Test Catalog

Test Id : CTDC

Connective Tissue Diseases Cascade, Serum

Useful For
Suggests clinical disorders or settings where the test may be helpful

Evaluation of patients with signs and symptoms compatible with connective tissue diseases

 

Initial evaluation of patients in clinical situations in which the prevalence of disease is low (6)

 

This test is not recommended for:

-Testing in clinical situations in which there is a high prevalence of connective tissue diseases (eg, rheumatology specialty practice)

-Follow-up evaluation of patients with known connective tissue diseases

Profile Information
A profile is a group of laboratory tests that are ordered and performed together under a single Mayo Test ID. Profile information lists the test performed, inclusive of the test fee, when a profile is ordered and includes reporting names and individual availability.

Test Id Reporting Name Available Separately Always Performed
ANA2 Antinuclear Ab, S Yes Yes
CCP Cyclic Citrullinated Peptide Ab, S Yes Yes
IM_01 Interpretation No Yes

Reflex Tests
Lists tests that may or may not be performed, at an additional charge, depending on the result and interpretation of the initial tests.

Test Id Reporting Name Available Separately Always Performed
CMA Centromere Ab, IgG, S Yes No
CASMT ANA2 Cascade No No
RIB Ribosome P Ab, IgG, S Yes No
ENAE Ab to Extractable Nuclear Ag Eval,S Yes No
CRITH dsDNA Ab by Crithidia IFA, IgG, S No No
ADNAR dsDNA Ab with Reflex, IgG, S Yes No

Testing Algorithm
Delineates situations when tests are added to the initial order. This includes reflex and additional tests.

If antinuclear antibodies are greater than or equal to 3.0 U, then antibodies to double-stranded DNA (dsDNA), extractable nuclear antigen evaluation, ribosome P, and centromere are performed at an additional charge.

 

If result from dsDNA test is borderline, then dsDNA antibody by the Crithidia immunofluorescence assay will be performed at an additional charge.

 

For more information see Connective Tissue Disease Cascade.

Special Instructions
Library of PDFs including pertinent information and forms related to the test

Method Name
A short description of the method used to perform the test

Enzyme-Linked Immunosorbent Assay (ELISA)

NY State Available
Indicates the status of NY State approval and if the test is orderable for NY State clients.

Yes

Reporting Name
Lists a shorter or abbreviated version of the Published Name for a test

Connective Tissue Disease Cascade,S

Aliases
Lists additional common names for a test, as an aid in searching

Ab to Extractable Nuclear Ag

ANA (Antinuclear Antibodies)

ANA Reflex Testing

ANA Test algorithm

Anti-CCP (Cyclic Citrullinated Peptide)

Anti-Citrullinated Antibody

Anti-Cyclic Citrullinated Peptide (CCP)

Anti-DNA

Anti-ds (Anti-Double-Stranded) DNA

Anti-ENA (Antibodies to Extractable Nuclear Antigens)

Anti-La

Anti-Ribonuclear Protein

Anti-Ribosome P Antibodies

Anti-RNP (Anti-Ribonucleoprotein)

Anti-Ro

Anti-Sjogren's Syndrome

Anti-Sm (Smith)

Anti-Smith (Sm) Antigen

Anti-SSA (Anti-Sjogren's Syndrome A)

Anti-SSB (Anti-Sjogren's Syndrome B)

Anti-U(1)RNP (Anti-Ribonucleoprotein)

Antibodies to Extractable Nuclear Antigens

Antibody to Native DNA (n-DNA)

Antinuclear Antibodies (ANA)

Autoantibodies to Jo 1 Antigen

Autoantibodies to Jo1

Autoantibodies to Scl 70

Autoantibodies to Scl 70 Antigen

Autoantibodies to Sm (Smith)

Autoantibodies to SSA (Ro)

Autoantibodies to SSB (La)

Autoantibodies to U(1)RNP

Cascade

CCP (Cyclic Citrullinated Peptide)

