Geniş ve Rastgele Bir Örneklemde Antinötrofil Sitoplazmik Antikor İlişkili Durumların İncelenmesi: Enzyme-Linked ImmunoSorbent Assay ve İndirekt İmmunfloresan Testlerinin Karşılaştırılması

Abstract

Amaç: Bu çalışmanın amacı, Türkiye'nin çeşitli bölgelerinden üçüncü basamak bir hastaneye başvuran farklı hasta gruplarında antinötrofil sitoplazmik antikor (ANCA) prevalansını, klinik özelliklerini ve ANCA test sonuçlarını incelemektir. Gereç ve Yöntemler: Bu geriye dönük çalışmada, 4,5 yıl boyunca ANCA açısından test edilen 10.726 serum örneği analiz edildi. ANCA indirekt immünofloresan (IIF) ve enzyme-linked immunosorbent assay (ELISA) testleri talep edilen tüm hastalar çalışmaya dahil edildi. Bulgular: IIF/ELISA test sonuçları 973 (%9,1) hastada pozitifti, 875 IIF pozitif ve 98 ELISA pozitif ancak IIF negatifti. IIF pozitif 875 hastanın 631'inde (%72,1) p-ANCA paterni, 222'sinde (%25,4) c-ANCA paterni gözlendi. p-ANCA pozitiflerin %16,6'sında (n=105) MPO ELISA pozitif ve %0,8'inde (n=5) PR3 ELISA pozitif iken, c-ANCA pozitiflerin ise %0,9'unda (n=2) MPO ELISA pozitif ve %36,5'inde (n=81) PR3 ELISA pozitifti. IIF/ELISA pozitiflerin %11,6'sı (n=113) ANCA ilişkili vaskülit (AAV) idi. ELISA testi, AAV hastalarının 91'inde (%80,5) ANCA tespit etti. IIF'nin pozitif prediktif değeri (PPV) %11,89 iken, ELISA'nın pozitif prediktif değeri %29,84 olarak bulundu. Hem IIF hem de ELISA kullanımı %41,75'lik bir PPV ile sonuçlandı. Sonuç: Antijene özgü immünoassayler, IIF'ye kıyasla daha iyi tanısal kesinlik sergilemektedir. Bu nedenle, AAV taraması için PR3- ve MPO-ANCA ELISA önerilmektedir. AAV şüphesi olmayan hastalarda, daha hassas olan IIF testi kullanılmalıdır. IIF pozitifse, anti-MPO veya anti-PR3 ELISA gibi antijene özgü testler antijenleri doğrulamalıdır.

Keywords

• Antinötrofil sitoplazmik antikor
• indirekt immünofloresan testi
• ELISA

Analyzing Antineutrophil Cytoplasmic Antibody Associated Conditions in a Large, Random Sample of Patients: A Comparison of Enzyme-Linked Immunosorbent Assay and Indirect Immunofluorescence Tests

Abstract

Aim: The aim of this study was to examine the prevalence of antineutrophil cytoplasmic antibodies (ANCA) in a diverse group of Turkish patients admitted to a tertiary care hospital, their clinical characteristics, and ANCA test results. Material and Methods: This retrospective study analyzed 10,726 serum samples tested for ANCA over 4.5 years. All patients requested ANCA indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) tests were included. Results: IIF/ELISA test results were positive for 973 (9.1%) patients, 875 IIF positive and 98 ELISA positive with negative IIF. Of the 875 IIF-positive patients, the p-ANCA pattern was observed in 631 (72.1%), and the c-ANCA pattern was observed in 222 (25.4%). MPO ELISA was positive in 16.6% (n=105), and PR3 ELISA was positive in 0.8% (n=5) of the p-ANCA positives, while MPO ELISA was positive in 0.9% (n=2), and PR3 ELISA was positive in 36.5% (n=81) of the c-ANCA positives. 11.6% (n=113) of the IIF/ELISA positives were ANCA-associated vasculitis (AAV). The ELISA test detected ANCA in 91 (80.5%) of the AAV patients. The positive predictive value (PPV) of IIF was 11.89%, while the PPV of the ELISA was 29.84%. The utilization of both IIF and ELISA resulted in a PPV of 41.75%. Conclusion: Antigen-specific immunoassays exhibit better diagnostic precision compared to IIF. Therefore, PR3- and MPO-ANCA ELISA are recommended for AAV screening. In patients with no suspicion of AAV, the more sensitive IIF test should be used. If IIF is positive, antigen-specific assays such as anti-MPO or anti-PR3 ELISA should confirm antigens.

Keywords

• Antineutrophil cytoplasmic antibody
• indirect immunofluorescence assay
• ELISA

References

1. Tsukui D, Kimura Y, Kono H. Pathogenesis and pathology of anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis. J Transl Autoimmun. 2021;4:100094.
2. Davies DJ, Moran JE, Niall JF, Ryan GB. Segmental necrotising glomerulonephritis with antineutrophil antibody: possible arbovirus aetiology?. Br Med J (Clin Res Ed). 1982;285(6342):606.
3. Walulik A, Łysak K, Błaszkiewicz M, Górecki I, Gomułka K. The role of neutrophils in ANCA-associated vasculitis: the pathogenic role and diagnostic utility of autoantibodies. Int J Mol Sci. 2023;24(24):17217.
4. Ponte C, Grayson PC, Robson JC, Suppiah R, Gribbons KB, Judge A, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Arthritis Rheumatol. 2022;74(12):1881-9.
5. Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as disease biomarkers: clinical implications beyond vasculitis. Clin Rev Allergy Immunol. 2022;63(2):107-23.
6. FijoŁek J, Wiatr E. Antineutrophil cytoplasmic antibodies (ANCA) - their role in pathogenesis, diagnosis, and treatment monitoring of ANCA-associated vasculitis. Cent Eur J Immunol. 2020;45(2):218-27.
7. Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 1994;37(2):187-92.
8. Savige J, Gillis D, Benson E, Davies D, Esnault V, Falk RJ, et al. International Consensus Statement on Testing and Reporting of Antineutrophil Cytoplasmic Antibodies (ANCA). Am J Clin Pathol. 1999;111(4):507-13.

9. Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, et al. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis. 2024;83(1):30-47.
10. Paroli M, Gioia C, Accapezzato D. New insights into pathogenesis and treatment of ANCA-associated vasculitis: autoantibodies and beyond. Antibodies (Basel). 2023;12(1):25.
11. Rao DA, Wei K, Merola JF, O'Brien WR, Takvorian SU, Dellaripa PF, et al. Myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA) and proteinase 3-ANCA without immunofluorescent ANCA found by routine clinical testing. J Rheumatol. 2015;42(5):847-52.
12. Guchelaar NAD, Waling MM, Adhin AA, van Daele PLA, Schreurs MWJ, Rombach SM. The value of anti-neutrophil cytoplasmic antibodies (ANCA) testing for the diagnosis of ANCA-associated vasculitis, a systematic review and meta-analysis. Autoimmun Rev. 2021;20(1):102716.
13. Stone JH, Talor M, Stebbing J, Uhlfelder ML, Rose NR, Carson KA, et al. Test characteristics of immunofluorescence and ELISA tests in 856 consecutive patients with possible ANCA-associated conditions. Arthritis Care Res. 2000;13(6):424-34.
14. McLaren JS, Stimson RH, McRorie ER, Coia JE, Luqmani RA. The diagnostic value of anti-neutrophil cytoplasmic antibody testing in a routine clinical setting. QJM. 2001;94(11):615-21.
15. Menezes JM, Rossener R, Silva APMAD, Rodrigues SS, Mangueira CLP. Comparison between enzyme-linked immunosorbent assay and indirect immunofluorescence for detection of antineutrophil cytoplasmic antibodies. Einstein (Sao Paulo). 2020;18:eAO5132.
16. Csernok E, Ahlquist D, Ullrich S, Gross WL. A critical evaluation of commercial immunoassays for antineutrophil cytoplasmic antibodies directed against proteinase 3 and myeloperoxidase in Wegener's granulomatosis and microscopic polyangiitis. Rheumatology (Oxford). 2002;41(11):1313-7.
17. Walker BS, Peterson LK, Koening C, White SK, Schmidt RL, Tebo AE. Performance of MPO-ANCA and PR3-ANCA immunoassays for the stratification of specific ANCA-associated vasculitis: A systematic review and meta-analysis. Autoimmun Rev. 2022;21(6):103100.
18. Pollock W, Clarke K, Gallagher K, Hall J, Luckhurst E, McEvoy R, et al. Immunofluorescent patterns produced by antineutrophil cytoplasmic antibodies (ANCA) vary depending on neutrophil substrate and conjugate. J Clin Pathol. 2002;55(9):680-3.
19. Mandl LA, Solomon DH, Smith EL, Lew RA, Katz JN, Shmerling RH. Using antineutrophil cytoplasmic antibody testing to diagnose vasculitis: can test-ordering guidelines improve diagnostic accuracy? Arch Intern Med. 2002;162(13):1509-14.
20. Hagen EC, Daha MR, Hermans J, Andrassy K, Csernok E, Gaskin G, et al. Diagnostic value of standardized assays for anti-neutrophil cytoplasmic antibodies in idiopathic systemic vasculitis. EC/BCR Project for ANCA Assay Standardization. Kidney Int. 1998;53(3):743-53.
21. Damoiseaux J. ANCA testing in clinical practice: from implementation to quality control and harmonization. Front Immunol. 2021;12:656796.
22. Kronbichler A, Bajema IM, Bruchfeld A, Mastroianni Kirsztajn G, Stone JH. Diagnosis and management of ANCA-associated vasculitis. Lancet. 2024;403(10427):683-98.
23. Vermeersch P, Vervaeke S, Blockmans D, van Hoovels L, Mariën G, Vanmaele H, et al. Determination of anti-neutrophil cytoplasmic antibodies in small vessel vasculitis: comparative analysis of different strategies. Clin Chim Acta. 2008;397(1-2):77-81.
24. Chevet B, Cornec D, Casal Moura M, Cornec-Le Gall E, Fervenza FC, Warrington KJ, et al. Diagnosing and treating ANCA-associated vasculitis: an updated review for clinical practice. Rheumatology (Oxford). 2023;62(5):1787-803.
25. Cohen A, Weerasinghe N, Lemmert K, de Malmanche T, Myint T. Diagnostic accuracy of ANCA serology in ANCA-associated vasculitis with renal involvement. Intern Med J. 2024;54(9):1497-505.
26. Trevisin M, Neeson P, Savige J. The binding of proteinase 3 antineutrophil cytoplasmic antibodies (PR3-ANCA) varies in different ELISAs. J Clin Pathol. 2004;57(3):303-8.