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Nagy G, Földesi R, Csípő I, Tarr T, Szűcs G, Szántó A, Bubán T, Szekanecz Z, Papp M, Kappelmayer J, Antal-Szalmás P. A novel way to evaluate autoantibody interference in samples with mixed antinuclear antibody patterns in the HEp-2 cell based indirect immunofluorescence assay and comparison of conventional microscopic and computer-aided pattern recognition. Clin Chim Acta 2024; 553:117747. [PMID: 38154766 DOI: 10.1016/j.cca.2023.117747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND A major challenge of the HEp-2 cell-based indirect immunofluorescence (IIF) assays is the correct identification of the individual anti-nuclear antibodies (ANAs) if more than one is present in a sample. We created artificial mixes by pooling two different samples with a single autoantibody in different titers. Comparison of the expected and observed patterns and titers clarifies the interference between the two tested ANAs. METHODS Serum samples with a single homogeneous or speckled ANA pattern were serially diluted and mixed in 16 combinations, providing end-point titers of 1:5,120 to 1:80 for both patterns. These mixes were tested by a HEp-2 IIF assay and were evaluated by conventional evaluation, the EUROPattern (EPa) system and on-screen analysis. RESULTS Homogeneous pattern can alter the identification of the speckled pattern much more than vice versa, but both has an interfering effect on the other. The effect of the interfering on the tested pattern was higher if the titer of the former one was higher. The pattern recognition efficacy of conventional and the on-screen evaluation was similar and superior compared to the EPa analysis. CONCLUSIONS The application of artificial mixed samples can help the evaluation of the efficacy of manual and computer-aided ANA HEp-2 pattern recognition.
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Affiliation(s)
- Gábor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Róza Földesi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Csípő
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tünde Tarr
- Institute of Internal Medicine, Department of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gabriella Szűcs
- Institute of Internal Medicine, Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Antónia Szántó
- Institute of Internal Medicine, Department of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Bubán
- Department of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Institute of Internal Medicine, Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mária Papp
- Department of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; European Reference Network on Hepatological Diseases, ERN RARE-LIVER, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Hu WT, Nayyar A, Kaluzova M. Charting the Next Road Map for CSF Biomarkers in Alzheimer's Disease and Related Dementias. Neurotherapeutics 2023; 20:955-974. [PMID: 37378862 PMCID: PMC10457281 DOI: 10.1007/s13311-023-01370-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 06/29/2023] Open
Abstract
Clinical prediction of underlying pathologic substrates in people with Alzheimer's disease (AD) dementia or related dementia syndromes (ADRD) has limited accuracy. Etiologic biomarkers - including cerebrospinal fluid (CSF) levels of AD proteins and cerebral amyloid PET imaging - have greatly modernized disease-modifying clinical trials in AD, but their integration into medical practice has been slow. Beyond core CSF AD biomarkers (including beta-amyloid 1-42, total tau, and tau phosphorylated at threonine 181), novel biomarkers have been interrogated in single- and multi-centered studies with uneven rigor. Here, we review early expectations for ideal AD/ADRD biomarkers, assess these goals' future applicability, and propose study designs and performance thresholds for meeting these ideals with a focus on CSF biomarkers. We further propose three new characteristics: equity (oversampling of diverse populations in the design and testing of biomarkers), access (reasonable availability to 80% of people at risk for disease, along with pre- and post-biomarker processes), and reliability (thorough evaluation of pre-analytical and analytical factors influencing measurements and performance). Finally, we urge biomarker scientists to balance the desire and evidence for a biomarker to reflect its namesake function, indulge data- as well as theory-driven associations, re-visit the subset of rigorously measured CSF biomarkers in large datasets (such as Alzheimer's disease neuroimaging initiative), and resist the temptation to favor ease over fail-safe in the development phase. This shift from discovery to application, and from suspended disbelief to cogent ingenuity, should allow the AD/ADRD biomarker field to live up to its billing during the next phase of neurodegenerative disease research.
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Affiliation(s)
- William T Hu
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA.
