Professional Documents
Culture Documents
The pattern of the ANA test can give information about the type of
autoimmune disease present and the appropriate treatment program. A
homogenous (diffuse) pattern appears as total nuclear fluorescence and is
common in people with systemic lupus. A peripheral pattern indicates that
fluorescence occurs at the edges of the nucleus in a shaggy appearance; this
pattern is almost exclusive to systemic lupus. A speckled pattern is also
found in lupus. Another pattern, known as a nucleolar pattern, is common in
people with scleroderma.
It is important to realize that even though 98% of people with lupus will have
a positive ANA, ANAs are also present in healthy individuals (5-10%) and
people with other connective tissue diseases, such as scleroderma and
rheumatoid arthritis. Moreover, about 20% of healthy women will have a
weakly positive ANA, and the majority of these people will never develop any
signs of lupus. One source cites that some ten million Americans have a
positive ANA, but fewer than 1 million of them have lupus. Therefore, a
positive ANA test alone is never enough to diagnosis systemic lupus. Rather,
a physician will order an ANA test if the patient first exhibits other signs of
lupus. This is because by itself, the test has low diagnostic specificity for
systemic lupus, but its value increases as a patient meets other clinical
criteria. It is possible for people with lupus to have a negative ANA, but these
instances are rare. In fact, only 2% of people with lupus will have a negative
ANA. People with lupus who have a negative ANA test may have anti-Ro/SSA
or antiphospholipid antibodies.
In people with a positive ANA, more tests are usually performed to check for
other antibodies that can help to confirm the diagnosis. Certain
autoantibodies and substances in the blood can give information about which
autoimmune disease, if any, is present. To check for these antibodies,
doctors usually order what is called an ANA panel, which checks for the
following antibodies: anti-double-stranded DNA, anti-Smith, anti-U1RNP, anti-
Ro/SSA, and anti-La/SSB. Some laboratories also include other antibodies in
their panel, including antinucleoprotein, anticentromere, or antihistone.
Anti-dsDNA Antibody
Anti-Smith Antibody
Anti-U1RNP Antibody
Anti-Histone Antibodies
Antiphospholipid Antibodies
Lupus Anticoagulant
In the late 1940s, it was found that an antibody present in some lupus
patients prolonged a clotting test dependent on phospholipids. For this
reason, it was thought that this antibody increased the tendency to bleed,
and thus it was deemed the lupus anticoagulant. However, this name is now
recognized as a misnomer for two reasons. First, the term anticoagulant is
a false label, since lupus anticoagulant actually increases the ability of the
blood to clot. Second, the term lupus in the name of the antibody is
misleading, since more than half of all people who possess this antibody do
not have lupus.
Tests called coagulation tests are used to detect the lupus anticoagulant
(LA). Remember that even though the lupus anticoagulant causes the blood
to clot more easily in vivo (i.e., in a persons body), they actually cause
prolonged clotting times in vitro (i.e., in a test tube). Therefore, if it takes
more time than normal for the blood to clot, the lupus anticoagulant is
usually suspected. The activated partial thromboplastin time (aPTT) is often
used to test for LA. If this test is normal, more sensitive coagulation tests are
performed, including the modified Russell viper venom time (RVVT), platelet
neutralization procedure (PNP), and kaolin clotting time (KCT). Normally, two
of these tests (the apt and the RVVT) are performed to detect whether lupus
anticoagulant is present.
Anticardiolipin Antibody
Even though the false-positive syphilis test and the lupus anticoagulant were
identified in the 1940s, the link between these entities was not investigated
until the 1980s, when a researcher at the Graham Hughes laboratory in
Britain named Nigel Harris began looking at antibodies to the phospholipid
antigens. Harris realized that cardiolipin was a major element of the false-
positive syphilis test, and he developed a more specific test for the antibody.
He also determined that the presence of these anticardiolipin antibodies was
associated with recurrent thromboses (blood clots) and pregnancy losses.
Others in Hughes laboratory began to publish studies showing the link
between anticardiolipin antibodies and stroke, deep vein thrombosis (DVT),
recurrent pregnancy loss, livedo, seizures, and other conditions. In fact, what
we now know as antiphospholipid syndrome was known as the anticardiolipin
syndrome even though other antiphospholipids, namely the lupus
anticoagulant, were known to produce similar effects.
