ANCA: Methods and Clinical Significance

  • Elena CsernokEmail author
  • Antonella Radice
Part of the Rare Diseases of the Immune System book series (RDIS)


Antineutrophil cytoplasmic antibodies (ANCAs) detection is a well-established diagnostic approach for patients suspected of having ANCA-associated vasculitis (AAV). Such autoantibodies may also be detected in a wide range of inflammatory and infectious diseases leading to a critical reappraisal in the diagnostic significance. ANCA-associated vasculitides are a heterogeneous group of rare syndromes characterized by necrotizing inflammation of small-/medium-sized blood vessels, which are granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA). ANCAs in these diseases are almost always directed against proteinase 3 (PR3-ANCA) and myeloperoxidase (MPO-ANCA). Most laboratories worldwide use a standard indirect immunofluorescence technique (IFT) on human neutrophils to screen for ANCA, and then confirm positive IFT results with antigen-specific immunoassays for PR3-ANCA and MPO-ANCA. New guidelines for ANCA testing have been developed based on a recent European multicenter study, and according to the revised 2017 international consensus recommendations, testing for ANCA in small-vessel vasculitis can be done by PR3-ANCA and MPO-ANCA immunoassays, without the categorical need for IFT. The clinical utility of ANCA depends on the appropriate ordering of testing (the right clinical setting) and on type of assay performed. Accurate identification of all patients with AAV and the avoidance of misdiagnosis can be achieved by the use of a “gating policy” based on clinical information given to the laboratory at the time of request. This policy limits requests for ANCA testing exclusively to clinical scenarios that may suggest a diagnosis of necrotizing vasculitis. The clinical utility of serial ANCA measurements for predicting and assessing clinical relapses is under discussion, but may be informative in subsets of patients, such as patients with renal involvement or alveolar hemorrhage and in patients treated with rituximab.

The new testing strategy for ANCA in vasculitis directly identifies the ANCA target antigen (PR3-ANCA and MPO-ANCA) and has a particular value for the AAV subclassification. Indeed, new studies have shown that AAV can be classified based on ANCA serotype, since PR3-ANCA and MPO-ANCA diseases are strongly associated with distinguishable genetic alleles and different clinical and histological features. ANCA presence and the antigen specificity also may have important value as a prognostic factor and may serve as a guide for immunosuppressive therapy.


Proteinase 3-ANCA Myeloperoxidase-ANCA Methods New recommendations Clinical significance 