- Center for Innovation in Health and Aging Research, Institute for Health, Health Care Policy, and Aging Research, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA.
| | - Ashima Nayyar
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
| | - Milota Kaluzova
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
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3
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Vercammen M, Bonroy C, Broeders S, Chan EKL, Bizzaro N, Bogdanos DP, Andrade L, Coucke W, de Melo Cruvinel W, Kozmar A, Kuhi L, Lutteri L, Rego de Sousa MJ, Schouwers S, Van Hoovels L, Bossuyt X. Analytical aspects of the antinuclear antibody test by HEp-2 indirect immunofluorescence: EFLM report on an international survey. Clin Chem Lab Med 2023; 61:1199-1208. [PMID: 36989428 DOI: 10.1515/cclm-2023-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Detection of antinuclear antibodies (ANA) by indirect immunofluorescence assay using HEp-2 cells (HEp-2 IFA) is used to screen for various autoimmune diseases. HEp-2 IFA suffers from variability, which hampers harmonization. METHODS A questionnaire was developed to collect information on HEp-2 IFA methodology, computer-assisted diagnosis (CAD) systems, training, inter-observer variability, quality assessment, reagent lot change control, and method verification. The questionnaire was distributed to laboratories by Sciensano (Belgium), national EASI groups (Italy, Croatia, Portugal, Estonia, Greece) and ICAP (worldwide). Answers were obtained by 414 laboratories. The results were analysed in the framework of the recent EFLM/EASI/ICAP ANA recommendations (companion paper). RESULTS Laboratories used either HEp-2, HEp-2000, or HEp-20-10 cells and most laboratories (80%) applied the same screening dilution for children and adults. The conjugate used varied between laboratories [IgG-specific (in 57% of laboratories) vs. polyvalent]. Sixty-nine percent of CAD users reviewed the automatic nuclear pattern and 53% of CAD users did not fully exploit the fluorescence intensity for quality assurance. Internal quality control was performed by 96% of the laboratories, in 52% of the laboratories only with strongly positive samples. Interobserver variation was controlled by 79% of the laboratories. Limited lot-to-lot evaluation was performed by 68% of the laboratories. Method verification was done by 80% of the respondents. CONCLUSIONS Even though many laboratories embrace high-quality HEp-2 IFA, substantial differences in how HEp-2 IFA is performed and controlled remain. Acting according to the EFLM/EASI/ICAP ANA recommendations can improve the global performance and quality of HEp-2 IFA and nurture harmonization.
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Affiliation(s)
- Martine Vercammen
- Department of Laboratory Medicine, AZ St-Jan Hospital Bruges-Ostend, Bruges, Belgium
- Reproductive Immunology and Transplantation, Vrije Universiteit Brussel, Brussels, Belgium
| | - Carolien Bonroy
- Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | | | - Edward K L Chan
- Department of Oral Biology, University of Florida, Gainesville, FL, USA
| | - Nicola Bizzaro
- Laboratory of Clinical Pathology, Azienda Sanitaria Universitaria Integrata di Udine, Tolmezzo, Italy
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Volos, Greece
- University General Hospital of Larissa, Larissa, Greece
| | - Luis Andrade
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
- Immunology Division, Fleury Medicine and Health Laboratories, Sao Paulo, Brazil
| | - Wim Coucke
- Sciensano, Quality of Laboratories, Brussels, Belgium
| | | | - Ana Kozmar
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Liisa Kuhi
- Central Laboratory, East Tallinn Central Hospital, Tallinn, Estonia
| | - Laurence Lutteri
- Department of Clinical Chemistry, CHU Sart-Tilman, Liège, Belgium
| | | | - Sofie Schouwers
- Department of Laboratory Medicine, GZA Hospital, Antwerp, Belgium
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital Aalst, Aalst, Belgium
- Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine, UZ Leuven, Leuven, Belgium
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4
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Bonroy C, Vercammen M, Fierz W, Andrade LEC, Van Hoovels L, Infantino M, Fritzler MJ, Bogdanos D, Kozmar A, Nespola B, Broeders S, Patel D, Herold M, Zheng B, Chan EYT, Uibo R, Haapala AM, Musset L, Sack U, Nagy G, Sundic T, Fischer K, Rego de Sousa MJ, Vargas ML, Eriksson C, Heijnen I, García-De La Torre I, Carballo OG, Satoh M, Kim KH, Chan EKL, Damoiseaux J, Lopez-Hoyos M, Bossuyt X. Detection of antinuclear antibodies: recommendations from EFLM, EASI and ICAP. Clin Chem Lab Med 2023; 61:1167-1198. [PMID: 36989417 DOI: 10.1515/cclm-2023-0209] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Antinuclear antibodies (ANA) are important for the diagnosis of various autoimmune diseases. ANA are usually detected by indirect immunofluorescence assay (IFA) using HEp-2 cells (HEp-2 IFA). There are many variables influencing HEp-2 IFA results, such as subjective visual reading, serum screening dilution, substrate manufacturing, microscope components and conjugate. Newer developments on ANA testing that offer novel features adopted by some clinical laboratories include automated computer-assisted diagnosis (CAD) systems and solid phase assays (SPA). METHODS A group of experts reviewed current literature and established recommendations on methodological aspects of ANA testing. This process was supported by a two round Delphi exercise. International