Anti-beta2 glycoprotein 1
Beta2 glycoprotein 1 is the protein in the body to which anticardiolipin
antibodies bind, and it is also possible to measure antibodies to beta2
glycoprotein 1. An individual can be positive for anticardiolipin antibodies
and negative for anti-2 GPI and vice versa, and detection of anti-2 GPI is
not yet part of routine testing done for patients with an increased likelihood
of blood clots.
The following tests provide the starting point of any medical workup. By
comparing your test results to the normal values for your age, sex, and
personal circumstances (i.e., medications you may be taking, health
conditions you might have, etc.), your doctor can monitor changes in your
disease activity and overall health.
Complete Blood Count (CBC) A complete blood count (CBC) is the most
commonly performed lab test in the U.S. and is used to analyze red blood
cells (RBCs), white blood cells (WBCs), and platelets. Many people with
systemic lupus have abnormal CBCs.
The creatinine blood test and blood urea nitrogen (BUN) test are used to
assess kidney function in people with lupus kidney disease (nephritis).
Blood urea nitrogen (BUN): The BUN test measures the amount of urea
nitrogen in your blood. The liver produces nitrogen in the form of ammonia
(NH3) as it breaks down proteins into their constituent amino acids. From the
liver, urea travels in your blood to the kidneys, which filter the urea and flush
it from your body in the form of urine. To evaluate an individuals BUN level,
blood is drawn from the vein, and the concentration of urea nitrogen in the
blood is evaluated and compared to a standard value for that persons age
range. Even though increased protein levels in a persons diet can cause their
blood urea nitrogen levels to increase, elevated BUN may suggest kidney
involvement due to lupus or another condition such as dehydration that
causes decreased blood flow to the kidneys. Low BUN levels are uncommon
and are usually not as important; they can suggest certain conditions, such
as malnutrition, over-hydration, or liver disease, but doctors usually use other
tests to monitor these conditions.
A fasting lipid profile is performed only when a patient is fasting (i.e., has not
eaten since midnight of the previous night). Fasting ensures an accurate
reading of your baseline total cholesterol, HDL, LDL, and triglyceride levels.
However, please understand that it is alright to take your medications with
water upon the day you are fastingwater does not affect the fasting lipid
profile.
Protein
Albumin: Albumin is a small protein made in the liver that constitutes the
major protein in blood serum. Albumin performs many functions in your body,
including nourishing tissues, transporting various substances through the
body (hormones, vitamins, drugs, and ions), and preventing fluid from leaking
out of your blood vessels. Albumin concentration will drop if a person suffers
from liver damage, kidney disease, malnourishment, serious inflammation, or
shock. Abumin levels allow your doctor to assess for or monitor liver or
kidney disease due to lupus and other factors.
Electrolytes
Electrolytes are ions (electrically charged chemicals) in the blood and other
body fluids. The concentration of electrolytes in your body depends on
adequate intake of nutrients, proper absorption of nutrients by the intestines,
and proper kidney and lung function. Abnormal electrolyte concentrations
can indicate abnormalities in certain organs and bodily processes. For
example, retention of sodium, bicarbonate, or calcium can indicate problems
with kidney function. Hormones also help to control electrolyte
concentrations, so abnormal electrolyte levels can also reveal certain
hormone deficiencies or problems with certain hormone-regulating glands or
organs. Some of the electrolytes measured in a comprehensive metabolic
panel are explained below.
Sodium (Na+): Sodium helps to regulate your bodys water balance and
plays an important role in proper heart rhythm, blood pressure, blood volume,
and brain and nerve function. Hypernatremia refers to having too much
sodium in the blood; this can occur, for example, due to a high-salt diet. Too
much sodium in your blood can cause high blood pressure, among other
things. Hyponatremia refers to having too little sodium in the blood.
Hyponatremia can cause confusion, restlessness, anxiety, weakness, and
muscle cramps. Sodium levels in the blood are regulated by a hormone called
aldosterone that is secreted by the adrenal glands. Aldosterone works to
regulate sodium levels by increasing your kidneys reabsorption of sodium
ions.
Chloride (Cl-): Chloride ions help your body in maintaining proper pH and
fluid balance. It also secreted by the stomach during digestion. Excessive
sweating, vomiting, or diarrhea can cause chloride levels to drop. Low
chloride levels may alter the pH of your blood, cause dehydration; they may
also cause you to lose potassium.