Centromere Antibodies, IgG

Citrullinated Antibody

Connective Tissue

Connective Tissue Disease algorithm

Connective Tissue Disease panel

Cyclic Citrullinated Peptide Antibodies

DNA Double-Stranded (ds-DNA) Antibody

DNA Topoisomerase 1 Antibodies

DNA, Anti

ENA (Extractable Nuclear Antigens), Anti

Extractable Nuclear Antigens, Anti

Histidyl-tRNA Synthetase Antibodies

Jo 1 Antibodies

La (Anti-SSB)

LE (Lupus Erythematosus)

Lupus

Lupus algorithm

Lupus Cascade

Lupus Erythematosus (LE)

Lupus Profile

Polymyositis Antibodies

Ribonucleoprotein (RNP) Autoantibodies

RNA (Ribonucleoprotein) Autoantibodies)

Ro (Anti-SSA)

Scl 70 Antibodies

Scleroderma Antibodies

Sjogren's Syndrome

SLE (Systemic Lupus Erythematosus)

Sm (Anti-Sm) Smith

Smith Antigen, Anti

SmRNP Autoantibodies

SSA (Anti-SSA)

SSB (Anti-SSB)

Systemic Lupus Erythematosus (SLE)

Tissue, Connective

Topoisomerase 1 Antibodies

U(1)RNP (Ribonucleoprotein) Autoantibodies

Antinuclear Antibody

Anti Citrulline

Testing Algorithm
Delineates situations when tests are added to the initial order. This includes reflex and additional tests.

If antinuclear antibodies are greater than or equal to 3.0 U, then antibodies to double-stranded DNA (dsDNA), extractable nuclear antigen evaluation, ribosome P, and centromere are performed at an additional charge.

 

If result from dsDNA test is borderline, then dsDNA antibody by the Crithidia immunofluorescence assay will be performed at an additional charge.

 

For more information see Connective Tissue Disease Cascade.

Specimen Type
Describes the specimen type validated for testing

Serum

Specimen Required
Defines the optimal specimen required to perform the test and the preferred volume to complete testing

Collection Container/Tube:

Preferred: Serum gel

Acceptable: Red top

Submission Container/Tube: Plastic vial

Specimen Volume: 1 mL

Collection Information: Centrifuge and aliquot serum into plastic vial.

Special Instructions
Library of PDFs including pertinent information and forms related to the test

Specimen Minimum Volume
Defines the amount of sample necessary to provide a clinically relevant result as determined by the Testing Laboratory

0.7 mL

Reject Due To
Identifies specimen types and conditions that may cause the specimen to be rejected

Gross hemolysis Reject
Gross lipemia Reject
Gross icterus OK

Specimen Stability Information
Provides a description of the temperatures required to transport a specimen to the performing laboratory, alternate acceptable temperatures are also included

Specimen Type Temperature Time Special Container
Serum Refrigerated (preferred) 21 days
Frozen 21 days

Useful For
Suggests clinical disorders or settings where the test may be helpful

Evaluation of patients with signs and symptoms compatible with connective tissue diseases

 

Initial evaluation of patients in clinical situations in which the prevalence of disease is low (6)

 

This test is not recommended for:

-Testing in clinical situations in which there is a high prevalence of connective tissue diseases (eg, rheumatology specialty practice)

-Follow-up evaluation of patients with known connective tissue diseases

Testing Algorithm
Delineates situations when tests are added to the initial order. This includes reflex and additional tests.

If antinuclear antibodies are greater than or equal to 3.0 U, then antibodies to double-stranded DNA (dsDNA), extractable nuclear antigen evaluation, ribosome P, and centromere are performed at an additional charge.

 

If result from dsDNA test is borderline, then dsDNA antibody by the Crithidia immunofluorescence assay will be performed at an additional charge.

 

For more information see Connective Tissue Disease Cascade.

Clinical Information
Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

The following diseases are often referred to as connective tissue diseases (CTD): rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis including CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), Sjogren syndrome, mixed connective tissue disease, and idiopathic inflammatory myopathies. CTD (also known as systemic rheumatic diseases) are characterized by immune-mediated inflammation that involves the joints, skin, and visceral organs. These diseases are also accompanied by antibodies to a host of nuclear and cytoplasmic autoantigens.

