Interaction of thyroid-stimulating antibodies with the human thyrotrophin receptor

Functional autoantibodies: Definition, mechanisms, origin and contributions to autoimmune and non-autoimmune disorders

A growing body of evidence underscores the relevance of functional autoantibodies in the development of various pathogenic conditions but also in the regulation of homeostasis. However, the definition of functional autoantibodies varies among studies and a comprehensive overview on this emerging topic is missing. Here, we do not only explain functional autoantibodies but also summarize the mechanisms underlying the effect of such autoantibodies including receptor activation or blockade, induction of receptor internalization, neutralization of ligands or other soluble extracellular antigens, and disruption of protein-protein interactions. In addition, in this review article we discuss potential triggers of production of functional autoantibodies, including infections, immune deficiency and tumor development. Finally, we describe the contribution of functional autoantibodies to autoimmune diseases including autoimmune thyroid diseases, myasthenia gravis, autoimmune pulmonary alveolar proteinosis, autoimmune autonomic ganglionopathy, pure red cell aplasia, autoimmune encephalitis, pemphigus, acquired thrombotic thrombocytopenic purpura, idiopathic dilated cardiomyopathy and systemic sclerosis, as well as non-autoimmune disorders such as allograft rejection, infectious diseases and asthma.

Brief Report - Monoclonal Antibodies Illustrate the Difficulties in Measuring Blocking TSH Receptor Antibodies

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.

The aptamer BC 007 for treatment of dilated cardiomyopathy: evaluation in Doberman Pinschers of efficacy and outcomes

Aims

Aptamer BC 007, a 15‐mer single‐strand DNA oligonucleotide (5'‐GGTTGGTGTGGTTGG‐3'), was developed to neutralize functional autoantibodies that bind to the extracellular domains of G protein‐coupled receptors (GPCR‐AAB), leading to the modulation of receptor‐mediated signalling cascades that induce pathophysiological states. Among the GPCR‐AAB, there are those directed against the β1‐adrenergic receptor (β1‐AAB) that are highly present in patients with dilated cardiomyopathy (DCM) and are increasingly accepted as disease drivers.

Using Doberman Pinschers (DP) with DCM, which possess similarities with human DCM among these β1‐AAB positivity for that the disease‐driving role in DP DCM was demonstrated, the safety of BC 007, efficacy for neutralizing β1‐AAB, and the DP's outcome were investigated.

Methods and results

Fourteen client‐owned β1‐AAB‐positive DP with electrocardiographically and echocardiographically indicated DCM were treated with BC 007. For controlling, two groups were created: 14 β1‐AAB‐positive DP with DCM not treated with BC 007 (Control 1) and 14 DP with DCM closely matched to the BC 007‐treated DP (Control 2), retrospectively selected from the institutional database of DP. After treatment, DP were monitored both echocardiographically, and for β1‐AAB, and survival curves were calculated. Based on clinical and laboratory examination, no adverse effects associated with BC 007 treatment were observed during the study. Forty‐eight hours after treatment, the DP's blood was free of β1‐AAB, which led to a reduction or stabilization of left ventricular end‐systolic volume (ESVI) during β1‐AAB free time in 10 of the treated DP. In one DP, where β1‐AAB returned after 3 months and ESVI worsened again, a second BC 007 treatment after 9 months again cleared the blood from β1‐AAB and improved the ESVI. Compared with the controls, DP treated with BC 007 showed a significantly longer survival time [572 days, interquartile range (IQR) 442–840 days] vs. Control group 1 (266 days, IQR 97–438 days; logrank: P = 0.009) and Control group 2 (229 days, IQR 174–319 days; logrank: P = 0.012).

Conclusions

Treatment with BC 007 for β1‐AAB neutralization was safe, resulted in a long‐lasting reduction of β1‐AAB combined with improved cardiac function and prolonged the survival of DP with DCM. Using a natural large animal model of DCM considered superior to small animal models of immunization‐induced cardiomyopathy, combined with a study design comparable with clinical trials, we believe that our results provide the basis for optimism that treatment with BC 007 might also be effective in human patients with DCM.