expert groups that participated in this initiative included (i) the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group "Autoimmunity Testing"; (ii) the European Autoimmune Standardization Initiative (EASI); and (iii) the International Consensus on ANA Patterns (ICAP). RESULTS In total, 35 recommendations/statements related to (i) ANA testing and reporting by HEp-2 IFA; (ii) HEp-2 IFA methodological aspects including substrate/conjugate selection and the application of CAD systems; (iii) quality assurance; (iv) HEp-2 IFA validation/verification approaches and (v) SPA were formulated. Globally, 95% of all submitted scores in the final Delphi round were above 6 (moderately agree, agree or strongly agree) and 85% above 7 (agree and strongly agree), indicating strong international support for the proposed recommendations. CONCLUSIONS These recommendations are an important step to achieve high quality ANA testing.
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Affiliation(s)
- Carolien Bonroy
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Martine Vercammen
- Department of Laboratory Medicine, AZ Sint-Jan, Brugge, Belgium
- Research Group REIM, Vrije Universiteit Brussel, Brussels, Belgium
| | - Walter Fierz
- Schweizerischer Verband der Diagnostikindustrie (SVDI-ASID), Bern, Switzerland
| | - Luis E C Andrade
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
- Immunology Division, Fleury Medicine and Health Laboratories, Sao Paulo, Brazil
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Maria Infantino
- Immunology and Allergology Laboratory, S. Giovanni di Dio Hospital, Florence, Italy
| | - Marvin J Fritzler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dimitrios Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University General Hospital of Larissa, Larissa, Greece
| | - Ana Kozmar
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Benoit Nespola
- Laboratory of Immunology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Dina Patel
- UK NEQAS Immunology, Immunochemistry & Allergy, Sheffield Teaching Hospitals, Sheffield, UK
| | - Manfred Herold
- Department of Internal Medicine II, Rheumatology Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - Bing Zheng
- Department of Laboratory Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Eric Y T Chan
- Department of Pathology, Queen Mary Hospital, Hong Kong, P.R. China
| | - Raivo Uibo
- Department of Immunology, Medical Faculty, University of Tartu, Tartu, Estonia
| | | | - Lucile Musset
- Department of Immunology, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Ulrich Sack
- Medical Faculty, Leipzig University, Leipzig, Germany
| | - Gabor Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tatjana Sundic
- Department of Immunology and Transfusion Medicine, Haugesund Hospital, Helse Fonna, Haugesund, Norway
| | - Katarzyna Fischer
- Individual Laboratory for Rheumatologic Diagnostics, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Maria-José Rego de Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | | | - Catharina Eriksson
- Department of Clinical Microbiology Section of Infection and Immunology, Umeå University, Umeå, Sweden
| | - Ingmar Heijnen
- Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Ignacio García-De La Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente, Universidad de Guadalajara, Guadalajara, Mexico
| | - Orlando Gabriel Carballo
- Laboratory of Immunology, Hospital Carlos G. Durand, Buenos Aires, Argentina
- Department of Microbiology and Immunology, Instituto Universitario, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Minoru Satoh
- Department of Human, Information and Life Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
- Department of Medicine, Kitakyushu Yahata-Higashi Hospital, Kitakyushu, Japan
| | - Kyeong-Hee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Edward K L Chan
- Department of Oral Biology, University of Florida, Gainesville, FL, USA
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcos Lopez-Hoyos
- Immunology Service, University Hospital Marques de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Xavier Bossuyt
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
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5
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Cinquanta L, Bizzaro N, Pesce G. Standardization and Quality Assessment Under the Perspective of Automated Computer-Assisted HEp-2 Immunofluorescence Assay Systems. Front Immunol 2021; 12:638863. [PMID: 33717188 PMCID: PMC7947926 DOI: 10.3389/fimmu.2021.638863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022] Open
Abstract
The recent availability of automated computer-assisted diagnosis (CAD) systems for the reading and interpretation of the anti-nuclear antibody (ANA) test performed with the indirect immunofluorescence (IIF) method on HEp-2 cells, has improved the reproducibility of the results and initiated a process of harmonization of this test. Furthermore, CAD systems provide quantitative expression of fluorescence intensity, allowing the introduction of objective quality control procedures to the monitoring of the entire process. The calibration of the reading systems and the automated image interpretation are essential prerequisites for obtaining reproducible and harmonized IIF test results and form the basis for standardization, regardless of the computer algorithms used in the different systems. The use of automated CAD systems, facilitating control procedures, represents a step forward for the quality certification of the laboratory.
