Detection of antinuclear antibodies: recommendations from EFLM, EASI and ICAP.

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.

Erythrocytapheresis compared with whole blood phlebotomy for the treatment of hereditary haemochromatosis.

BACKGROUND: Hereditary haemochromatosis may result in severe organ damage which can be prevented by therapy. We studied the possible advantages and disadvantages of erythrocytapheresis as compared with phlebotomy in patients with hereditary haemochromatosis. MATERIALS AND METHODS: In a prospective, randomised, open-label study, patients with hereditary haemochromatosis were randomised to bi-weekly apheresis or weekly whole blood phlebotomy. Primary end-points were decrease in ferritin levels and transferrin saturation. Secondary endpoints were decrease in haemoglobin levels, discomfort during the therapeutic procedure, costs and technicians' working time. RESULTS: Sixty-two patients were included. Thirty patients were randomised to apheresis and 32 to whole blood phlebotomy. Initially, ferritin levels declined more rapidly in the apheresis group, and the difference became statistically highly significant at 11 weeks; however, time to normalisation of ferritin level was equal in the two groups. We observed no significant differences in decline of transferrin saturation, haemoglobin levels or discomfort. The mean cumulative technician time consumption until the ferritin level reached 50 µg/L was longer in the apheresis group, but the difference was not statistically significant. The cumulative costs for materials until achievement of the desired ferritin levels were three-fold higher in the apheresis group. CONCLUSION: Treatment of hereditary haemochromatosis with erythrocytapheresis instead of whole blood phlebotomy results in a more rapid initial decline in ferritin levels and a reduced number of procedures per patient, but not in earlier achievement of target ferritin level. The frequency of discomfort was equally low with the two methods. The costs and, probably, technician time consumption were higher in the apheresis group.

[Autoimmune hemolytic anemia]. / Autoimmun hemolytisk anemi.

BACKGROUND: Knowledge of autoimmune hemolytic anemia is rapidly increasing, especially on pathogenesis, associated disorders and aspects of transfusion immunology. New treatment options have emerged. MATERIAL AND METHOD: This review is based on selected publications, a non-systematic search in PubMed and the authors' own research. RESULTS: Autoimmune hemolytic anemia is a heterogeneous group of diseases. The warm-antibody type is frequently associated with chronic lymphocytic leukemia or autoimmune systemic disease. Corticosteroids are still the first-line therapy and splenectomy is second-line, while rituximab has become an option in refractory disease. Blood transfusions require specific precautions such as restrictive use, extensive phenotyping of antigens and testing for alloantibodies and biological compatibility. Primary chronic cold agglutinin disease, a subgroup of cold-antibody autoimmune hemolytic anemia, is a clonal lymphoproliferative bone marrow disease. This subgroup is usually refractory to corticosteroids and patients with few clinical symptoms and slight anemia may not require drug therapy. However, in a majority, effective drugs are needed. The best documented therapy is infusions with rituximab, but new options are being tested. Immune hemolytic anemia associated with drugs occurs less frequently now than before. INTERPRETATION: Subgroups and associated or underlying disease should be identified in patients with autoimmune hemolytic anemia. The therapeutic implications of subclassification are important. Patients who have cold agglutinin disease and need therapy should be included in prospective trials.