Olsen et al.

Arthritis Research & Therapy (2017) 19:172

DOI 10.1186/s13075-017-1380-3

REVIEW Open Access

Emerging technologies in autoantibody

testing for rheumatic diseases
Nancy J. Olsen1*, May Y. Choi2 and Marvin J. Fritzler2

therapeutic trials, and understanding the pathogenesis

Abstract
of the SARD [4–7]. While the ANA test is generally re-
Testing for the presence of antinuclear antibodies quested as a means of confirming a diagnosis and intent
(ANAs) is a key step in the diagnosis of systemic lupus to treat a specific SARD, in a general practice setting it is
erythematosus (SLE) and other systemic autoimmune also used as an approach to case finding [8]. Although
rheumatic diseases (SARD). The standard slide-based clinicians formulate a differential diagnosis based on
indirect immunofluorescence (IIF) test is widely used, history and physical examination, practice analysis
but is limited by a relative lack of specificity for SLE shows that most readily act only after receiving confirma-
and not all SARD-ANAs are detected. Alternative tory or exclusionary laboratory test results [9, 10]. Hence, it
immunoassays that might offer enhanced diagnostic is important to have an understanding of the proper use of
and prognostic information have evolved, and some autoantibody testing and its value, as well as limitations [4].
of these have entered clinical practice. This review One of the major challenges in adopting an evidence-
summarizes the current state of ANA testing and based approach to ANA testing is the discrepancies ob-
multiplex techniques for detecting other autoantibodies, served in studies that characterize autoantibodies as
the possibility of point-of-care testing, and approaches biomarkers of disease onset and disease activity. These
for applications in early disease stages. discrepancies are due to a wide range of variables that
Keywords: Systemic autoimmune rheumatic diseases, include technical aspects of clearly defined method-
Systemic lupus erythematosus, Antinuclear antibodies, ology and assay performance, but are also due to a lack
Autoantibodies, Biomarkers, Point of care testing, of prospective or longitudinal studies, patient selection
Immunoassays bias, use of inconsistent definitions for disease activity,
variations in nomenclature of autoantibodies, frequency
of testing, and effects of therapy, which contribute to
Background conflicting results [11, 12]. It should also be noted that
Systemic autoimmune rheumatic diseases (SARD) afflict disease activity, disease severity, and the ensuing irrevers-
3–5% of the population [1] and are associated with enor- ible tissue and organ damage should be conceptually dis-
mous burdens on individuals and society due to poor tinguished, and measurement tools for these parameters
quality of life, lower productivity, and growing direct may be different [13]. Despite these potential problems in
and indirect healthcare costs [2, 3]. A hallmark of SARD interpreting ANA results, the clinician’s goal of making an
is the presence of autoantibodies directed against a early and accurate diagnosis as well as judging disease ac-
spectrum of intracellular autoantigens, in general re- tivity has made the practice of ordering autoantibodies
ferred to as antinuclear antibodies (ANAs) [4]. Often, widespread and frequent [14, 15]. For example, more than
ANAs are the only disease-specific serological markers 90% of US rheumatologists use serial anti-dsDNA auto-
for an underlying SARD and, as such, many have be- antibody titers to monitor disease activity in systemic
come part of classification criteria developed to provide lupus erythematosus (SLE) [10].
a common basis for disease prediction and prognosis, In this review, we outline the use of common and
an accurate diagnosis, disease monitoring, entry into emerging technologies that are used to detect antinu-
clear and related autoantibodies (Table 1).
* Correspondence: [email protected]
1
Penn State M.S. Hershey Medical Center, 500 University Drive, Hershey, PA
17033, USA
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 2 of 10

Table 1 Advantages of various ANA immunoassay techniques

Assay Type Low cost Rapid Automated Sensitivity Specificity Quantitative Availability Reproducibility High throughput Small sample
volume
IIF + + (++)* ++ + ++ ++ + + –
ELISA ++ ++ ++ +++ ++ ++ ++ ++ ++ +
LIA – ++ ++ ++ ++ ++ ++ + + ++
ALBIA, CIA, other ++ +++ +++ +++ ++ +++ ++ + +++ +++
bead-based arrays
Planar array ++ ++ ++ ++ ++ + – – ++ ++
Point-of-Care + +++ – + ++ + – ++ – +
*Automated antinuclear antibody (ANA)-indirect immunofluorescence (IIF), antineutrophil cytoplasmic antibody (ANCA), and Crithidia luciliae fluorescent test
(anti-dsDNA; CLIFT) used in some laboratories
ALBIA addressable laser bead immunoassays, CIA chemiluminescence immunoassay, ELISA enzyme-linked immunosorbent assay, LIA line immunoassay

Autoantibody detection Novel approaches to improving the sensitivity and spe-

Indirect immunofluorescence (IIF): including automated, cificity of the IIF ANA test include both ‘knock-in’ and
digital IIF ‘knock-out’ gene technology. In the former, to improve
Indirect immunofluorescence (IIF) for the detection of the ability to detect anti-SSA/Ro60 on HEp-2 substrates,
ANAs and other autoantibodies has been in use for Tom Gordon at Flinders University in Adelaide devel-
more than 50 years and the substrates have evolved from oped a ‘knock-in’ cell line where the corresponding Ro60
rodent organ sections to tissue culture (i.e., HEp-2) cells cDNA was transfected and overexpressed in HEp-2 cells
[4]. The IIF method has the advantages of providing a [25], an approach that led to the HEp2000 substrate
semiquantitative result, unlike the LE cell preparation (ImmunoConcepts, Sacramento, CA, USA) that is used
that it displaced, and offers insights about other poten- in some diagnostic laboratories [26]. More recently, a
tial antigen reactivities by displaying staining patterns ‘knock-out’ substrate has been developed as an approach
that provide a clue to the specific autoantibody targets to detecting antibodies to dense fine speckles (DFS70)
[16, 17]. Although diagnostic technologies have evolved antigen (discussed later) during the screening ANA IIF
from low-resolution microscopy to highly automated, test. In this substrate, ‘normal’ HEp-2 cells are admixed
robotic, and digital microscopy [4, 18], IIF remains one with HEp-2 cells that have the DFS70 gene knocked out
of the most widely used screening tests for SARD [4, 19, at a ratio of 9:1, allowing detection of DFS70 [27]. It
20]. In 2010, due to concerns about other technologies must be emphasized that this approach only detects sera
such as enzyme linked immunosorbent assays (ELISAs) with monospecific anti-DFS70 autoantibodies and still
and other diagnostic kits that were being increasingly requires wider interlaboratory validation.
used as the ANA screening test by high-throughput la-
boratories, the American College of Rheumatology en- ELISA
gaged a study group which eventually published a ELISAs used for the detection of autoantibodies in
position paper indicating that IIF on HEp-2 cells should SARD sera came into wide use in the 1980s and have be-
remain the “gold standard” for the detection of ANAs come a mainstay in many diagnostic laboratories. In this
[21]. While this might have been expected to encourage setting, they have two main uses: 1) as a quantitative
diagnostic laboratories to return to the IIF ANA test, screening test to detect a wide variety of ANAs without
there is little evidence that this has happened. Indeed, indicating the specificity of a positive test result; and 2)
when an ANA IIF on HEp-2 substrates is used as a as an approach to identifying specific autoantibody tar-
screening test for the wide spectrum of SARD, it is trou- gets. Standard available ELISA panels used for SARD
bled by both false positive and false negative results and diagnosis usually include SSA/Ro, SSB/La, Sm, Sm/RNP,
other limitations that may mislead the clinician [4, 9, Scl-70/topoisomerase I, Jo-1, anti-centromere, and anti-
22]. Despite decades of effort, standardization of the IIF cardiolipin, and others are increasingly available. ELISA
ANAs has been a challenge due to intermanufacturer results are reported as quantitative units rather than as
variations in the production of the HEp-2 substrate, serum dilutions as for IIF.
characteristics of the secondary antibody, and expertise During the last decade, different strategies have been
and subjectivity of the person(s) performing and reading utilized to develop, evaluate, and commercialize several
the slides [20, 23]. In addition, the lack of consensus on ANA screening ELISAs in an attempt to eliminate the
ANA pattern nomenclature was a major issue which is more labor-intensive and subjective ANA IIF assay
now being resolved due to the efforts of the International (reviewed in [28, 29]). The majority of these ANA screening
Consensus on ANA Patterns (ICAP) group [24]. ELISAs make use of blends of purified proteins derived
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 3 of 10

