Clinical Information

CD20 (cluster of differentiation 20) is a protein that is expressed on the surface of B cells, starting at the pre-B cell stage and on mature B cells in the bone marrow and in the periphery. CD20 is not expressed on hematopoietic stem cells, pro-B cells, or normal plasma cells.(1) Plasmablasts and stimulated plasma cells may express CD20.(2) CD20 is generally coexpressed on B cells with CD19, another B-cell differentiation marker. CD20 appears to play a role in B-cell development, differentiation, B-cell receptor (BCR) signaling, and cell-cycle initiation events.(3) CD20 is not shed from the surface of B cells and does not internalize on binding with anti-CD20 antibody, nor is it typically present as a soluble free antigen in circulation.(3) Certain primary humoral immunodeficiencies, such as X-linked agammaglobulinemia and autosomal recessive agammaglobulinemia, are characterized by a complete absence or profound reduction of peripheral B cells, expressing both CD20 and CD19.

Variants in the CD19 gene have been shown to be associated with a primary humoral immunodeficiency, sometimes classified as common variable immunodeficiency (CVID).(4) This defect accounts for less than 1% of CVID patients and appears to be inherited as an autosomal recessive defect.(4) Since these patients have normal numbers of B cells with absent CD19 expression on the cell surface (4), CD20 can be used as a marker to help identify these patients. Genetic CD20 deficiency (autosomal recessive) is also associated with a primary humoral immunodeficiency. In this disease, B cells can be identified by CD19 expression.(5) Similarly, patients receiving anti-CD19 monoclonal antibody therapeutics, such as inebilizumab (6) may show loss of CD19 staining as well.

A contrasting situation exists for patients with genetic defects in CD20 (5) or receiving rituximab, ofatumumab, and other anti-CD20 monoclonal antibodies that are used to treat certain cancers, autoimmune diseases, or for B-cell depletion to prevent humoral rejection in positive crossmatch kidney transplantation. These agents block available CD20-binding sites and, therefore, the antibody used for this flow cytometric assay cannot recognize the CD20 molecule on B cells. The concomitant use of the CD19 marker provides information on the extent of B-cell depletion when using this particular treatment strategy.

The absolute counts of lymphocyte subsets are known to be influenced by a variety of biological factors, including hormones, the environment, and temperature. The studies on diurnal (circadian) variation in lymphocyte counts have demonstrated progressive increase in CD4 T-cell count throughout the day, while CD8 T cells and CD19+ B cells increase between 8:30 a.m. and noon, with no change between noon and afternoon. Natural killer cell counts, on the other hand, are constant throughout the day.(6) Circadian variations in circulating T-cell counts have been shown to be negatively correlated with plasma cortisol concentration.(7-9) In fact, cortisol and catecholamine concentrations control distribution and, therefore, numbers of naive versus effector CD4 and CD8 T cells.(7) It is generally accepted that lower CD4 T-cell counts are seen in the morning compared with the evening(10), and during summer compared to winter.(11) These data, therefore, indicate that timing and consistency in timing of blood collection is critical when serially monitoring patients for lymphocyte subsets.