Specific targeting of a pro-inflammatory B cell subset in rheumatoid arthritis.

Lead Research Organisation: University of Birmingham
Department Name: Immunity and Infection


In autoimmune diseases the immune system, which should defend us against infection, mistakes some of our body's tissues as a threat. It responds to this mistaken threat by attacking the tissue in question with the multiple types of leucocytes (white blood cells) that it has at its disposal. B cells are a particular type of leucocyte that has been shown to pay an important role in the ongoing disease processes faced by patients with rheumatoid arthritis (RA). This is highlighted by how well RA symptoms respond to B cell-depleting therapy (BCDT) using rituximab, an antibody drug which removes the vast majority of B cells. However, not all B cells are involved the pathology of RA and most are actually helpful and enable us to respond to infection and vaccination. The major disadvantage of BCDT is that it indiscriminately removes most B cells without specifically targeting those that are involved in pathology. In the long term, this puts patients at risk of infection, especially elderly patients, who often have difficulties defending themselves against viruses and bacteria already. Also, for several months after the treatment the patients will not respond efficiently to vaccination. In our work, we have identified a subtype of B cells, which is present in the inflamed joints of patients with RA and produces factors that activate inflammation and joint destruction. They do this by producing two small proteins, TNF and RANKL, which activate other cells to invade the joint and to destroy bone structure. We have also found that some these cells are specifically involved in the autoimmune process, and may be part of the process that starts off the disease. In our most recent work, we have identified a marker protein that is found only on this type of cells. It is called FcRL4. We now plan to develop a new drug, which like rituximab is an antibody that specifically targets FcRL4+ B cells. With this drug we hope to remove just the B cells that are aggressive in disease while the rest of the B cells will be maintained and will be available to defend us against infection. We plan to do this by having a range of different antibodies specific for FcRL4 produced and will then will run a series of experiments to test firstly whether these antibodies can be used to remove FcRL4+ B cells and then secondly choose the best antibodies to test whether removing FcRL4+B cells from samples of patient synovium will effectively reduce inflammation. This work will be done by a dedicated team of medical doctors, scientists and nurses who work together in a new institute built into the New Queen Elizabeth Hospital. We endeavor to involve the patients into our research to help us to understand this devastating disease better and to develop new and safe therapies.

Technical Summary

The importance of B cells in the pathophysiology of rheumatoid arthritis is highlighted by the clinical effectiveness of B cell-depleting therapy (BCDT) using rituximab, an anti CD20 antibody(1). Potential mechanisms by which B cells may drive disease processes in RA include their ability to produce autoantibody, act as antigen-presenting cells, or secrete cytokines. The best characterized autoantigens in RA are posttranslationally citrullinated proteins. The major disadvantage of currently available BCDT is that it indiscriminately removes the vast majority of B cells without specifically targeting those that are involved in pathology.
In a systematic study of synovial cytokine expression we have identified a pro-inflammatory B cell population that expresses high levels of RANKL and TNF at the site of inflammation, in the synovial fluid and tissue of patients with RA (2, 3). In an extensive study of the immunophenotype of these cells we have established that they are characterized by surface expression of FcRL4, a transmembrane protein that is related to Fc receptors (3). FcRL4+ B cells express high levels of the costimulatory molecules CD80 and CD86 (3, 4). Expression of FcRL4 is highly restricted to this B cell subset and FcRL4 mRNA expression was detected in inflamed but not in uninflamed synovium. Due to their expression of pro-inflammatory cytokines, their capacity for costimulation and their recognition of citrullinated autoantigens we propose that FcRL4+ B cells are a promising clinical target. We plan to use a custom service offered by AbD Serotec under license from Morphosys to generate human antibodies and use them to target FcRL4+ inflammatory B cells in vitro and in mouse/human chimeric models. Starting with a range of antibodies, we will select the most promising clones over a series of in vitro and in vivo experiments. These experiments will provide data that will allow us to assess the potential of FcRL4 as a target for a novel therapy for RA.

Planned Impact

In England some 580,000 adults have RA, with around 26,000 new diagnoses each year. B cell depleting therapy (BCDT), is currently the preferred treatment for RA patients failing TNF blocking therapy. As around 50% of patients treated with TNF blockade show an unsatisfactory response, BCDT is used in a considerable number of patients. BCDT is effective, but has the disadvantage that it impairs the patient's ability to respond to vaccination and to infection with newly encountered pathogens. Patients with RA are already at a more than twofold higher risk of infection when compared to the general public.The safer therapy we are aiming to develop would impact on patient's quality of life and their ability to stay in the workforce by reducing their risk of infections.

