A hierarchical bivariate meta-analysis of diagnostic test accuracy to provide direct comparisons of immunoassays vs. indirect immunofluorescence for initial screening of connective tissue diseases

Abstract

ObjectivesTo compare indirect immunofluorescence (IIF) for antinuclear antibodies (ANA) against immunoassays (IAs) as an initial screening test for connective tissue diseases (CTDs).MethodsA systematic literature review identified cross-sectional or case-control studies reporting test accuracy data for IIF and enzyme-linked immunosorbent assays (ELISA), fluorescence enzyme immunoassay (FEIA), chemiluminescent immunoassay (CLIA) or multiplex immunoassay (MIA). The meta-analysis used hierarchical, bivariate, mixed-effect models with random-effects by test.ResultsDirect comparisons of IIF with ELISA showed that both tests had good sensitivity (five studies, 2321 patients: ELISA: 90.3% [95% confidence interval (CI): 80.5%, 95.5%] vs. IIF at a cut-off of 1:80: 86.8% [95% CI: 81.8%, 90.6%]; p = 0.4) but low specificity, with considerable variance across assays (ELISA: 56.9% [95% CI: 40.9%, 71.5%] vs. IIF 1:80: 68.0% [95% CI: 39.5%, 87.4%]; p = 0.5). FEIA sensitivity was lower than IIF sensitivity (1:80: p = 0.005; 1:160: p = 0.051); however, FEIA specificity was higher (seven studies, n = 12,311, FEIA 93.6% [95% CI: 89.9%, 96.0%] vs. IIF 1:80 72.4% [95% CI: 62.2%, 80.7%]; p < 0.001; seven studies, n = 3251, FEIA 93.5% [95% CI: 91.1%, 95.3%] vs. IIF 1:160 81.1% [95% CI: 73.4%, 86.9%]; p < 0.0001). CLIA sensitivity was similar to IIF (1:80) with higher specificity (four studies, n = 1981: sensitivity 85.9% [95% CI: 64.7%, 95.3%]; p = 0.86; specificity 86.1% [95% CI: 78.3%, 91.4%]). More data are needed to make firm inferences for CLIA vs. IIF given the wide prediction region. There were too few studies for the meta-analysis of MIA vs. IIF (MIA sensitivity range 73.7%–86%; specificity 53%–91%).ConclusionsFEIA and CLIA have good specificity compared to IIF. A positive FEIA or CLIA test is useful to support the diagnosis of a CTD. A negative IIF test is useful to exclude a CTD.

The Past, Present, and Future in Antinuclear Antibodies (ANA)

“…Is it time to compare solid-phase assays and automated IIF for detection of ANAs? [21][22][23]. Can solid-phase assays replace immunofluorescence for ANA screening?…”

“…However, it is essential to take into account how the different cut-off points of the assays are chosen in order to consider a positive result, since the differences observed in the performance between assays are largely related to these. Thus, in a meta-analysis of paired studies and considering the cut-off value for HEp-2 IIF as 1:80 the sensitivity of IIF, FEIA, and CIA was 89.2%, 78.5%, and 85.9%, respectively, and the specificity was 70.9%, 93.6%, and 86.1%, respectively, for ANA-associated SARDs [22]. In contrast, studies that consider the cut-off point as the value that corresponds to a specificity of 95%, showed that HEp-2 IIF, FEIA, and CIA for ANA-associated SARDs presented similar sensitivities of 79%, 82%, and 78%, respectively [13].…”

Assessment of antinuclear antibodies (ANA): National recommendations on behalf of the Croatian society of medical biochemistry and laboratory medicine

“…The major drawbacks of these methods are the use of a limited number of purified or recombinant autoantigens, lack of standardization, and the prevalence of "false negative" ANA results, although some of them with questionable clinical significance. A recent meta-analysis compared IIF with solid-based immunoassays used as an initial screening method (49). No significant difference between ELISA and IIF (cut-off 1:80) was found both in terms of sensitivity and specificity.…”

Current state of technologies and recognition of anti‐SSA/Ro antibodies in China: A multi‐center study

“…A recent systematic meta‐analysis demonstrated that CLIA had good specificity compared with indirect immunofluorescence in ANA testing. 31 In addition, MBA has shown certain advantages over conventional techniques, including the feasibility of high‐throughput analyses for multiple antigens, minimal labor for automation, and reduced cost of samples. 32 However, the antigen composition of the bead‐based assays also varies significantly, and issues with false‐positive results are the main concern for MBAs.…”