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Affiliation(s)
- Luigi Cinquanta
- Laboratorio di Patologia Clinica, IRCCS S.D.N., Napoli, Italy
| | - Nicola Bizzaro
- Laboratorio di Patologia Clinica, Ospedale San Antonio, Tolmezzo-Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Giampaola Pesce
- Laboratorio Diagnostico di Autoimmunologia, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Dipartimento di Medicina Interna e Specialità Mediche (DIMI), Università Degli Studi di Genova, Genova, Italy
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6
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Van Hoovels L, Bossuyt X, Manfredi M, Grossi V, Benucci M, Van Den Bremt S, De Baere H, Franceschi D, Tosi E, Meoni M, Bizzaro N, Infantino M. Integrating quality assurance in autoimmunity: the changing face of the automated ANA IIF test. Clin Chem Lab Med 2021; 59:1247-1255. [PMID: 33594844 DOI: 10.1515/cclm-2020-1669] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/05/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Currently available computer-aided diagnosis (CAD) systems for the detection of anti-nuclear antibodies (ANA) by indirect immunofluorescence (IIF) assay enable a standardized measurement of system-specific fluorescent intensity (FI) measures. We aimed to evaluate an internal quality control (iQC) program that controls the total ANA IIF process in routine practice. METHODS In addition to the kit iQC materials, supplemental quality indicators were integrated in a total quality assurance (QA) program: patient-derived iQC's samples (negative, 1/160 fine speckled and 1/160 homogeneous), median sample FI per run and percentage of ANA IIF positive samples per run. Analytical rejection criteria were based on the imprecision of the positivity index (PI) measure of the Zenit PRO system (Menarini). Clinical rejection criteria were based on changes in FI that correspond to a change in ANA IIF titer of ≥2. To evaluate the QA program, different artificial errors were introduced during the ANA IIF process. After every run, quality indicators were evaluated and compared to the pre-set target values. RESULTS Rescanning the ANA IIF slides five times, using an old conjugate and a needle obstruction resulted in analytically and even clinically relevant errors in ANA IIF results. All errors were correctly detected by the different defined quality indicators. Traditional Westgard rules, including analytically (and clinically) defined rejection limits were useful in monitoring quality indicators. CONCLUSIONS The integration of a total process iQC program in CAD systems, based on the specific FI measurands and performance criteria of the system, adds value to QA.
