CCR6⁺ Th cell populations distinguish ACPA positive from ACPA negative rheumatoid arthritis

Introduction: Patients with rheumatoid arthritis (RA) can be separated into two major subpopulations based on the absence or presence of serum anti-citrullinated protein antibodies (ACPAs). The more severe disease course in ACPA⁺ RA and differences in treatment outcome between these subpopulations suggest that ACPA⁺ and ACPA^- RA are different disease subsets. The identification of T-helper (Th) cells specifically recognizing citrullinated peptides, combined with the strong association between HLA-DRB1 and ACPA positivity, point toward a pathogenic role of Th cells in ACPA⁺ RA. In this context we recently identified a potential pathogenic role for CCR6⁺ Th cells in RA. Therefore, we examined whether Th cell population distributions differ by ACPA status. Methods: We performed a nested matched case-control study including 27 ACPA⁺ and 27 ACPA^- treatment-naive early RA patients matched for disease activity score in 44 joints, presence of rheumatoid factor, sex, age, duration of complaints and presence of erosions. CD4⁺CD45RO⁺ (memory) Th cell distribution profiles from these patients were generated based on differential chemokine receptor expression and related with disease duration. Results: ACPA status was not related to differences in total CD4⁺ T cell or memory Th cell proportions. However, ACPA⁺ patients had significantly higher proportions of Th cells expressing the chemokine receptors CCR6 and CXCR3. Similar proportions of CCR4⁺ and CCR10⁺ Th cells were found. Within the CCR6⁺ cell population, four Th subpopulations were distinguished based on differential chemokine receptor expression: Th17 (CCR4⁺CCR10^-), Th17.1 (CXCR3⁺), Th22 (CCR4⁺CCR10⁺) and CCR4/CXCR3 double-positive (DP) cells. In particular, higher proportions of Th22 (p = 0.02), Th17.1 (p = 0.03) and CCR4/CXCR3 DP (p = 0.01) cells were present in ACPA⁺ patients. In contrast, ACPA status was not associated with differences in Th1 (CCR6^-CXCR3⁺; p = 0.90), Th2 (CCR6^-CCR4⁺; p = 0.27) and T-regulatory (CD25^hiFOXP3⁺; p = 0.06) cell proportions. Interestingly, CCR6⁺ Th cells were inversely correlated with disease duration in ACPA^- patients (R² = -0.35; p < 0.01) but not in ACPA⁺ (R² < 0.01; p = 0.94) patients. Conclusions: These findings demonstrate that increased peripheral blood CCR6⁺ Th cells proportions distinguish ACPA⁺ RA from ACPA^- RA. This suggests that CCR6⁺ Th cells are involved in the differences in disease severity and treatment outcome between ACPA⁺ and ACPA^- RA.