132-135
Clinicalrheumatology, 1990, 9, N ~ 1 Suppl. N ~ 1
Antineutrophil cytoplasmic antibodies (ANCA) and vasculitis. C.G.M.
KALLENBERG
D e p a r t m e n t o f Clinical I m m u n o l o g y , Groningen, The Netherlands.
ANCA and Wegener's Granulomatosis Five years ago, Allan Wiik f r o m Copenhagen submitted an abstract to the first European conference on antinuclear antibodies organized by dr. Walravens in Leuven, on the occurrence of autoantibodies reacting with neutrophils in patients with Wegener's granulomatosis (WG). At the same time, Van der W o u d e f r o m our department in Groningen, the Netherlands, in search for circulating immune complexes using the indirect granulocyte phagocytosis test (1), had observed that IgG-class antibodies f r o m patients with W G reacted with the cytoplasm of granulocytes. As a chairman of one of the sections in Leuyen in 1984, I had a preview of the titles of the abstracts, and so I got the opportunity to bring both investigators together at the 1984 meeting in Leuven. Their cooperation resulted in the recognition o f antineutrophil cytoplasmic antibodies (ANCA) as a sensitive and specific m a r k e r for active W G (2). These antibodies produced a granular staining of the cytoplasm of ethanol-fixed granulocytes with accentuation o f the fluorescence within the area surrounded by the nuclear lobes. These original data have been confirmed by m a n y groups. Liidemann et al. (3) described a sensitivity o f A N C A of 100~ for active W G (57 out of 57 patients). Concerning specificity, they found a positive test for A N C A only in 6 cases of polyarteriitis nodosa out of a group of 1600 sera f r o m patients with connective tissue diseases (n = 148), R A (n = 109), glomerulonephritis (n = 107), vasculitis (n = 101), other internal diseases (n = 785) and normal controls (n = 350). A high sensitivity of A N C A for W G (93o70) in combination with a high degree of specificity (97o7o) was also
University Hospital Groningen,
9713 E Z
found in a collaborative study on Dutch and American patients with W G and closely related diseases (4). In all the afore mentioned studies, it was observed that high titres of A N C A were associated with active disease whereas A N C A titres declined during remission of WG. In order to evaluate whether changes in ANCA-titre could predict the occurrence of relapses of WG, we performed a 16 months prospective study on 35 patients with W G (4). Patients were seen monthly at the out-patient clinic and blood was drawn for ANCA-titration. During the study period seventeen relapses were observed which were all preceded (by a mean period of 7 weeks) by a significant rise of the ANCA-titre. Only one patient demonstrated several rises in titre without an ensuing relapse. These results suggest that treatment based on changes in ANCA-titre may prevent relapses of WG. Such a clinical study is going on at present in The Netherlands.
Identification of the target antigen(s) recognized by ANCA The afore mentioned data demonstrate a close relation between A N C A and disease activity. In order to get more insight in the possible pathophysiological role of A N C A for W G studies were performed to characterize the antigen(s) recognized by A N C A (5). For this purpose, nitrogen-cavitated neutrophils were fractionated by density centrifugation into 4 preparations containing the azurophilic or primary granules, the specific granules, the phosphosomes and plasma membranes, and the cytosol, respectively. The ANCA-antigen co-purified with the azuro-
A N C A and vasculitis
philic granules. By Western blotting it was demonstrated that ANCA reacted with a soluble 29-31 KD glycoprotein triplet. Stimulation of cytochalasin B primed neutrophils with fMLP revealed that upon degranulation these cells release the ANCA-antigen. Finally, the ANCA-antigen bound to (tritiated) diisopropylfluorophosphate suggesting that the antigen is a serine protease. This serine protease proved to be different from the two known serine proteases from neutrophil granules, namely elastase and cathepsin G. Thus, the antigen is clearly different from leucocyte alkaline phosphatase, an enzyme present in the phosphosome/plasma membrane fraction that has been suggested as the ANCA-antigen by others (6).