from native sources (i.e., cells or tissues) and/or synthetic, Hence, it is important to be aware of the performance
recombinant technologies [30]. The composition of these characteristics of the specific ALBIA/CIA kits used by
preparations is as diverse as the various manufacturers pro- diagnostic laboratories. A study comparing ALBIA, ANA
ducing them but, in general, they contain many of the key IIF and different ELISA assays for the detection of ANA
target autoantigens associated with SARD. Despite remark- found that 7.4% of healthy donors had a positive test and,
able progress, they are attended by technical challenges of those, the majority had a speckled IIF staining pattern
of combining different autoantigens in a single assay, [41], raising the question whether these ‘false positive’
and reactivity to some SARD-related autoantibody targets ANAs detected by IIF might represent autoantibodies
can be missed even if the autoantigens are contained in to DFS70, a marker that has been shown to be more
the mixtures [31]. This is probably due to differences in common in healthy or nonSARD patients than in SARD
physicochemical properties of individual autoantigens and patients [44, 45]. A recent study of a large international in-
it is suspected that some antigens also bind to other tar- ception SLE cohort confirmed that isolated anti-DFS70
gets in the same mixture, resulting in a masking effect that antibodies using CIAs are rare in SLE (1.1%) [46]. There-
may lead to poor autoantibody binding. Although ELISAs fore, this antibody may be helpful in distinguishing ANA-
that are widely used to detect individual autoantibodies positive individuals and SLE. Of note, the DFS70 nomencla-
generally perform much better than ELISAs that use anti- ture, also termed lens epithelium-derived growth factor
gen mixtures, some limitations of autoantibody binding to (LEDGF), refers to the IIF staining pattern characterized by
exposed epitopes on the autoantigens that are absorbed to uniformly distributed fine speckles throughout the inter-
the plastic microtiter plates are observed in those assays phase nucleus and on metaphase chromatin along with the
as well. autoantigen target having a molecular mass of 70 kDa in
immunoblots [47]. Although anti-DFS antibodies were
Line immunoassays first reported in interstitial cystitis and were later found to
Line immunoassays (LIAs) are considered a variation of be associated with a number of other conditions, includ-
immunoblots and dot-blots [4]. A wide assortment of ing atopic dermatitis, the current consensus is that they
LIAs are commercially available and they are typically rarely occur in isolation in SLE, systemic sclerosis, Sjög-
used to identify not just ANAs, but also other autoanti- ren’s syndrome, and mixed connective tissue diseases [44].
bodies [4, 32, 33]. In some settings, LIAs also have been
used to screen for disease-specific autoantibodies that Multiplexed autoantibody arrays
are seen in SARD, paraneoplastic, and autoimmune liver Planar arrays
diseases, and one standard kit includes 15 different SLE is characterized by humoral autoimmunity and over
SARD-related autoantibody specificities [4, 33]. One 180 distinct autoantibodies have been associated with
limitation of LIAs is that they are not as adaptable to the disease [48]. This means that usual laboratory panels
high-volume and high-throughput laboratories, although of ANA-related autoantibodies, designed to detect 10 to
components of the technology have been automated 15 different types, provide a view of less than 10% of the
making them more suitable in these settings. The reactiv- autoreactivity that may be present in a patient. SLE is
ity of autoantibodies to specific LIA targets can be quanti- therefore an ideal disease for diagnostic approaches using
tated by densitometry. Despite their ease of use, LIAs have planar arrays that detect hundreds or more different
other drawbacks, including the lack of sensitivity and autoantibodies.
specificity for certain autoantibodies [32, 33]. Most of these techniques involve robotic spotting of
purified autoantigen proteins or selected oligonucleotides
Addressable laser bead immunoassays on glass slides, although other support matrices have also
Addressable laser bead immunoassays (ALBIAs) were in- been used. Investigators at Stanford University first re-
troduced approximately 15 years ago as a rapid, eco- ported, about 15 years ago, studies using an array consist-
nomical, quantitative, and reliable technology to detect ing of 196 molecules corresponding to major autoantigens
autoantibodies directed to a range of target autoantigens associated with human diseases [49]. Autoantibodies in
in SARD sera (reviewed in [34]). Multiplexed bead-based human serum that recognize these targets are quantita-
technologies have been adopted by several diagnostic kit tively detected by a secondary fluorescent antibody, and
manufacturers based on two main technology platforms, results show greater sensitivity than those obtained using
Luminex and BioFlash chemiluminescence immunoassay standard ELISAs. In a more recent iteration, these investi-
(CIA) [34–38]. Similar to ELISA and LIA kits, ALBIA/ gators have developed a protein microarray with other
CIAs are used for the detection of autoantibodies to a components that are capable of detecting antibodies to
variety of autoantigens, [39–43] and the number and soluble mediators including cytokines [50].
characteristics of autoantigens employed in ALBIA/CIAs A similar type of array was developed by Zhu, Li and
and their performance vary between kit manufacturers. colleagues at the University of Texas Southwestern,
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 4 of 10