Analytics of Functional Autoantibodies in Patients with Chagas Disease

Autoantibodies directed against G-protein-coupled receptors (GPCR-AAB), an autoantibody type discovered in the 1970s, affect functionally their targets and are therefore called functional autoantibodies. GPCR-AAB are increasingly accepted as the origin or amplifier of various diseases. Here, we describe the present "gold standard" for measurement of GPCR-AAB in human blood. This bioassay monitors the chronotropic activity of GPCR-AAB by recording the spontaneous beating of cultured neonatal rat cardiomyocytes. The construction of this bioassay and its procedure and standardization for GPCR-AAB measurement are described in detail and also include the application of the bioassay for GPCR-AAB differentiation related to first the targeted receptors and IgG subclasses carrying the GPCR-AAB and second the extracellular receptor-binding site and specific epitopes targeted by the GPCR-AAB.

Cardiomyopathy - An approach to the autoimmune background

Autoimmunity is increasingly accepted as the origin or amplifier of various diseases. In contrast to classic autoantibodies (AABs), which induce immune responses resulting in the destruction of the affected tissue, an additional class of AABs is directed against G-protein-coupled receptors (GPCRs; GPCR-AABs). GPCR-AABs functionally affect their related GPCRs for activation of receptor mediated signal cascades. Diseases which are characterized by the presence of GPCR-AABs with evidence for disease-specific pathogenic activity could be named "functional autoantibody disease". We briefly summarize here the historical view on autoimmunity in cardiomyopathy, followed by an approach to the mechanistic autoimmunity background. Furthermore, autoantibodies with outstanding importance for cardiomyopathies as a functional autoantibody disease, such as GPCR-AABs, and mainly those directed against the beta1-adrenergic and muscarinic 2 receptor autoantibodies, are introduced. Anti-cardiac myosin and anti-cardiac troponin autoantibodies, as further potential players in autoimmune cardiomyopathy, are additionally taken into account. The basic view on the autoantibodies, their related receptor interactions and pathogenic consequences are presented. Focused specifically on GPCR-AABs, "pros and cons" of assays such as indirect assays (functional changes of cell preparations are monitored after GPCR-AAB receptor binding) and direct assays based on the ELISA technologies (GPCR epitope mimics for GPCR-AAB binding) are critically discussed. Last but not least, treatment strategies for "functional autoantibody disease", such as for GPCR-AAB removal (therapeutic plasma exchange, immunoadsorption) and in vivo GPCR-AAB attack such as intravenous IgG treatment (IVIG), B-cell depletion and GPCR-AAB binding and neutralization, are critically reflected with respect to their patient benefits.

Structure-function relations of the thyrotropin receptor

The thyrotropin (thyroid-stimulating hormone or TSH) receptor is an amphiphilic membrane component with a relative molecular mass of about 200,000 as judged by gel filtration and an isoelectric point close to pH 5. Analyses with chemical, enzymic and affinity probes indicate that the receptor is a glycoprotein containing a disulphide bridge and that the integrity of the disulphide bond is essential for maintaining the structure of the TSH-binding site. Serum from patients with Graves' disease contains antibodies which inhibit the binding of TSH to its receptor and there is considerable evidence that this effect is due to a direct interaction between the antibodies and the receptor. The antibody-receptor interaction is probably responsible for the TSH agonist properties of Graves' serum and, similarly, the TSH antagonist properties of the sera from a small number of patients can be explained on the basis of antibody-receptor binding. Although TSH and IgG from Graves' disease patients appear to bind to the same receptor, the relationship between the sites for the two substances is not clearly understood. However, Fab fragments of Graves' IgG are as effective as intact IgG in competing with TSH for the receptor and gel filtration and immunoprecipitation studies indicate that the binding of hormone and antibody to the receptor is mutually exclusive. Current evidence suggests therefore that the binding sites for TSH and TSH receptor antibodies are very closely related and may well be identical.