Autoantibodies to myeloperoxidase and elastase
In search for the antigens recognized by ANCA, we observed that monoclonal antibodies to human neutrophil elastase and to myeloperoxidase (MPO) produced a perinuclear staining (p-ANCA) by indirect immunofluorescence on ethanol-fixed granulocytes. This pattern was different from the typical cytoplasmic staining produced by sera from patients with WG (c-ANCA). Interestingly, we had already observed, during routine serum testing for ANCA, that some human sera also produced a perinuclear staining pattern. Next, we developed ELISA's for c-ANCA, anti-MPO- and anti-elastase antibodies using monoclonal antibodies (MoAb 12.8 to c-ANCA-antigen (7), and MoAbs to M P O and human neutrophil elastase) to catch their respective antigens from an extract of azurophilic granules (8). Many sera producing perinuclear staining were, indeed, directed to MPO and some other sera were positive for antielastase antibodies as detected by ELISA, whereas nearly all sera positive for c-ANCA by immunofluorescence gave positive results by ELISA using MoAb 12.8 as catching antibody. The specific binding of these sera to
133
c-ANCA-antigen, M P O and elastase was confirmed by immunoprecipitation experiments (9). Antibodies to M P O were independently described by Falk and Jennette in patients with necrotizing crescentic glomerulonephritis with or without systemic vasculitis (10). To further delineate the clinical significance of autoantibodies to myeloid lysozomal enzymes in patients with crescentic glomerulonephritis (CGN), we tested sera from 35 consecutive patients with CGN with non-diagnostic IF-findings in their renal biopsy for the presence of ANCA, anti-MPO and anti-elastase. A N C A were present in the sera of all 9 patients with CGN as part of biopsy proven WG, in 10 out o f 15 patients with CGN and clinically suspected WG, and in 2 out of 8 patients with idiopathic CGN. The remaining 5 patients with clinically suspected WG and the remaining 6 patients with idiopathic CGN were positive for anti-MPO. In contrast, sera from patients with CGN of infectious origin (n = 3), different forms o f CGN with specific fluorescence findings (n = 7), other renal lesions (n = 34), and normal volunteers (n -- 52) were negative for ANCA and anti-MPO (11). Very recently, we have evaluated the clinical associations of anti-MPO. Anti-MPO were detected not only in the sera from patients with CGN with or without vasculitis, but also in sera from patients with polyarteriitis nodosa and the Churg-Strauss syndrome. These findings place the idiopathic vasculitic syndromes in a spectrum comparable with that of the connective tissue diseases. Biopsyproven WG with granulomatous vasculitis stands on one side of the spectrum and is strongly associated with autoantibodies to a putative serine protease ("29 KD A N C A " or c-ANCA), whereas polyarteriitis nodosa and the Churg-Strauss syndrome constitute the other side of the spectrum and are associated with autoantibodies to MPO. Overlap syndromes with CGN and signs of systemic vasculitis ("microscopic polyarteriitis"), associ-
134
C.G.M. Kallenberg
ated with c - A N C A or a n t i - M P O , are in between.
A u t o a n t i b o d i e s to m y e l o i d l y s o z o m a i enzymes - pathophysiological considerations Relapses o f W G are f r e q u e n t l y associated with or preceeded b y (upper airway) infect i o n s (12), resulting in the local a c t i v a t i o n o f n e u t r o p h i l s followed b y release o f lysozomal enzymes. T h e latter are r a p i d l y inactivated by a n t i p r o t e i n a s e s which reduces local tissue des t r u c t i o n (13). I n the presence o f a u t o a n t i bodies, l y s o z o m a l e n z y m e s m i g h t escape their i n a c t i v a t i o n as a c o n s e q u e n c e o f b i n d i n g to these a u t o a n t i b o d i e s , c o m p a r a b l e to the effect o f a u t o a n t i b o d y to C3 c o n v e r t a s e in patients with m e m b r a n o p r o l i f e r a t i v e g l o m e r u l o n e p h r i t i s (14). As a result, extensive local tissue d e s t r u c t i o n m a y occur as is seen in W G . I n a d d i t i o n , complexed lysozomal enzymes, which are cationic proteins, m a y localize to the p o l y a n i o n i c g l o m e r u l a r basem e n t m e m b r a n e (GBM). S u b s e q u e n t l y , d a m age to the G B M m a y occur as has been dem-
o n s t r a t e d for elastase in vitro (15) a n d for M P O in vivo (16). A l t h o u g h these concepts still have to be p r o v e n , the d a t a presently available are c o m p a t i b l e with a p a t h o p h y s i ological role for the a u t o a n t i b o d i e s in quest i o n (17).