using known autoantigens for various human diseases healthy controls. Serendipitously, one healthy control
[51]. Detection of autoantibodies in different classes was in this study, who initially classified within the SLE
shown to be correlated with some types of SLE-related con- domain, subsequently developed an illness that was
ditions. For example, patients with incomplete forms of consistent with SLE, suggesting that the array could
lupus, designated as incomplete lupus erythematosus (ILE), detect preclinical stages of the disease.
were comparable to SLE patients in terms of the total Insights into genetic effects on the autoantibody pro-
quantity of serum autoreactivity, but relatively more of file were provided by studies of SLE twins using arrays
these autoantibodies were in the IgM class [52]. These array detecting 65 autoantigens [55]. The arrays in this ana-
data were analyzed using unbiased clustering programs lysis provided a panoramic view of IgG and IgM pat-
similar to those employed for gene expression microarrays terns, permitting detection of what were essentially
(Fig. 1). The computer algorithms produced clusters of re- shared IgG fingerprints or signatures in monozygotic
lated autoantibodies, such as ones that reacted with struc- SLE twins. While previous studies had suggested this
tural or nuclear antigens, providing insights into how type of association in twins, the scope of autoantibodies
autoantibodies might be related to each other. Further in- detected with the arrays provided the opportunity to
sights were developed when the autoantibody array data establish a much more detailed concordance.
were correlated with gene signatures expressed in the same An advantage of the planar array approach is that only
ILE or SLE patients. Expression of the Type I interferon very small volumes of serum sample are required to de-
(IFN) gene signature that is characteristic of SLE and other tect hundreds of specificities (Table 1). When a fluid is
autoinflammatory conditions was found to be correlated not available in abundance, and especially for studies de-
with high levels of the IgG autoantibodies. This suggests a signed to explore novel specificities, this feature assumes
role for IFN in driving the class switch from IgM to IgG, greater importance. An example is the use of array profil-
thus probably contributing to more active disease manifes- ing to study biomarkers in cerebrospinal fluid (CSF) [56].
tations in the SLE patients [53]. Using a human proteome microarray with approximately
Related findings were reported by others using a differ- 17,000 proteins, patients with neuropsychiatric (NP)SLE
ent array that detected 930 autoreactivities, split between were found to have significantly more autoreactive anti-
IgMs and IgGs [54]. Patients with SLE in this study had bodies in CSF than patients who did not have NPSLE. A
upregulation of IgG autoantibodies, while some IgM network analysis of these data using the Ingenuity Pathway
autoantibodies were distinctly downregulated. This Analysis tool (Ingenuity System Inc, USA) showed that
study also showed that SLE patients in remission had most of these samples were enriched in pathways related
autoantibody patterns that were distinct from those of to neurologic disease; not a surprising result, perhaps, but

Fig. 1 Heat map for 58 IgG autoantibody specificities analyzed on a planar array. Serum samples were obtained from normal controls (NC),
first-degree relatives of patients (FDR), and patients with incomplete lupus (ILE), or systemic lupus (SLE). The normalized fluorescent intensity
values were used to generate the heat map. Clustering algorithms were used to detect autoantibodies that grouped together for the tested
samples. Red color indicates reactivities that are above the mean of all samples, green corresponds to values below that mean and values close to
the mean are black. From Li et al., Clin Exp Immunol 2007 [52] with permission
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 5 of 10

reassuring that the method does detect physiologically diagnosis of greater than 97%, with a positive likelihood
relevant specificities. Furthermore, this is another demon- ratio of 7.45 to 28.
stration of how array autoantibodies might be analyzed to One array platform that has been developed for clin-
give a more complete picture of overall relatedness. ical applications has the specific objective of excluding
In patients seen in a pediatric setting, detection of of the likelihood of a diagnosis of SLE [62, 63]. The low
large numbers of analytes from small volume samples is specificity of ANA testing for SLE makes this a very sig-
also especially useful. An array displaying 140 autoanti- nificant problem for clinical rheumatologists, who are
gens was used to compare pediatric patients with lupus confronted with screening large numbers of referred in-
nephritis (LN) to aged-matched healthy controls [57]. dividuals, only a few of whom actually have disease [8].
Candidate autoantigens for pediatric LN identified by A more predictive test would be welcome as a tool to
cluster analyses were validated with ELISA. Specificities prioritize patients for evaluation. For the SLE exclusion
that were associated with LN included some that are test, an array of 200 specificities, including known auto-
generally known, such as C1q and dsDNA, but others antigens and a set of proprietary oligonucleotides, was
that are relatively novel, such as collagens IV and X. Pre- used to generate a dataset from SLE patients and healthy
vious studies in adult SLE using a different autoantigen controls that was then analyzed by linear discriminant
array had also shown clustering of collagen IV with analysis to optimize sensitivity and specificity. A sche-
dsDNA, suggesting that these independent results have matic of the data might be presented to the clinician,
broad validity [52]. Furthermore, the pediatric patients showing where the individual tested fits into the profile
were found to have elevated levels of antibodies to B cell (Fig. 2). The cutoff chosen for a negative result, meaning
activating factor (BAFF), as had been described previ- SLE is unlikely, performs with a sensitivity of 94%, speci-
ously by this group in adult SLE [50]. The pediatric stud- ficity of 75%, and negative predictive value of 93%. While
ies also attempted to develop a predictive signature for the separation is imperfect, the test has potential to help
LN from a longitudinal subset of the patients, and these overbooked rheumatologists to triage consults for pos-
data suggest that persistently low nephritis scores de- sible lupus evaluations.
rived from array analyses might be associated with a The strengths and weaknesses of planar autoantigen
stable course. arrays have been well described (Table 2) [51, 64]. In
Urine is a very relevant biosample to study in SLE, general, the unbiased approach to collecting data on a
given the high prevalence of renal involvement and the large number of autoantibodies is a major advantage for
need for sensitive and noninvasive biomarkers of LN. exploratory studies. Given the relatively small number of
Array analyses of urine samples offer the potential for autoantibodies detected in clinical diagnostic laborator-
insights into mediators that may be specific for renal in- ies compared to the many known antibodies in SLE and
jury. One recent report utilized a commercially available other SARD, it is highly likely that new specificities can
investigational array of 274 human cytokines that is de- be found that offer greater utility for successful disease
scribed as being suitable for all liquid sample types [58]. classification and for predicting flares. A major challenge
The study included serum and urine samples from SLE
patients and the array findings were validated by ELISA.
This approach identified adipokines, including adipo-
nectin, resistin, and leptin, as potentially important me-
diators in LN and utilized pathways analysis to show
relationships between different specificities. This illus-
trates the utility of an array approach for biomarker
discovery.
The use of selected autoantigen arrays carries with it
the limitation of bias for known specificities. Alterna-
tives to the use of known autoantigens include synthetic
ligands such as peptoids which have been used to create
highly diverse unbiased libraries that have potential for Fig. 2 Example of array data, the SLE-key® rule-out test, that might be
used to predict likelihood of an accurate systemic lupus erythematosus
uncovering novel specificities and biomarkers [59, 60].
(SLE) diagnosis. Samples of known classification, SLE (blue) or non-SLE
Isolation of IgGs binding to arrayed peptoids in patients (red) are shown. An unknown sample in such a system would be tested
with SLE identified autoantibodies to RNA-binding pro- to generate a score that in turn would be plotted on this curve (shown
teins [61]. An unexpected result in this study was that one as “X”). Samples lower than a validated threshold (blue line) would have
ligand bound several different autoantibodies, possibly a low likelihood of an SLE diagnosis. Such data could be useful for
triaging ANA-positive patients referred for rheumatology consultation
indicating polyreactivity of these autoantibodies. These
(see references [62, 63])
data generated an estimated specificity for an SLE
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 6 of 10