  1. 1.
    Davies DJ, Moran JE, Niall JF, et al. Segmental necrotizing glomerulonephritis with antineutrophil antibody: possible arbovirus aetiology? Br Med J. 1982;285:606.CrossRefGoogle Scholar
  2. 2.
    Van der Woude FJ, Rasmussen N, Lobatto S. Autoantibodies against neutrophils and monocytes: tool for diagnosis and marker of disease activity in Wegener’s granulomatosis. Lancet. 1985;1:425–9.CrossRefGoogle Scholar
  3. 3.
    Csernok E, Lamprecht P, Gross WL. Diagnostic significance of ANCA in vasculitis. Nat Clin Pract Rheumatol. 2006;2(4):174–5.CrossRefGoogle Scholar
  4. 4.
    Kallenberg CGM. Usefulness of antineutrophil cytoplasmic autoantibodies in diagnosing and managing systemic vasculitis. Rheumatology. 2015;28(1):1–14.Google Scholar
  5. 5.
    Sinico RA, Radice A. Antineutrophil cytoplasmic antibodies (ANCA) testing: detection methods and clinical application. Clin Exp Rheumatol. 2014;32:S112.Google Scholar
  6. 6.
    Savige J, Gillis D, Benson E, et al. International consensus statement on testing and reporting of antineutrophil cytoplasmic antibodies (ANCA). Am J Clin Pathol. 1999;111:507–13.CrossRefGoogle Scholar
  7. 7.
    Savige J, Dimech W, Fritzler M, et al. Addendum to the International Consensus Statement on testing and reporting of antineutrophil cytoplasmic antibodies. Quality control guidelines, comments, and recommendations for testing in other autoimmune diseases. Am J Clin Pathol. 2003;120:312–8.CrossRefGoogle Scholar
  8. 8.
    Csernok E, Moosig F. Current and emerging techniques for ANCA detection in vasculitis. Nat Rev Rheumatol. 2014;10:494–501.CrossRefGoogle Scholar
  9. 9.
    Cohen Tervaert JW, Damoiseaux J. Antineutrophil cytoplasmic autoantibodies: how are they detected and what is their use for diagnosis, classification and follow-up? Clin Rev Allergy Immunol. 2012;43:211–9.CrossRefGoogle Scholar
  10. 10.
    Tomasson G, Grayson PC, Mahr AD, Lavalley M, Merkel PA. Value of ANCA measurements during remission to predict a relapse of ANCA-associated vasculitis - a meta-analysis. Rheumatology (Oxford). 2012;51:100–9.CrossRefGoogle Scholar
  11. 11.
    Fussner LA, Hummel AM, Schroeder DR, et al. Factors determining the clinical utility of serial measurements of ANCA targeting proteinase 3. Arthritis Rheumatol. 2016;68:1700–10.Google Scholar
  12. 12.
    Kemna MJ, Damoiseaux J, Austen J, et al. ANCA as predictor of relapse: useful in patients with renal involvement but not i9n patients with nonrenal disease. J Am Soc Nephrol. 2015;26:537–42.CrossRefGoogle Scholar
  13. 13.
    Boomsma MM, Damoiseaux FGMC, Stegeman CA, et al. Image analysis: a novel approach for the quantification of ANCA levels in patients with Wegener’s granulomatosis. J Immunol Methods. 2003;274:27–35.CrossRefGoogle Scholar
  14. 14.
    Knütter I, Hiemann R, Brumma T, et al. Automated interpretation of ANCA patterns - a new approach in the serology of ANCA-associated vasculitis. Arthritis Res Ther. 2012;14(6):R271.CrossRefGoogle Scholar
  15. 15.
    Choi HK, Liu S, Merkel PA, et al. Diagnostic performance of antineutrophil cytoplasmic antibody tests for idiopathic vasculitides: metaanalysis with a focus on antimyeloperoxidase antibodies. J Rheumatol. 2001;28:1584–90.PubMedGoogle Scholar
  16. 16.
    Radice A, Bianchi L, Sinico RA. Anti-neutrophil cytoplasmic autoantibodies: methodological aspects and clinical significance in systemic vasculitis. Autoimmun Rev. 2013;12:487–95.CrossRefGoogle Scholar
  17. 17.
    Damoiseaux J, Steller U, Buschtez M, et al. EUROPLUS ANCA BIOCHIP mosaic: PR3 and MPO antigen microdots improve the laboratory diagnostics of ANCA-associated vasculitis. J Immunol Methods. 2009;348(1-2):67–73.CrossRefGoogle Scholar
  18. 18.
    Csernok E, Damoiseaux J, Rasmussen N, et al. Evaluation of automated multi-parametric indirect immunofluorescence assays to detect anti-neutrophil cytoplasmic antibodies (ANCA) in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Autoimmun Rev. 2016;15:736–41.CrossRefGoogle Scholar
  19. 19.
    Damoiseaux J, Csernok E, Rasmussen N, et al. Detection of antineutrophil cytoplasmic antibodies (ANCAs): a multicentre European Vasculitis Study Group (EUVAS) evaluation of the value of indirect immunofluorescence (IIF) versus antigen-specific immunoassays. Ann Rheum Dis. 2017;76:647–53.CrossRefGoogle Scholar
  20. 20.
    Bossuyt X, Rasmussen N, van Paassen P, et al. A multicentre study to improve clinical interpretation of proteinase-3 and myeloperoxidase anti-neutrophil cytoplasmic antibodies. Rheumatology. 2017a;56:1533. Scholar
  21. 21.
    Bossuyt X, Cohen Tervaert JW, Arimura Y, et al. Revised 2017 international consensus on testing of ANCAs in granulomatosis with polyangiitis and microscopic polyangiitis. Nat Rev Rheumatol. 2017b;13:683. Scholar