Conclusion The d e m o n s t r a t i o n o f a u t o a n t i b o d i e s to different m y e l o i d lysozomal enzymes has o p e n e d a new area for the study o f vasculitic syndromes. Autoantibodies producing a g r a n u l a r cytoplasmic s t a i n i n g b y I I F (c-ANC A , p r o b a b l y directed to a putative serine protease) are closely associated with Wegener's granulomatosiso A u t o a n t i b o d i e s to myeloperoxydase ( p r o d u c i n g a perinuclear staining by IIF, p - A N C A ) are associated with idiopathic crescentic g l o m e r u l o n e p h r i t i s a n d polyarteriitis n o d o s a / C h u r g Strauss synd r o m e . These strong associations suggest a p a t h o p h y s i o l o g i c a l role for the a u t o a n t i b o d ies in the diseases with which they are associated.
REFERENCES 1.
2.
3.
4.
van Wingerden, I., van der Giessen, M., The, T.H., Rfimke, Ph. Demonstration of circulating immune complexes in melanoma patients by means of a granulocyte phagocytosis test. Protides Biol Fluids, Proceedings 1978, 26, 345-348. van der Woude, F.J., Rasmussen, N., Lobatto, S., Wiik, A., Permin, H., van Es, L.A., van der Giessen, M., van der Hem, G.K. The, T.H. Autoantibodies to neutrophils and monocytes : a new tool for diagnosis and a marker of disease activity in Wegener's Granulomatosis. Lancet 1985, i, 425429. Lfidemann, G., N611e, B., Rautmann, A., Rosenboom, S., Kekow, J., Gross, W.L. ACPA als Seromarker und Aktivit~tsparameter der Wegener'schen Granulomatose: Eine prospektive Studie. Dtsch Med Wochenschr 1988, 113, 413-417. Cohen Tervaert, 3.W., van der Woude, F.J., Fauci, A.S., Ambrus, J.L., Velosa, J., Keane, W.F., Meijer, S., van der Giessen, M. The, T.H. van der
5.
6.
7.
Hem, G.K., Kallenberg, C.G.M. Association between active Wegener's Granulomatosis and anticytoplasmic antibodies (ACPA). Arch Intern Med 1989, 149, 2461-2465. Goldschmeding, R., ten Bokkel Huinink, D., Faber, N., Tetteroo, P.A.T., Vroom, T.M., Hack, C.E., von dem Borne, A.E.G.Kr. Identification of the ANCA-antigen as a novel myeloid lysozomal serine protease. APMIS 1989, 97, $6, 48. Lockwood, C.M., Bakes, D., Jones, S., Whitaker, K.B., Moss, D.W., Savage, C.O.S. Association of alkaline phosphatase with an autoantigen recognized by circulating anti-neutrophil antibodies in systemic vasculitis. Lancet 1987, i, 716-720. Goldschmeding, R., van der Schoot, C.E., van der Snoek, M.A., von dem Borne, A.E.G.Kr. A monoclonal antibody against the 29 KD ANCA-antigen: application as catching antibody in a sandwich-ELISA for ANCA detection. APMIS 1989, 97, $6, 47.
A N C A and vasculitis
8.