Table 2 Strengths and Weaknesses of Autoantigen Array be associated with SLE. The latter included some related
Methods to apoptosis and neutrophil extracellular traps (NETs)
Strengths Permits screening of many autoantigen targets simultaneously which have been shown to contain SLE-related autoanti-
Uses very small sample volumes
Can make use of stored samples
gens [68]. Multivariate analyses showed clear separation
May detect multiple antibody classes or subclasses of healthy controls from the SLE patients, and clusters
Has high throughput capabilities of related autoantibodies in the SLE patients were dem-
Permits exploratory approaches to find new targets
Applies unbiased analytics onstrated using a heat map. A limitation of this study
Carries generally lower cost per specificity than ELISA was that other autoimmune diseases or conditions were
Develops insights into autoantibody clusters and relatedness
not included, so performance for distinguishing condi-
Weaknesses Potentially difficult to optimize all targets in one array tions related to SLE or subsets of SLE such as ILE or LN
Has batch-to-batch variability
Generally lacks standardization between laboratories is unknown. The authors raised the question of whether
Normalization standards are variable bead arrays might have less batch-to-batch variability
Has diminished sensitivity for low-affinity autoantibodies
May miss autoantibodies present at low concentrations which would make this approach possibly preferable to
Some autoantigens are not suitable as targets planar designs for applications in clinical assays, but
Results may be semiquantitative direct comparisons of bead and planar arrays have not
been reported, so this remains speculative. Bead-based
arrays do likely have some distinct advantages including
is the jurisdictional (i.e., Food and Drug Administration) reproducibility, rapid and high-throughput design, and
approval and certification of array assays for routine use reasonable cost.
in diagnostic laboratories. Clinical diagnostic applications
will require reproducibility between different platforms, Detection of early disease
decreased inter- and intratest variability, standardized In the past decade, it has become clear that autoanti-
quantitation, and interlaboratory validation; the lupus bodies are present in the preclinical stages of SARD
rule-out test discussed above may have overcome some of including SLE [69, 70]. This information has raised
these obstacles [51, 62]. interest in pushing the diagnostic window earlier in the
Detection of rare or low-affinity autoantibodies is time course, prior to the development of significant
another challenge. Addressing these issues likely will morbidity or organ damage. Patients with ILE have fewer
require advances in materials science in terms of de- autoantibodies than SLE patients as well as lower ANA
veloping better platforms and detection methods. An titers [71]. Studies using two-dimensional autoantigen
example is the use of plasmonic gold substrates with arrays have shown that ILE patients have patterns of
near-infrared fluorescence enhanced imaging, which autoreactivity that lie intermediate between healthy indi-
has been shown to deliver a broader dynamic range viduals and those with SLE [52]. Furthermore, ratios of
and improved performance in detection of low-affinity autoantibodies expressed in IgG and IgM classes differ,
antibodies compared to results obtained with glass slides with the ILE patients showing relatively greater IgM-class
[65]. Labeling modifications might include use of two- autoreactivity. ILE patients are not necessarily individuals
color antigen-binding antibody fragments (Fabs), which who are in early stages of lupus, but ILE is clearly a cat-
has been shown to enhance reproducibility of autoanti- egory that includes patients at high risk of progression to
body detection [66]. classifiable SLE. In one small study, 3 of 22 patients with
ILE who progressed to SLE over a mean time period of 2.4
Bead-based arrays years showed significant increases in some IgG specific-
An alternative to the two dimensional or planar array ities detected on an array [72]. One of these was SSB, con-
platform is the use of beads to carry the targets, such as sistent with other findings indicating that this specificity
those in ALBIAs and CIAs, discussed above. This ap- increases late in the preclinical period [73]. Whether
proach also has been used to produce an 86-specifity something like the SLE exclusion test array that has
assay for selected autoantigens [67]. The target proteins already been discussed [62] might help to discriminate ILE
were from commercial sources or were produced in an patients with and without risk of progression is an inter-
E. coli expression system. Antibody binding from diluted esting possibility that has not been investigated.
serum samples was measured using a fluorochrome-
labeled secondary antibody, and an instrument was used Point of care (POC) diagnostic technologies
to quantitate fluorescence intensity. Analysis of single The consultative and diagnostic services in rheumatol-
autoantibodies demonstrated the expected wide range of ogy are not typically considered clinical emergencies,
prevalence in SLE patients (n = 69). These included well- which require same-day diagnostic or clinical decisions.
known associations such as with dsDNA, but also re- While this may hold true for certain chronic and nonin-
vealed autoantibodies that were not known previously to flammatory conditions, it is important to appreciate that
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 7 of 10

SLE, vasculopathies, and antiphospholipid syndrome can demand. Availability of a POC for ANA testing has the
present with or develop intercurrent acute and life- potential to change practice patterns, not just in rheuma-
threatening features which need to be diagnosed and tology but also in primary care [80].
acted upon quickly to prevent irreversible immune- New technologies ranging from fairly simple lateral
mediated damage and mortality. It is in this and other flow technologies to more sophisticated lab-on-a-chip
clinical settings that POC testing may be useful [74]. It that deliver rapid, low-cost, highly specific, and quantita-
has been estimated that 10–25% of all patients with tive results is a goal of point of care testing. Current
rheumatologic disorders visiting emergency departments POC immunoassay technologies come in various config-
require hospital admission, and up to one-third of hospi- urations and complexities (reviewed in [74, 81]). Several
talized patients need intensive care [75–78]. These emer- of the newer biosensors have equaled or surpassed
gencies may present as a rapidly evolving multisystem traditional central laboratory methods in performance
organ failure, as a mimic of other conditions such as an metrics such as sensitivity, specificity, and especially
infectious disease, or with misleading, deceptively benign time to result. Devising reliable assays for measuring a
clinical signs. In a clinic setting, a negative result of a specific antibody in human serum is more difficult than
POC ANA test might offer immediate insight and elim- measuring most nonantibody analytes in biological
inate the need for ordering other expensive autoantibody fluids, because any one antibody specificity is usually a
profiles or referral to a specialist (Fig. 3). Similar ap- tiny fraction of total serum immunoglobulin. Nonspe-
proaches could apply to acute-onset vasculopathies such cific binding of immunoglobulin may have impeded the
as granulomatosis with polyangiitis or renal-pulmonary development of reliable antibody biosensors. However,
syndrome where a specific POC test based on proteinase recent and evolving advances in the technologies of
3, myeloperoxidase, and/or glomerular basement mem- immunosensors have provided improving accuracy in
brane antibodies might have value as an adjunct to ini- quantification and low detection limit in testing for
tiating immediate immunotherapy [79]. Having a high some autoantibodies (i.e., anti-dsDNA) commonly used
level of suspicion, sufficient clinical knowledge, and a in rheumatology clinical practice [82, 83]. By virtue of
method for detection of circulating autoantibody markers its rapid, bed-side, real-time data collection capability,
are factors that contribute significantly to a timely diagno- POC testing has the potential to change the practice of
sis. The use of specific autoantibody testing for the diag- medicine, and rheumatology will not be an exception.
nostic process in an acute clinical setting is growing in Commercialization, regulatory certification, and clinician

