/l and 555.10%, respectively, with assay specificities of 84.9 and 89.0%. The TBII assay predictive power (area under the curve (AUC)=0.817; 95% confidence interval (CI) =0.732-0.902) was equivalent to the TSI bioassay (AUC=0.868, 95% CI=0.803-0.934) (P=0.203). CONCLUSIONS The predictive power of the third-generation TBII assay and Mc4-TSI bioassay are similarly strong. Measurement of TRAb using either third-generation TBII or Mc4-TSI in early GO periods would provide important prognostic information on future GO course.
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Leschik JJ, Diana T, Olivo PD, König J, Krahn U, Li Y, Kanitz M, Kahaly GJ. Analytical performance and clinical utility of a bioassay for thyroid-stimulating immunoglobulins. Am J Clin Pathol 2013; 139:192-200. [PMID: 23355204 DOI: 10.1309/ajcpzut7cnueu7op] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The analytical performance and the clinical utility of a thyrotropin receptor (TSHR)-stimulating immunoglobulin (TSI) bioassay were compared with those of a TSHR-binding inhibitory immunoglobulin (TBII) assay. Limits of detection (LoD) and quantitation (LoQ), assay cutoff, and the half-maximal effective concentration (EC(50)) were measured. Dilution analysis was performed in sera of hyperthyroid patients with Graves disease (GD) during antithyroid treatment (ATD). Titer was defined as the first dilution step at which measurement of TSI or TBII fell below the assay cutoff. The LoD, LoQ, cutoff, and EC(50) of the bioassay were 251-, 298-, 814-, and 827-fold lower than for the TBII assay. There were 22%, 42%, 23%, and 14% more positive samples in the TSI bioassay at dilutions of 1:3, 1:9, 1:27, and 1:81 (P < .0001), respectively. Responders to ATD demonstrated marked differences in titers compared with nonresponders. The bioassay detected lower levels of TSHR autoantibodies, and the dilution analysis provided similar predictive values of both assays in GD.
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Affiliation(s)
- Johannes J. Leschik
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Tanja Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | | | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Medical Biometry, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Ulrike Krahn
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Medical Biometry, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Yunsheng Li
- Diagnostic Hybrids, a Quidel Company, Athens, OH
| | - Michael Kanitz
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - George J. Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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The role of thyrotrophin receptor antibody assays in graves' disease. J Thyroid Res 2012; 2012:525936. [PMID: 22577596 PMCID: PMC3345237 DOI: 10.1155/2012/525936] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/27/2012] [Indexed: 11/17/2022] Open
Abstract
Thyrotrophin receptor antibodies (TRAb) exist as stimulating or blocking antibodies in the serum (neutral TRAb have been identified recently). The clinical features of GD occur when stimulating TRAb predominate. But the relationship of TRAb to clinical phenotype and outcome is not clear when current assay methods are used. Therefore no consensus exists about its utility in diagnosing and predicting outcome in GD. The most commonly used TRAb assays, measure thyroid binding inhibiting immunoglobulins (TBII or “receptor assays”) and don't differentiate between stimulating and blocking antibodies. However, the more expensive, technically demanding and less freely available “biological assays” differentiate between them by their ability to stimulate cyclic AMP or failure to do so. Failure to differentiate between TRAb types and its heterogeneous molecular and functional properties has limited TBII use to GD diagnosis and differentiating from other forms of thyrotoxicosis. The current 2nd-3rd generation receptor assays are highly sensitive and specific when used for this purpose. TRAb assays should also be done in appropriate pregnant women. Current data do not support its use in outcome prediction as there is a significant variability of assay methodology, population characteristics and study design in published data, resulting in a lack of consensus.
