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Artikel Penelitian

Diagnostic Value of Anti-Mutated Citrullinate
Vimentin and Rheumatoid Factor With
Immunochromatographic Method in Early
Rheumatoid Arthritis Patients
Jusak Nugraha,*’*** Febtarini Rahmawati,* Joewono Soeroso**
*Dep.Clinical Pathology, Medical Faculty Airlangga University/Dr. Soetomo Hospital, Surabaya,
**Dep.Internal Medicine, Medical Faculty Airlangga University/Dr. Soetomo Hospital, Surabaya,
***Tropical Disease Center, Airlangga University, Surabaya

Abstract:
Background: The ACR/EULAR (American College of Rheumatology and European League
Against Rheumatism) criteria for rheumatoid artritis (RA) 2010 includes two laboratory parameters, which are rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA), such
as anti-MCV (anti-mutated citrullinated vimentin) or anti-CCP (anti-cyclic citrullinated protein antibody), besides ESR or CRP. Diagnostic specificity of RF is poor, especially in elderly.
Most specific autoantibody system for RA is the family of autoantibodies directed to citrullinecontaining proteins. The biomarker of anti-MCV is a further development after the anti-CCP;
and anti-MCV shows a superior sensitivity compared to anti-CCP2 and RF for early RA patients.
The aim of study: Was to confirm the efficacy of a new practical, accurate, and efficient test for
diagnosys of rheumatoid arthritis.
Methods: From the patients attending rheumatology outpatient clinics in Dr. Soetomo Hospital
Surabaya during April to September 2011, 33 new RA patients fulfilling ACR/EULAR criteria
and 32 other arthritis patients with the same age characteristic were obtained.
Results: The new and combined anti-MCV and RF-ICT test revealed sensitivity of 100%, specificity of 68,75% , positive predictive value of 76,74% and negative predictive value of 100%.
When each parameter was compared to standard Elisa method, they showed a good conformity
and no significance difference was shown.
Conclusion: This new test is suitable for screening purpose because it has a high sensitivity and
also have a high negative predictive value to rule out the possibility of RA. J Indon Med
Assoc. 2012;62:189-93.
Keywords: rheumatoid arthritis - ACR/EULAR 2010 - anti-MCV