Fig. 3 A schematic of one possible algorithm for evaluation of an SLE diagnosis using existing and proposed technologies. A point of care (POC)
test for antinuclear antibodies (ANA) might be used as an office screening tool in primary care. A positive result would prompt further screening
by measuring ANA by indirect immunofluorescence (IIF); the SLE-key® rule-out test might be also used. Positivity for ANA and a “not-ruled out”
result for the SLE-key® test would then suggest a need for further autoantibody profiling using an antigen-specific assay. A negative test result for
ANA, even with a “ruled-out” result on the SLE-key® test, may require further evaluation depending on the clinical scenario. DFS70 testing might
be used to further improve diagnostic accuracy. The blue box indicates testing that might be done in primary care, with other tests being done
after rheumatology referral. Yellow boxes indicate tests in development or not widely available; green boxes indicate tests that are clinically available, at
least in the USA. aCL anti-cardiolipin antibodies, DFS70 dense fine speckles 70, SARD systemic autoimmune rheumatic diseases
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 8 of 10

acceptance of POC autoantibody testing in rheumatology Consent for publication

is a work in progress. Not applicable.

Competing interests
Other technologies NJO has a research grant from Mallinckrodt Pharmaceuticals and has been a
A number of other technologies have been developed for site investigator for Resolve Therapeutics, Aurina Pharmaceuticals, Pfizer, and
Horizon Pharmaceuticals. She has been an unpaid consultant for Immunarray
the high-throughput testing of sera for autoantibodies. Ltd. and IQuity, Inc. MJF is a consultant to Inova Diagnostics Inc. (San Diego,
These include a fully automated ANA screening assay CA, USA), Werfen International (Barcelona, Spain), and has received gifts in
[84], a microbead-based ELISA system [85], and nanobar- kind from Euroimmun GmbH (Luebeck, Germany) and Alexion Pharma Canada.
MYC declares that she has no competing interests.
code technology [86].

Publisher’s Note
Conclusion Springer Nature remains neutral with regard to jurisdictional claims in
ANA testing has been in clinical use for more than 60 published maps and institutional affiliations.
years and was a major advancement in defining SLE as a
Author details
disease. Measurements of ANAs and related autoanti- 1
Penn State M.S. Hershey Medical Center, 500 University Drive, Hershey, PA
bodies are now commonly used by rheumatologists and 17033, USA. 2Cumming School of Medicine, University of Calgary, Calgary, AB
nonspecialist providers for diagnosis and classification of T2N4N1, Canada.
SLE and other SARD. However, limitations of the cur-
rently available tests have prompted development of other
approaches that would offer greater specificity, prognostic References
value, cost efficiency, and other advantages. These ap- 1. Maas K, Chan S, Parker J, Slater A, Moore J, Olsen N, Aune TM. Cutting
edge: molecular portrait of human autoimmune disease. J Immunol.
proaches include multiplexed planar and bead arrays as 2002;169(1):5–9.
well as rapid detection methods for POC testing, with 2. Jacobson DL, Gange SJ, Rose NR, Graham NM. Epidemiology and estimated
small sample volumes. Applications including those that population burden of selected autoimmune diseases in the United States.
Clin Immunol Immunopathol. 1997;84(3):223–43.
would provide assessment of the risk of disease progres- 3. Cooper GS, Stroehla BC. The epidemiology of autoimmune diseases.
sion are likely to enter clinical practice in the next decade. Autoimmun Rev. 2003;2(3):119–25.
4. Mahler M, Meroni PL, Bossuyt X, Fritzler MJ. Current concepts and future
Abbreviations directions for the assessment of autoantibodies to cellular antigens referred
ALBIA: Addressable laser bead immunoassay; ANA: Antinuclear antibody; to as anti-nuclear antibodies. J Immunol Res. 2014;2014:315179.
BAFF: B cell activating factor; CIA: Chemiluminescence immunoassay; 5. Valenzuela A, Chung L, Casciola-Rosen L, Fiorentino D. Identification of
CSF: Cerebrospinal fluid; DFS70: Dense fine speckles 70; ELISA: Enzyme-linked clinical features and autoantibodies associated with calcinosis in
immunosorbent assay; Fab: Antigen-binding antibody fragment; dermatomyositis. JAMA Dermatol. 2014;150(7):724–9.
IFN: Interferon; IIF: Indirect immunofluorescence; ILE: Incomplete lupus 6. Choi MY, Barber MR, Barber CE, Clarke AE, Fritzler MJ. Preventing the
erythematosus; LEDGF: Lens epithelium-derived growth factor; LIA: Line development of SLE: identifying risk factors and proposing pathways for
immunoassay; LN: Lupus nephritis; NET: Neutrophil extracellular trap; clinical care. Lupus. 2016;25(8):838–49.
NPSLE: Neuropsychiatric systemic lupus erythematosus; POC: Point of care; 7. Olsen NJ, McAloose C, Carter J, Han BK, Raman I, Li QZ, Liao D. Clinical and
SARD: Systemic autoimmune rheumatic diseases; SLE: Systemic lupus immunologic profiles in incomplete lupus erythematosus and improvement
erythematosus with hydroxychloroquine treatment. Autoimmune Dis. 2016;2016:8791629.
8. Fritzler MJ. Choosing wisely: review and commentary on anti-nuclear
antibody (ANA) testing. Autoimmun Rev. 2016;15(3):272–80.
Acknowledgements
9. Hu SL, Wang D, Gou WJ, Lei QF, Ma TA, Cheng JZ. Diagnostic value of
Not applicable.
phospholipase A2 receptor in idiopathic membranous nephropathy: a
systematic review and meta-analysis. J Nephrol. 2014;27(2):111–6.
Funding 10. Dougherty ER. Biomarker development: prudence, risk, and reproducibility.
Not applicable. Bioessays. 2012;34(4):277–9.
11. Kavanaugh AF, Solomon DH. American College of Rheumatology Ad Hoc
Availability of data and materials Committee on Immunologic Testing Guidelines. Guidelines for
Not applicable. immunologic laboratory testing in the rheumatic diseases: anti-DNA
antibody tests. Arthritis Rheum. 2002;47(5):546–55.
Authors’ contributions 12. Conrad K, Andrade LE, Chan EK, Mahler M, Meroni PL, Pruijn GJ, Steiner G,
NJO and MJF organized the topics for review. NJO, MYC, and MJF contributed Shoenfeld Y. From autoantibody research to standardized diagnostic assays
equally to the writing and preparation of illustrations. All authors reviewed and in the management of human diseases—report of the 12th Dresden
approved the final version submitted for publication. Symposium on Autoantibodies. Lupus. 2016;25(8):787–96.
13. Guillemin F. How to assess musculoskeletal conditions. Assessment of
disease activity. Best Pract Res Clin Rheumatol. 2003;17(3):415–26.
Authors’ information 14. Yazdany J, Schmajuk G, Robbins M, Daikh D, Beall A, Yelin E, Barton J,
NJO is Professor of Medicine and Chief of Rheumatology at the Penn State Carlson A, Margaretten M, Zell J, et al. Choosing wisely: the American
M.S. Hershey Medical Center in Hershey PA. MYC is a member of the Division College of Rheumatology's top 5 list of things physicians and patients
of Rheumatology at the University of Calgary, Alberta, Canada. MJF is a should question. Arthritis Care Res (Hoboken). 2013;65(3):329–39.
professor in the Department of Medicine and Department of Biochemistry 15. Kleinnijenhuis J, van der Molen RG, Franssen PM, Berden JH, van der Meer
and Molecular Biology at the University of Calgary. JW, Jacobs JF. Anti-ribosomal P antibodies as a single serological marker in
SLE: lupus in disguise. Scand J Rheumatol. 2013;42(2):165–6.
Ethical approval and consent to participate 16. Pisetsky DS. Antinuclear antibody testing—misunderstood or misbegotten?
Not applicable. Nat Rev Rheumatol. 2017. doi:10.1038/nrrheum.2017.74.
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 9 of 10