Goldschmeding, R., Cohen Tervaert, J.W., van der Schoot, C.E., van der Giessen, M., von dem Borne, A.E.G.Kr., Kallenberg, C.G.M. Autoantibodies against myeloid lysozomal enzymes: a novel class of autoantibodies associated with vasculitic syndromes. Kidney Int 1988, 34, 558. 9. Goldschmeding, R., Cohen Tervaert, J.W., van der Schoot, C.E., van der Veen, C., Kallenberg, C.G.M., yon dem Borne, A.E.G.Kr. ANCA, antimyeloperoxydase, and elastase : three members of a novel class of autoantibodies against myeloid lysozomal enzymes. APMIS 1989, 97, $6, 48-49. 10. Falk, R.J., Jennette, J.C. Anti-neutrophil cytoplasmic autoantibodies with specificity for myeloperoxydase in patients with systemic vasculitis and idiopathic necrotizing and crescentic glomerulonephritis. N Engl J Med 1988, 318, 1651-1657. 11. Cohen Tervaert, J.W., Goldschmeding, R., Elema, J.D., van der Hem, G.K., Kallenberg, C.G.M. Association of segmental crescentic glomerulonephritis with autoantibodies directed against different lysozomal enzymes. Kidney Int 1989, 35, 208. 12. Pinching, A.J., Rees, A.J., Pussell, B.A., Lockwood, C.M., Mitchison, P.S., Peters, D.K. Relaps-
13. 14.
15.
16.
17.
135
es in Wegener's granulomatosis : the role of infection. Br Med J 1980, 281, 836-838. Weiss, S.J. Tissue destruction by neutrophils. N Engl J Med 1989, 320, 365-376. Daha, M.R., van Es, L.A. Further evidence for the antibody nature of C3 nephritic factor (C3NeF). J Immunol 1979, 123, 755-758. Davies, M., Barrett, A.J., Travis, J., Sanders, E., Coles, G.A. The degradation of human glomerular basement membrane with purified lysozomal proteinases : evidence for the pathogenic role of polymorphonuclear leucocyte in glomerulonephritis. Clin Sci Mol Med 1978, 54, 233-240. Johnson, R.J., Guggenheim, S.J., Klebanoff, S.J., et al. Morphologic correlates of glomerular oxidant injury induced by the myeloperoxydase-hydrogen peroxide-halide system of the neutrophil. Lab Invest 1988, 58, 294-301. Kallenberg, C.G.M., Goldschmeding, R., Cohen Tervaert, J.W., von dem Borne, A.E.G.Kr. Autoantibodies to myeloid enzymes : new clues to vasculitis and glomerulonephritis. Neth J Med 1990, in press.
Clinicalrheumatology, 1990, 9, N ~ 1 Suppl. N ~ 1
Antineutrophil cytoplasmic antibodies (ANCA) and vasculitis. C.G.M.
KALLENBERG
D e p a r t m e n t o f Clinical I m m u n o l o g y , Groningen, The Netherlands.
ANCA and Wegener's Granulomatosis Five years ago, Allan Wiik f r o m Copenhagen submitted an abstract to the first European conference on antinuclear antibodies organized by dr. Walravens in Leuven, on the occurrence of autoantibodies reacting with neutrophils in patients with Wegener's granulomatosis (WG). At the same time, Van der W o u d e f r o m our department in Groningen, the Netherlands, in search for circulating immune complexes using the indirect granulocyte phagocytosis test (1), had observed that IgG-class antibodies f r o m patients with W G reacted with the cytoplasm of granulocytes. As a chairman of one of the sections in Leuyen in 1984, I had a preview of the titles of the abstracts, and so I got the opportunity to bring both investigators together at the 1984 meeting in Leuven. Their cooperation resulted in the recognition o f antineutrophil cytoplasmic antibodies (ANCA) as a sensitive and specific m a r k e r for active W G (2). These antibodies produced a granular staining of the cytoplasm of ethanol-fixed granulocytes with accentuation o f the fluorescence within the area surrounded by the nuclear lobes. These original data have been confirmed by m a n y groups. Liidemann et al. (3) described a sensitivity o f A N C A of 100~ for active W G (57 out of 57 patients). Concerning specificity, they found a positive test for A N C A only in 6 cases of polyarteriitis nodosa out of a group of 1600 sera f r o m patients with connective tissue diseases (n = 148), R A (n = 109), glomerulonephritis (n = 107), vasculitis (n = 101), other internal diseases (n = 785) and normal controls (n = 350). A high sensitivity of A N C A for W G (93o70) in combination with a high degree of specificity (97o7o) was also
University Hospital Groningen,
9713 E Z
found in a collaborative study on Dutch and American patients with W G and closely related diseases (4). In all the afore mentioned studies, it was observed that high titres of A N C A were associated with active disease whereas A N C A titres declined during remission of WG. In order to evaluate whether changes in ANCA-titre could predict the occurrence of relapses of WG, we performed a 16 months prospective study on 35 patients with W G (4). Patients were seen monthly at the out-patient clinic and blood was drawn for ANCA-titration. During the study period seventeen relapses were observed which were all preceded (by a mean period of 7 weeks) by a significant rise of the ANCA-titre. Only one patient demonstrated several rises in titre without an ensuing relapse. These results suggest that treatment based on changes in ANCA-titre may prevent relapses of WG. Such a clinical study is going on at present in The Netherlands.