Korespondensi: Jusak Nugraha, Email: jusak.nugraha@yahoo.com

J Indon Med Assoc, Volum: 62, Nomor: 5, Mei 2012

189

3 Meeting the demand for better. spesifisitas 68. such as anti-citrullinated J Indon Med Assoc. Surabaya **Dep. J Indon Med Assoc.bahwa tes baru ini cocok untuk pemeriksaan penapisan pada dugaan RA karena mempunyai sensitivitas yang tinggi. the rheumatoid factor is not specific to rheumatoid arthritis. Surabaya Abstrak: Latar Belakang: Kriteria ACR/EULAR (American College of Rheumatology and European League Against Rheumatism) 2010 untuk diagnosis artritis rheumatoid (RA) mencantumkan dua parameter laboratorium yaitu faktor rematoid (RF) dan anti-citruliinated protein antibodies (ACPA).4 The “old” 1987 ACR criteria includes only rheumatoid factor for laboratory examination and much rely on physical sign and symptoms.6% in the urban areas. nilai prediksi positif 76. Surabaya. Volum: 62. seperti anti-CCP (anti-cyclic citrullinated protein antibody) atau anti-MCV (anti-mutated citrullinated Vimentin). Soetomo. maka terdapat kesesuaian yang baik dan tidak terdapat perbedaan yang bermakna. Besides joints and connective tissues.1.anti-MCV Introduction Rheumatoid arthritis (RA) is an inflammatory disease of the joints and connective tissue.62:189-93. Nomor: 5. Kata kunci: artritis rematoid . yang menggabungkan anti-MCV dan IgM-RF terbukti mempunyai sensitivitas 100%.2 The prevalence of rheumatoid arthritis in over 40 years old Indonesian population was 0.74% dan nilai prediksi negatife 100%. Medical Fakultas Kedokteran Universitas Airlangga/ Rumah Sakit Umum. Marker alami anti-MCV merupakan pengembangan lebih lanjut dari anti-CCP dan anti-MCV menunjukkan sensitivitas yang lebih tinggi dibanding anti-CCP2 mauapun RF untuk diagnosis dini RA. ***Lembaga Penyakit Tropis. Metode: Dari kunjungan pasien poliklinik Rheumatologi RSU Dr. all the organs in the body could also be affected by this disease. yaitu perubahan dari gugus arginin menjadi citrulin karena proses inflamasi sehingga dianggap sebagai benda asing oleh tubuh. Mei 2012 . which is progressive. setelah penyaringan didapatkan 33 pasien RA baru yang memenuhi kriteria ACR/EULAR 2010 dan dicari 32 pasien artritis lain dengan karakteristik umur yang mirip. accurate. Universitas Airlangga. Soetomo selama periode April sampai September 2011. selain laju endap darah atau CRP. Hasil: Statistik menunjukkan bahwa tes yang baru ini.5% in rural and 0. and systemic. 190 and fast service.ACR/EULAR 2010 . symmetric. Therefore early diagnosis of rheumatoid arthritis is essential prior to the destruction resulting in joint deformity. Kebanyakan auto-antibodi spesifik yang ditemukan pada pasien RA merupakan antibodi terhadap protein yang tersitrullinasi . Tujuan penelitian ini adalah untuk mengonfirmasi efikasi sebuah tes yang baru yang akurat dan untuk mendiagnosis RA. with affordable price by the public is the purpose of this study as an attempt to give solution to early diagnosis of rheumatoid arthritis.Penyakit Dalam.I.*’*** Febtarini Rahmawati. Soetomo. Dr.* Joewono Soeroso** *Departemen Patologi Klinik Fakultas Kedokteran Universitas Airlangga/ Rumah Sakit Umum Dr. Setelah masing-masing parameter ini dibandingkan dengan metode standar ELISA. Kesimpulan: Dapat disimpulkan. meanwhile in early rheumatoid arthritis these symptoms have not developed yet.75%. Unfortunately. Selanjutnya hasil pemeriksaan fisik dan laboratorium terhadap pasien-pasien tersebut dievaluasi. Nilai spesifisitas RF untuk diagnosis RA biasanya rendah terutama pada orang tua. Therefor more specific serologic markers for rheumatoid arthritis are needed. 2012. dan juga sekaligus mampu menyingkirkan dugaan adanya RA bila negatif karena mempunyai nilai prediksi negatif yang tinggi.Diagnostic Value of Anti-Mutated Citrullinate Vimentin and Rheumatoid Factor With Immunochromatographic Method Nilai Diagnostik Uji Anti-Mutated Citrullinated Vimentin dan Rheumatoid Factor Metode Imunokromatografi pada Pasien Artritis Rematoid Dini Jusak Nugraha. Early diagnosis of rheumatoid arthritis is very important to prevent disability due to joint damage.