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Clinical relevance of thyroid-stimulating immunoglobulins in graves' ophthalmopathy. Ophthalmology 2011; 118:2279-85. [PMID: 21684605 DOI: 10.1016/j.ophtha.2011.03.030] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 03/14/2011] [Accepted: 03/21/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Thyroid-stimulating immunoglobulins (TSIs) likely mediate Graves' ophthalmopathy (GO). The clinical relevance of these functional autoantibodies was assessed in GO. DESIGN Cross-sectional trial. PARTICIPANTS A total of 108 untreated patients with GO. METHODS Thyroid-stimulating immunoglobulins, assessed with a novel bioassay, bind to the thyrotropin receptor (TSHR) and transmit signals for cyclic adenosine monophosphate (cAMP)-dependent activation of luciferase gene expression. The cAMP/cAMP response element-binding protein/cAMP-regulatory element complex induces luciferase that is quantified after cell lysis. The TSI levels were correlated with activity and severity of GO and compared with a TSHR binding inhibitory immunoglobulin (TBII) assay. MAIN OUTCOME MEASURES Thyroid-stimulating immunoglobulins, activity and severity of GO, diplopia, and TBII. RESULTS Thyroid-stimulating immunoglobulins were detected in 106 of 108 patients (98%) with GO. All 53 hyperthyroid patients were TSI positive versus 47 patients (89%) who were TBII positive. All 69 patients with active GO were TSI positive, whereas only 58 of 69 patients (84%) were TBII positive. Thyroid-stimulating immunoglobulins correlated with the activity (r=0.83, P < 0.001) and severity (r=0.81, P < 0.001) of GO. All 59 patients with GO with diplopia were TSI positive, and 50 of 59 patients (85%) were TBII positive. Among patients with moderate-to-severe and mild GO, 75 of 75 (100%) and 31 of 33 (94%) were TSI positive compared with TBII positivity in 63 of 75 (84%) and 24 of 33 (73%), respectively. The TSI levels were higher in moderate-to-severe versus mild GO (489%±137% vs. 251%±100%, P < 0.001). Chemosis and GO activity predicted TSI levels alone (P < 0.001, multivariable analysis). The TSI levels were higher in patients with chemosis (527%±131%) than in patients without chemosis (313%±127%, P < 0.001). CONCLUSIONS Thyroid-stimulating immunoglobulins show more significant association with clinical features of GO than TBII and may be regarded as functional biomarkers for GO. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Kamijo K, Murayama H, Uzu T, Togashi K, Olivo PD, Kahaly GJ. Similar clinical performance of a novel chimeric thyroid-stimulating hormone receptor bioassay and an automated thyroid-stimulating hormone receptor binding assay in Graves' disease. Thyroid 2011; 21:1295-9. [PMID: 22066477 DOI: 10.1089/thy.2011.0056] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Graves' disease (GD) is caused by the continuous stimulation of the thyroid gland by autoantibodies directed against the thyroid-stimulating hormone receptor (TSHR). Two frequent assays for the measurement of TSHR autoantibodies (TSHRAb) were compared, one measuring stimulation of cyclic adenosine monophosphate (cAMP) production and one measuring inhibition of TSH binding, with regard to diagnostic accuracy for GD as well as whether there was an existence of their discordant results in patients with GD and painless thyroiditis (PT). METHODS Using 106 sera from untreated GD and 80 sera from autoimmune PT, we compared the diagnostic performance of two TSHRAb assays that have been recently developed. The first one is a bioreporter assay using chimera TSHR (Mc-4), which detects a stimulation signal of cAMP level in cultured CHO cells (Mc4-TSAb assay). The second is a binding inhibition assay using the extracelluar domain of porcine TSHR and a monoclonal antibody (M22) closely mimicking the binding to TSH (M22-TRAb assay). In addition, we compared both assays by using eight sera from eight GD subjects becoming spontaneously hypothyroid due to appearance of thyroid blocking autoantibodies (TBAb) that were measured with inhibition rates of TSH-stimulated cAMP in porcine cells. RESULTS The Mc4-TSAb assay and the M22-TRAb assay were positive in 94.3% and 92.5% of the GD patients, respectively, whereas they were negative in 95.0% and 98.8% of the PT subjects. However, 10 of 106 GD sera (9.4%) showed discordant results. Six of 106 cases with untreated GD (5.7%) were Mc4-TSAb positive and M22-TRAb negative. In contrast, 4 of 106 sera (3.8%) were Mc4-TSAb negative but M22-TRAb positive. Two cases of untreated GD were negative for both Mc4-TSAb and M22-TRAb. In eight GD subjects with TBAb and hypothyroidism, the binding assay was highly positive, although Mc4-TSAb was negative. CONCLUSION Similar and excellent performance was noted for the Mc4-TSAb and M22-TRAb assays in a large group of patients with GD. However, there was 9.4% discordance with regard to false negatives for GD and 3.8% discordance between the two tests with regard to false positives for PT. With regard to the relatively high rate of discordancy, a combination of both assays could reduce the presence of TSHRAb-seronegative GD.
