ANCA BACK TO BASICS · Classification criteria idiopathic vasculitis . 2. Role in diagnosis •...

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WIV NIS, 06/06/2015 Lieve Van Hoovels ANCA BACK TO BASICS

Transcript of ANCA BACK TO BASICS · Classification criteria idiopathic vasculitis . 2. Role in diagnosis •...

Page 1: ANCA BACK TO BASICS · Classification criteria idiopathic vasculitis . 2. Role in diagnosis • Histopathology of the lesions 1,2,3 • Size of the vessles involved 1,2,3 • Clinical

WIV NIS, 06/06/2015

Lieve Van Hoovels

ANCA BACK TO BASICS

Page 2: ANCA BACK TO BASICS · Classification criteria idiopathic vasculitis . 2. Role in diagnosis • Histopathology of the lesions 1,2,3 • Size of the vessles involved 1,2,3 • Clinical

ANCA – Back to basics

International guidelines: revision

Laboratory diagnosis

Role in follow-up

Role in diagnosis

ANCA definition

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1. ANCA definition Anti-neutrophil cytoplasmic antibodies

Proteinase 3 Myeloperoxidase BPI

Elastase

Lysozyme

Cathespin G

Lactoferrin

Azurocidin

β-glucuronidase

hLAMP-2

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2. Role in diagnosis Chapel Hill Consensus Conference 2012

Jennette et al. Arthritis Rheum 2013; 65: 1-11

MPA GPA

EGPA

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2. Role in diagnosis

Jennette et al. Arthritis Rheum 2013; 65: 1-11

ANCA-Associated Vasculitis (AAV)

NCGN MPA GPA EGPA

Renal-limited Systemic manifestations

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2. Role in diagnosis

Jennette et al. Arthritis Rheum 2013; 65: 1-11

ANCA-Associated Vasculitis (AAV)

NCGN MPA GPA EGPA

Renal-limited Systemic manifestations

Abscent Granulomatous airway lesions

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Jennette et al. Arthritis Rheum 2013; 65: 1-11

NCGN MPA GPA EGPA

Renal-limited Systemic manifestations

Abscent

Asthma Eosinophilia Abscent

Granulomatous airway lesions

ANCA-Associated Vasculitis (AAV)

2. Role in diagnosis

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Classification criteria idiopathic vasculitis

2. Role in diagnosis

• Histopathology of the lesions 1,2

• Size of the vessles involved 1,2

• Clinical symptoms 1

• ANCA

1 American College of rheumatology

2 Chapel Hill Consensus Conference

Fries et al. Arthritis Rheum 1994; 33: 1135-1136

Jennette et al. Arthritis Rheum 1994; 37: 187-192

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Classification criteria idiopathic vasculitis

2. Role in diagnosis

• Histopathology of the lesions 1,2,3

• Size of the vessles involved 1,2,3

• Clinical symptoms 1,3

• ANCA 3

1 American College of rheumatology

2 Chapel Hill Consensus Conference

3 European Medicines Agency

Fries et al. Arthritis Rheum 1994; 33: 1135-1136

Jennette et al. Arthritis Rheum 1994; 37: 187-192

Watts et al. Ann Rheum Dis 2007; 66: 222-227

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PR3-ANCA MPO-ANCA Negative

NCGN § 20% 70% 10%

MPA 40% 50% 10%

GPA 75% 20% 5%

EGPA * 5% 40% 55%

ANCA-Associated Vasculitis (AAV)

2. Role in diagnosis

§ 90% hLAMP-2 positive

* EAPG with GN is > 75% ANCA positive

Jennette et al. Annu Rev Pathol Mech Dis 2013; 8: 139-160

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Cohen Tervaert, Damoiseaux. Clin Rev Allergy Immunol 2012; 43: 211-219; Lyons et al. NEJM 2012; 367: 214-223

“Genetics, clinical manifestations and response to therapy are more related to ANCA serotype than to clinical subtype”

2. Role in diagnosis ANCA-Associated Vasculitis (AAV)

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Genetics

Lyons et al. NEJM 2012; 367: 214-223

HLA-DP SERPINA1 PRTN3

HLA-DQ

2. Role in diagnosis

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Clinical manifestations

Lionakiet al. Arthritis Rheum 2012; 64: 3452-3462

2. Role in diagnosis

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Respons to therapy

Lionaki et al. Arthritis Rheum 2012; 64: 3452-3462

2. Role in diagnosis

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Hilhorst et al. J Am Soc Nephrol 2015; 26: ISSN: 1046-6673/2610

“Genetics, clinical manifestations and response to therapy are more related to ANCA serotype than to clinical subtype”