It is simple. After blood examination the data met the criteria of the ACR-EULAR 2010 sections A and D. Acute-phase reactants (at least 1 tes result is needed for classification) Normal CRP and normal ESR Abnormal CRP or abnormal ESR D.10 A laboratory test could be classified roughly based on its diagnostic value (sensitivity) percentage into five categories as follows : 1. who is suspected to have RA by medical interview and physical examination. a rapid detection of both anti-MCV and RF was developed (Rheumachec™).11 As gold standard an ACR/EULAR 2012 criteria was used to classify the patient as Rheumatoid arthritis and the laboratory results used were from standard ELISA methods instead of ICT methods. Volum: 62. Duration of symptoms <6 weeks >6 weeks 0 1 2 3 5 0 2 3 0 1 0 1 tion. 3. Low. arginine residues in proteins such as vimentin can be enzymatically converted into citrulline (a process called citrullination). Very low. All samples were examined according to the procedure protocol written in the instruction manual. Joint involvement 1 large joint 2-10 large joints 1-3 small joints (with or without involvement of large joints) 4-10 small joints (with or without involvement of large joints) >10 joints (at least 1 small joint) B. Serology (at least 1 test result is needed for classification) Negative RF and negative ACPA Low-positive RF or low-positive ACPA High-positive RF or high-positive ACPA C. 65 subjects obtained from outpatient clinic of rheumatology in Dr. specificity. if the value is less than 50%. Following the blood collecJ Indon Med Assoc. Classification of rheumatoid arthritis according to ACR EULAR 2010 are as follows2 : For use as POCT (point of care testing) test. thereby generating an immune response.2 Nowadays a rapid test for diagnosing early RA patients with a simple ICT (lateral flow) laboratory method is available for POCT (point of care testing) purpose. who visited the rheumatologic clinic Dr. The anti MCV ELISA kit was purchased from Orgentec. The study population was adults 16 years old or older. easy and fast and only needs one drop of 10 µl capillary blood. This test measures rheumatoid factor together with anti-mutated vimentin within 10 minutes. Soetomo Hospital Surabaya as new patients with the symptoms of rheumatoid arthritis for more than six weeks. Soetomo Hospital’s Ethical Committee. negative predictive value and diagnostic efficiency) of anti-MCV & RF rapid test (Rheumachec™) was calculated in 2 X 2 table formula. Anti-citrulinnated protein antibodies (ACPAs) are highly specific biomarkers that allow the diagnosis of RA to be made at a very early stage. The 2010 Classification of Rheumatoid Arthritis Score-Based Algorithm Score Classification criteria for RA (score-based algorithm: add score of categories A-D. if the value ranges between 65-79%. and overruled the “old” ACR criteria of 1987 and are adapted for early RA diagnosis.11 years old (range. Inclusion criteria for the control group (non-AR) are new female patient more than 16 years old. a score of >6/10 is needed for classification of a patient as having definite RA) A. Results During the screening period from April to September 2011.5. During inflammation. high. Inclusion criteria for rheumatoid arthritis patient group are new female patients (most of RA patients visiting Rheumatology clinic are females and to exclude hormonal influence) more 16 years old.5–7 The presence of autoantibodies against citrullinated proteins in rheumatoid arthritis patients was first described in the mid-1970s when the biochemical basis of antibody reactivity against keratin and filaggrin was investigated. 2. and are willing to participate in this study (signed the informed-consent form). Mei 2012 Table 1. consisted of 33 subjects of rheumatoid arthritis patients and 32 subjects of other arthritis as a control group. 21 to 58 years). who suffered from joint pain due to arthritis caused by other than RA by medical interview and physical examination and are willing to participate this study (signed informed-consent form ) and their definite diagnosis was established thereafter. the proteins may be seen as antigens by the immune system. Methods A cross-sectional study design was conducted in rheumatologic outpatient clinic in Dr. These new classification criteria included ACPA testing. All of them were female with age average age 47±9. 4.8 The aim of this study is to evaluate the role of Rheumachec™ (anti-MCV and RF-ICT method) in diagnosis of early rheumatoid arthritis. Germany. The minimum sample size calculated was 28. In July 2010. if the value ranges between 50-64%. if the diagnostic value (sensitivity) is equal or greater than 95%. positive predictive value. The result could be read in 10-15 minutes.Diagnostic Value of Anti-Mutated Citrullinate Vimentin and Rheumatoid Factor With Immunochromatographic Method protein (anti-CCP) or anti-mutated citrullinated vimentin (antiMCV). and if their shapes are significantly altered. if the sensitivity is between 80-94%. moderate. the 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria were introduced. Ethical clearance for this study was granted by Dr. 5. Nomor: 5. 191 . Germany and IgM RF ELISA was purchased from Euroimmune. Soetomo Hospital Surabaya. Very high. The diagnostic value (sensitivity. Soetomo Hospital Surabaya during April to September 2011. add 6 drops of buffer solution provided in the same well.