Kinetics of thyrotropin-stimulating hormone (TSH) and thyroid-stimulating antibody binding and action on the TSH receptor in intact TSH receptor-expressing CHO cells

The kinetics of TSH binding and the effects of TSH and thyroid-stimulating antibody (TSAb) on cAMP accumulation have been measured in TSH receptor-expressing CHO cells (CHO-TSHR cells). The parallel kinetics of TSH binding to its receptor and of cell cAMP concentration after the addition and withdrawal of TSH show that in the case of this receptor, signal generation and concentration are at all times proportional to occupancy. In physiological ionic medium, TSAb, but not TSH, action is slowed and in some cases almost nonexistent. The kinetics of cAMP disappearance after washout of TSAb is also slower. cAMP accumulation is faster for Fabs than for the TSAb from which they derive. Analysis of the data suggest that 1) serum TSAb are oligoclonal antibodies sets, at low concentrations, with a high affinity for the TSH receptor; 2) ionic interactions are involved in the action of TSAb on the TSH receptor; and 3) TSAb activation of the TSH receptor is at least a two-step process. Among others, a possible explanation is that the full activation of the receptor requires the binding of two or more different antibody molecules on different sites of the same TSH receptor. This analysis provides a benchmark for studies of experimentally induced monoclonal antibodies activating the TSH receptor.

Thyroid stimulating immunoglobulins, like thyrotropin activate both the cyclic AMP and the PIP2 cascades in CHO cells expressing the TSH receptor

In human thyrocytes and in a permanent CHO cell line expressing the human thyroid stimulating hormone (TSH) receptor cDNA (JP09 cells), TSH activates both the cyclic AMP and the phosphatidylinositol 4,5-bisphosphate (PIP2) cascade, although the latter effect requires higher TSH concentrations. Thyroid stimulating autoantibodies (TSAb) activate also the human thyroid leading to the hyperthyroidism of Graves' disease. They bind to the TSH receptor and mimic the TSH stimulation of the gland by increasing intracellular cyclic AMP, but they do not enhance PIP2 hydrolysis in human thyroid slices. We show in this study that TSAb are able to activate the PIP2 cascade in JP09 cells, a cell line expressing high levels of TSH receptor. This suggests that the mechanism of action of TSAb on the TSH receptor is qualitatively similar to that of TSH.

Immunocytochemical localization of bovine thyrotropin and thyroid auto-antibodies in porcine thyrocytes

Interactions of receptor-bound bovine thyrotropin (bTSH) and immunoglobulins G from sera of patients with Graves' (G-IgG) or Hashimoto's (H-IgG) disease with porcine thyrocytes were studied by immunocytochemistry. Porcine thyroid fragments were fixed and prepared for immunoreaction or enzymatically dissociated with collagenase and dispase II. The dispersed cells were cultured in primary monolayer in a hormone-free medium or in a medium with bTSH (150 micrograms/ml) for 7 days. After immunostaining the thyrocytes in fragments and monolayers were stained with periodic acid Schiff (PAS) or with PAS and haemalum. Cultivation of the isolated thyrocytes in bTSH-enriched medium leads to a monolayer with globular aggregates, i.e., reconstructed three-dimensional follicles. Follicular cells in these monolayers and in fragments give a weak to moderate immunoreaction to anti-bTSH and a strong reaction to G-IgG and H-IgG (vs. control IgG). Precipitate is found particularly in the perinuclear area and to a lesser degree throughout the cytoplasm. Cells cultured in the absence of bTSH show minimal immunoreaction to anti-bTSH, but moderate reaction to G-IgG and H-IgG. Preincubation with bTSH leads to a strong reduction of immunoreaction to G-IgG but does not affect reaction to H-IgG. Morphological results indicate that G-IgG and H-IgG interact with the same cellular sites as bTSH. Hashimoto's disease antibodies bind to a determinant on the TSH receptor separate from the one on which TSH and Graves' IgG bind.