Identification of the target antigen(s) recognized by ANCA The afore mentioned data demonstrate a close relation between A N C A and disease activity. In order to get more insight in the possible pathophysiological role of A N C A for W G studies were performed to characterize the antigen(s) recognized by A N C A (5). For this purpose, nitrogen-cavitated neutrophils were fractionated by density centrifugation into 4 preparations containing the azurophilic or primary granules, the specific granules, the phosphosomes and plasma membranes, and the cytosol, respectively. The ANCA-antigen co-purified with the azuro-
A N C A and vasculitis
philic granules. By Western blotting it was demonstrated that ANCA reacted with a soluble 29-31 KD glycoprotein triplet. Stimulation of cytochalasin B primed neutrophils with fMLP revealed that upon degranulation these cells release the ANCA-antigen. Finally, the ANCA-antigen bound to (tritiated) diisopropylfluorophosphate suggesting that the antigen is a serine protease. This serine protease proved to be different from the two known serine proteases from neutrophil granules, namely elastase and cathepsin G. Thus, the antigen is clearly different from leucocyte alkaline phosphatase, an enzyme present in the phosphosome/plasma membrane fraction that has been suggested as the ANCA-antigen by others (6).
Autoantibodies to myeloperoxidase and elastase
In search for the antigens recognized by ANCA, we observed that monoclonal antibodies to human neutrophil elastase and to myeloperoxidase (MPO) produced a perinuclear staining (p-ANCA) by indirect immunofluorescence on ethanol-fixed granulocytes. This pattern was different from the typical cytoplasmic staining produced by sera from patients with WG (c-ANCA). Interestingly, we had already observed, during routine serum testing for ANCA, that some human sera also produced a perinuclear staining pattern. Next, we developed ELISA's for c-ANCA, anti-MPO- and anti-elastase antibodies using monoclonal antibodies (MoAb 12.8 to c-ANCA-antigen (7), and MoAbs to M P O and human neutrophil elastase) to catch their respective antigens from an extract of azurophilic granules (8). Many sera producing perinuclear staining were, indeed, directed to MPO and some other sera were positive for antielastase antibodies as detected by ELISA, whereas nearly all sera positive for c-ANCA by immunofluorescence gave positive results by ELISA using MoAb 12.8 as catching antibody. The specific binding of these sera to
133
c-ANCA-antigen, M P O and elastase was confirmed by immunoprecipitation experiments (9). Antibodies to M P O were independently described by Falk and Jennette in patients with necrotizing crescentic glomerulonephritis with or without systemic vasculitis (10). To further delineate the clinical significance of autoantibodies to myeloid lysozomal enzymes in patients with crescentic glomerulonephritis (CGN), we tested sera from 35 consecutive patients with CGN with non-diagnostic IF-findings in their renal biopsy for the presence of ANCA, anti-MPO and anti-elastase. A N C A were present in the sera of all 9 patients with CGN as part of biopsy proven WG, in 10 out o f 15 patients with CGN and clinically suspected WG, and in 2 out of 8 patients with idiopathic CGN. The remaining 5 patients with clinically suspected WG and the remaining 6 patients with idiopathic CGN were positive for anti-MPO. In contrast, sera from patients with CGN of infectious origin (n = 3), different forms o f CGN with specific fluorescence findings (n = 7), other renal lesions (n = 34), and normal volunteers (n -- 52) were negative for ANCA and anti-MPO (11). Very recently, we have evaluated the clinical associations of anti-MPO. Anti-MPO were detected not only in the sera from patients with CGN with or without vasculitis, but also in sera from patients with polyarteriitis nodosa and the Churg-Strauss syndrome. These findings place the idiopathic vasculitic syndromes in a spectrum comparable with that of the connective tissue diseases. Biopsyproven WG with granulomatous vasculitis stands on one side of the spectrum and is strongly associated with autoantibodies to a putative serine protease ("29 KD A N C A " or c-ANCA), whereas polyarteriitis nodosa and the Churg-Strauss syndrome constitute the other side of the spectrum and are associated with autoantibodies to MPO. Overlap syndromes with CGN and signs of systemic vasculitis ("microscopic polyarteriitis"), associ-
134
C.G.M. Kallenberg
ated with c - A N C A or a n t i - M P O , are in between.
