Immunology AUTOANTIBODY SCREEN Screen Includes

Specific Information Laboratory Immunology Specimen type Serum Container - Standard 4.0 mL White top yellow ring Vacuette - Paediatric 2.5 mL Yellow top white ring Reduced draw - Neonates 0.8 mL Ochre top MiniCollect

Clinical information Please supply sufficient clinical information necessary for test interpretation Special If ANF is positive, sample will automatically be tested for extractable nuclear antigen considerations and antibodies (ENA) including Ro, La, Sm, RNP, Jo-1, ScL-70, Centromere antibody and limitations double-stranded DNA antibodies (ds-DNA); it is therefore sufficient to request autoantibodies only Samples positive for AMA and LKM antibodies will be automatically tested for additional liver autoantigens Titres of ANA do not correlate with disease activity; repeat assessment of ANA is not indicated in routine monitoring; if repeat assessment is required, it should not be requested in less than 3-monthly intervals as existing antibody will not be degraded. Reference ranges Normal result = Negative The frequency of low titre ANA in normal individuals increases with increasing age. Please note negative autoantibody screens are authorised automatically. Clinical significance ANA: of test Antinuclear antibodies can appear as homogenous (common in SLE), speckled (common in SLE, MCTD and other rheumatic diseases), centromere (common in Raynauds, and CREST), nucleolar (common in scleroderma), multiple nuclear dots (seen in PBC/Sjogren’s and SLE) as well as other variants mostly seen in rheumatic diseases. More specifically: Homogeneous/speckled: Indicated in the investigation of suspected “connective tissue disorders” (see also under autoantibody screen). If positive, a sample will be automatically tested for ENA and dsDNA. ANA are present in elevated titres, and usually of IgG class in >95% of untreated cases of SLE. The absence of an ANA virtually excludes this diagnosis. It is very sensitive but not very specific for SLE as ANA may also occur in a number of other conditions including all other connective tissue diseases, juvenile chronic arthritis, fibrosing alveolitis, chronic active hepatitis, viral infections particularly EBV and CMV and in drug reactions. Centromere Ab: Indicated in the investigation of unexplained Raynaud’s; positive in ~50% of patients with primary Raynauds, 60 - 70% of patients with the CREST variant of scleroderma and 20% of patients with generalised scleroderma. Nucleolar Ab: Seen primarily in patients with scleroderma where they are found in high titres and often with overlap features of myositis. This ANA specificity is less frequently encountered in systemic lupus erythematosus (SLE), chronic polyarthritis, primary Sjogren's syndrome and Raynaud's phenomenon, where they may be present, generally at low titres. Nucleolar antibodies are not uncommon in patients with non- autoimmune liver disease and other conditions. Nuclear lamins: Non-specific and may be associated with SLE autoimmune hepatitis, thrombocytopaenia and vasculitis.

Index no: QF/ND/IM/HB.005 Page 1 of 2 Version no. 1 Editor: Rebecca Haycox Date of issue: May 2017

Clinical Specialist Services Care Group

Department of Pathology - Immunology

Multiple nuclear dots: Seen in approximately 6% of Primary Biliary Cirrhosis (PBC) cases, which may be AMA negative.

AMA: High titres of AMA are found in >95% of patients with Primary Biliary Cirrhosis (PBC). AMA antibodies can be directed to a total of 9 different mitochondrial antigens (M1- M9) although in PBC AMA are directed toward the M2 antigen, now known to be the enzyme pyruvate dehydrogenase. Low titres of AMA may also be found in chronic active hepatitis. There is an association of PBC with other autoimmune diseases particularly Sjogren’s Syndrome, CREST and Systemic Sclerosis. All AMA positive samples will be automatically assessed for M2 confirmation

SMA: Higher titres are found in patients with chronic active hepatitis both viral and autoimmune. Lower titers can also be seen in PBC or infections. Autoimmune hepatitis (AIH) type 1 is characterised by antibodies ANA and SMA, AIH type 2 by liver-kidney microsomal (LKM) antibody and AIH type 3 by soluble liver antigen (SLA) and liver-pancreas antibody (LP). Type 2 is usually seen in children and has a more severe course.

GPC: Present in 95% of patients with pernicious anaemia but also occurs in immune thyroid disease, up to 30% of patients with iron deficiency anaemia and 3% of the normal population (the incidence rising with increasing age). Positive sera should be tested for vitamin B12 levels

LKM: Identifies a sub-group of patients with autoimmune chronic active hepatitis (CAH type 2). This is the most common form of CAH in childhood and has a poor prognosis. There is no known association with infection. Availability of testing Routine in-house Turnaround time Up to 6 days

General Information Optimal time and Collect using aseptic technique method of collection Volume / quantity Minimum 1 mL or one full neonatal container requirements Transportation Please see “Safe Working Practice for Courier/Taxi Drivers Carrying Pathological Specimens” (SF/PA/GP/004) and “Use and Maintenance of the Pneumatic Air Tube System (PTS)” (LP/PA/GR/021) Storage Specimens that cannot be transported or processed immediately should be refrigerated (2-8°C). Consent information The trust consent policy requires that the patient has been informed of the possible use of their specimens by the pathology laboratories for quality control, education or research as part of the quality management system. If the patient declines use other than for the tests specifically requested, please indicate by marking the box provided on the front of the request form. Information for Please see NHS Choices website patients

Index no: QF/ND/IM/HB.005 Page 2 of 2 Version no. 1 Editor: Rebecca Haycox Date of issue: May 2017