 

The diagnosis of any CTD is based on clinical signs and symptoms and characteristic radiographic, histopathologic, and serologic findings. Certain CTD are characterized by autoantibodies that are highly specific for individual diseases as outlined in the Table. CTD often present clinically with signs and symptoms that are nonspecific, including constitutional signs such as fever, weight loss, fatigue, and arthralgias.

 

Table. Autoantibodies and Clinical Associations with Specific Connective Tissue Diseases

Cyclic citrullinated peptide antibodies

Rheumatoid arthritis

Double-Stranded DNA (dsDNA)

Systemic lupus erythematosus (SLE)

Smith (Sm)

SLE

Ribosome P

SLE

SS-B/La

Sjogren syndrome (SjS)

SS-A/Ro (Ro52 or Ro60)

SjS, SLE, systemic sclerosis (SSc), antisynthetase syndrome

RNP 68 and A (RNP)

Mixed connective tissue disease

Topoisomerase 1 (topo-1, Scl-70)

SSc

Histidyl tRNA synthetase (JO1)

Idiopathic inflammatory myositis (commonly anti-synthetase syndrome)

Centromere B

SSc (most commonly the limited cutaneous forms: LcSSc)

 

In this testing cascade, serum is tested initially for the presence of antinuclear antibodies (ANA) and for cyclic citrullinated peptide (CCP) antibodies. The presence of CCP antibodies indicates a strong likelihood of rheumatoid arthritis (RA).(1) However, additional testing for rheumatoid factor, which is not included in the cascade, is important for optimal diagnosis as per the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria.(2) The presence of ANA supports the possibility of a CTD, and the level of ANA is used to identify sera for second-order testing for antibodies to dsDNA and the other autoantigens. The decision threshold for performing second-order tests is based on empirical data derived from testing patients with varying levels of ANA and is chosen to minimize testing in situations in which positive results for dsDNA and other antibodies is very unlikely.(3) However, a negative ANA enzyme immunoassay result does not rule out a diagnosis of CTD as has been reported in a number of studies. Therefore, in patients with a strong clinical suspicion of CTD, testing for ANA by indirect immunofluorescence assay may be warranted.(4,5)

Reference Values
Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.

ANTINUCLEAR ANTIBODIES (ANA)

< or =1.0 U (negative)

1.1-2.9 U (weakly positive)

3.0-5.9 U (positive)

> or =6.0 U (strongly positive)

Reference values apply to all ages.

 

CYCLIC CITRULLINATED PEPTIDE ANTIBODIES, IgG

<20.0 U (negative)

20.0-39.9 U (weak positive)

40.0-59.9 U (positive)

> or =60.0 U (strong positive) 

Reference values apply to all ages.

Interpretation
Provides information to assist in interpretation of the test results

Interpretive comments are provided.

 

See individual test IDs for additional information.

 

Differential testing for Ro52 and Ro60 antibodies in SS-A/Ro positive patients may be useful in the diagnosis of specific CTD clinical subset, disease stratification, and prognosis. Consider testing for Ro52 and Ro60 antibodies (ROPAN / Ro52 and Ro60 Antibodies, IgG, Serum) if the patient is positive for SS-A/Ro.

Cautions
Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances

The results of tests for autoantibodies must be interpreted in the appropriate clinical context.

 

The presence of detectable levels of antinuclear antibodies (ANA) in solid-phase immunoassays, such as enzyme-linked immunosorbent assay (ELISA), is not specific for connective tissue disease.

 

Positive results may occur prior to onset of clinical diseases as well as in the absence of connective tissue disease.

 

Negative ANA by ELISA results may not be reliable for the evaluation of patients at-risk for systemic sclerosis and inflammatory myopathies.

 

Weak-to-moderate positive results for cyclic citrullinated peptide antibodies may occur in patients with connective tissue diseases other than rheumatoid arthritis.

