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Gosselin RC, Moore GW, Kershaw GW, Montalvão S, Adcock DM. International Council for Standardization in Haematology Field Study Evaluating Optimal Interpretation Methods for Activated Partial Thromboplastin Time and Prothrombin Time Mixing Studies. Arch Pathol Lab Med 2024; 148:880-889. [PMID: 38031817 DOI: 10.5858/arpa.2023-0030-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 12/01/2023]
Abstract
CONTEXT.— The prothrombin time (PT) and activated partial thromboplastin time (APTT) are screening tests used to detect congenital or acquired bleeding disorders. An unexpected PT and/or APTT prolongation is often evaluated using a mixing test with normal plasma. Failure to correct ("noncorrection") prolongation upon mixing is attributed to an inhibitor, whereas "correction" points to factor deficiency(ies). OBJECTIVE.— To define an optimal method for determining correction or noncorrection of plasma mixing tests through an international, multisite study that used multiple PT and APTT reagents and well-characterized plasma samples. DESIGN.— Each testing site was provided 22 abnormal and 25 normal donor plasma samples, and mixing studies were performed using local PT and APTT reagents. Mixing study results were evaluated using 11 different calculation methods to assess the optimal method based on the expected interpretation for factor deficiencies (correction) and noncorrection (inhibitor effect). Misprediction, which represents the failure of a mixing study interpretation method, was assessed. RESULTS.— Percentage correction was the most suitable calculation method for interpreting PT mixing test results for nearly all reagents evaluated. Incubated PT mixing tests should not be performed. For APTT mixing tests, percentage correction should be performed, and if the result indicates a factor deficiency, this should be confirmed with the subtraction III calculation where the normal pooled plasma result (run concurrently) is subtracted from the mixing test result with correction indicated by a result of 0 or less. In general, other calculation methods evaluated that performed well in the identification of factor deficiency tended to have high misprediction rates for inhibitors and vice versa. CONCLUSIONS.— No single method of mixing test result calculation was consistently successful in accurately distinguishing factor deficiencies from inhibitors, with between-reagent and between-site variability also identified.
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Affiliation(s)
- Robert C Gosselin
- From the Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento (Gosselin)
| | - Gary W Moore
- the Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Moore)
- the Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, United Kingdom (Moore)
| | - Geoffrey W Kershaw
- the Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (Kershaw)
| | - Silmara Montalvão
- Laboratory Hemostasis and Thrombosis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas-SP, Brazil (Montalvão)
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Adcock DM, Moore GW, Kershaw GW, Montalvao SAL, Gosselin RC. International Council for Standardization in Haematology (ICSH) recommendations for the performance and interpretation of activated partial thromboplastin time and prothrombin time mixing tests. Int J Lab Hematol 2024. [PMID: 39009028 DOI: 10.1111/ijlh.14344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024]
Abstract
This guidance document has been prepared on behalf of the International Council for Standardization in Haematology (ICSH). The aim of the document is to provide guidance and recommendations for the performance and interpretation of activated partial thromboplastin time (APTT) and prothrombin time (PT) plasma mixing tests in clinical laboratories in all regions of the world. The following areas are included in this document: preanalytical, analytical, postanalytical, and quality assurance considerations as they relate to the proper performance and interpretation of plasma mixing tests. The recommendations are based on good laboratory practice, published data in peer-reviewed literature, and expert opinion.
