ACR2010_在高风险人群中应用新版RA分类标准可能发现更多临床前RA

在高风险人群中应新版RA分类标准能识别“明确的RA”个体。关节受累为积分≥ 6贡献较多，而这其中主要由关节压痛贡献，而非关节肿胀，压痛可能提示在医院就诊之前的RA更早期阶段。

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[658] - Application of the New ACR/EULAR Classification Criteria for Rheumatoid Arthritis to At-Risk Populations May Identify RA Prior to Clinical Presentation.

Jason R Kolfenbach, MD ¹,Lezlie Derber²,Kevin D Deane, MD³,Jan Hughes-Austin⁴,Michael H Weisman, MD⁵,Jane Buckner⁶,Ted R Mikuls, MD⁷,James R O'Dell, MD⁸,Peter K Gregersen, MD⁹,Richard M Keating,Jill Norris, MPH, PhD¹⁰,V Michael Holers, MD¹¹. ¹Division of Rheumatology, University of Colorado Denver, Aurora, CO,²Division of Rheumatology, University of Colorado Denver,³Division of Rheumatology, Division of Rheumatology, University of Colorado Denver, Aurora, CO,⁴Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver,⁵Rheumatology, Cedars Sinai Medical Center, Los Angeles, CA,⁶4Benaroya Research Institute at Virginia Mason,⁷Internal Medicine, University of Nebraska Medical Center, Omaha, NE,⁸Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE,⁹Biology & Human Genetics, N Shore Univ Hosp Rsch Ctr, Manhasset, NY,¹⁰,¹¹Epidemiology, University of Colorado Denver, Aurora, CO,¹²Rheumatology Division, University of Colorado School of Medicine, Aurora, CO

Objective: The proposed ACR/EULAR classification criteria were developed in part to identify early RA. Applying the new criteria to at-risk populations prior to evaluation in the health care setting may identify a unique cohort in which to study the evolution of very early symptomatic RA. We have established prospective cohorts of subjects at potentially higher risk for RA based on genetic risk factors as part of the SERA study (Studies of the Etiology of RA). The purpose of the current analysis was to identify and characterize a cohort within these populations with 'definite RA' according to the newly proposed criteria.
Methods: We have established a cohort of first-degree relatives (FDRs) of probands with RA. FDRs without RA by the 1987 ACR criteria undergo a joint exam and have laboratory data obtained. Identical data is collected on a second at-risk DR4-enriched population containing parents of children with high risk HLA alleles and/or Type I diabetes. The proposed RA criteria were applied to subjects in these cohorts with swelling suggestive of synovitis in ≥ 1 joint on clinical exam after exclusion of findings attributed to alternative diagnoses (e.g. trauma, osteoarthritis). Data regarding joint distribution, duration of symptoms, antibody status and presence of elevated inflammatory markers were used to apply the new criteria. Descriptive statistics were calculated for the identified cases.
Results: 1790 subjects were available for analysis. 153 subjects (8.5%) had synovitis in ≥ 1 joint on clinical exam. 21 subjects (1.17%) had 'definite RA' according to the proposed algorithm. 17/21 (81%) subjects were female with a mean age of 48.9 years old. 6/21 subjects (28.6%) were positive for rheumatoid factor (RF), one (4.8%) was positive for anti-cyclic citrullinated peptide antibody, and 11 (52.4%) had elevated levels of CRP. Median swollen and tender joint counts were 3 and 11, respectively. The average total score in the 21 subjects was 6.76. The mean scores for joint involvement, serology, acute phase reactant and duration were 4.33, 0.9, 0.52 and 1.0, respectively (Table 1).

 

在高风险人群中应用新版RA分类标准可能发现更多临床前RA

 

Kolfenbach JR, et al. ACR 2010. Present No: 658.

 

目的：制订新的ACR/EULAR分类标准的一个原因是为了发现早期RA。在高风险人群中应用新标准可能可以发现一个特殊群体，以研究极早期有症状的RA的演变。我们根据SERA研究（Studies of the Etiology of RA）中的遗传危险因素，将RA潜在高风险的个体组成前瞻性队列。本研究旨在根据新建议的标准，在这些人群中发现“明确的RA”，并明确其特征。

方法：我们建立了一个RA患者一级亲属（FDRs）的队列。根据1987年ACR标准，对不符合RA诊断的FDRs进行关节检查，并采集其实验室资料。另一个队列纳入DR4阳性的高危人群，包括含有高危HLA等位基因和/或1型糖尿病儿童的父母。通过临床检查，在这些队列中挑选出有一个以上关节肿胀（提示滑膜炎）、排除其它诊断（如创伤、骨关节炎）的个体，对其应用新版RA分类标准。根据新标准，采集关节分布、症状持续时间、自身抗体、升高的炎性指标等数据。对这些病例进行描述性统计分析。

结果：共有1790人纳入分析。153例（8.5%）在临床检查中有一个以上关节滑膜炎。根据新建议标准，21例（1.17%）为“明确的RA”。 17/21例（81%）为女性，平均年龄48.9岁。6/21例（28.6%）RF阳性，1例（4.8%）抗CCP抗体阳性，11例（52.4%）CRP升高。平均肿胀关节数和压痛关节数分别为3和11。21人的平均总积分为6.76。关节受累、血清学、急性期反应物和病程的平均积分分别为4.33、0.9、0.52和1.0（表1）。

Conclusion: Individuals with 'definite RA' according to the new criteria can be identified in these unique at-risk populations. A score ≥ 6 was driven primarily by joint involvement with the majority stemming from tender rather than swollen joints, a finding which may indicate an earlier phase of RA development than individuals presenting for clinical care. The identification of these subjects in a research rather than clinical setting may allow us to study an earlier phase of RA than possible in usual clinical practice. These subjects will be followed prospectively with multiple modalities including serial joint evaluations and biomarker assessments to evaluate the relationship between the new RA criteria and the longer-term evolution of RA.

结论：在这些高风险人群中应用新标准能识别“明确的RA”个体。关节受累为积分≥ 6贡献较多，而这其中主要由关节压痛贡献，而非关节肿胀，压痛可能提示在医院就诊之前的RA更早期阶段。在研究中、而非在临床上识别这些个体可能有助于我们对更早期RA进行研究。我们将对这些个体进行前瞻性随访，包括关节评估、生物标记物评估，以明确新标准与RA长期演变的关系。

 

表1  根据新建议的RA ACR/EULAR分类标准所发现的“明确的RA”中，临床与血清学因素的相对贡献*
患者	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21
ACR关节积分	5	3	5	5	3	2	5	5	5	5	5	5	2	5	5	5	5	5	5	3	3
ACR血清学积分	0	3	0	0	2	3	0	0	0	0	0	0	3	0	0	0	0	3	0	2	3
急性期反应物积分	1	1	0	0	0	1	1	1	1	1	0	0	0	0	0	0	1	1	0	1	1
病程积分	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
总积分	7	8	6	6	6	7	7	7	7	7	6	6	6	6	6	6	7	10	6	7	8
根据新标准，积分≥ 6提示“明确的RA” (*:原图片中的相关文字过于模糊，无法辨识)