Highlights of the Rheumatology Nurses Society Inaugural Annual Conference

Basic Immunology for the Nonimmunologist, From Pathophysiology to Therapeutics

As presented by Dr. Bingham,^[2] the immune system is complex, with an elaborate and dynamic communication and signaling network. For rheumatology nurses, Dr. Bingham stressed that it is vital to establish a good basic understanding of both the innate and adaptive defense mechanisms. From this basic understanding, the rheumatology nurse is better equipped to understand and convey to the rheumatology patient the pathophysiology of the disease and mechanism of action of current therapeutic agents.

Innate and Adaptive Immune Systems

Dr. Bingham presented basic schematics to illustrate the immune responses of the innate and adaptive immune defense systems. He explained that the innate immune system is the basic immunity defense from birth. It is a rapid response system and nonspecific. The body recognizes its own cells as "self"; anything else is "non-self" or foreign. Non-self cells are rapidly attacked in the innate immune system. Key players in the innate system are neutrophils, macrophages, pattern recognition receptors, natural killer (NK) cells, and complement. Complement is a series of serum proteins which simply "complements" the work of serum antibodies through a complex network of recruitment and activation of effector cells (Figure 1). The desired end result is the destruction of the foreign substance, the "non-self" cell.

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Figure 1.

The innate immune response.
Published with permission from Clifton Bingham III, MD

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Figure 2.

The adaptive immune response.
Published with permission from Clifton Bingham III, MD

The adaptive (or acquired) immune response is very specific in action and takes time to evolve. The major players in this response are the B lymphocytes, T lymphocytes, and NK cells. (Figure 2) The natural process essentially involves the same rudimentary mechanisms of the innate response but with the addition of a multitude of costimulatory signals to produce the numerous chemokines and cytokines; these communicate and also move activated immune cells throughout the body. The desired end result is destruction of the "non-self" cell -- but in this case, through a more complex and tightly orchestrated series of events.

Shared Disease Mechanism

Understanding the basic immune response becomes important to the rheumatology nurse in order to appreciate the events that occur when the body begins to interpret some "self "cells as "non-self" or when an unknown antigen-presenting cell is present which triggers an inflammatory cascade. Many of the diseases that rheumatology nurses encounter in practice involve the immune-mediated inflammatory diseases (IMIDs). Examples include:

• Rheumatoid arthritis;

• Scleroderma;

• Psoriasis;

• Ankylosing spondylitis;

• Multiple sclerosis;

• Systemic lupus erythematosus;

• Ulcerative colitis;

• Crohn's disease;

• Myositis; and

• Sjögren's syndrome.

Features of the IMIDs include activation of the inflammatory cascade response, effector cell-mediated damage, and the production of antibodies. Multiple mechanisms contribute to this response, and results vary from an organ-specific destruction to a full systemic cascade. The IMIDs have a shared mechanism of disease, and many medications used to arrest the cascade response in one specific disease condition may be effective in another disease condition. Several agents used in the therapeutic arsenal to treat rheumatoid arthritis are also effective in treating other related conditions, such as systemic lupus erythematosus. For this reason, it is important for the rheumatology nurse to understand both the pathway of disease and the mechanism of action of current Food and Drug Administration-approved drug therapies.

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Cite this: Highlights of the Rheumatology Nurses Society Inaugural Annual Conference - Medscape - Sep 08, 2008.