Carbon dioxide (CO2): This test measures the amount of carbon dioxide
(CO2) in the blood, which is present in the form of CO2, bicarbonate (HCO3-),
and carbonic acid (H2CO3). These three forms are involved in the equilibrium
that maintains the pH of your blood (7.35-7.45). Bicarbonate also works with
other electrolytes to maintain a certain charge balance in your cells. The
concentration of carbon dioxide in your blood is maintained by your lungs and
kidneys. High or low levels of CO2 may prompt your doctor to order other
tests to check your kidney and lung function, blood gases, or fluid retention.
Liver Tests
Lupus and some of the medications used to treat lupus can affect the liver. In
addition, factors such as excessive alcohol intake or viral hepatitis can affect
the liver in people with lupus, just as they can in the normal population.
Certain tests can be performed as part of a comprehensive metabolic panel
to give insight into the function of your liver. In addition, your doctor may
order a test called a liver panel if she/he suspects that you have symptoms
of a liver disorder. Usually these tests measure certain liver enzymes, namely
alkaline phosphatase (ALP), alanine amino transferase (ALT), and aspartate
amino transferase (AST). Bilirubin, a waste product of the liver that is stored
in the gall bladder, is also measured. These values can be used by your
doctor as a screening or monitoring tool for liver involvement. About 30-60%
of lupus patients experience abnormal liver function tests; some have no
symptoms of liver disorder. Generally, increased levels correlate with
increased activity, but other factors can contribute to elevated levels of liver
enzymes in the blood. For example, NSAIDs, acetaminophen (Tylenol), and
aspirin can cause liver enzyme values to increase, especially in people with
lupus. If your doctor notices abnormal liver enzyme levels, she/he may ask
you to undergo additional tests for hepatitis.
Urinalysis
Urine samples can be given at any time while at the doctors office. A urine
culture is performed to assess for a bladder infection and to determine
appropriate antibiotics. Before giving a urine sample, ask a medical
professional to counsel you on how to prevent contamination. Several
analytical elements of the complete urinalysis are explained below.
In this portion of the analysis, the color, clarity, and concentration of the
urine are evaluated. Abnormal colors can result from disease, certain foods,
or contamination, so the physical examination is generally viewed as a crude
assessment. Light or dark coloration also suggests how much water is being
excreted. The clarity of urine is measured as either clear, slightly clear,
cloudy, or turbid. Urine clarity, like urine color, suggests that substances may
be present in the urine; for example, turbid urine suggests the presence of
protein or excess cellular material. However, accurate conclusions regarding
the origin of the urine clarity cannot be drawn until further chemical and
microscopic tests are performed. The physical examination also includes
specific gravity, which measures the concentration of the urine sample.
Specific gravity compares the concentration of urine to that of water (1.000).
Usually it is better for the urine given in a sample to be more concentrated;
this allows the laboratory to more accurately detect substances being
excreted by your body. If your urine is very dilute (i.e., you have been
drinking lots of water or receiving fluid via IV), you may be asked to give
another urine sample.
Chemical Analysis
The chemical examination measures several features of the urine. Most
laboratories use chemical test strips (dipsticks) that change colors when
dipped into the urine. Either the laboratory technician or an automated
instrument will then read the reaction color for each test pad to determine
the result for each test. The use of automated instruments helps to eliminate
discrepancies that arise with human interpretation.
pH: Usually, the pH of urine is between 4.5 and 8.0. The kidneys regulate this
acid-base chemistry by reabsorbing sodium and secreting hydrogen and
ammonium ions. When the body retains excess sodium or acid, urine
becomes more acidic (i.e., the pH is lower). Highly acidic urine can occur with
uncontrolled diabetes, diarrhea, starvation, dehydration, and certain
respiratory diseases. When your body retains excess base, your urine
becomes more basic, or alkaline (i.e., the pH is higher). This can occur with
urinary tract infections and certain kidney and lung conditions. Certain foods
can also alter the pH of your urine. For example, eating excessive protein or
cranberries can make your urine more acidic, whereas eating a low-
carbohydrate or vegetarian diet can make your urine more basic. Sometimes
people are asked by their doctors to regulate the pH of their urine through
diet in order to manage certain diseases or medications. For example, kidney
stones can occur if urine pH is too high or too low.