Autoimmune thyroid disease: immunological, pathological, and clinical aspects

Autoimmune thyroiditis, most notably Hashimoto's thyroiditis, appears to be increasing in prevalence and is now more easily detected by sensitive laboratory tests and more invasive procedures such as fine needle aspiration. During the last decade, marked progress has been made in the understanding of these diseases. There is a greater awareness of the interaction between the humoral and cell-mediated arms of the immune system in autoimmune thyroiditis. Recent studies implicate a subpopulation of suppressor T lymphocytes which have an antigen-specific defect, resulting in their suboptimal interaction with the helper T lymphocytes and subsequent autoimmune manifestations. There is some evidence that thyroid epithelial cells which inappropriately express HLA-DR may enhance presentation of thyroid antigens to the immune system, possibly significant in the initiation or enhancement of the autoimmune response. The presence of various antithyroid autoantibodies allows the use of laboratory assays to confirm the clinical diagnosis and predict the results of treatment. There appears to be predisposing genetic factors in the development of autoimmune thyroiditis, with some geographical and racial differences. Environmental factors, most notably dietary intake of iodine, have also been implicated in the pathogenesis of Hashimoto's thyroiditis. Several animal models have been developed addressing such issues. Ongoing studies in the areas of postpartum thyroiditis and childhood thyroiditis are helpful in clarifying their relationship with Hashimoto's thyroiditis. Graves' disease and postpartum thyroiditis are being investigated as possible causes of postpartum depression. The association of Hashimoto's thyroiditis and carcinoma of the thyroid gland is still controversial, but its relationship with malignant lymphoma is now well accepted. Thus, although the pathogenesis of autoimmune thyroiditis remains elusive, there has been significant refinement of the clinical diagnosis, and immunological abnormalities of specific intrathyroidal lymphocytes have been identified. Hopefully, these new areas of knowledge will assist in the treatment of these diseases and in the prevention of the development of malignant lymphomas of the thyroid gland.

Thyroid stimulation by (Fab)2 and Fab fragments of TSH receptor antibody

The TSH receptor binding and thyroid stimulating properties of (Fab)2 and Fab fragments of Graves' IgG have been investigated. (Fab)2 fragments were prepared by pepsin digestion of IgG and Fab fragments by reduction of (Fab)2 or papain digestion of IgG. (Fab)2 and Fab were effective in inhibiting TSH binding to its receptor with all five patients' sera studied and both preparations stimulated cyclic AMP release from isolated thyroid cells. However Fab fragments were less active thyroid stimulators than their parent (Fab)2 in all five cases. These studies indicate that antibody divalency is not essential for thyroid stimulation by TSH receptor antibodies.

The pathogenesis of Graves' disease

The abnormally increased thyroid activity that is characteristic of Graves' disease is caused by immunoglobulins which specifically interact with the thyroid cell and stimulate it. Increases and decreases in thyroid activity in Graves' disease can be clearly related to rise and fall of these immunoglobulin-mediated activities. The level of immunoglobulin stimulatory activity can be used for prediction of the likelihood of neonatal Graves' disease and of recurrence of disease after cessation of treatment with antithyroid drugs. Investigation of patients with Graves' disease and their families has led to identification of particular human leukocyte antigens and genetically linked markers on immunoglobulins which both appear to incur increased susceptibility to certain autoimmune diseases. Differences in immune function, when compared with control populations, have been found in patients with these genetically linked markers. Protection against autoimmune disease is maintained by purposeful inhibition of any self-directed activity within each function of the immune system and by the controlling interaction of other immune functions. No single deficiency of immune function can be selected as giving the major risk of autoimmune disease, but rather a sum of relative defects resulting in an increased risk. In some patients with Graves' disease the self-protection mechanisms regain sufficient control of the immune functions to reduce the activity of the autoimmune disease, and the patient may achieve clinical remission. Often, however, there is evidence that abnormal immune activity directed against thyroid tissue has persisted with liability to recurrence of the Graves' disease.