A u t o a n t i b o d i e s to m y e l o i d l y s o z o m a i enzymes - pathophysiological considerations Relapses o f W G are f r e q u e n t l y associated with or preceeded b y (upper airway) infect i o n s (12), resulting in the local a c t i v a t i o n o f n e u t r o p h i l s followed b y release o f lysozomal enzymes. T h e latter are r a p i d l y inactivated by a n t i p r o t e i n a s e s which reduces local tissue des t r u c t i o n (13). I n the presence o f a u t o a n t i bodies, l y s o z o m a l e n z y m e s m i g h t escape their i n a c t i v a t i o n as a c o n s e q u e n c e o f b i n d i n g to these a u t o a n t i b o d i e s , c o m p a r a b l e to the effect o f a u t o a n t i b o d y to C3 c o n v e r t a s e in patients with m e m b r a n o p r o l i f e r a t i v e g l o m e r u l o n e p h r i t i s (14). As a result, extensive local tissue d e s t r u c t i o n m a y occur as is seen in W G . I n a d d i t i o n , complexed lysozomal enzymes, which are cationic proteins, m a y localize to the p o l y a n i o n i c g l o m e r u l a r basem e n t m e m b r a n e (GBM). S u b s e q u e n t l y , d a m age to the G B M m a y occur as has been dem-
o n s t r a t e d for elastase in vitro (15) a n d for M P O in vivo (16). A l t h o u g h these concepts still have to be p r o v e n , the d a t a presently available are c o m p a t i b l e with a p a t h o p h y s i ological role for the a u t o a n t i b o d i e s in quest i o n (17).
Conclusion The d e m o n s t r a t i o n o f a u t o a n t i b o d i e s to different m y e l o i d lysozomal enzymes has o p e n e d a new area for the study o f vasculitic syndromes. Autoantibodies producing a g r a n u l a r cytoplasmic s t a i n i n g b y I I F (c-ANC A , p r o b a b l y directed to a putative serine protease) are closely associated with Wegener's granulomatosiso A u t o a n t i b o d i e s to myeloperoxydase ( p r o d u c i n g a perinuclear staining by IIF, p - A N C A ) are associated with idiopathic crescentic g l o m e r u l o n e p h r i t i s a n d polyarteriitis n o d o s a / C h u r g Strauss synd r o m e . These strong associations suggest a p a t h o p h y s i o l o g i c a l role for the a u t o a n t i b o d ies in the diseases with which they are associated.
REFERENCES 1.
2.
3.
4.
van Wingerden, I., van der Giessen, M., The, T.H., Rfimke, Ph. Demonstration of circulating immune complexes in melanoma patients by means of a granulocyte phagocytosis test. Protides Biol Fluids, Proceedings 1978, 26, 345-348. van der Woude, F.J., Rasmussen, N., Lobatto, S., Wiik, A., Permin, H., van Es, L.A., van der Giessen, M., van der Hem, G.K. The, T.H. Autoantibodies to neutrophils and monocytes : a new tool for diagnosis and a marker of disease activity in Wegener's Granulomatosis. Lancet 1985, i, 425429. Lfidemann, G., N611e, B., Rautmann, A., Rosenboom, S., Kekow, J., Gross, W.L. ACPA als Seromarker und Aktivit~tsparameter der Wegener'schen Granulomatose: Eine prospektive Studie. Dtsch Med Wochenschr 1988, 113, 413-417. Cohen Tervaert, 3.W., van der Woude, F.J., Fauci, A.S., Ambrus, J.L., Velosa, J., Keane, W.F., Meijer, S., van der Giessen, M. The, T.H. van der
5.