Industry: Our aims are aligned with industry needs in terms of identification and exploitation of novel therapeutic targets. It also maps onto government's strategy for life sciences aiming to make the UK a world-leading place for life sciences investment: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/32457/11-1429-strategy-for-uk-life-sciences.pdf
The Rheumatology Research Group at Birmingham is an active participant and one of nine Centres involved in the NIHR TRP initiative supporting joint-related inflammatory disease, and we expect this to facilitate interaction with industry through the NIHR Office for Clinical Research Infrastructure (NOCRI). To-date, there are 12 ongoing interactions with industry, all at varying stages of development.

Economic impacts: The National Audit Office (NAO; 2009) has estimated that RA costs the NHS around £560 million a year and that the additional cost to the economy of sick leave and work-related disability is £1.8 billion a year. Development and delivery of a novel therapy that is, importantly, more safe than existing strategies for the targeting of B cells would bring economic and industrial growth both through revenues generated by the drug and by reduction of costs and loss of revenue due to infections. Enhanced UK competitiveness and prosperity would result through international commercialisation and exploitation alongside the planned programme to build the UK's capacity and research strength to tackle a chronic disease that is a heavy burden to the NHS.

Voluntary sector: This study will deliver enhanced returns on, and enhanced collaboration within existing Arthritis Research UK investment in Birmingham. This includes the Centre of Excellence in the pathology of RA, and delivering synergy with the Birmingham Experimental Arthritis Treatment Centre - one of seven linked units designed to enhance early phase trial infrastructure for initiatives including the Translational Research Partnerships.

The General Public: Through public engagement, including the voluntary sector, we will continue to deliver information about the progress of our study.

Academia: The identification of FcRL4 B cells in the rheumatoid synovium has already raised significant interest in the field. We will continue to report our advances, not only in the context of target development but also in the new understanding of disease processes generated by our studies. Researchers working on other inflammatory diseases will benefit from discovery
of a newly identified and validated clinical target and the associated shift in our understanding of mechanisms of chronic inflammation.


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Carr HL (2020) New Developments in Transcriptomic Analysis of Synovial Tissue. in Frontiers in medicine

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Patel AM (2021) The Role of B Cells in Adult and Paediatric Liver Injury. in Frontiers in immunology

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Schiffer L (2021) Peripheral blood mononuclear cells preferentially activate 11-oxygenated androgens. in European journal of endocrinology