Clinical Reference
Recommendations for in-depth reading of a clinical nature

1. Tomar R, Homburger H: Assessment of immunoglobulins and antibodies. In: Rich R, Fleisher T, Shearer W, et al, eds. Clinical Immunology: Principles and Practice. 2nd ed. Mosby-Year Book Inc; 2001:120.1-120.14

2. Aletaha D, Neogi T, Silman AJ, et al: 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569-2581

3. Deng X, Peters B, Ettore MW, et al: Utility of antinuclear antibody screening by various methods in a clinical laboratory patient cohort. J Appl Lab Med. 2016 Jul 1;1(1):36-46

4. Pisetky DS, Spencer DM, Lipsky PE, Rovin BH: Assay variation in the detection of antinuclear antibodies in the sera of patients with established SLE. Ann Rheum Dis. 2018 Jun;77(6):911-913

5. Claessens J, Belmondo T, De Langhe E, et al: Solid phase assays versus automated indirect immunofluorescence for detection of antinuclear antibodies. Autoimmun Rev. 2018 Jun;17(6):533-540

6. van Boekel MAM, Vossenaar ER, van den Hoogen FHJ, van Venrooij WJ: Autoantibody systems in rheumatoid arthritis: specificity, sensitivity and diagnostic value. Arthritis Res. 2002;4(2):87-93

7. Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA: Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. Arch Pathol Lab Med. 2000 Jan;124(1):71-81

Special Instructions
Library of PDFs including pertinent information and forms related to the test

Method Description
Describes how the test is performed and provides a method-specific reference

Antinuclear Antibodies:

The method used to detect antinuclear antibodies (ANA) is enzyme-linked immunosorbent assay (ELISA). A HEp-2 lysate supplemented with specific purified antigens (double-stranded [ds] DNA, histone, SS-A [Ro], SS-B [La], Smith, sm/RNP, Scl-70, Jo-1, and centromere B antigen) are coated onto microtiter plate wells. A dilution of patient serum is added to the well and incubated. After washing to remove unbound serum protein, an enzyme conjugated antihuman IgG antibody is added to detect human IgG bound to the microtiter plate well. After incubation and washing to remove unbound conjugate, a substrate to the enzyme is added to the well. After incubation, the enzyme substrate reaction is stopped. The complete assay is measured on a spectrophotometer plate reader. The optical density measured is proportional to the antibody present in the patient serum. Testing is performed on the Agility instrument by Dynex.(Package insert: ELISA kits. Bio-Rad Laboratories; 07/2014)

 

Cyclic Citrullinated Peptide:

Cyclic citrullinated peptide (CCP) antibodies in serum are detected by binding to the wells of a commercial microtiter plate coated with synthetic CCP. During the first incubation, serum antibodies bind to adsorbed, solid phase CCP. The wells are then washed to remove unbound serum constituents, and horse radish peroxidase-labeled goat anti-human IgG antibody is added. After further incubation and washing to remove unbound conjugate, substrate (3,3',5,5'-tetramethylbenzidine) is added and allowed to incubate. The reaction between enzyme and substrate is stopped and color in the wells is measured in a microtiter plate reader. The concentration of CCP antibodies is determined by comparison to a 5 point standard curve (15.6-250 U). Testing is performed on the Agility instrument by Dynex.(Package insert: Quanta Lite CCP3 IgG ELISA. INOVA Diagnostics; 02/2020)

 

dsDNA:

Microwells are precoated with calf thymus dsDNA antigen. The calibrators, controls, and diluted patient samples are added to the wells and autoantibodies recognizing the dsDNA antigen bind during the first incubation. After washing the wells to remove all unbound proteins, purified peroxidase-labeled goat antihuman IgG conjugate is added. The conjugate binds to the captured human autoantibody, and the excess unbound conjugate is removed by a further wash step. The bound conjugate is visualized with 3,3',5,5'-tetramethylbenzidine substrate, which gives a blue reaction product, the intensity of which is proportional to a concentration of autoantibody in the sample. Sulfuric acid is added to each well to stop the reaction. This produces a yellow end-point color, which is read at 450 nm.(Package insert: QUANTA Lite dsDNA SC ELISA. INOVA Diagnostics Inc; 08/2018)

 

Confirmatory testing for borderline dsDNA by ELISA testing is performed by immunofluorescence assay. Autoantibodies in the test specimen bind to the kinetoplast of Crithidia luciliae, a flagellate parasite which is bound to the slide. Washing removes excess serum from the substrate. Fluorescein-conjugated antiserum added to the substrate attaches to the bound autoantibody. After a second washing step to remove excess conjugate, the substrate is coverslipped and viewed for fluorescent patterns with a fluorescent microscope. Observation of specific fluorescent patterns on the substrate indicates the presence of autoantibodies in the test sample.(Package insert: Bio-Rad Kallestad Crithidia luciliae Substrate. Bio-Rad Laboratories; 06/2015)