The RF rapid test has similar diagnostic sensitivity and specificity for IgM RF ELISA in supporting the diagnosis of rheumatoid arthritis diseases. Diagnostic efficiency for anti-MCV rapid test is 95. such as tumor necrosis factor-alpha (TNF-α).12% 94. Citrullinated vimentin is a very promising autoantigen in RA. analysis of the correlation of anti-CCP antibody titre with RA disease activity yielded conflicting results. It is not necessary to see both results to get good specificity because anti-MVC band is good enough. The Diagnostic Value of Each Parameter Diagnostic Anti-MCV Va l u e ICT ELISA IgM-RF ICT ELISA Sensitivity Specificity PPV NPV Diagnostic efficiency 78. easy.78% 75% 76. quick (15 minutes) and practical. various detection kits had sensitivity between 69. for example CCPassays. Positive predictive value of RF and anti-MCV rapid test were 76. max 58).83%.12 Despite the excellent performance of these immunoassays.75%. present in other disease such as Sjogren Syndrome.12% respectively. Conclusion Anti-MCV test & RF rapid test (Rheumachec™) is a useful screening test to diagnose patients with early rheumatoid arthritis. psoriasis arthritis (1) and arthropathy (1). the specificity decreased to 68. does not require any additional equipment (the kit is completed with a sterile lancet). In RA group. Meanwhile in control group the average age was 47. min 23. When combined together in a single test.62% *PPV=Positive Predictive Value *ICT=Immunochromatographic Testing *NPV=Negative Predictive Value *MCV=Mutated citrullinated Vimentin *ELISA=Enzyme Linked Immuno. Discussion In this study the diagnostic values of anti-MCV was very high but the RF was only moderately high.RF and anti MCV rapid test with the standard ELISA methods.3%). so a negative Rheumachec’ test could be used to rule out RA from suspected arthritis patients.33% Rheumachec ICT: RF + MCV 100% 68.75% 93. Our result data showed the diagnostic sensitivity of RF and anti-MCV rapid test was 78.75% 94. spondyloarthritis (3). Zhao et al. Therefore RheumachecTM is a suitable screening test for early rheumatoid arthritis.75% 76.15.13. the usage and implementation of anti-MCV test and rheumatoid factor ICT is simple. and therefore are probably not directly involved in the pathogenesis of RA.18 (median 50.75% respectively. It is very practical. Table 2. they only provide a sensitivity comparable with that of rheumatoid factor (RF). so the Rheumachec as a POCT or rapid test has similar diagnostic value as ELISA to diagnose RA.33% 96. Positive predictive value of combined RF and anti-MCV rapid test together was 76.8% and 96.08 (median 51. Volum: 62. fast and reliable in its implementation as a means of supporting the early diagnosis of rheumatoid arthritis.92% 78.28% 96. so the anti-MCV rapid test has very high value in supporting the diagnosis of rheumatoid arthritis disease. low back pain (1). The other studies suggested that anti-MCV could help to diagnose RA in earlier stage. So the anti-MCV is superior in comparison to anti-CCP.Diagnostic Value of Anti-Mutated Citrullinate Vimentin and Rheumatoid Factor With Immunochromatographic Method Sixty five samples in this study consisted of 33 cases of rheumatoid arthritis and 32 other arthritis which consist of osteoarthritis (22 cases). this is mainly because RF could also . systemic lupus erythematosus (4).24 Negative predictive value diagnostic of RF and anti MCV rapid test were 77.74%.47% 77. min 21.77% respectively.23.42% and 96. max 56). This results is in concordance with the result of Egerer et al. the average age was 46.47% 77. Vimentin is secreted and citrullinated by macrophages or by pro-inflammatory cytokines. J Indon Med Assoc. a naturally occurring isoform of vimentin to optimize the performance of the test. needing only 10 ìl capillary blood.19-20 Anti-MCV is produced earlier than anti-CCP in the course of the synovial and joint damage.22 has also questioned the necessity to combine anti-CCP with other antibodies to diagnosis of RA.77% 100% 95% 96.14 Unfortunately. Other studies has revealed that anti-MCV ELISA has good specificity of more than 95% in rheumatoid arthritis. Nomor: 5.18 in which the role of serological tests was found very important. When combined together the negative predictive value of RF and anti-MCV ICT together was 100%. these artificial antigens are not expressed in the affected tissue.21 Looking at anti MCV rapid test alone in RheumachecTM we found the specificity was 93. There was a good conformity and no significant difference between the diagnostic value of both IgM. This is in concordance with a comparative study in 2007.74% 100% 84.0% and 93.6% and 77.75% which is not different with MCV ELISA (93. in response to apoptosis.96% respectively. and a suitable tool for studying this systemic autoimmune disease.*RF=Rheumatoid Factor sorbent Assay From the practical point of view. SLE and normal elderly patients.42% 83. The diagnostic specificity of RF and anti MCV rapid test alone was 75.16 A newly developed immunoassay system utilizes genetically modified citrullinated vimentin (MCV).96% 100% 93. It means that the anti-MCV test & RF ICT method has very high diagnostic value in predicting the absence of rheumatoid arthritis.42% 83.47% and 94. Merging the two parameters of anti-MCV & RF in a single kit increased sensitivity to 100%.17 Noteworthy are the findings of a recently published study that highly valuates anti-MCV test systems for diagnosing 192 rheumatoid arthritis in anti-CCP-negative patients. Mei 2012 .78% and 96..92±9.13±9. Moreover.4%.5% and a specificity between 87.78% 75% 76.

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