AccScience Publishing / ITPS / Volume 5 / Issue 2 / DOI: 10.36922/itps.v5i2.338
Cite this article
44
Download
1497
Views
Journal Browser
Volume | Year
Issue
Search
News and Announcements
View All
RESEARCH ARTICLE

Poor Adherence to Indications for Anti-neutrophil Cytoplasmic Antibody Testing in a South African Tertiary Hospital

Ramona Govender1 Bridget Hodkinson1*
Show Less
1 Division of Rheumatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
INNOSC Theranostics and Pharmacological Sciences 2022, 5(2), 15–21; https://doi.org/10.36922/itps.v5i2.338
Submitted: 26 January 2023 | Accepted: 26 June 2023 | Published: 12 July 2023
© 2023 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution -Noncommercial 4.0 International License (CC-by the license) ( https://creativecommons.org/licenses/by-nc/4.0/ )
Abstract

Appropriate use of laboratory investigations is increasingly important in resource-constrained environments. In this study, we reviewed the anti-neutrophil cytoplasmic antibody (ANCA) testing practices in a tertiary hospital in South Africa. A retrospective file review was conducted, encompassing all ANCA tests ordered over 12 months, including both inpatients and outpatients. Sociodemographic and clinical details were extracted from the patient records. All requests were assessed against the International Consensus Statement of 1999, which provides clinical guidelines for the indications for ANCA testing. Of the 945 ANCA tests requested, 790 patient records were reviewed, while 155 records were found to be missing, and 62 patients had multiple tests. Only 193 patients (24.4%) had indications for ANCA testing that met the guidelines. The most common tests done outside guideline indications were critical limb ischemia (9.6%), stroke (7.3%), uveitis (5.7%), renal impairment (4.9%), and interstitial lung disease (4.4%). Among the patients, ten (1.3%) were diagnosed with ANCA-associated vasculitis (AAV), of whom nine had renal-limited vasculitis. Twenty-six patients tested positive for ANCA without any evidence of AAV. Of these false positives, 10 (38.4%) were human immunodeficiency virus (HIV) positive, 3 (11.5%) had tuberculosis (TB), and 3 (11.5%) had other autoimmune diseases. The annual cost of ANCA tests amounted to ZAR274,046, with ZAR17,490 spent on duplicate testing and ZAR208,275 on non-indicated clinical conditions. The study revealed that ANCA testing was performed outside standard guidelines in three-quarters of requests, and duplicate testing was common, resulting in large cost implications. Chronic infections, such as HIV and TB, and autoimmune conditions accounted for half of the false-positive tests. The findings suggest that training of clinicians is likely to reduce unnecessary tests.

Keywords
Anti-neutrophil cytoplasmic antibody
ANCA-associated vasculitis
Gated testing
Funding
None.
References

[1] Savige, J.; Gillis, D.; Benson, E.; Davies, D.; Esnault, V.; Falk, R.J.; Hagen, E.C.; Jayne, D.; Jennette, J.C.; Paspaliaris, B.; Pollock, W.; Pusey, C.; Savage, C.O.; Silvestrini, R.; van der Woude, F.; Wieslander, J.; Wiik, A. International Consensus Statement on Testing and Reporting of Antineutrophil Cytoplasmic Antibodies (ANCA). Am. J. Clin. Pathol., 1999, 111(4), 507–513.

 

[2] Bossuyt, X.; Tervaert, J.W.C.; Arimura, Y.; Blockmans, D.; Flores- Suárez, L.F.; Guillevin, L.; Hellmich, B.; Jayne, D.; Jennette, J.C.; Kallenberg, C.G.M.; Moiseev, S.; Novikov, P.; Radice, A.; Savige, J.A.; Sinico, R.A.; Specks, U.; van Paassen, P.; Zhao, M.H.; Rasmussen, N.; Damoiseaux, J.; Csernok, E. Position Paper: Revised 2017 International Consensus on Testing of ANCAs in Granulomatosis with Polyangiitis and Microscopic Polyangiitis. Nat. Rev. Rheumatol., 2017, 13(11), 683–692.

 

[3] Mandla, L.A.; Solomon, D.H.; Smith, E.L.; Lew, R.A.; Katz, J.N.; Shmerling, R.H. Using Antineutrophil Cytoplasmic Antibody Testing to Diagnose Vasculitis: Can Test-ordering Guidelines Improve Diagnostic Accuracy? Arch. Intern. Med., 2002, 162(13), 1509–1514.

 

[4] Genga, E.; Oyoo, O.; Adebajo, A. Vasculitis in Africa. Curr. Rheumatol. Rep., 2018, 20(2), 4.