Immunoprecipitation of TSH-TSH receptor complexes

The ability of Graves' sera to interact with the TSH receptor crosslinked to a 125I-labelled photoactive derivative of TSH has been investigated. Crosslinked complexes were prepared using non-purified detergent solubilized human thyroid and guinea pig fat TSH receptors. Affinity purified porcine TSH receptor preparations wee also used. After crosslinking, the crosslinked TSH-TSH receptor complexes were separated from aggregates and free TSH on Sephacryl S-300, incubated with test sera followed by immunoprecipitation using anti-IgG or Protein A. Using non-purified human TSH receptors crosslinked to TSH, a mean +/- SD of 12.1 +/- 4.9% of the crosslinked complex was immunoprecipitated with Graves' sera (n = 7) compared with 10.3 +/- 2.6% with Hashimoto sera (n = 6; P greater than 0.14) and 3.8 +/- 1.0% with normal sera (n = 6; P less than 0.004). These values were markedly reduced when TSH receptor preparations free of other thyroid autoantigens (guinea pig fat TSH receptors) were used. Under these conditions immunoprecipitation with Graves' sera (n = 24) was 1.6 +/- 1.3% compared with 0.8 +/- 0.6% for Hashimoto sera (n = 13) and 0.8 +/- 0.4% for normal sera (n = 12; P less than 0.003). In addition complexes formed between TSH and affinity purified porcine TSH receptors gave low immunoprecipitation values for Graves' (1.44 +/- 0.73%; n = 20) and Hashimoto sera (1.7 +/- 0.94; n = 11) which were not significantly different (P greater than 0.4). Overall, therefore, the effects of Graves' and Hashimoto sera were similar and the amounts of material immunoprecipitated were markedly reduced when TSH receptor preparations containing reduced amounts of other autoantigens were used. Consequently the Graves' sera did not appear to interact specifically with crosslinked TSH-TSH receptor complexes. However the Graves' sera studied did contain TSH receptor antibodies which could inhibit the binding of labelled TSH to TSH receptors in the preparations used and our results suggest that the binding of TSH and these antibodies to the receptor is mutually exclusive. There is considerable evidence that serum from patients with Graves' disease contains antibodies to the TSH receptor (Rees Smith, 1981). Several studies have suggested that binding of the receptor antibody and TSH to the TSH receptor is mutually exclusive (Manley et al., 1977; Petersen et al., 1977; Rickards et al., 1981) but recently the formation of termolecular complexes consisting of detergent solubilized receptors, labelled TSH and Graves' IgG has been reported (Konishi et al., 1982; De Bruin et al., 1984).(ABSTRACT TRUNCATED AT 400 WORDS)

Evidence that thyroid-stimulating antibody is produced in the thyroid gland

The hyperthyroidism in Graves' disease results from the action of thyroid-stimulating antibodies (TSAb). The thyroid gland in Graves' disease shows diffuse lymphocytic infiltration, and after removal of the gland antibody titres usually decline and patients go into remission. It is postulated that the lymphocytes in the thyroid may be an important site of TSAb production. 10 patients with Graves' disease and 8 patients with other thyroid disorders were studied. Blood was taken during operation, but before thyroid mobilisation, from the thyroid vein and simultaneously from a peripheral vein. In patients with Graves' disease the concentration of TSAb activity in the thyroid vein was much greater than that in the peripheral vein. TSAb was not detected in either peripheral vein or thyroid vein samples in the other patients. The increase in TSAb concentration in the thyroid vein indicates production of antibodies by lymphocytes within the thyroid and could explain why removal of the thyroid results in disappearance of TSAb from the circulation.

