The generation and persistence of autoreactive B and plasma cells is crucial to the pathogenesis of many human autoimmune diseases. Secreted autoantibodies frequently serve as biomarkers in clinical practice and, in some cases, function as pathogenic effector molecules. Nonetheless, the primary break of B cell tolerance against autoantigens, the triggers that maintain autoreactive B cell memory, and the phenotype that autoreactive B cells adopt during the disease course are poorly understood.

To study phenotype and functional characteristics of human autoreactive B cells in the course of human disease using rheumatoid arthritis and the B cell response against posttranslationally modified antigens as prototype.

Combinatorial, antigen-specific identification and multiparameter phenotyping of autoreactive B cells by conventional and spectral flow cytometry in cohorts with well-defined clinical phenotypes, including patients in the phase preceding disease and in those reaching long-term, drugfree remission.

Autoreactive B cells against post-translationally modified proteins operate as remarkably activated effector memory cells in patients with established disease and maintain this state throughout the disease course. The activation generates cytokine-secreting germinal center emigrants that resist conventional therapy, and migratory plasmablasts expressing homing markers that can direct the cells to sites of inflammation. In the pre-clinical at-risk phase, the degree of activation is lower, and migratory plasmablasts are less frequent. The cells are cross-reactive to different posttranslational modifications and express B cell receptors that are extensively glycosylated in the variable domain.

Immune phenotyping of disease-specific, autoreactive B cells reveals heterogeneous features of human autoimmunity that reflect disease stage and course and that are only revealed upon antigen-specific cellular analysis. In rheumatoid arthritis, the picture of germinal center-derived B cell autoreactivity against post-translationally modified antigens emerges that displays extensive cross-reactivity and a likely dependence on T cell help. Such features may be different for other human autoimmune diseases with different disease kinetics, which each may require different strategies for (autoreactive) B cell targeting.