17. Chan EK, Damoiseaux J, De Melo CW, Carballo OG, Conrad K, 39. Shovman O, Gilburd B, Barzilai O, Shinar E, Larida B, Zandman-Goddard G,
Francescantonio PL, Fritzler MJ, Garcia-De La Torre I, Herold M, Mimori T, Binder SR, Shoenfeld Y. Evaluation of the BioPlex 2200 ANA screen: analysis
et al. Report on the second International Consensus on ANA Pattern (ICAP) of 510 healthy subjects: incidence of natural/predictive autoantibodies. Ann
workshop in Dresden 2015. Lupus. 2016;25(8):797–804. N Y Acad Sci. 2005;1050:380–8.
18. Lakos G, Gonzalez M, Flaherty D, Bentow C, Ibarra C, Stimson D, Nacario L, 40. Shovman O, Gilburd B, Zandman-Goddard G, Yehiely A, Langevitz P,
Hiemann R, Dervieux T. Detection of anti-dsDNA antibodies by computer-aided Shoenfeld Y. Multiplexed AtheNA multi-lyte immunoassay for ANA
automated immunofluorescence analysis. J Immunol Methods. 2016;433:17–22. screening in autoimmune diseases. Autoimmunity. 2005;38(1):105–9.
19. Nossent H, Rekvig OP. Antinuclear antibody screening in this new 41. Avaniss-Aghajani E, Berzon S, Sarkissian A. Clinical value of multiplexed
millennium: farewell to the microscope? Scand J Rheumatol. 2001;30(3): bead-based immunoassays for detection of autoantibodies to nuclear
123–6. discussion 127–8. antigens. Clin Vaccine Immunol. 2007;14(5):505–9.
20. Fritzler MJ. The antinuclear antibody test: last or lasting gasp? Arthritis 42. Hanly JG, Su L, Farewell V, Fritzler MJ. Comparison between multiplex assays
Rheum. 2011;63(1):19–22. for autoantibody detection in systemic lupus erythematosus. J Immunol
21. Meroni P, Schur P. ANA screening: an old test with new recommendations. Methods. 2010;358(1–2):75–80.
Ann Rheum Dis. 2010;69(8):1420-2. 43. Nifli AP, Notas G, Mamoulaki M, Niniraki M, Ampartzaki V, Theodoropoulos
22. Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines PA, Kopnitsky MJ, Castanas E. Comparison of a multiplex, bead-based
for clinical use of the antinuclear antibody test and tests for specific fluorescent assay and immunofluorescence methods for the detection of
autoantibodies to nuclear antigens. American College of Pathologists. Arch ANA and ANCA autoantibodies in human serum. J Immunol Methods.
Pathol Lab Med. 2000;124(1):71–81. 2006;311(1–2):189–97.
23. Mahler M, Ngo JT, Schulte-Pelkum J, Luettich T, Fritzler MJ. Limited reliability 44. Mahler M, Meroni PL, Andrade LE, Khamashta M, Bizzaro N, Casiano CA,
of the indirect immunofluorescence technique for the detection of anti-Rib- Fritzler MJ. Towards a better understanding of the clinical association of
P antibodies. Arthritis Res Ther. 2008;10(6):R131. anti-DFS70 autoantibodies. Autoimmun Rev. 2016;15(2):198–201.
24. Damoiseaux J, von Mühlen CA, Garcia-De La Torre I, Carballo OG, de Melo 45. Seelig CA, Bauer O, Seelig HP. Autoantibodies against DFS70/LEDGF
Cruvinel W, Francescantonio PL, Fritzler MJ, Herold M, Mimori T, Satoh M, et al. exclusion markers for systemic autoimmune rheumatic diseases (SARD). Clin
International consensus on ANA patterns (ICAP): the bumpy road towards a Lab. 2016;62(4):499–517.
consensus on reporting ANA results. Auto Immun Highlights. 2016;7(1):1. 46. Choi MY, Clarke AE, St Pierre Y, Hanly JG, Urowitz MB, Romero-Diaz J,
25. Keech CL, McCluskey J, Gordon TP. Transfection and overexpression of the Gordon C, Bae SC, Bernatsky S, Wallace DJ, et al. The prevalence and
human 60-kDa Ro/SS-A autoantigen in HEp-2 cells. Clin Immunol determinants of anti-DFS70 autoantibodies in an international inception
Immunopathol. 1994;73(1):146–51. cohort of systemic lupus erythematosus patients. Lupus. 2017. doi:10.1177/
26. Fritzler MJ, Hanson C, Miller J, Eystathioy T. Specificity of autoantibodies to 0961203317692437.
SS-A/Ro on a transfected and overexpressed human 60 kDa Ro autoantigen 47. Ochs RL, Mahler M, Basu A, Rios-Colon L, Sanchez TW, Andrade LE, Fritzler
substrate. J Clin Lab Anal. 2002;16(2):103–8. MJ, Casiano CA. The significance of autoantibodies to DFS70/LEDGFp75 in
27. Malyavantham K, Suresh L. Analysis of DFS70 pattern and impact on ANA health and disease: integrating basic science with clinical understanding.
screening using a novel HEp-2 ELITE/DFS70 knockout substrate. Auto Clin Exp Med. 2016;16(3):273–93.
Immun Highlights. 2017;8(1):3. 48. Yaniv G, Twig G, Shor DB, Furer A, Sherer Y, Mozes O, Komisar O, Slonimsky
28. Sinclair D, Saas M, Williams D, Hart M, Goswami R. Can an ELISA replace E, Klang E, Lotan E, et al. A volcanic explosion of autoantibodies in systemic
immunofluorescence for the detection of anti-nuclear antibodies? The routine lupus erythematosus: a diversity of 180 different antibodies found in SLE
