Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Current and emerging techniques for ANCA detection in vasculitis

Nature Reviews Rheumatology volume 10, pages 494–501 (2014)Cite this article

Subjects

Key Points

  • Screening for antineutrophil cytoplasmic antibodies (ANCAs) specific for proteinase 3 (PR3) and myeloperoxidase (MPO) remains a basic tool in the serological evaluation of systemic vasculitic disorders

  • Automated analysis of ANCA immunofluorescence demonstrates good agreement with conventional techniques when assessing patients with suspected vasculitis and, in the future, might improve efficiency and standardization in clinical laboratories

  • Antigen-specific ANCA assays that use bridging molecules exhibit superior performance compared with conventional assays and can be used for PR3-ANCA and MPO-ANCA detection

  • The new methods for ANCA detection and evaluation in ANCA-associated vasculitis should be urgently evaluated in multicentre studies, in anticipation of updating of standardization processes and a revision of existing strategies

Abstract

Detection of antineutrophil cytoplasmic antibodies (ANCAs) is a well-established diagnostic test used to evaluate suspected necrotizing vasculitis of small blood vessels. Conditions associated with these antibodies, collectively referred to as ANCA-associated vasculitides, include granulomatosis with polyangiitis (formerly known as Wegener granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (formerly known as Churg–Strauss syndrome). The diagnostic utility of ANCA testing depends on the type of assay performed and on the clinical setting. Most laboratories worldwide use standard indirect immunofluorescence tests (IFT) to screen for ANCA and then confirm positive IFT results with antigen-specific tests for proteinase 3 (PR3) and myeloperoxidase (MPO). Developments such as automated image analysis of immunofluorescence patterns, so-called third-generation PR3-ANCA and MPO-ANCA ELISA, and multiplex technology have improved the detection of ANCAs. However, challenges in routine clinical practice remain, including methodological aspects of IFT performance, the diverse antigen-specific assays available, the diagnostic value of testing in clinical settings and the prognostic value of serial ANCA monitoring in the prediction of disease relapse. This Review summarizes the available data on ANCA testing, discusses the usefulness of the various ANCA assays and advises on the clinical indications for the use of ANCA testing.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: ANCA IIF pattern differentiation by automated signal intensity analysis.
Figure 2: Characterization of neutrophils by automated pattern-recognition image analysis.
Figure 3: Overview of ELISA procedures for ANCA detection.
Figure 4: ANCA testing algorithm routinely used in the authors' laboratory.

Similar content being viewed by others

References

  1. Davies, D. J. et al. Segmental necrotizing glomerulonephritis with antineutrophil antibody: possible arbovirus aetiology? Br. Med. J. (Clin. Res. Ed.) 285, 606 (1982).

    Article  CAS  Google Scholar 

  2. Van der Woude, F. J., Rasmussen, N. & Lobatto, S. Autoantibodies against neutrophils and monocytes: tool for diagnosis and marker of disease activity in Wegener's granulomatosis. Lancet 1, 425–429 (1985).

    Article  CAS  Google Scholar 

  3. Jennette, J. C. et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 37, 187–192 (1994).

    Article  CAS  Google Scholar 

  4. Jennette, J. C. et al. 2012 revised international Chapel Hill consensus conference nomenclature of vasculitides. Arthritis Rheum. 65, 1–11 (2013).

    Article  CAS  Google Scholar 

  5. Schmitt, W. H. & van der Woude, F. J. Clinical applications of antineutrophil cytoplasmic antibody testing. Curr. Opin. Rheumatol. 16, 9–17 (2004).

    Article  Google Scholar 

  6. Csernok, E., Lamprecht, P. & Gross, W. L. Diagnostic significance of ANCA in vasculitis. Nat. Clin. Pract. Rheumatol. 2, 174–175 (2006).

    Article  Google Scholar 

  7. Cohen Tervaert, J. W. & Damoiseaux, J. Antineutrophil cytoplasmic autoantibodies: how are they detected and what is their use for diagnosis, classification and follow-up? Clin. Rev. Allergy Immunol. 43, 211–219 (2012).

    Article  CAS  Google Scholar 

  8. Specks, U. Controversies in ANCA testing. Cleve. Clin. J. Med. 79 (Suppl. 3), S7–S11 (2012).

    Article  Google Scholar 

  9. Savige, J. et al. International Consensus Statement on testing and reporting of antineutrophil cytoplasmic antibodies (ANCA). Am. J. Clin. Pathol. 111, 507–513 (1999).

    Article  CAS  Google Scholar 

  10. Savige, J. et al. Addendum to the International Consensus Statement on testing and reporting of anti-neutrophil cytoplasmatic antibodies. Quality control guidelines, comments and recommendations for testing in other autoimmune diseases. Am. J. Clin. Pathol. 120, 312–314 (2003).