Direct and quantitative measurement by immunoprecipitation assay of anti-thyrotrophin receptor antibodies in sera of patients with Graves' disease

The presence of anti-TSH receptor antibodies in the sera of 32 patients with untreated Graves' disease, 21 patients with euthyroid autonomous multinodular goitre, nine patients with Hashimoto's disease and 22 normal controls, was investigated by means of a direct and quantitative immunoprecipitation assay (IPA). A comparison was made between the IPA anti-TSH receptor antibody titres, the thyrotrophin-binding inhibitor immunoglobulins (TBII) index determined by radio-receptor assay and the presence of circulating immune complexes (CIC); no correlation was found. Twenty-six (81%) of the 32 untreated patients with Graves' disease were IPA-positive; 16 (50%) had a positive TBII index. None of the patients with euthyroid autonomous multinodular goitre and none of the normal controls were IPA-positive and their TBII index was normal in all cases. Of the nine patients with Hashimoto's disease seven were IPA-positive and three had a positive TBII index. Of ten patients with Graves' disease still in remission none was IPA-positive and their TBII index was normal. Of 18 patients who relapsed after treatment, 13 were IPA-positive and only five had a positive TBII index. In seven patients with Graves' disease studied serially, anti-TSH receptor antibodies remained present in the sera of four, although the TBII indices normalized. For the five patients who relapsed, a rise in the anti-TSH receptor antibody titre at the time of the relapse was observed. It is concluded that not all anti-TSH receptor antibodies cause TSH-binding inhibition in the radio-receptor assay, and further evidence has been obtained that anti-TSH receptor antibodies are the cause of the hyperfunctioning of the thyroid gland in Graves' disease.

The species specificity of TSH receptor binding antibodies as measured by radioreceptor study

The species specificity of TSH binding inhibitory antibodies was compared for patients with untreated Graves' hyperthyroidism, past Graves' hyperthyroidism, active ophthalmopathy with past hyperthyroidism, and subacute thyroiditis, by measuring inhibition of TSH binding to plasma membranes prepared from human, guinea-pig, calf, pig, and dog thyroid glands in a radioreceptor assay. Results were expressed as TSH binding inhibition indices (TBII). Broad species reactivity was demonstrated. This was greatest with pig and least with guinea-pig thyroid membranes. Immunoglobulin (Ig) from patients in whom strongly positive tests with human thyroid preparations were demonstrated were usually strongly positive with all other species tested, whereas Ig from patients which were less strongly positive with human were, generally, also less positive with the other species. There was a tendency for greater species reactivity of TSH binding inhibiting antibodies from patients with treated Graves' hyperthyroidism (with or without eye disease) than of those from untreated patients with Graves' hyperthyroidism or subacute thyroiditis. Combining the data from all groups, correlation between TBII for human membranes and those of other species was best for dog and least for guinea-pig. It is concluded that the TSH binding inhibiting antibody is a polyclonal antibody against a single antigen at or near the TSH receptor, and that the degree of reactivity with its antigen in other species depends, mainly, on the amount of antibody present in the serum.

Binding of solubilized human TSH-receptor protein by peripheral blood lymphocytes of patients with Graves' disease

Peripheral blood lymphocytes (PBL) from patients with hyperthyroidism due to Graves' disease (GD) were investigated for the ability to bind radioiodinated TSH receptor protein as hypothetical autoantigen (ABL). Thyrotropin-displacing antibody (TDA)-positive patients, who relapsed and were investigated shortly after starting antithyroid drug therapy, as well as TDA-positive patients with a first diagnosis of GD, who were investigated before starting therapy, showed significantly increased numbers of ABLs (0.2 +/- 0.17%, p less than 0.01 and 0.15 +/- 0.08%, p less than 0.001, respectively) when compared to controls (0.018 +/- 0.016%). In contrast, TDA - negative patients had no significant increase of ABLs (0.08 +/- 0.09%). Preincubation of PBLs with excess unlabelled antigen and nylon wool filtration of PBLs, reduced the number of ABLs markedly. Blocking of the binding sites on the lymphocytes with anti-Ig serum and blocking of the antigen itself by TSH depleted PBLs almost totally from ABLs. The present data indicate that: i) there are lymphocytes of B-cell characteristics capable of binding TSH-receptor; ii) there is a correlation between appearance of ABLs in hyperthyroid GD patients and the detection of TDA in patients' sera; iii) in Hashimoto, toxic nodular goiter and in some normals, a small amount of TSH receptor binding ABLs are detectable.