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Affiliation(s)
- Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital, Aalst, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Xavier Bossuyt
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
| | - Mariangela Manfredi
- Immunology and Allergy Laboratory Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Valentina Grossi
- Immunology and Allergy Laboratory Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | | | | | | | | | | | - Nicola Bizzaro
- Laboratorio di Patologia Clinica, Ospedale San Antonio, Tolmezzo, Italy
| | - Maria Infantino
- Immunology and Allergy Laboratory Unit, San Giovanni di Dio Hospital, Florence, Italy
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7
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Choi HW, Kwon YJ, Park JH, Lee SY, Chun S, Won EJ, Lee JH, Choi HJ, Kim SH, Shin MG, Shin JH, Kee SJ. Evaluation of a Fully Automated Antinuclear Antibody Indirect Immunofluorescence Assay in Routine Use. Front Immunol 2020; 11:607541. [PMID: 33343581 PMCID: PMC7746920 DOI: 10.3389/fimmu.2020.607541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
Indirect immunofluorescence assay (IFA) using HEp-2 cells as a substrate is the gold standard for detecting antinuclear antibodies (ANA) in patient serum. However, the ANA IFA has labor-intensive nature of the procedure and lacks adequate standardization. To overcome these drawbacks, the automation has been developed and implemented to the clinical laboratory. The purposes of this study were to evaluate the analytical performance of a fully automated Helios ANA IFA analyzer in a real-life laboratory setting, and to compare the time and the cost of ANA IFA testing before and after adopting the Helios system. A total of 3,276 consecutive serum samples were analyzed for ANA using the Helios system from May to August 2019. The positive/negative results, staining patterns, and endpoint titers were compared between Helios and visual readings. Furthermore, the turnaround time and the number of wells used were compared before and after the introduction of Helios system. Of the 3,276 samples tested, 748 were positive and 2,528 were negative based on visual readings. Using visual reading as the reference standard, the overall relative sensitivity, relative specificity, and concordance of Helios reading were 73.3, 99.4, and 93.4% (κ = 0.80), respectively. For pattern recognition, the overall agreement was 70.1% (298/425) for single patterns, and 72.4% (89/123) for mixed patterns. For titration, there was an agreement of 75.9% (211/278) between automated and classical endpoint titers by regarding within ± one titer difference as acceptable. Helios significantly shortened the median turnaround time from 100.6 to 55.7 h (P < 0.0001). Furthermore, routine use of the system reduced the average number of wells used per test from 4 to 1.5. Helios shows good agreement in distinguishing between positive and negative results. However, it still has limitations in positive/negative discrimination, pattern recognition, and endpoint titer prediction, requiring additional validation of results by human observers. Helios provides significant advantages in routine laboratory ANA IFA work in terms of labor, time, and cost savings. We hope that upgrading and developing softwares with more reliable capabilities will allow automated ANA IFA analyzers to be fully integrated into the routine operations of the clinical laboratory.
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Affiliation(s)
- Hyun-Woo Choi
- Department of Laboratory Medicine, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Yong Jun Kwon
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Ju-Heon Park
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - Seung-Yeob Lee
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Sejong Chun
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea.,Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Eun Jeong Won
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea.,Department of Parasitology and Tropical Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Jun Hyung Lee
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - Hyun-Jung Choi
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea.,Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Soo Hyun Kim
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea.,Department of Microbiology, Chonnam National University Medical School, Gwangju, South Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, South Korea.,Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Jong-Hee Shin
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea.,Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea.,Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
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8
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Naides SJ, Genzen JR, Abel G, Bashleben C, Ansari MQ. Antinuclear Antibodies Testing Method Variability: A Survey of Participants in the College of American Pathologists' Proficiency Testing Program. J Rheumatol 2020; 47:1768-1773. [PMID: 32173652 DOI: 10.3899/jrheum.190933] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was conducted to determine the spectrum of laboratory practices in antinuclear antibody (ANA) test target, performance, and result reporting. METHODS A questionnaire on ANA testing was distributed by the Diagnostic Immunology and Flow Cytometry Committee of the College of American Pathologists (CAP) to laboratories participating in the 2016 CAP ANA proficiency survey. RESULTS Of 5847 survey kits distributed, 1206 (21%) responded. ANA screening method varied: 55% indirect immunofluorescence assay, 21% ELISA, 12% multibead immunoassay, and 18% other methods. The name of the test indicated the method used in only 32% of laboratories; only 39% stated the method used on the report. Of 644 laboratories, 80% used HEp-2 cell substrate, 18% HEp-2000 (HEp-2 cell line engineered to overexpress SSA antigen, Ro60), and 2% other. Slides were prepared manually (67%) or on an automated platform (33%) and examined by direct microscopy (84%) or images captured by an automated platform (16%). Only 50% reported a positive result at the customary 1:40 dilution. Titer was reported to endpoint routinely by 43%, only upon request by 23%, or never by 35%. Of the laboratories, 8% did not report dual patterns. Of those reporting multiple patterns, 23% did not report a titer with each pattern. CONCLUSION ANA methodology and practice, and test naming and reporting varies significantly between laboratories. Lack of uniformity in testing and reporting practice and lack of transparency in communicating the testing method may misdirect clinicians in their management of patients.