    Article  CAS  Google Scholar 

  11. Hagen, E. C. 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. 53, 743–753 (1998).

    Article  CAS  Google Scholar 

  12. Csernok, E. & Holle, J. U. Twenty-eight years with antineutrophil cytoplasmic antibodies (ANCA): how to test for ANCA—evidence-based immunology? Autoimmunity Highlights 1, 39–43 (2010).

    Article  CAS  Google Scholar 

  13. Russell, K. A., Wiegert, E., Schroeder, D. R., Homburger, H. A. & Specks, U. Detection of anti-neutrophil cytoplasmic antibodies under actual clinical testing conditions. Clin. Immunol. 103, 196–203 (2002).

    Article  CAS  Google Scholar 

  14. Willitzki, A. et al. New platform technology for comprehensive serological diagnostics of autoimmune diseases. Clin. Dev. Immunol. http://dx.doi.org/10.1155/2012/284740 (2012).

  15. Boomsma, M. M. et al. Image analysis: a novel approach for the quantification of ANCA levels in patients with Wegener's granulomatosis. J. Immunol. Methods 274, 27–35 (2003).

    Article  CAS  Google Scholar 

  16. Melegari, A. et al. A comparative study on the reliability of an automated system for the evaluation of cell-based indirect immunofluorescence. Autoimmun. Rev. 11, 713–716 (2012).

    Article  CAS  Google Scholar 

  17. Knütter, I. et al. Automated interpretation of ANCA patterns—a new approach in the serology of ANCA-associated vasculitis. Arthritis Res Ther. 14, R271 (2012).

    Article  Google Scholar 

  18. Damoiseaux, J., Mallet, K., Vaessen. M., Austen, J. & Cohen Tervaert, J. W. Automatic reading of ANCA-slides: evaluation of the AKLIDES system. Clin. Dev. Immunol. http://dx.doi.org/10.1155/2012/762874 (2012).

  19. Franssen, C. et al. Disease spectrum of patients with antineutrophil cytoplasmic autoantibodies of defined specificity: distinct differences between patients with anti-proteinase 3 and anti-myeloperoxidase autoantibodies. J. Intern. Med. 244, 209–216 (1998).

    Article  CAS  Google Scholar 

  20. Schönermarck, U., Lamprecht, P., Csernok, E. & Gross, W. L. Prevalence and spectrum of rheumatic diseases associated with proteinase 3-antineutrophil cytoplasmic antibodies (ANCA) and myeloperoxidase-ANCA. Rheumatology (Oxford) 40, 178–184 (2001).

    Article  Google Scholar 

  21. Hauer, H. A. et al. Renal histology in ANCA-associated vasculitis: differences between diagnostic and serologic subgroups. Kidney Int. 61, 80–89 (2002).

    Article  Google Scholar 

  22. Lyons, P. A. et al. Genetically distinct subsets within ANCA-associated vasculitis. N. Engl. J. Med. 367, 214–223 (2012).

    Article  CAS  Google Scholar 

  23. Holle, J. U., Hellmich, B., Backes, M., Gross, W. L. & Csernok, E. Variations in performance characteristics of commercial enzyme immunoassay kits of the detection of antineutrophil cytoplasmatic antibodies: what is the optimal cut-off? Ann. Rheum. Dis. 64. 1773–1779 (2005).

    Article  CAS  Google Scholar 

  24. Westman, K. et al. Clinical evaluation of a capture-ELISA for PR3-ANCA. Kidney Int. 53, 1230–1236 (1998).

    Article  CAS  Google Scholar 

  25. Sun, J. et al. Capture-ELISA based on recombinant PR3 is sensitive for PR3-ANCA testing and allows detection of PR3 and PR3-ANCA/PR3 immunocomplexes. J. Immunol. Meth. 211, 111–123 (1998).

    Article  CAS  Google Scholar 

  26. Csernok, E. et al. Evaluation of capture ELISA for detection of antineutrophil cytoplasmic antibodies against proteinase-3 in Wegener's granulomatosis: first results from a multicenter study. Rheumatology (Oxford) 43, 174–180 (2004).

    Article  CAS  Google Scholar 

  27. Gisslen, K., Wieslander, J., Westberg, K. & Herlitz, H. Relationship between anti-neutrophil cytoplasmatic antibody determined with conventional binding and the capture assay, and long-term clinical course in vasculitis. J. Int. Med. 251, 129–135 (2002).

    Article  CAS  Google Scholar 

  28. Hellmich, B., Csernok, E., Fredenhagen, G. & Gross, W. L. A novel high sensitivity ELISA for detection of antineutrophil cytoplasm antibodies against proteinase-3. Clin. Exp. Rheumatol. 25 (1 Suppl. 44), S1–S5 (2007).

    CAS  PubMed  Google Scholar 

  29. Holle, J. U., Csernok, E., Fredenhagen, G. & Gross, W. L. Clinical evaluation of hsPR3-ANCA ELISA for detection of antineutrophil cytoplasmic antibodies directed against proteinase 3. Ann. Rheum. Dis. 69, 468–469 (2010).

