风湿免疫科ANCA指标解读,别看它“冷门”,却很有价值

2022-04-10 木木 MedSci原创

不容错过的风湿免疫科指标解读:ANCA阳性的临床意义。

什么是ANCA?  

1882年,由DAVIES等最早由在6例原发性局灶节段坏死性肾小球肾炎患者的血清中检测到抗中性粒细胞胞浆抗体(ANCA)。

1985年,VAN DER WOUDE发现韦格纳肉芽肿(WG)患者血清中存在ANCA并认定其为WG的特异性血清学诊断标志物,此时ANCA的重要临床作用才得到认识。

ANC是以中性粒细胞单核细胞中的初级颗粒为靶抗原的自身抗体,是抗中性粒细胞胞浆抗体相关性血管炎(AAV)的血清学标志物之一。此外,在类风湿关节炎(rheumatoid arthritis,RA)、系统性红斑狼疮(systemic lupus erythematosus,SLE)等许多结缔组织疾病患者血清中均能检测出ANCA。

如何检测ANCA  

目前,ANCA的检测主要有两种方法,分别是

●间接免疫荧光法(IIF),使用乙醇固定的血沉棕黄层白细胞

●酶联免疫吸附试验(ELISA),使用纯化的特异性抗原

在这两种技术中,免疫荧光法更灵敏,可以区分C-ANCA与P-ANCA,而 ELISA 更特异,可见检测PR3和MPO抗体。因此,有条件的话,最好同时选择这两种方法检测ANCA。

在ANCA的间接免疫荧光试验中,当 ANCA 相关性血管炎患者的血清与乙醇固定的人中性粒细胞一起孵育时有两种荧光模式,分别是:

●C-ANCA 模式–——对于细胞质 ANCA (C-ANCA) 模式,染色弥漫在整个细胞质中。在大多数情况下,针对 PR3 的抗体会导致这种模式,但也有可能是 MPO-ANCA 。

 

图片

C-ANCA:细胞质中有重度染色,而多叶核(透明区)无反应。这些抗体通常针对蛋白酶 3 (PR3),大多数患者患有肉芽肿性多血管炎 (GPA)

●P-ANCA 模式——核周 ANCA (P-ANCA) 模式是由细胞核周围的染色模式产生的,它代表弱乙醇固定的伪影。随着中性粒细胞底物的乙醇固定,带正电荷的颗粒成分在带负电荷的核膜周围重新排列,导致核周荧光 。在患有血管炎的患者中,导致这种模式的抗体通常针对 MPO(仅偶尔针对 PR3)。

 

图片

P-ANCA:染色仅限于核周区域,细胞质无反应。在血管炎患者中,抗体通常针对髓过氧化物酶 (MPO)。然而,针对许多其他抗原(包括乳铁蛋白和弹性蛋白酶)的自身抗体也可以看到 P-ANCA 模式。非 MPO P-ANCA 可见于多种非血管炎性疾病。

ANCA阳性的意义

 

图片

另外,单独存在ANCA(+),无临床症状的患者也有可能是假阳性,建议患者过段时间更换医院进行复查。

总结  

ANCA是风湿免疫科疾病筛查的重要指标之一,临床医生可以根据患者的临床症状再结合ANCA的指标做出更为准确的诊断。需注意,ANCA阳性不一定就是自身免疫疾病,也有可能是由药物、感染甚至是假阳性引起的,临床医生应该辨证的看这一指标。

参考文献:

[1]瞿转,王惠明.抗中性粒细胞胞浆抗体相关性肾小球肾炎生物标志物研究进展[J].中华实用诊断与治疗杂志,2021,35(07):739-742.DOI:10.13507/j.issn.1674-3474.2021.07.022.

[2]谭立明,焦安君,冯晓晶,徐镠粤,谭福燕,何思齐,罗姮,陈娟娟,蒋永清,李华.抗中性粒细胞胞浆抗体检测对系统性血管炎的临床价值[J].检验医学,2018,33(02):101-105.

[3]刘霞,胡伟新.抗中性粒细胞胞浆抗体相关性血管炎的临床研究进展[J].医学研究生学报,2016,29(03):323-326.DOI:10.16571/j.cnki.1008-8199.2016.03.022.

[4]uptidate:Clinical spectrum of antineutrophil cytoplasmic autoantibodies

 

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