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International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies
  1. Nancy Agmon-Levin1,2,
  2. Jan Damoiseaux3,
  3. Cees Kallenberg4,
  4. Ulrich Sack5,
  5. Torsten Witte6,
  6. Manfred Herold7,8,
  7. Xavier Bossuyt9,
  8. Lucille Musset10,
  9. Ricard Cervera11,
  10. Aresio Plaza-Lopez12,
  11. Carlos Dias13,
  12. Maria José Sousa14,
  13. Antonella Radice15,
  14. Catharina Eriksson16,
  15. Olof Hultgren17,
  16. Markku Viander18,
  17. Munther Khamashta19,
  18. Stephan Regenass20,
  19. Luis Eduardo Coelho Andrade21,
  20. Allan Wiik22,
  21. Angela Tincani23,
  22. Johan Rönnelid24,
  23. Donald B Bloch25,
  24. Marvin J Fritzler26,
  25. Edward K L Chan27,
  26. I Garcia-De La Torre28,
  27. Konstantin N Konstantinov29,
  28. Robert Lahita30,
  29. Merlin Wilson31,
  30. Olli Vainio32,
  31. Nicole Fabien33,
  32. Renato Alberto Sinico34,
  33. Pierluigi Meroni35,
  34. Yehuda Shoenfeld1,2,36
  1. 1The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel
  2. 2Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
  3. 3Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
  4. 4Department of Rheumatology and Clinical Immunology, University of Groningen, Groningen, The Netherlands
  5. 5University Leipzig, Institute for Clinical Immunology and Transfusion Medicine, Leipzig, Germany
  6. 6Department of Clinic for Immunology and Rheumatology, Medical School, Hanover, Germany
  7. 7Department of Internal Medicine 1, Rheumatology Unit, Innsbruck Medical University, Innsbruck, Austria
  8. 8Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
  9. 9Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
  10. 10Immunology Department, GH Pitie-Salpêtriere, Paris, France
  11. 11Department of Autoimmune Diseases, Hospital Clínic Barcelona, Catalonia, Spain
  12. 12Servicio de Inmunología, Hospital Universitario Pueta de Hierro. Majadahonda, Madrid, Spain
  13. 13Autoimmune Diseases Unit, Medicine Department, S. João Hospital, Porto, Portugal
  14. 14Autoimmunity and PreNatal Diagnostic Laboratory Unit, Fernando Fonseca Hospital, Porto, Portugal
  15. 15Institute of Microbiology, Azienda Ospedaliera Ospedale San carlo Borromeo, Milano, Italy
  16. 16Department of Clinical Microbiology, Clinical Immunology, Umeå University, Umeå, Sweden
  17. 17Department of Laboratory Medicine, Clinical Immunology, University Hospital of Orebro and Orebro University, Orebro, Sweden
  18. 18Department of Medical Microbiology and Immunology, University of Turku, Turku, Finland
  19. 19Lupus Research Laboratory Division of Women's Health, King's College London, London, UK
  20. 20Klinik für Immunologie, DIA UniversitätsSpital, Zürich, Switzerland
  21. 21Rheumatology Division, Universidade Federal de São Paulo’, Sao Paulo, Brazil
  22. 22Department of Clinical Chemistry and Immunology, Statens Serum Institut, Copenhagen S, Denmark
  23. 23Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, Spedali Civili and University of Brescia, Brescia, Italy
  24. 24Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
  25. 25Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital and Harvard Medical School, Harvard, Massachusetts, USA
  26. 26Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
  27. 27Department of Oral Biology, University of Florida, Gainesville, Florida, USA
  28. 28Department Immunology and Rheumatology, Hospital General de Occidente and University of Guadalajara, Guadalajara, Jal, Mexico
  29. 29Medicine/Rheumatology, UNM School of Medicine, New Mexico, USA
  30. 30Medicine and VP, Newark Beth Israel Medical Center UMDNJ, Newark, USA
  31. 31LSU School of Medicine, USA
  32. 32Department of Medical Microbiology and Immunology, Institute of Diagnostics, University of Oulu and NordLab Oulu, Oulu, Finland
  33. 33Department of Immunology, CH Lyon Sud, Pierre-Benite, France
  34. 34Clinical Immunology Unit and Renal Unit, Azienda Ospedaliera Ospedale San carlo Borromeo, Milano, Italy
  35. 35Division of Rheumatology, Ist G. Pini, Istituto Auxologico Italiano, University of Milan, Milan, Italy
  36. 36Sackler Faculty of Medicine, Incumbent of the Laura Schwarz-Kip Chair for Research of Autoimmune Diseases, Tel-Aviv University, Tel-Aviv, Israel
  1. Correspondence to Professor Yehuda Shoenfeld, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer 52621, Israel; shoenfel{at}


Anti-nuclear antibodies (ANA) are fundamental for the diagnosis of autoimmune diseases, and have been determined by indirect immunofluorescence assay (IIFA) for decades. As the demand for ANA testing increased, alternative techniques were developed challenging the classic IIFA. These alternative platforms differ in their antigen profiles, sensitivity and specificity, raising uncertainties regarding standardisation and interpretation of incongruent results. Therefore, an international group of experts has created recommendations for ANA testing by different methods.

Two groups of experts participated in this initiative. The European autoimmunity standardization initiative representing 15 European countries and the International Union of Immunologic Societies/World Health Organization/Arthritis Foundation/Centers for Disease Control and Prevention autoantibody standardising committee. A three-step process followed by a Delphi exercise with closed voting was applied.

Twenty-five recommendations for determining ANA (1–13), anti-double stranded DNA antibodies (14–18), specific antibodies (19–23) and validation of methods (24–25) were created. Significant differences between experts were observed regarding recommendations 24–25 (p<0.03). Here, we formulated recommendations for the assessment and interpretation of ANA and associated antibodies. Notably, the roles of IIFA as a reference method, and the importance of defining nuclear and cytoplasmic staining, were emphasised, while the need to incorporate alternative automated methods was acknowledged. Various approaches to overcome discrepancies between methods were suggested of which an improved bench-to-bedside communication is of the utmost importance. These recommendations are based on current knowledge and can enable harmonisation of local algorithms for testing and evaluation of ANA and related autoantibodies. Last but not least, new more appropriate terminologies have been suggested.

  • Autoantibodies
  • Autoimmunity
  • Systemic Lupus Erythematosus
  • Sjøgren's Syndrome

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