    Article  CAS  Google Scholar 

  30. Damoiseaux, J. et al. A novel enzyme-linked immunosorbent assay using a mixture of human native and recombinant proteinase-3 significantly improves the diagnostic potential for antineutrophil cytoplasmic antibody-associated vasculitis. Ann. Rheum. Dis. 68, 228–233 (2009).

    Article  CAS  Google Scholar 

  31. Roggenbuck, D. et al. High sensitivity detection of autoantibodies against proteinase 3 by a novel third-generation enzyme-linked immunoabsorbent assay. Ann. NY Acad Sci. 1173, 41–46 (2009).

    Article  CAS  Google Scholar 

  32. Holle, J. U., Hermann K., Gross, W. L. & Csernok, E. Comparative analysis of different commercial ELISA systems for detection of anti-neutrophil cytoplasm antibodies in ANCA-associated vasculitides. Clin. Exp. Rheumatol. 30 (Suppl. 70), S66–S69 (2012).

    PubMed  Google Scholar 

  33. Radice, A., Bianchi, L., Maggiore, U., Vaglio, A. & Sinico, R. A. Comparison of PR3-ANCA specific assay performance for the diagnosis of granulomatosis with polyangiitis (Wegener's). Clin. Chem. Lab. Med. 51, 2141–2149 (2013).

    Article  CAS  Google Scholar 

  34. Vermeersch, P. et al. Determination of anti-neutrophil cytoplasmic antibodies in small vessel vasculitis: comparative analysis of different strategies. Clin. Chim. Acta. 397, 77–81 (2008).

    Article  CAS  Google Scholar 

  35. Damoiseaux, J. et al. EUROPLUS ANCA BIOCHIP mosaic: PR3 and MPO antigen microdots improve the laboratory diagnostics of ANCA-associated vasculitis. J. Immunol. Meth. 348, 67–73 (2009).

    Article  CAS  Google Scholar 

  36. Trevisin, M., Pollock, W. & Savige, J. Evaluation of a multiplex flow cytometric immunoassay to detect PR3- and MPO-ANCA in active and treated vasculitis, and in inflammatory bowel disease. J. Immunol. Meth. 336, 104–112 (2008).

    Article  CAS  Google Scholar 

  37. Finkielman, J. D. et al. ANCA are detectable in nearly all patients with active severe Wegener's granulomatosis. Am. J. Med. 120, 643.e9–643.e14 (2007).

    Article  Google Scholar 

  38. Westman, K. W. et al. Rapid screening assay for anti-GBM antibody and ANCAs; an important tool for the differential diagnosis of pulmonary renal syndromes. Nephrol. Dial. Transplant. 12, 1863–1868 (1997).

    Article  CAS  Google Scholar 

  39. Tomasson, G. et al. Value of ANCA measurements during remission to predict a relapse of ANCA-associated vasculitis: a meta-analysis. Rheumatology (Oxford) 51, 100–109 (2012).

    Article  CAS  Google Scholar 

  40. McLaren, J. S., Stimson, R. H., McRorie, E. R., Coia, J. E. & Luqmani, R. A. The diagnostic value of anti-neutrophil cytoplasmic antibody testing in a routine clinical setting. QJM 94, 615–621 (2001).

    Article  CAS  Google Scholar 

  41. Mandl, L. A. Using antineutrophil cytoplasmic antibody testing to diagnose vasculitis: can test-ordering guidelines improve diagnostic accuracy? Arch. Intern. Med. 162, 1509–1514 (2002).

    Article  Google Scholar 

  42. Sinclair, D., Saas M. & Stevens, J. M. The effect of a symptom related ''gating policy'' on ANCA requests in routine clinical practice. J. Clin. Pathol. 57, 131–134 (2004).

    Article  CAS  Google Scholar 

  43. Arnold, D. F. et al. Does a gating policy for ANCA overlook patients with ANCA associated vasculitis? An audit of 263 patients. J. Clin. Pathol. 63, 678–680 (2010).

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Rheumatology, Klinikum Bad Bramstedt & University Hospital of Schleswig-Holstein, Oskar-Alexanderstrasse 26, 24576, Bad Bramstedt, Germany

    Elena Csernok & Frank Moosig

Authors
  1. Elena Csernok
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Frank Moosig
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

E.C. researched data for and wrote the article, F.M. made a substantial contribution to discussion of content, and both authors reviewed/edited the manuscript before submission.

Corresponding author

Correspondence to Elena Csernok.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Csernok, E., Moosig, F. Current and emerging techniques for ANCA detection in vasculitis. Nat Rev Rheumatol 10, 494–501 (2014). https://doi.org/10.1038/nrrheum.2014.78

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrrheum.2014.78

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Translational Research

Sign up for the Nature Briefing: Translational Research newsletter — top stories in biotechnology, drug discovery and pharma.

Get what matters in translational research, free to your inbox weekly. Sign up for Nature Briefing: Translational Research