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Affiliation(s)
- Keiichi Kamijo
- Kamijo Thyroid Clinic and Kamijo Thyroid Research Institute, Sapporo, Japan.
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Lee JI, Jang HW, Kim SK, Choi JY, Kim JY, Hur KY, Kim JH, Min YK, Chung JH, Kim SW. Diagnostic value of a chimeric TSH receptor (Mc4)-based bioassay for Graves' disease. Korean J Intern Med 2011; 26:179-86. [PMID: 21716594 PMCID: PMC3110850 DOI: 10.3904/kjim.2011.26.2.179] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 02/17/2011] [Accepted: 03/28/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Graves' disease (GD) is caused by thyroid-stimulating hormone receptor (TSHR) and thyroid-stimulating immunoglobulin (TSI). We used a recently introduced, technically enhanced TSI bioassay to assess its diagnostic value and determine the cut-off in patients in high iodine intake area. METHODS In a cross-sectional setting, we collected serum from 67 patients with untreated GD, 130 with GD under treatment, 22 with GD in remission, 42 with Hashimoto's thyroiditis, 12 with subacute thyroiditis, 20 with postpartum thyroiditis, and 93 euthyroid controls. TSI was measured using the Thyretain™ bioassay, which is based on Chinese hamster ovary cells transfected with chimeric TSHR (Mc4). TSI levels are reported as a specimen-to-reference ratio percentage (SRR%). RESULTS The TSI levels in patients with GD (either treated or not) were significantly higher than those of the remaining patients (p < 0.05). The new bioassay showed a sensitivity of 97.0% and a specificity of 95.9% with a cut-off value of 123.0 SRR% for GD. A weak correlation was found between TSI and thyrotropin-binding inhibiting immunoglobulin (TBII) (r(s) = 0.259, p = 0.03), but no correlation was found between TSI and tri-iodothyronine or free thyroxine. CONCLUSIONS The Mc4-CHO bioassay showed comparable diagnostic value for GD with the conventional TBII assay. We propose a cut-off of 123.0 SRR% in areas where iodine intake is high.
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Affiliation(s)
- Ji In Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Young Kim
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Ki Min
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kahaly GJ, Bartalena L, Hegedüs L. The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective. Thyroid 2011; 21:585-91. [PMID: 21663420 DOI: 10.1089/thy.2011.2106.ed3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lytton SD, Kahaly GJ. Bioassays for TSH-receptor autoantibodies: an update. Autoimmun Rev 2010; 10:116-22. [PMID: 20807591 DOI: 10.1016/j.autrev.2010.08.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
Immunoglobulins in patients with Graves' disease (GD) that modulate the thyroid stimulating hormone receptor (TSH-R) do so via stimulating cAMP dependent signals (TSI), blocking TSH or inhibition of TSH-receptor activation (TBI) or inducing apoptotic signals. These functional immunoglobulins represent powerful biomarkers of anti-self reactivity in the thyroid and systemic tissues that harbor TSH-R expressing target cells. TSI on thyrocytes induce hyperthyroidism, and TSI on TSH-R fibroblasts of orbital muscles, skin and heart provoke the release of cytokines and antigen-specific T-cell responses leading to systemic inflammation. Bioassays of anti-TSH-R autoantibodies provide decisive information on GD activity. This review examines the past and present bioassays in GD. The critical goal of cell-based anti-TSH-R autoantibody bioassays, to identify the pathogenic immunoglobulins in GD under robust and standardized conditions suitable for routine clinical laboratory practice, is discussed.
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Affiliation(s)
- Simon D Lytton
- Thyroid Research Laboratory, Department of Medicine I, Gutenberg University Medical Center, Mainz 55101, Germany.
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