  22. 22.
    Wiik A, Rasmussen N, Wieslander J. Methods to detect autoantibodies to neutrophilic granulocytes. Man Biol Markers Dis. 1993;A9:1–14.Google Scholar
  23. 23.
    Holle JU, Gross WL, Holl-Ulrich K, et al. Prospective long-term follow-up of patients with localised Wegener’s granulomatosis: does it occur as persistent disease stage? Ann Rheum Dis. 2010;69:1934–9.CrossRefGoogle Scholar
  24. 24.
    Sinico RA, Di Toma L, Maggiore U, et al. Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. Arthritis Rheum. 2005;52:2926.CrossRefGoogle Scholar
  25. 25.
    Mandl LA, Solomon DH, Smith EL, Lew RA, Katz JN, Shmerling RH. Using antineutrophil cytoplasmic antibody testing to diagnose vasculitis: can test-ordering guidelines improve diagnostic accuracy? Arch Intern Med. 2002;162:1509–14.Google Scholar
  26. 26.
    Sinclair D, Saas M, Stevens JM. The effect of a symptom related “gating policy” on ANCA requests in routine clinical practice. J Clin Pathol. 2004;57:131–4.CrossRefGoogle Scholar
  27. 27.
    Arnold DF, Timms A, Luqmani R, Misbah SA. Does a gating policy for ANCA overlook patients with ANCA associated vasculitis? An audit of 263 patients. J Clin Pathol. 2010;63:678–80.CrossRefGoogle Scholar
  28. 28.
    Fussner LA, Specks U. Can antineutrophil cytoplasmic antibody levels be used to inform treatment of pauci-immune vasculitis? Curr Opin Rheum. 2015;27:231–40.CrossRefGoogle Scholar
  29. 29.
    Mukhtyar C, Guillevin L, Cid MC, et al. EULAR recommendations for the management of primary small and medium vessel vasculitis. Ann Rheum Dis. 2016;68:310–7.CrossRefGoogle Scholar
  30. 30.
    Cornec D, Cornec-Le Gall E, Fervenza FC, Specks U. ANCA-associated vasculitis – clinical utility of using ANCA specificity to classify patients. Nat Rev Rheumatol. 2016;12:570–9.CrossRefGoogle Scholar
  31. 31.
    Watts R, Lane S, Hanslik T, et al. Development and validation of a consensus methodology for the classification of the ANCA-associated vasculitides and polyarteritis nodosa for epidemiological studies. Ann Rheum Dis. 2007;66:222–7.CrossRefGoogle Scholar
  32. 32.
    Ntatsaki E, Watts RA, Scott DG. Epidemiology of ANCA-associated vasculitis. Rheum Dis Clin North Am. 2010;36:447–61.CrossRefGoogle Scholar
  33. 33.
    Scott DG, Watts RA. Epidemiology and clinical features of systemic vasculitis. Clin Exp Nephrol. 2013;17:607–10.CrossRefGoogle Scholar
  34. 34.
    Lyons PA, Rayner TF, Trivedi S, et al. Genetically distinct subsets within ANCA-associated vasculitis. N Engl J Med. 2012;367:214–23.Google Scholar
  35. 35.
    Ciavatta DJ, Yang J, Preston G, et al. Epigenetic basis for aberrant up regulation of autoantigen genes in humans with ANCA vasculitis. J Clin Investig. 2010;120:3209–19.CrossRefGoogle Scholar
  36. 36.
    Franssen CF, Stegeman CA, Kallenberg CG, et al. Antiproteinase 3- and antimyeloperoxidase-associated vasculitis. Kidney Int. 2000;57:2195–206.CrossRefGoogle Scholar
  37. 37.
    Schönermarck U, Lamprecht P, Csernok E, Gross WL. Prevalence and spectrum of rheumatic diseases associated with proteinase 3-antineutrophil cytoplasmic antibodies (ANCA) and myeloperoxidase-ANCA. Rheumatology. 2001;40:178–84.CrossRefGoogle Scholar
  38. 38.
    Hauer HA, Bajema IM, van Houwelingen HC, et al. Renal histology in ANCA-associated vasculitis: differences between diagnostic and serologic subgroups. Kidney Int. 2002;61:80–9.CrossRefGoogle Scholar
  39. 39.
    Quintana LF, Peréz NS, De Sousa E, et al. ANCA serotype and histopathological classification for the prediction of renal outcome in ANCA-associated glomerulonephritis. Nephrol Dial Transplant. 2014;29:1764.CrossRefGoogle Scholar
  40. 40.
    Lionaki S, Blyth ER, Hogan SL, et al. Classification of antineutrophil cytoplasmic autoantibody vasculitides: the role of antineutrophil cytoplasmic autoantibody specificity for myeloperoxidase or proteinase 3 in disease recognition and prognosis. Arthritis Rheum. 2012;64:3452–62.CrossRefGoogle Scholar
  41. 41.
    Mahr A, Katsahian S, Varet H, et al. Revisiting the classification of clinical phenotypes of anti-neutrophil cytoplasmic antibody-associated vasculitis: a cluster analysis. Ann Rheum Dis. 2013;72:1003–10.CrossRefGoogle Scholar
  42. 42.
    Hagen EC, Daha MR, Hermans J, 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. 1998;53:743–53.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center South Tübingen-Kirchheim, Medius Klinik KirchheimAkademisches Lehrkrankenhaus der Universität TübingenKirchheim unter TeckGermany
  2. 2.Department of Microbiology and VirologySan Carlo Borromeo Hospital—ASST Santi Paolo e CarloMilanItaly

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