Description NIHR Race Equality Framework Pilot
Geographic Reach National 
Policy Influence Type Contribution to a national consultation/review
Impact We are working towards improving NHS interaction with local ethnic mionorities
URL https://www.nihr.ac.uk/news/nihr-recruits-research-organisations-to-promote-race-equality-in-health-...
Description College of Medical and Dental Sciences PhD/ MRC DTG PhD studentship
Amount £70,000 (GBP)
Organisation University of Birmingham 
Sector Academic/University
Country United Kingdom
Start 09/2015 
End 10/2018
Description EU Innovative Medicines Initiative
Amount € 6,000,000 (EUR)
Organisation European Commission 
Department Innovative Medicines Initiative (IMI)
Sector Public
Country Belgium
Start 08/2017 
End 08/2023
Description MIDAS PhD Studentship Programme
Amount £100,000 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 09/2017 
End 09/2020
Description MRC Confidence in Concepts
Amount £800,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 02/2019
Description PhD studentship jointly with Dr Andrew Filer from IMPACT DTP
Amount £100,000 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 09/2017 
End 09/2020
Description RACE - Research into Inflammatory Arthritis Centre Versus Arthritis
Amount £1,999,997 (GBP)
Funding ID 22072 
Organisation Versus Arthritis 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2019 
End 03/2024
Description Analysis of B cell receptor sequences 
Organisation University of Oxford
Department Wellcome Trust Centre for Human Genetics
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We are interested in investigation of B cell subpopulations and their tracking at the single cell level
Collaborator Contribution Analysis of B cell receptor genes
Impact It is a multidisciplinary collaboration involving Bioinformatics and B cell immunology
Start Year 2019
Description Can FcRL4+ B cells capture bacterial extracellular vesicles? 
Organisation Quadram Institute Bioscience
Country United Kingdom 
Sector Academic/University 
PI Contribution In our collaboration with Berlin and Stockholm we have demonstrated a strong B cell response to gramnegative bacteria in the joints of patients with rheumatoid arthritis. There are no intact bacterial traveling in the blood of our patients, but we plan top assess whether BEV can be detected in blood or synovial fluid of RA patients. As our work on FcRL4+ B cells has shown that they capture IgA aggregates, and circulating BEV are likely to be covered in IgA, we plan to assess whether FcRL4 + B cells capture IgA coated BEV in RA joints. We will send samples of sorted cells and synovial fluid to the Quadram Institute.
Collaborator Contribution Professor Carding is an expert in the research of bacterial extracellular vesicles (BEV), small vesicles shed by gramnegative bacteria. As our work on FcRL4+ B cells has shown that they capture IgA aggregates, and circulating BEV are likely to be covered in IgA, we plan to assess whether FcRL4 + B cells capture IgA coated BEV in RA joints. Prof Carling will determine BEV content in our samples of FcRL4+ B cells, synovial fluid and pserum of controls and RA patients
Impact We have received a small grant from the MRC VA Centre of Musculoskeletal Ageing
Start Year 2022
Description Collaboration with German Rheumatism Research Centre 
Organisation Charité - University of Medicine Berlin
Country Germany 
Sector Academic/University 
PI Contribution We have started to collaborate with colleagues at the German Rheumatism Research Centre to investigate whether FcRL4+ B cells are specifically recognising gut bacteria. A PhD student working with me has travelled to Berlin to modify the technique used at the (DRFZ) and to run his experiments. He has now moved to Berlin and is working as a postdoctoral researcher at the DRFZ. We are continuing with our collaborative project and are hoping to publish our first shared manuscript in the near future.
Collaborator Contribution They have hosted the student in their lab and are sequencing and are analysing the sorted bacteria. They are now employing the researcher who developed this project during his PhD project with me as a post doc to allow continuation of this work in Berlin.
Impact We are planning to jointly publish the data once the work is completed
Start Year 2018
Description Investigation of Immunoglobulin genes in FcRL4+ B cells 
Organisation Karolinska University Hospital
Country Sweden 
Sector Hospitals 
PI Contribution We have been sorting individual FcRL4+ and FcRL4- B cell from synovial tissue and fluid of RA patients and shipped them to the collaborating team. We have now extensively characterised the specificity of these antibodies. I have been on collaborative visits to the Karolinska in Nov 0214, June 2015 and June 2016, July 2017 and we have been interacting in the frequent meetings of the EU IMI RT-CURE.
Collaborator Contribution The team at the KI has cloned and characterised the B cell receptors from the individual B cells and we are now jointly characterising their antigen specificity. This has important implications for the consequences for targeting FcRL4+ B cells.
Impact We have presented the first data from this study at the European Rheumatology Congress (EULAR) and related workshops in 2015, 2019 and 2020 and at the Annual meeting of the American College of Rheumatology in 2014 where Khaled Amara ( Karolinska) gave an oral presentation. The first three manuscript has been accepted for publication in the Journal of Autoimmunity and Data in Brief, a fourth publication is currently being written.. Amara K, Clay E, Yeo L, Ramsköld D, Spengler J, Sippl N, Cameron JA... Scheel-Toellner D. (2017). B cells expressing the IgA receptor FcRL4 participate in the autoimmune response in patients with rheumatoid arthritis.. Journal of autoimmunity, pp. 34-43 Amara K, Clay E, Yeo L, Ramsköld D, Spengler J, Sippl N, Cameron J... Scheel-Toellner D. (2017). Immunoglobulin characteristics and RNAseq data of FcRL4+ B cells sorted from synovial fluid and tissue of patients with rheumatoid arthritis.. Data in brief, pp. 356-370 Grönwall C, Amara K, Hardt U, Krishnamurthy A, Steen J, Engström M..... Silverman GJ, (2017). Autoreactivity to malondialdehyde-modifications in rheumatoid arthritis is linked to disease activity and synovial pathogenesis.. Journal of autoimmunity, pp. 29-45
Start Year 2014
Description Oxford PSA 
Organisation University of Oxford
Department Wellcome Trust Centre for Human Genetics
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution I am co-supervising a Wellcome Trust funded PhD student working on Psoriatic Arthritis. I am providing support in research of B cells in chronic inflammation.
Collaborator Contribution The project is led by Dr Rachael Bashford-Rogers, a B cell Immunologist and another co-supervisor is Prof Paul Bowness, a clinical expert on PsA. We are sdharing a PhD student who investigates the B cell response in PsA
Impact Funding by Wellcome Trust
Start Year 2021
Description Meeting with R2P" patient partners to discuss research plans 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Patients, carers and/or patient groups
Results and Impact I was speaking at a meeting with our local Patient Partner organisation about research plans.
Year(s) Of Engagement Activity 2018