If there is a large amount of protein in the urine, your doctor may request
that you give a 24-hour urine sample or obtain a random protein to
creatinine ratio. These two tests are used to monitor lupus affecting the
kidneys (lupus nephritis).
Glucose: Your urine should not contain glucose. If it does, your doctor will
order further bloodwork and urine tests to determine the cause. Glucose in
the urine is called glucosuria; it can occur in people with diabetes that is not
properly regulated with insulin, in people with kidney problems that affect the
absorption of glucose, in pregnant women, and in people with liver
abnormalities or hormonal disorders.
Blood: The chemical examination of urine also measures the amount of red
blood cells in the urine sample. The presence of red blood cells in the urine is
known as hematuria, and the presence of hemoglobin (from red blood cells) is
known as hemoglobinuria. Usually people have very small amounts of red
blood cells in their urine, but even a minute increase can indicate a problem,
such as a disease of the kidney or urinary tract, trauma, medications,
smoking, or intense exercise (e.g., running a marathon). When the chemical
test for blood in the urine is negative but the microscopic assessment shows
the presence of red blood cells, the laboratory will usually check for the
presence of vitamin C, which can interfere with test results. [It is important
to also note that contamination of the urine sample with menstrual
blood or hemorrhoids cannot be distinguished from the presence of
red blood cells in the sample. Therefore, it is very important to tell
your physician if you are menstruating or are experiencing any other
condition that could contaminate your urine sample. It is also very
important that you speak to your lab technician about proper aseptic
technique when giving a urine sample.]
Leukocyte Esterase: Leukocyte esterase is an enzyme present in your
white blood cells. Therefore, the presence of this substance in the urine
indicates the presence of white blood cells (leukocyturia). White blood cells in
the urine may indicate inflammation of the kidneys or urinary tract due to
bacterial infection. It is important to note, however, that contamination of the
urine can also cause the presence of white blood cells in the urine, so
remember to practice proper aseptic technique when giving the sample.
Bilirubin: Bilirubin is made by the liver from old red blood cells; it is then
processed by the intestine and excreted from the body. Therefore, healthy
individuals do not have bilirubin in their urine. The presence of bilirubin in the
urine indicates that the liver is allowing the substance to leak back into the
blood. This can be an early indication of liver disease, even when other
symptoms, such as jaundice, are not present.
Microscopic Analysis
Red Blood Cells: The microscopic examination looks at how many red blood
cells are present per HPF. As discussed above, the presence of red blood cells
in the urine can indicate a problem, such as a disease of the kidney or urinary
tract, trauma, medications, smoking, or intense exercise (e.g., running a
marathon). However, contamination of the urine sample with menstrual blood
or hemorrhoids cannot be distinguished from the presence of red blood cells
in the sample. Therefore, it is very important to tell your physician if you are
menstruating or are experiencing any other condition that could
contamination your urine sample. It is also very important that you speak to
your lab technician about proper aseptic technique when giving a urine
sample.
White Blood Cells: A high number of white blood cells in the urine indicates
inflammation of the kidneys or urinary tract. Like the test for red blood cells,
this test can be misread if the sample is contaminated; in this instance,
contamination can occur from vaginal secretions, which are high in white
blood cells. Therefore it is important that you speak to your lab technician
about proper aseptic technique before giving a urine sample.
Epithelial Cells: The tissue that lines the surfaces of cavities and structures
in your body is called epithelial tissue. In healthy individuals, epithelial cells
from the bladder and external urethra are normally present in the urine in
small amounts. However, the amount of epithelial cells in the urine increases
when someone has a urinary tract infection or some other cause of
inflammation. Your doctor will evaluate the source of the problem by
evaluating the type of epithelial cells that are present. For example, the
presence of renal tubular epithelial cells (from your kidneys) may indicate
kidney involvement. The presence of squamous epithelial cells may indicate
contamination of the urine specimen.
Casts: Casts are formed in the tubules of they kidney when the tubules
secrete a protein called Tamm-Horsfall protein. The origin of the casts causes
them to take on a tubular or hotdog-like shape. These casts are known as
hyaline casts and can be present in normal adults on the order of 0-5 per LPF.