use of anti-nuclear antibody screening ELISAs. Clin Lab. 2007;53(3–4):183–91. patients. Autoimmun Rev. 2015;14(1):75–9.
29. López-Hoyos M, Rodríguez-Valverde V, Martinez-Taboada V. Performance of 49. Robinson WH, DiGennaro C, Hueber W, Haab BB, Kamachi M, Dean EJ,
antinuclear antibody connective tissue disease screen. Ann N Y Acad Sci. Fournel S, Fong D, Genovese MC, de Vegvar HE, et al. Autoantigen
2007;1109:322–9. microarrays for multiplex characterization of autoantibody responses. Nat
30. Fenger M, Wiik A, Høier-Madsen M, Lykkegaard JJ, Rozenfeld T, Hansen MS, Med. 2002;8(3):295–301.
Samsoe BD, Jacobsen S. Detection of antinuclear antibodies by solid-phase 50. Price JV, Haddon DJ, Kemmer D, Delepine G, Mandelbaum G, Jarrell JA,
immunoassays and immunofluorescence analysis. Clin Chem. 2004;50(11):2141–7. Gupta R, Balboni I, Chakravarty EF, Sokolove J, et al. Protein microarray
31. Copple SS, Sawitzke AD, Wilson AM, Tebo AE, Hill HR. Enzyme-linked analysis reveals BAFF-binding autoantibodies in systemic lupus
immunosorbent assay screening then indirect immunofluorescence erythematosus. J Clin Invest. 2013;123(12):5135–45.
confirmation of antinuclear antibodies: a statistical analysis. Am J Clin 51. Zhu H, Luo H, Yan M, Zuo X, Li QZ. Autoantigen microarray for high-
Pathol. 2011;135(5):678–84. throughput autoantibody profiling in systemic lupus erythematosus.
32. Almeida González D, Cabrera de León A, Rodríguez Pérez MC, Brito Díaz B, Genomics Proteomics Bioinformatics. 2015;13(4):210–8.
González Hernández A, García García D, Vázquez Moncholi C, Aguirre Jaime 52. Li Q, Zhou J, Wandstrat A, Carr-Johnson F, Branch V, Karp D, Mohan C,
A. Efficiency of different strategies to detect autoantibodies to extractable Wakeland E, Olsen N. Protein array autoantibody profiles for insights into
nuclear antigens. J Immunol Methods. 2010;360(1–2):89–95. systemic lupus erythematosus and incomplete lupus syndromes. Clin Exp
33. Lee SA, Kahng J, Kim Y, Park YJ, Han K, Kwok SK, Park SH, Oh EJ. Immunol. 2007;147(1):60–70.
Comparative study of immunofluorescent antinuclear antibody test and line 53. Li Q, Zhou J, Lian Y, Zhang B, Branch V, Carr-Johnson F, Karp D, Mohan C,
immunoassay detecting 15 specific autoantibodies in patients with systemic Wakeland E, Olsen N. Interferon signature gene expression is correlated
rheumatic disease. J Clin Lab Anal. 2012;26(4):307–14. with autoantibody profiles in patients with incomplete lupus syndromes.
34. Fritzler MJ, Fritzler ML. Microbead-based technologies in diagnostic Clin Exp Immunol. 2010;159(3):281–91.
autoantibody detection. Expert Opin Med Diagn. 2009;3(1):81–9. 54. Fattal I, Shental N, Mevorach D, Anaya JM, Livneh A, Langevitz P,
35. Mahler M, Bentow C, Serra J, Fritzler MJ. Detection of autoantibodies Zandman-Goddard G, Pauzner R, Lerner M, Blank M, et al. An antibody
using chemiluminescence technologies. Immunopharmacol profile of systemic lupus erythematosus detected by antigen microarray.
Immunotoxicol. 2016;38(1):14–20. Immunology. 2010;130(3):337–43.
36. Ghillani P, Rouquette AM, Desgruelles C, Hauguel N, Le Pendeven C, Piette JC, 55. Silverman G, Srikrishnan R, Germar K, Goodyear C, Andrews K, Ginzler E,
Musset L. Evaluation of the LIAISON ANA screen assay for antinuclear antibody Tsao B. Genetic imprinting of autoantibody repertoires in systemic lupus
testing in autoimmune diseases. Ann N Y Acad Sci. 2007;1109:407–13. erythematosus patients. Clin Exp Immunol. 2008;153(1):102–16.
37. Zafrir Y, Gilburd B, Carrasco MG, Kivity S, Sánchez-Castañón M, López-Hoyos 56. Hu C, Huang W, Chen H, Song G, Li P, Shan Q, Zhang X, Zhang F, Zhu H,
M, Mandel M, Szmyrka M, Shoenfeld Y, Agmon-Levin N. Evaluation of an Wu L, et al. Autoantibody profiling on human proteome microarray for
automated chemiluminescent immunoassay kit for antinuclear antibodies in biomarker discovery in cerebrospinal fluid and sera of neuropsychiatric
autoimmune diseases. Immunol Res. 2013;56(2–3):451–6. lupus. PLoS One. 2015;10(5):e0126643.
38. Xu X, Wu WY, Tu WZ, Chu HY, Zhu XX, Liang MR, Xue Y, Wang JC, Zou HJ. 57. Haddon DJ, Diep VK, Price JV, Limb C, Utz PJ, Balboni I. Autoantigen
Increased expression of S100A8 and S100A9 in patients with diffuse microarrays reveal autoantibodies associated with proliferative nephritis and
cutaneous systemic sclerosis. A correlation with organ involvement and active disease in pediatric systemic lupus erythematosus. Arthritis Res Ther.
immunological abnormalities. Clin Rheumatol. 2013;32(10):1501–10. 2015;17:162.
Olsen et al. Arthritis Research & Therapy (2017) 19:172 Page 10 of 10