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Affiliation(s)
- D M Adcock
- Retired Labcorp, Burlington, North Carolina, USA
| | - G W Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals Foundation Trust, Cambridge, UK
- Department of Natural Sciences, Middlesex University, London, UK
| | - G W Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S A L Montalvao
- Laboratory Hemostasis and Thrombosis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas, Brazil
| | - R C Gosselin
- Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California, USA
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Rabichow L, Dinh J, Nguyen L, Qiao J. In vitro differential inhibition of the factor XI activity assay in the setting of a lupus anticoagulant. Blood Coagul Fibrinolysis 2024; 35:217-222. [PMID: 38358905 DOI: 10.1097/mbc.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Acquired factor XI deficiencies due to factor-specific inhibitors are rare and may be associated with lupus anticoagulant. We report a 63-year-old male with suspected postsurgical bleeding, prior surgical site infection, an isolated prolonged activated partial thromboplastin time, and a positive lupus anticoagulant. Although the factor II assay was normal, factor VIII and IX assays initially demonstrated nonparallelism with factor activity that consistently increased to normal reference ranges with serial dilutions. A discrepancy in factor XI activity results was discovered when the in-house method demonstrated undetectable activity (<3%); send-out testing using different instrument/reagent combinations revealed the presence of factor XI activity between 70% and 76%. The patient received surgical follow-up and was subsequently discharged home. Given the differential in vitro inhibition of factor XI activity on our initial in-house testing, this case highlights the importance of recognizing factor assay interference in the presence of a known lupus anticoagulant inhibitor, with strategies to mitigate potentially erroneous results.
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Affiliation(s)
| | | | | | - Jesse Qiao
- Department of Pathology and Laboratory Medicine, University of California, Irvine, Orange, California, USA
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Terrett JA, Ly JQ, Katavolos P, Hasselgren C, Laing S, Zhong F, Villemure E, Déry M, Larouche-Gauthier R, Chen H, Shore DG, Lee WP, Suto E, Johnson K, Brooks M, Stablein A, Beaumier F, Constantineau-Forget L, Grand-Maître C, Lépissier L, Ciblat S, Sturino C, Chen Y, Hu B, Elstrott J, Gandham V, Joseph V, Booler H, Cain G, Chou C, Fullerton A, Lepherd M, Stainton S, Torres E, Urban K, Yu L, Zhong Y, Bao L, Chou KJ, Lin J, Zhang W, La H, Liu L, Mulder T, Chen J, Chernov-Rogan T, Johnson AR, Hackos DH, Leahey R, Shields SD, Balestrini A, Riol-Blanco L, Safina BS, Volgraf M, Magnuson S, Kakiuchi-Kiyota S. Discovery of TRPA1 Antagonist GDC-6599: Derisking Preclinical Toxicity and Aldehyde Oxidase Metabolism with a Potential First-in-Class Therapy for Respiratory Disease. J Med Chem 2024; 67:3287-3306. [PMID: 38431835 DOI: 10.1021/acs.jmedchem.3c02121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Transient receptor potential ankyrin 1 (TRPA1) is a nonselective calcium ion channel highly expressed in the primary sensory neurons, functioning as a polymodal sensor for exogenous and endogenous stimuli, and has been implicated in neuropathic pain and respiratory disease. Herein, we describe the optimization of potent, selective, and orally bioavailable TRPA1 small molecule antagonists with strong in vivo target engagement in rodent models. Several lead molecules in preclinical single- and short-term repeat-dose toxicity studies exhibited profound prolongation of coagulation parameters. Based on a thorough investigative toxicology and clinical pathology analysis, anticoagulation effects in vivo are hypothesized to be manifested by a metabolite─generated by aldehyde oxidase (AO)─possessing a similar pharmacophore to known anticoagulants (i.e., coumarins, indandiones). Further optimization to block AO-mediated metabolism yielded compounds that ameliorated coagulation effects in vivo, resulting in the discovery and advancement of clinical candidate GDC-6599, currently in Phase II clinical trials for respiratory indications.