Strenuous exercise can cause more hyaline casts to be present. However,
casts made from red or white blood cells indicate problems in the kidney. Red
blood cells that stick together and form red blood cell casts usually indicate
problems with the glomeruli, tiny ball-shaped structures in your kidneys that
help filter blood and prevent the loss of valuable substances, such as blood
cells and proteins. White blood cells casts indicate inflammation in the kidney.
Cellular casts that remain in the nephron of your kidney for a long time
before they are flushed out become granular casts and eventually waxy
casts.
Bacteria: Bacteria in your urine can suggest infection, especially if you have
other suggestive symptoms. If your doctor suspects that you may have a
urinary tract infection, she/he will most likely order a culture or count of the
bacteria. However, bacteria on the skin can also contaminate the urine
sample and skew the results, so it is very important that you understand
proper aseptic technique when giving a urine sample.
Erythrocyte is another word for red blood cell. The erythrocyte (or, red blood
cell) sedimentation rate (ESR) is a test that measures the amount of
inflammation in your body. For the test, blood is drawn from a vein in your
arm into a special tube. The rate of fall (sedimentation) of red blood cells is
then measured, as the red blood cells become sediment at the bottom of the
tube, leaving blood plasma at the top of the column. The results are reported
in terms of how many millimeters of clear blood plasma are present at the
top of the column after one hour. Usually red blood cells fall slowly so that
there is little clear plasma left at the top. However, when the blood contains
higher amounts of certain proteins involved in inflammation, namely
fibrinogen and immunoglobulins (antibodies), the red blood cells fall more
rapidly, resulting in an increased ESR. Therefore, sedimentation rate
increases with more inflammation. A normal ESR is usually about 0-20
millimeters per hour in females and 0-12 millimeters per hour in males. The
ESR is nonspecific, meaning that it does not tell your doctor exactly where
the inflammation is occurring in your body and is thus not a very strong
indicator of lupus activity.
Like the erythrocyte sedimentation rate, the C-reactive protein (CRP) test
measures inflammation. However, CRP usually changes more rapidly than
ESR because it is made by the liver and secreted hours after the beginning of
infection or inflammation. CRP plays a part in your immune response by
interacting with your bodys complement system. The CRP is non-specific,
meaning it cannot give your doctor information about where inflammation is
occurring in your body. However, the amount of CRP can give an idea as to
the degree of inflammation your body is experiencing, and it is used by
doctors in lupus treatment to monitor flares and to assess how well your
medications are working. It is important to realize, though, that a low CRP
value does not necessarily mean that an individual is experiencing no
inflammation; a low CRP can be seen in lupus patients with active
inflammation. An elevated CRP can also be seen after someone has a heart
attack, surgical procedure, or infection.
In the hospital, a persons CK-MB level is often checked when they exhibit
signs of heart attack. However, in lupus treatment, an elevated CPK may
suggest muscle inflammation due to disease activity or an overlapping
condition. CPK levels can also be high after strenuous exercise, so your
doctor may wish to recheck your CPK after several days of rest. If your CPK is
high with no exercise or remains high with rest, your doctor may order
additional tests to determine which type (isoenzyme) of CPK is elevated. This
information will help her/him to determine the source of the damage
(skeletal muscles, heart, or brain). Certain medications, such as statins, can
cause increases in CPK, so be sure to tell your doctor about any medications
you currently take.
Coombs Test
The Coombs test is used to detect antibodies that act against the surface of
your red blood cells. The presence of these antibodies indicates a condition
known as hemolytic anemia, in which your blood does not contain enough
red blood cells because they are destroyed prematurely. A healthy red blood
cell lives for about 120 days; in people with hemolytic anemia, red blood
cells are destroyed long before the 120-day marker. Sometimes, bone
marrow can compensate for the early destruction of red blood cells by
working overtime to make more of them. However, this extra effort may not
be enough to combat hemolytic anemia.
There are two types of Coombs tests: direct and indirect. The direct Coombs
test, also known as the direct antiglobulin test, is the test usually used to
identify hemolytic anemia. [The indirect Coombs test is used only in prenatal
testing of pregnant women and in testing blood prior to a transfusion.] For
the direct Coombs test, blood is drawn from the vein in your arm and then
washed to isolate your red blood cells. The red blood cells are then
incubated (combined in a controlled environment) with a substance called
Coombs reagent. If the red blood cells clump together (a process called
agglutination), then the Coombs test is said to be positive.