2. Role in diagnosis ANCA-Associated Vasculitis (AAV)

Patient classification based on ANCA subtype? Contra:

ANCA negative AAV

No difference in treatment strategies

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IIF Antigens

Rheumatoid arthritis P-ANCA atypical

- lactoferrin - cathepsin G - elastase - lysozyme - unknown

SLE

Sjögren’s syndrome

Juvenile chronic arthritis

Reactive arthritis

Sclerodermia

Antiphospholipid syndrome

Rheumatic disorders

2. Role in diagnosis

Savige. Best Prac Res Clin Rheum 2005; 19: 263-276

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AI gastrointestinal disorders IIF Antigens

Ulcerative colitis (60-80%) (pANCA) atypisch

- (PR3) - BPI - lactoferrin - cathepsin G - elastase - lysozyme

Crohn’s disease (10-30%)

Primary sclerosing cholangitis + UC (85-95%)

Primary sclerosing cholangitis – UC (15-20%)

Chronic AI hepatitis (70%)

pANCA + en ASCA - => PPV UC= 82-100% pANCA – en ASCA + => PPV CD= 75-96%

2. Role in diagnosis

Savige. Best Prac Res Clin Rheum 2005; 19: 263-276

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Gaffo et al. Rheum Dis Clin North Am 2010; 36: 491-506

Others

Categorie

Vasculitis Cryoglobulinemic Giant cell arteritis Behçet syndrome Polyarteritis nodosa Goodpasture’s syndrome

Infections Mycobacterium tuberculosis HIV Hepatitis C Endocarditis

Others Sarcoïdosis Interstitial lung fibrosis Medication (oa. propylthiouracil) Mucoviscidosis Cocaine (levamisole) …

2. Role in diagnosis

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Tomasson et al. Rheumatology 2012; 51: 100-109

3. Role in follow-up ANCA titer ~ clinical relaps

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Verstockt et al. Clin Exp Rheum 2015; 33: S72-S76

3. Role in follow-up ANCA titer ~ clinical relaps

Kemna et al. J Am Soc Nephrol 2015; 26: 537-542

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3. Role in follow-up

For ANCA positive patients at diagnosis of AAV: • Serial ANCA measurement in AAV patients without renal involvement: limited value

• In patients with renal involvement: clinical relapse is unlikely without rise in ANCA level a rise in ANCA level should warn the clinician for relapse

ANCA titer ~ clinical relaps

Kemna et al. J Am Soc Nephrol 2015; 26: 537-542

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1999/2003 International consensus statement on testing and reporting ANCA

Gating policy

- Glomerulonephritis, especially RPGN - Pulmonary hemorrhage, especially pulmonary renal syndrome - Cutaneous vasculitis with systemic features - Multiple lung nodules - Chronic destructive disease of the upper airways - Long-standing sinusitis or otitis - Subglottic tracheal stenosis - Mononeuritis multiplex or other peripheral neuropathy - Retro-orbital mass

*

* When there is no other obvious cause

Clinical manifestations suggestive of AAV

4. Laboratory diagnosis

Savige et al. Am J Clin Pathol 1999; 111: 507-13; Arnold et al. J Clin Pathol 2010; 63: 678-680

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1999/2003 International consensus statement on testing and reporting ANCA

Clinical manifestations suggestive of AAV

4. Laboratory diagnosis

IIF ANCA= screening assay PPV IIF ANCA non selected population < 5% PPV IIF ANCA correct clinical context > 90%

Savige et al. Am J Clin Pathol 1999; 111: 507-13 ; Savige et al. Am J Clin Pathol 2003; 120: 312-8

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IIF ANCA

4. Laboratory diagnosis

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Nomenclature P-ANCA

Perinuclear staining, with or without nuclear extension

ethanol formol

4. Laboratory diagnosis

Savige et al. Am J Clin Pathol 1999; 111: 507-513

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Nomenclature P-ANCA

ethanol formol

4. Laboratory diagnosis

ANA interference

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Nomenclature C-ANCA

ethanol formol

Granular, cytoplasmatic fluorescence with central or interlobular accentuation

4. Laboratory diagnosis

Savige et al. Am J Clin Pathol 1999; 111: 507-513

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Nomenclature atypical ANCA

ethanol ethanol

Atypical ANCA Atypical C-ANCA

4. Laboratory diagnosis

Savige et al. Am J Clin Pathol 1999; 111: 507-513

Combination of cytoplasmic and perinuclear staining

Cytoplasmic without interlobular accentuation

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IIF ANCA

P-ANCA C-ANCA

>MPO > PR3 Atypical ANCA Cathepsine G

BPI Lactoferrin Lysozyme

Elastase …

4. Laboratory diagnosis

Savige et al. Am J Clin Pathol 1999; 111: 507-513

min. ethanol fixed min. dilution 1/20

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IIF ANCA automatisation

4. Laboratory diagnosis

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IIF ANCA automatisation

4. Laboratory diagnosis

Sensitivity ~ visual scoring systems

Csernok et al. Nat Rev Rheumatol 2014; 10: 494-501

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1999/2003 International consensus statement on testing and reporting ANCA