 

SS-A/Ro, SS-B/La, RNP, Sm, Scl 70, Jo 1, ribosome P, and centromere B antibodies are measured by a commercial multiplex flow immunoassay system. Recombinant or purified antigens are coupled covalently to polystyrene microspheres that are impregnated with fluorescent dyes to create unique fluorescent signatures, one microsphere type for each antigen. Diluted sera, calibrators, and controls are added to a mixture containing the antigen-coupled microspheres. Antibodies to each antigen bind to their homologous antigen-coupled microspheres. The microspheres are washed to remove extraneous serum proteins. Phycoerythrin (PE)-conjugated antihuman IgG antibody is then added to detect IgG antibodies bound to the microspheres. The microspheres are washed to remove unbound conjugate, and bound conjugate is detected by laser photometry. A primary laser determines the fluorescent signature of each microsphere, and a secondary laser reveals the level of PE fluorescence associated with the microsphere surface. Results are calculated for each antigen-coated microsphere type by comparing the median fluorescence response to a series of multipoint calibration curves.(Package insert: BioPlex 2200 ANA Screen. Bio-Rad Laboratories; 2019)

PDF Report
Indicates whether the report includes an additional document with charts, images or other enriched information

No

Day(s) Performed
Outlines the days the test is performed. This field reflects the day that the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time before the test is performed. Some tests are listed as continuously performed, which means that assays are performed multiple times during the day.

Monday through Saturday

Report Available
The interval of time (receipt of sample at Mayo Clinic Laboratories to results available) taking into account standard setup days and weekends. The first day is the time that it typically takes for a result to be available. The last day is the time it might take, accounting for any necessary repeated testing.

3 to 4 days

Specimen Retention Time
Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded

14 days

Performing Laboratory Location
Indicates the location of the laboratory that performs the test

Rochester

Fees
Several factors determine the fee charged to perform a test. Contact your U.S. or International Regional Manager for information about establishing a fee schedule or to learn more about resources to optimize test selection.

  • Authorized users can sign in to Test Prices for detailed fee information.
  • Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
  • Prospective clients should contact their Regional Manager. For assistance, contact Customer Service.

Test Classification
Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR) product.

This test has been cleared, approved, or is exempt by the US Food and Drug Administration and is used per manufacturer's instructions. Performance characteristics were verified by Mayo Clinic in a manner consistent with CLIA requirements.

CPT Code Information
Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Clinic Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.

CPT codes are provided by the performing laboratory.

86038

86200

83516-Centromere (if appropriate)

83516-Ribosome (if appropriate)

86225-ds-DNA Ab with Reflex (if appropriate)

86255-ds-DNA Ab by Crithidia IFA (if appropriate)

86235 x 6-RNP, Sm, SS-B, SS-A, Jo 1, and Scl 70 (if appropriate)

LOINC® Information
Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the order and results codes of this test. LOINC values are provided by the performing laboratory.

Test Id Test Order Name Order LOINC Value
CTDC Connective Tissue Disease Cascade,S 95267-1
Result Id Test Result Name Result LOINC Value
Applies only to results expressed in units of measure originally reported by the performing laboratory. These values do not apply to results that are converted to other units of measure.
ANA2 Antinuclear Ab, S 94875-2
CCP Cyclic Citrullinated Peptide Ab, S 94874-5
IM_01 Interpretation 69048-7

Test Setup Resources

Setup Files
Test setup information contains test file definition details to support order and result interfacing between Mayo Clinic Laboratories and your Laboratory Information System.

Excel | Pdf

Sample Reports
Normal and Abnormal sample reports are provided as references for report appearance.

Normal Reports | Abnormal Reports

SI Sample Reports
International System (SI) of Unit reports are provided for a limited number of tests. These reports are intended for international account use and are only available through MayoLINK accounts that have been defined to receive them.

SI Normal Reports | SI Abnormal Reports