In both patients, dominant IgG4+ clones were recovered in the BCR

In both patients, dominant IgG4+ clones were recovered in the BCR repertoire of the biopsy material (Fig. 2A,D). In line with peripheral blood, the rank of the highest IgG4+ clone find more is again 1st when selecting the IgG+ repertoire only. Comparing the retrieved IgG+ clones, a strong overlap was present between the clones found

in blood and inflamed tissue (Fig. 2B,C,E), mainly consisting of IgG4+ clones suggestive of specific enrichment of the infiltrating cells with these IgG4+ BCR clones (Supporting Fig. 3A,B). Collectively, IgG4+ clones were detectable in inflamed tissue, and these clones showed marked overlap with those in peripheral blood. This suggests that these IgG4+ clones have a role in the pathogenesis of the disease, rather than being an epiphenomenon. If the dominant IgG4+ clones were indeed pathogenic, it would be expected that they would regress or even disappear following successful therapeutic intervention. We thus compared BCR repertoires in IAC patients before and 4 and 8 weeks after initiation

of their first immunosuppressive treatment episode. In patients treated with high-dose prednisolone, serum liver tests improved rapidly (Fig. 3A). Simultaneously, corticosteroid therapy induced a specific decline of serum IgG4 levels, while total IgG serum levels on average remained nearly stable within or close to physiological levels (Fig. 3B). In line, after 4 weeks of treatment, the contribution of IgG4+ clones to the total blood BCR repertoire already had become negligible. The IgG+ clones with an IgG4+ subtype fell from 9.2% at baseline to 0.3% and 0.2% after 4 and 8 weeks of therapy, respectively (Fig. 4A,B). Consequently, the contribution of individual dominant IgG4+ clones to the BCR repertoire regressed; the most dominant IgG4+ clone in IAC patients dropped in rank from a median of 1st to 51st (P < 0.001) and 67th (P < 0.001) after 4 and 8 weeks, respectively (Fig. 4C). Furthermore, corticosteroid therapy appears to have a more profound

effect on the presence of dominant IgG4+ clones than on other clones in the BCR repertoire. While dominant IgG4+ clones are rapidly suppressed by corticosteroid use, the majority of the non-IgG4 B cell clones remained stable during 4 and 8 weeks of immunosuppressive 上海皓元医药股份有限公司 therapy (median percentage of BCR clones recovered from the BCR repertoire after 4 and 8 weeks, 70.3% and 66.1%, respectively) (Fig. 4D). The notion that dominant IgG4+ clones can be found in patients with active IAC is also supported by observations in one patient who experienced a relapse of disease while using a maintenance dose of the enterotropic corticosteroid budesonide. In this patient, the repertoire was assessed at baseline and 4 and 8 weeks after the daily dose of budesonide was increased. Also in this patient, IgG4+ clones were present at the time of active relapsing disease and were suppressed by therapeutic intervention (Fig. 4E).

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