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Affiliation(s)
- Stanley J Naides
- S.J. Naides, MD, Scientific Affairs, Euroimmun US, a PerkinElmer company, Mountain Lakes, New Jersey, and Diagnostic Immunology and Flow Cytometry Committee, College of American Pathologists, Northfield, Illinois;
| | - Jonathan R Genzen
- J.R. Genzen, MD, PhD, Diagnostic Immunology and Flow Cytometry Committee, College of American Pathologists, Northfield, Illinois, and Pathology, University of Utah / ARUP Laboratories, Salt Lake City, Utah
| | - Gyorgy Abel
- G. Abel, MD, PhD, Diagnostic Immunology and Flow Cytometry Committee, College of American Pathologists, Northfield, Illinois, and Laboratory Medicine and Pathology, Lahey Hospital & Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts
| | - Christine Bashleben
- C. Bashleben, MT, Diagnostic Immunology and Flow Cytometry Committee, College of American Pathologists, Northfield, Illinois
| | - M Qasim Ansari
- M.Q. Ansari, MD, Diagnostic Immunology and Flow Cytometry Committee, College of American Pathologists, Northfield, Illinois, and Pathology and Laboratory Medicine, Louis Stokes VAMC, Cleveland, Ohio, USA
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9
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Challenges and Advances in SLE Autoantibody Detection and Interpretation. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00122-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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10
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Bogaert L, Van den Bremt S, Schouwers S, Bossuyt X, Van Hoovels L. Harmonizing by reducing inter-run variability: performance evaluation of a quality assurance program for antinuclear antibody detection by indirect immunofluorescence. ACTA ACUST UNITED AC 2019; 57:990-998. [DOI: 10.1515/cclm-2018-0933] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022]
Abstract
Abstract
Background
The introduction of automated anti-nuclear antibody (ANA) indirect immunofluorescence (IIF) analysis may allow for more harmonized ANA IIF reporting, provided that a thorough quality assurance program controls this process. The aim of this study was to evaluate various quality indicators used for ANA IIF analysis with the final goal of optimizing the iQC program.
Methods
In an experimental setup, we introduced artificial errors, mimicking plausible problems during routine practice on a QUANTA-Lyser-NOVA View® system (Inova Diagnostics, San Diego, CA, USA). Predetermined quality indicators were evaluated against predefined acceptance criteria. In addition, we retrospectively investigated the applicability of the selected quality indicators in the daily routine practice during three pre-defined periods.
Results
Both the experimental as the retrospective study revealed that pre-analytical, analytical and post-analytical errors were not highlighted by company internal quality control (iQC) materials. The use of patient derived iQC samples, median fluorescence intensity results per run and the percentage of positive ANA IIF results as additional quality indicators ensured a more adequate ANA IIF quality assurance. Furthermore, negative and moderate positive sample iQC materials merit clinical validation, as titer changes of >1 correspond to clinically important shifts. Traditional Westgard rules, including a clinically defined stop limit, revealed to be useful in monitoring of the supplemental quality indicators.
Conclusions
A thorough ANA IIF quality assurance for daily routine practice necessitates the addition of supplemental quality indicators in combination with well-defined acceptance criteria.
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Affiliation(s)
- Laura Bogaert
- Department of Laboratory Medicine , OLV Hospital Aalst , Aalst , Belgium
- Department of Laboratory Medicine , GZA Hospitals , Antwerp , Belgium
| | | | - Sofie Schouwers
- Department of Laboratory Medicine , GZA Hospitals , Antwerp , Belgium
| | - Xavier Bossuyt
- Department of Laboratory Medicine , University Hospital Leuven , Leuven , Belgium
- Department of Microbiology and Immunology, KU Leuven , Leuven , Belgium
| | - Lieve Van Hoovels
- Department of Laboratory Medicine , OLV Hospital Aalst , Moorselbaan 164 , 9300 Aalst , Belgium , Phone: +32 (0)53/72 42 91, Fax: +32 (0)53/72 45 88
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11
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van Beers JJBC, Hahn M, Fraune J, Mallet K, Krause C, Hormann W, Fechner K, Damoiseaux JGMC. Performance analysis of automated evaluation of antinuclear antibody indirect immunofluorescent tests in a routine setting. AUTOIMMUNITY HIGHLIGHTS 2018; 9:8. [PMID: 30238164 PMCID: PMC6147779 DOI: 10.1007/s13317-018-0108-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
