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This technique is most frequently used for detection of antinuclear antibody (ANA) Frozen sections of mouse liver or other substrates are cut and placed on glass slides or, alternatively, monolayers of cultured cell lines may be used A patient s serum is placed over the sections and incubated Fluorescein-conjugated rabbit anti-human immunoglobulin is then applied and washed ANA specifically binds to the nucleus, and the fluorescein conjugate binds to the human antibody Fluorescence of the cell nucleus on microscopy indicates a positive test
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Specific antigen, unknown serum, and complement are combined Sheep red blood cells coated with anti-sheep cell antibody are added for 30 minutes at 37 C If antigenspecific antibody is present in the patient s serum, complement is bound and consumed, preventing lysis of sheep red cells
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Organ transplants are in widespread use Limitations include the scarcity of donor organs and expense Failure to achieve successful grafts is primarily due to histoincom-
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Table 19 2 Autoantibodies: Associations with connective tissue diseases
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Primary Disease Association (Sensitivity, Specificity) CREST (70 90%, high)
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Suspected Disease State CREST syndrome
Test Anticentromere antibody
Other Disease Associations Scleroderma (10 15%), Raynaud s disease (10 30%) Rheumatoid arthritis (30 50%), discoid lupus, scleroderma (60%), drug-induced lupus (100%), Sj gren s syndrome (80%), miscellaneous inflammatory disorders Lupus nephritis, rarely rheumatoid arthritis, other connective tissue disease, usually in low titer
Comments Predictive value of a positive test is > 95% for scleroderma or related disease (CREST, Raynaud s) Diagnosis of CREST is made clinically Often used as a screening test; a negative test virtually excludes SLE; a positive test, while nonspecific, increases posttest probability of SLE Titer does not correlate with disease activity Predictive value of a positive test is > 90% for SLE if present in high titer; a decreasing titer may correlate with worsening renal disease Titer generally correlates with disease activity SLE-specific A positive test substantially increases posttest probability of SLE Test rarely indicated
Systemic lupus erythematosus (SLE)
Antinuclear antibody (ANA)
SLE (> 95%, low)
Anti-doublestranded-DNA (anti-ds-DNA)
SLE (60 70%, high)
Anti-Smith antibody (anti-Sm) Mixed connective tissue disease (MCTD) Rheumatoid arthritis Anti-ribonucleoprotein antibody (RNP) Rheumatoid factor (RF)
SLE (30 40%, high)
Scleroderma (20 30%, low), MCTD (95 100%, low) Rheumatoid arthritis (50 90%)
SLE (30%), Sj gren s syndrome, rheumatoid arthritis (10%), discoid lupus (20 30%) Other rheumatic diseases, chronic infections, some malignancies, some healthy individuals, elderly patients
A negative test essentially excludes MCTD; a positive test in high titer, while nonspecific, increases posttest probability of MCTD Titer does not correlate with disease activity
Scleroderma Sj gren s syndrome
Anti-Scl-70 antibody Anti-SS-A/Ro antibody
Scleroderma (15 20%, low) Sj gren s (60 70%, low) SLE (30 40%), rheumatoid arthritis (10%), subacute cutaneous lupus, vasculitis
Predictive value of a positive test is > 95% for scleroderma Useful in counseling women of child-bearing age with known connective tissue disease, since a positive test is associated with a small but real risk of neonatal SLE and congenital heart block Ability of this assay to reflect disease activity remains unclear
Wegener s granulomatosis
Antineutrophil cytoplasmic antibody (ANCA)
Wegener s granulomatosis (systemic necrotizing vasculitis) (56 96%, high)
Crescentic glomerulonephritis or other systemic vasculitis (eg, polyarteritis nodosa)
CREST, calcinosis, Raynaud s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia Data, from Harvey AM et al (editors) The Principles and Practice of Medicine, 22nd ed Appleton & Lange, 1988; White RH et al Clinical significance and interpretation of antinuclear antibodies West J Med 1987 Aug;147(2):210 3; and Tan EM Autoantibodies to nuclear antigens (ANA): their immunobiology and medicine Adv Immunol 1982;33:167 240
patibility and lack of safe and effective immunosuppressive regimens to halt rejection Avoiding transmission of infectious agents (eg, HIV, hepatitis B virus, hepatitis C virus, cytomegalovirus) from donor to recipient requires extensive pretransplant serologic testing
A Kidney Transplantation
End-stage renal disease is the indication for kidney transplantation Factors that determine outcome include antigenic disparity (ABO blood groups and major histocompatibility or HLA) between donor and recipient, the type of immunologic
response mounted by the host, and the immunosuppressive regimen used to prevent graft rejection Nonimmunologic factors that affect the risk of chronic rejection include age and race of recipient; donor age; length of time on dialysis; and coexisting hyperlipidemia, hypertension, or cytomegalovirus infection Kidneys from living related donors who are HLA-identical and also red cell ABO-matched grafts have 90% survival at 1 year; grafts from less-well matched relatives and from living unrelated donors have lower rates Antigens are matched for HLA-A, -B and -DR loci, with -DR compatibility most impor-
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