 

[5] Adebajo, A.O.; Charles, P.; Maini, R.N.; Hazleman, B.L. Autoantibodies in Malaria, Tuberculosis and Hepatitis B in a West African Population. Clin. Exp. Immunol., 1993, 92(1), 73–76.

 

[6] Moiseev, S. 2020 International Consensus on ANCA Testing Beyond Systemic Vasculitis. Autoimmun. Rev., 2020, 19, 102618.

 

[7] Damoiseaux, J.; Csernok, E.; Rasmussen, N.; Moosig, F.; van Paassen, P.; Baslund, B.; Vermeersch, P.; Blockmans, D.; Tervaert, J.W.C.; Bossuyt, X. 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, 647–653.

 

[8] Damoiseaux, J. ANCA Testing in Clinical Practice: From Implementation to Quality Control and Harmonization. Front. Immunol., 2021, 12, 656796.

 

[9] Robinson, P.C.; Steele, R.H. Appropriateness of Antineutrophil Cytoplasmic Antibody Testing in a Tertiary Hospital. J. Clin. Pathol., 2009, 62(8), 743–745.

 

[10] Houben, E.; Bax, WA.; van Dam, B.; Slieker, W.A.T.; Verhave, G.; Frerichs, F.C.P.; van Eijk, I.C.; Boersma, W.G.; de Kuyper, G.T.M.; Penne, E.L. Diagnosing ANCA-associated Vasculitis in ANCA Positive Patients: A Retrospective Analysis on the Role of Clinical Symptoms and the ANCA Titre. Medicine (Baltimore), 2016, 95(40), e5096.

 

[11] Arnold, D.; Timms, A.; Luqmani, R.; Misbah, S.A. Does a Gating Policy for ANCA Overlook Patients with ANCA Associated Vasculitis? An Audit of 263 Patients. J. Clin. Pathol., 2010, 63(8), 678–680.

 

[12] Tsiveriotis, K.; Tsirogianni, A.; Pipi, E.; Soufleros, K.; Papasteriades, C. Antineutrophil Cytoplasmic Antibodies Testing in a Large Cohort of Unselected Greek Patients. Autoimmune Dis., 2011, 2011, 626495.

 

[13] Phatak, S.; Aggarwal, A.; Agarwal, V.; Lawrence, A.; Misra, R. Antineutrophil Cytoplasmic Antibody (ANCA) Testing: Audit from a Clinical Immunology Laboratory. Int. J. Rheum. Dis., 2017, 20(6), 774–778.

 

[14] Chehroudi, C.; Booth, R.A.; Milman, N. Diagnostic Outcome and Indications for Testing in Patients with Positive ANCA at a Canadian Tertiary Care Centre. Rheumatol. Int., 2018, 38(4), 641–647.

 

[15] Kamar, F.B.; Hawkins, T.L.A. Antineutrophil Cytoplasmic Antibody Induction Due to Infection: A Patient with Infective Endocarditis and Chronic Hepatitis C. Can. J. Infect. Dis. Med. Microbiol., 2016, 2016, 3585860.

 

[16] Koderisch, J.; Andrassy, K.; Rasmussen, N.; Hartmann, M.; Tilgen, W. “False-positive” Anti-neutrophil Cytoplasmic Antibodies in HIV Infection. Lancet, 1990, 335(8699), 1227–1228.

 

[17] Iordache, L.; Bengoufa, D.; Taulera, O.; Rami, A.; Lascoux-Combe, C.; Day, N.; Parrinello, M.; Sellier, P.O.; Molina, J.M.; Mahr, A. Nonorgan-specific Autoantibodies in HIV-infected Patients in the HAART Era. Medicine (Baltimore), 2017, 96(10), e6230.

 

[18] Savige, J.; Pollock, W.; Trevisin, M. What do Antineutrophil Cytoplasmic Antibodies (ANCA) Tell Us? Best Pract. Res. Clin. Rheumatol., 2005, 19(2), 263–276.

 

[19] Chen, M.; Yu, F.; Wang, S.X.; Zou, W.Z.; Zhao, M.H.; Wang, H.Y. Antineutrophil Cytoplasmic Autoantibody-negative Pauci-immune Crescentic Glomerulonephritis. J. Am. Soc. Nephrol., 2007, 18(2), 599–605.

Conflict of interest
The authors declare that there are no conflicts of interest.
Share
Back to top
INNOSC Theranostics and Pharmacological Sciences, Electronic ISSN: 2705-0823 Published by AccScience Publishing