Purpose Indirect immunofluorescence (IIF) on the human epithelial cell-line HEp-2 (or derivatives) serves as the gold standard in antinuclear antibody (ANA) screening. IIF, and its evaluation, is a labor-intensive method, making ANA testing a major challenge for present clinical laboratories. Nowadays, several automated ANA pattern recognition systems are on the market. In the current study, the EUROPattern Suite is evaluated for its use in daily practice in a routine setting. Methods A total of 1033 consecutive routine samples was used to screen for ANA. Results (positive/negative ANA screening, pattern identification and titer) were compared between software-generated results (EUROPattern) and visual interpretation (observer) of automatically acquired digital images. Results Considering the visual interpretation as reference, a relative sensitivity of 99.3% and a relative specificity of 88.9% were obtained for negative and positive discrimination by the software (EPa). A good agreement between visual and software-based interpretation was observed with respect to pattern recognition (mean kappa: for 7 patterns: 0.7). Interestingly, EPa software distinguished more patterns per positive sample than the observer (on average 1.5 and 1.2, respectively). Finally, a concordance of 99.3% was observed within the range of 1 titer step difference between EPa and observer. Conclusions The ANA IIF results reported by the EPa software are in very good agreement with the results reported by the observer with respect to being negative/positive, pattern recognition and titer, making automated ANA IIF evaluation an objective and time-efficient tool for routine testing. Electronic supplementary material The online version of this article (10.1007/s13317-018-0108-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joyce J B C van Beers
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Melanie Hahn
- Institute for Experimental Immunology, EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560, Lübeck, Germany
| | - Johanna Fraune
- Institute for Experimental Immunology, EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560, Lübeck, Germany
| | - Kathleen Mallet
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Christopher Krause
- Institute for Experimental Immunology, EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560, Lübeck, Germany
| | - Wymke Hormann
- Institute for Experimental Immunology, EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560, Lübeck, Germany
| | - Kai Fechner
- Institute for Experimental Immunology, EUROIMMUN Medizinische Labordiagnostika AG, Seekamp 31, 23560, Lübeck, Germany
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
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12
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Pisetsky DS, Spencer DM, Lipsky PE, Rovin BH. Response to: 'Variation in antinuclear antibody detection by automated indirect immunofluorescence analysis' by van Hoovels et al. Ann Rheum Dis 2018; 78:e49. [PMID: 29730638 DOI: 10.1136/annrheumdis-2018-213558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 11/03/2022]
Affiliation(s)
- David S Pisetsky
- Department of Medicine and Immunology, Duke University Medical Center and Medical Research Service, Veterans Administration Medical Center, Durham, North Carolina, USA
| | - Diane M Spencer
- Department of Medicine and Immunology, Duke University Medical Center and Medical Research Service, Veterans Administration Medical Center, Durham, North Carolina, USA
| | - Peter E Lipsky
- RILITE Research Institute, Charlottesville, Virginia, USA
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
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13
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Van Hoovels L, Schouwers S, Van den Bremt S, Bossuyt X. Variation in antinuclear antibody detection by automated indirect immunofluorescence analysis. Ann Rheum Dis 2018; 78:e48. [PMID: 29678938 DOI: 10.1136/annrheumdis-2018-213543] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Sofie Schouwers
- Department of Laboratory Medicine, GZA Hospital, Antwerp, Belgium
| | | | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
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14
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Recent Approaches To Optimize Laboratory Assessment of Antinuclear Antibodies. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2017; 24:CVI.00270-17. [PMID: 29021301 DOI: 10.1128/cvi.00270-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The presence of antinuclear antibodies (ANAs) is a hallmark of a number of systemic autoimmune rheumatic diseases, and testing is usually performed as part of the initial diagnostic workup when suspicion of an underlying autoimmune disorder is high. The indirect immunofluorescence antibody (IFA) technique is the preferred method for detecting ANAs, as it demonstrates binding to specific intracellular structures within the cells, resulting in a number of staining patterns that are usually categorized based on the cellular components recognized and the degree of binding, as reflected by the fluorescence intensity or titer. As a screening tool, the ANA patterns can guide confirmatory testing useful in elucidating a specific clinical diagnosis or prognosis. However, routine use of ANA IFA testing as a global screening test is hampered by its labor-intensiveness, subjectivity, and limited diagnostic specificity, among other factors. This review focuses on current efforts to standardize the nomenclature of ANA patterns and on alternative methods for ANA determination, as well as on recent advances in image-based computer algorithms to automate IFA testing in clinical laboratories.
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