58. Hutcheson J, Ye Y, Han J, Arriens C, Saxena R, Li QZ, Mohan C, Wu T. 82. Rubin RL, Wall D, Konstantinov KN. Electrochemical biosensor for
Resistin as a potential marker of renal disease in lupus nephritis. Clin Exp quantitation of anti-DNA autoantibodies in human serum. Biosens
Immunol. 2015;179(3):435–43. Bioelectron. 2014;51:177–83.
59. Fritzler MJ. Toward a new autoantibody diagnostic orthodoxy: understanding 83. Poulsen NN, Pedersen ME, Østergaard J, Petersen NJ, Nielsen CT, Heegaard
the bad, good and indifferent. Autoimmunity Highlights. 2012;3(2):51–8. NH, Jensen H. Flow-induced dispersion analysis for probing anti-dsDNA
60. Lindstrom TM, Robinson WH. Fishing for biomarkers with antigen mimics. antibody binding heterogeneity in systemic lupus erythematosus patients:
Cell. 2011;144(1):13–5. toward a new approach for diagnosis and patient stratification. Anal Chem.
61. Quan J, Lakhanpal A, Reddy MM, Zaman S, Li QZ, German DC, Olsen NJ, 2016;88(18):9056–61.
Kodadek T, Karp DR. Discovery of biomarkers for systemic lupus 84. Hayashi N, Kawamoto T, Mukai M, Morinobu A, Koshiba M, Kondo S,
erythematosus using a library of synthetic autoantigen surrogates. J Maekawa S, Kumagai S. Detection of antinuclear antibodies by use of an
Immunol Methods. 2013;402(1–2):23–34. enzyme immunoassay with nuclear HEp-2 cell extract and recombinant
62. Cohen IR, Putterman C, Jordan N, Jakobi K, Sorek R, Blumenstein Y, Batty S. antigens: comparison with immunofluorescence assay in 307 patients. Clin
SLE-key Rule-out serologic test for SLE using the immunarray ICHIP. Annals Chem. 2001;47(9):1649–59.
Rheum Dis. 2015;74(Suppl 2) 85. Grossmann K, Roggenbuck D, Schröder C, Conrad K, Schierack P, Sack U.
63. Putterman C, Wu A, Reiner-Benaim A, Batty DS, Sanz I, Oates J, Jakobi K, Multiplex assessment of non-organ-specific autoantibodies with a novel
Petri M, Safer P, Gerwien R, et al. SLE-key(®) rule-out serologic test for microbead-based immunoassay. Cytometry A. 2011;79(2):118–25.
excluding the diagnosis of systemic lupus erythematosus: developing the 86. Smith J, Onley D, Garey C, Crowther S, Cahir N, Johanson A, Painter S,
ImmunArray iCHIP(®). J Immunol Methods. 2016;429:1–6. Harradence G, Davis R, Swarbrick P. Determination of ANA specificity using
64. Wang L, Mohan C, Li QZ. Arraying autoantibodies in SLE—lessons learned. the UltraPlex platform. Ann N Y Acad Sci. 2005;1050:286–94.
Curr Mol Med. 2015;15(5):456–61.
65. Zhang B, Jarrell JA, Price JV, Tabakman SM, Li Y, Gong M, Hong G, Feng J,
Utz PJ, Dai H. An integrated peptide-antigen microarray on plasmonic gold
films for sensitive human antibody profiling. PLoS One. 2013;8(7):e71043.
66. Kattah MG, Alemi GR, Thibault DL, Balboni I, Utz PJ. A new two-color Fab
labeling method for autoantigen protein microarrays. Nat Methods. 2006;
3(9):745–51.
67. Budde P, Zucht HD, Vordenbäumen S, Goehler H, Fischer-Betz R, Gamer M,
Marquart K, Rengers P, Richter J, Lueking A, et al. Multiparametric detection
of autoantibodies in systemic lupus erythematosus. Lupus. 2016;25(8):812–22.
68. Pisetsky DS. Anti-DNA antibodies—quintessential biomarkers of SLE. Nat Rev
Rheumatol. 2016;12(2):102–10.
69. Arbuckle M, McClain M, Rubertone M, Scofield R, Dennis G, James J, Harley
J. Development of autoantibodies before the clinical onset of systemic
lupus erythematosus. N Engl J Med. 2003;349(16):1526–33.
70. Olsen NJ, Karp DR. Autoantibodies and SLE: the threshold for disease. Nat
Rev Rheumatol. 2014;10(3):181–6.
71. Aberle T, Bourn RL, Munroe ME, Chen H, Roberts VC, Guthridge JM, Bean K,
Robertson JM, Sivils KL, Rasmussen A, et al. Clinical and serological features
distinguish patients with incomplete lupus classification from systemic lupus
erythematosus patients and controls. Arthritis Care Res (Hoboken). 2017. doi:10.
1002/acr.23201.
72. Olsen NJ, Li QZ, Quan J, Wang L, Mutwally A, Karp DR. Autoantibody profiling
to follow evolution of lupus syndromes. Arthritis Res Ther. 2012;14(4):R174.
73. Lu R, Munroe ME, Guthridge JM, Bean KM, Fife DA, Chen H, Slight-Webb SR,
Keith MP, Harley JB, James JA. Dysregulation of innate and adaptive serum
mediators precedes systemic lupus erythematosus classification and improves
prognostic accuracy of autoantibodies. J Autoimmun. 2016;74:182–93.
74. Fritzler MJ. Perspectives on the imperatives, opportunities and challenges
for point of care diagnostics in systemiclupus erythematosus. Int J Clin
Rheumatol. 2015;9:449–56.
75. Janssen NM, Karnad DR, Guntupalli KK. Rheumatologic diseases in the
intensive care unit: epidemiology, clinical approach, management, and
outcome. Crit Care Clin. 2002;18(4):729–48.
76. Sharma M, Leirisalo-Repo M. Arthritis patient as an emergency case at a
university hospital. Scand J Rheumatol. 1997;26(1):30–6.
77. Panopalis P, Gillis JZ, Yazdany J, Trupin L, Hersh A, Julian L, Criswell LA, Katz
P, Yelin E. Frequent use of the emergency department among persons with
systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2010;62(3):401–8.
78. Hanly JG, Thompson K, Skedgel C. Utilization of ambulatory physician
encounters, emergency room visits, and hospitalizations by systemic lupus
erythematosus patients: a 13-year population health study. Arthritis Care Res
(Hoboken). 2016;68(8):1128–34.
79. Offermann N, Conrad K, Fritzler MJ, Fooke AM. Development and validation
of a lateral flow assay (LFA) for the determination of IgG-antibodies to Pr3
(cANCA) and MPO (pANCA). J Immunol Methods. 2014;403(1–2):1–6.
80. Konstantinov KN, Rubin RL. The universe of ANA testing: a case for
point-of-care ANA testing. Auto Immun Highlights. 2017;8(1):4.
81. Konstantinov KN, Tzamaloukas A, Rubin RL. Detection of autoantibodies in a
point-of-care rheumatology setting. Auto Immun Highlights. 2013;4(2):55–61.