Savige et al. Am J Clin Pathol 1999; 111: 507-13 ; Savige et al. Am J Clin Pathol 2003; 120: 312-8

IIF ANCA= screening assay min. ethanol fixed granulocyten min. dilution 1/20

Antigen specific test: MPO/PR3 Specificity ELISA MPO + and IIF P-ANCA= 98,6% Specificity ELISA PR3 + and IIF C-ANCA= 87-99%

4. Laboratory diagnosis

Clinical manifestations suggestive of AAV

Page 33: ANCA BACK TO BASICS · Classification criteria idiopathic vasculitis . 2. Role in diagnosis • Histopathology of the lesions 1,2,3 • Size of the vessles involved 1,2,3 • Clinical

1999/2003 International consensus statement on testing and reporting ANCA

Savige et al. Am J Clin Pathol 1999; 111: 507-13 ; Savige et al. Am J Clin Pathol 2003; 120: 312-8

Antigen specific test: MPO/PR3 Specificity ELISA MPO + and IIF P-ANCA= 98,6% Specificity ELISA PR3 + and IIF C-ANCA= 87-99% = depends on ELISA test

Trevisin et al. Immunopathology 2008; 129: 42-53

4. Laboratory diagnosis

IIF ANCA= screening assay min. ethanol fixed granulocyten min. dilution 1/20

Clinical manifestations suggestive of AAV

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4. Laboratory diagnosis

Dot-blot

Line-blot

Bead-based multiplex testing

CytoBead technology

CLIA

FEIA

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Csernok et al. Nat Rev Rheumatol 2014; 10: 494-501

4. Laboratory diagnosis

1st generation 2nd generation 3rd generation

Direct ELISA Capture ELISA Anchor ELISA

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Holle et al. Clin Exp Rheumatol 2012; 30: S66-69; Csernok et al. Nat Rev Rheumatol 2014; 10: 494-501

Capture and anchor ELISAs are superior to direct ELISAs

Max. sensitivity = IIF + ELISA

Poor interassay standardization (even if expressed in IU)

4. Laboratory diagnosis

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4. Laboratory diagnosis ANCA reporting

• Minimum: ANCA IIF pattern MPO/PR3 quantification arbitrary units or IU (cut-off)

• LR: Test dependent (standardization!) Have to be determined locally

Vermeersch et al. Clin Chem 2009; 55: 1886-88

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Savige et al. Am J Clin Pathol 1999; 111: 507-13 ; Savige et al. Am J Clin Pathol 2003; 120: 312-8

4. Laboratory diagnosis

IIF ANCA= screening assay

Antigen specific test: MPO/PR3

Clinical manifestations suggestive of AAV

1999/2003 International consensus statement on testing and reporting ANCA

Histology

Necrotizing vasculitis

Pauci-immuun

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Revision necessary

5. International guidelines

• Expert opinion vs. evidence based guidelines

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Revision necessary

5. International guidelines

• Expert opinion vs. evidence based guidelines

• Test algorithm : new generation ELISA ↔ IIF

• Necessity of IIF formol

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Revision necessary

5. International guidelines

Van der Molen et al. Ned Tijdschr Klin Chem Labgeneesk 2014; 39: 19-24

Conclusions: A strategy based on screening for ANCA with ELISA or FEIA (without prior IIF) is a valuable alternative to screening with IIF and confirming with ELISA or FEIA.

Ongoing multicentre international study

Untill revision: IIF as screening assay is ‘the best we have’

Vermeersch et al. Clin Chim Acta 2008; 397: 77-81

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Revision necessary

5. International guidelines

• Expert opinion vs. evidence based guidelines

• Test algorithm : new generation ELISA ↔ IIF

• Necessity of IIF formol

• Role of new antigens (hLAMP-2)

• Reporting of LR

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ANCAs valuable serological marker for diagnosis of AAV

International ANCA standardization and evidence based revision of international guidelines is necessary

Untill revision of international guidelines: screening by IIF

For positive IIF: quantitative PR3/MPO ELISA

ANCA titer follow up: restricted use

6. Conclusion