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Understanding and interpreting antinuclear antibody tests in systemic rheumatic diseases

Nature Reviews Rheumatology volume 16, pages 715–726 (2020)Cite this article

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Abstract

Antinuclear antibodies (ANAs) are valuable laboratory markers to screen for and support the diagnosis of various rheumatic diseases (known as ANA-associated rheumatic diseases). The importance of ANA testing has been reinforced by the inclusion of ANA positivity as an entry criterion in the 2019 systemic lupus erythematosus classification criteria. In addition, specific ANAs (such as antibodies to Sm, double-stranded DNA (dsDNA), SSA/Ro60, U1RNP, topoisomerase I, centromere protein B (CENPB), RNA polymerase III and Jo1) are included in classification criteria for other rheumatic diseases. A number of techniques are available for detecting antibodies to a selection of clinically relevant antigens (such as indirect immunofluorescence and solid phase assays). In this Review, we discuss the advantages and limitations of these techniques, as well as the clinical relevance of the differences between the techniques, to provide guidance in understanding and interpreting ANA test results. Such understanding not only necessitates insight into the sensitivity and specificity of each assay, but also into the importance of the disease context and antibody level. We also highlight the value of titre-specific information (such as likelihood ratios).

Key points

  • Clinicians should be aware of the type of assay used for antinuclear antibody detection and the advantages and disadvantages of using immunofluorescence (IIF) assays and solid phase immunoassays (SPAs) for screening.

  • IIF assays can vary in performance between different laboratories, whereas the performance of fully automated assays is more consistent.

  • The performance characteristics of IIF assays and SPAs are disease-dependent; IIF assays are more sensitive than SPA for screening for systemic sclerosis (and systemic lupus erythematosus) but not Sjögren syndrome.

  • For both IIF assays and SPAs, no single cut-off has both good sensitivity and good specificity; combining IIF with SPA has the highest clinical value.

  • A dichotomous interpretation of test results overlooks important information at the antibody level; this limitation of antinuclear antibody testing can be overcome by reporting test result-specific likelihood ratios.

  • The differences among the assays are not only important considerations when screening and diagnosing patients, but also when using these assays for classifying patients (for example, for clinical trial enrolment).

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Fig. 1: Overview of methods used for ANA detection.

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Authors and Affiliations

  1. Department of Microbiology, Immunology and Transplantation, KU Leuven and Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium

    Xavier Bossuyt

  2. Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium

    Ellen De Langhe

  3. Laboratory of Tissue Homeostasis and Disease, Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium

    Ellen De Langhe

  4. Istituto Auxologico Italiano, IRCCS; Immunorheumatology Research Laboratory, Milan, Italy

    Maria Orietta Borghi & Pier Luigi Meroni

  5. Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy

    Maria Orietta Borghi

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Contributions

X.B. researched data for the article and wrote the article. P.L.M. and M.O.B. made substantial contributions to discussion of the content. E.D.L., M.O.B. and P.L.M. reviewed and edited the manuscript before submission

Corresponding author

Correspondence to Xavier Bossuyt.

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Competing interests

X.B. has been a consultant for Inova Diagnostics and Thermo-Fisher and has received lecture fees from Inova Diagnostics, Menarini and Thermo Fisher. P.L.M. has been a consultant for Inova Diagnostics and Thermo-Fisher and has received lecture fees from Inova Diagnostics, and Thermo Fisher. E.D.L. and M.O.B. declare no competing interests.

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Nature Reviews Rheumatology thanks L. Andrade, J. Damoiseaux and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Specificity

The ability of a test to correctly exclude individuals who do not have the disease; the specificity is calculated as the fraction of individuals without the disease who test negative.

Sensitivity

The ability of a test to correctly detect patients with a disease; the sensitivity of a test is calculated as the fraction of patients with the disease who test positive.

Likelihood ratio

The ratio of the probability of a particular test result for a patient with a particular disease and the probability of the same test result for an individual without the disease.

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Bossuyt, X., De Langhe, E., Borghi, M.O. et al. Understanding and interpreting antinuclear antibody tests in systemic rheumatic diseases. Nat Rev Rheumatol 16, 715–726 (2020). https://doi.org/10.1038/s41584-020-00522-w

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