6.
7.
Hem, G.K., Kallenberg, C.G.M. Association between active Wegener's Granulomatosis and anticytoplasmic antibodies (ACPA). Arch Intern Med 1989, 149, 2461-2465. Goldschmeding, R., ten Bokkel Huinink, D., Faber, N., Tetteroo, P.A.T., Vroom, T.M., Hack, C.E., von dem Borne, A.E.G.Kr. Identification of the ANCA-antigen as a novel myeloid lysozomal serine protease. APMIS 1989, 97, $6, 48. Lockwood, C.M., Bakes, D., Jones, S., Whitaker, K.B., Moss, D.W., Savage, C.O.S. Association of alkaline phosphatase with an autoantigen recognized by circulating anti-neutrophil antibodies in systemic vasculitis. Lancet 1987, i, 716-720. Goldschmeding, R., van der Schoot, C.E., van der Snoek, M.A., von dem Borne, A.E.G.Kr. A monoclonal antibody against the 29 KD ANCA-antigen: application as catching antibody in a sandwich-ELISA for ANCA detection. APMIS 1989, 97, $6, 47.
A N C A and vasculitis
8.
Goldschmeding, R., Cohen Tervaert, J.W., van der Schoot, C.E., van der Giessen, M., von dem Borne, A.E.G.Kr., Kallenberg, C.G.M. Autoantibodies against myeloid lysozomal enzymes: a novel class of autoantibodies associated with vasculitic syndromes. Kidney Int 1988, 34, 558. 9. Goldschmeding, R., Cohen Tervaert, J.W., van der Schoot, C.E., van der Veen, C., Kallenberg, C.G.M., yon dem Borne, A.E.G.Kr. ANCA, antimyeloperoxydase, and elastase : three members of a novel class of autoantibodies against myeloid lysozomal enzymes. APMIS 1989, 97, $6, 48-49. 10. Falk, R.J., Jennette, J.C. Anti-neutrophil cytoplasmic autoantibodies with specificity for myeloperoxydase in patients with systemic vasculitis and idiopathic necrotizing and crescentic glomerulonephritis. N Engl J Med 1988, 318, 1651-1657. 11. Cohen Tervaert, J.W., Goldschmeding, R., Elema, J.D., van der Hem, G.K., Kallenberg, C.G.M. Association of segmental crescentic glomerulonephritis with autoantibodies directed against different lysozomal enzymes. Kidney Int 1989, 35, 208. 12. Pinching, A.J., Rees, A.J., Pussell, B.A., Lockwood, C.M., Mitchison, P.S., Peters, D.K. Relaps-
13. 14.
15.
16.
17.
135
es in Wegener's granulomatosis : the role of infection. Br Med J 1980, 281, 836-838. Weiss, S.J. Tissue destruction by neutrophils. N Engl J Med 1989, 320, 365-376. Daha, M.R., van Es, L.A. Further evidence for the antibody nature of C3 nephritic factor (C3NeF). J Immunol 1979, 123, 755-758. Davies, M., Barrett, A.J., Travis, J., Sanders, E., Coles, G.A. The degradation of human glomerular basement membrane with purified lysozomal proteinases : evidence for the pathogenic role of polymorphonuclear leucocyte in glomerulonephritis. Clin Sci Mol Med 1978, 54, 233-240. Johnson, R.J., Guggenheim, S.J., Klebanoff, S.J., et al. Morphologic correlates of glomerular oxidant injury induced by the myeloperoxydase-hydrogen peroxide-halide system of the neutrophil. Lab Invest 1988, 58, 294-301. Kallenberg, C.G.M., Goldschmeding, R., Cohen Tervaert, J.W., von dem Borne, A.E.G.Kr. Autoantibodies to myeloid enzymes : new clues to vasculitis and glomerulonephritis. Neth J Med 1990, in press.