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Affiliation(s)
| | | | | | | | | | | | | | - Martin Déry
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | | | | | | | | | | | | | - Marjory Brooks
- Department of Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York 14853, United States
| | - Alyssa Stablein
- Department of Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York 14853, United States
| | - Francis Beaumier
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | | | - Chantal Grand-Maître
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | - Luce Lépissier
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | - Stéphane Ciblat
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | - Claudio Sturino
- Paraza Pharma, Incorporated, 2525 Avenue Marie-Curie, Montreal, Quebec H4S 2E1, Canada
| | - Yong Chen
- Pharmaron-Beijing Company Limited, 6 Taihe Road BDA, Beijing 100176, PR China
| | - Baihua Hu
- Pharmaron-Beijing Company Limited, 6 Taihe Road BDA, Beijing 100176, PR China
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Favaloro EJ, Pasalic L, Selby R. Testing for the lupus anticoagulant: the good, the bad, and the ugly. Res Pract Thromb Haemost 2024; 8:102385. [PMID: 38623474 PMCID: PMC11017341 DOI: 10.1016/j.rpth.2024.102385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024] Open
Abstract
Lupus anticoagulant (LA) represents 1 of the laboratory criteria for classification of patients as having definite antiphospholipid syndrome (APS). The other 2 laboratory criteria are anticardiolipin antibodies and anti-beta2-glycoprotein I antibodies. At least 1 of these antiphospholipid antibody (aPL) tests need to be positive, with evidence of persistence, together with evidence of at least 1 clinical criterion for APS, before a patient can be classified as having definite APS. LA and other aPL assays are also important for diagnosis or exclusion of APS, as well as for risk stratification, with triple-positive patients carrying the greatest risk. Whereas LA is identified through "uncalibrated" clot-based assays, the other aPL assays (anticardiolipin and anti-beta2-glycoprotein I antibodies) represent immunological assays, identified using calibrated solid-phase methods. Because LA is identified using clot-based assays, it is subject to considerable preanalytical and analytical issues that challenge accurate detection or exclusion of LA. In this narrative review, we take a look at the good, the bad, and the ugly of LA testing, primarily focusing on the last 10 years. Although harmonization of LA testing as a result of International Society on Thrombosis and Haemostasis guidance documents and other international activities has led to improvements in LA detection, many challenges remain. In particular, several anticoagulants, especially direct oral anticoagulants and also vitamin K antagonists, given as therapy to treat the pathophysiological consequences of aPL, especially thrombosis, interfere with LA assays and can generate false-positive or false-negative LA findings. Overcoming these diagnostic errors will require a multifaceted approach with clinicians and laboratories working together.
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Affiliation(s)
- Emmanuel J. Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | - Leonardo Pasalic
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Rita Selby
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Marumo A, Sugihara H, Omori I, Morishita E. Relapse of Acquired Hemophilia A after COVID-19 Infection. J NIPPON MED SCH 2024; 90:474-479. [PMID: 36823120 DOI: 10.1272/jnms.jnms.2023_90-609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Acquired hemophilia A (AHA) is a rare disease in which an autoantibody causes bleeding by interacting with and inhibiting the coagulation activity of endogenous factor VIII (FVIII). Most cases of AHA are idiopathic; known causes include autoimmune diseases, malignant tumors, pregnancy, drugs, and viral infections. An 86-year-old man was diagnosed with AHA based on the following results: an activated partial thromboplastin time (aPTT) extension of 130.7 seconds, presence of an inhibitor pattern in a mixing study, an endogenous factor VIII (FVIII) level of <1%, and an FVIII inhibitor titer of >5.1 Bethesda units (BU). The activity of von Willebrand factor (vWF) was diminished (<10%), which was considered a complication of acquired von Willebrand syndrome (AVWS). The patient was started on prednisolone, and the inhibitor level eventually became negative. vWF values also became normal. However, 1 year later, he was hospitalized for treatment of coronavirus disease 2019 (COVID-19). Blood testing showed an aPTT extension of 110.5 seconds, FVIII level of 4%, and FVIII inhibitor titer of 0.8 BU; thus, a relapse of AHA was diagnosed. After administration of corticosteroid and remdesivir, he recovered from COVID-19 and AHA. The inhibitor level became negative on the 9th day of admission. Several studies have implicated COVID-19 infection and vaccination in AHA. We recommend that aPTT be measured when patients with AHA are infected with SARS-CoV2, to confirm AHA relapse.
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Affiliation(s)
- Atsushi Marumo
- Division of Internal Medicine, Fussa Hospital
- Department of Hematology, Nippon Medical School
| | | | - Ikuko Omori
- Division of Internal Medicine, Fussa Hospital
- Department of Hematology, Nippon Medical School
| | - Eriko Morishita
- Department of Clinical Laboratory Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Faculty of Health Sciences, Kanazawa University
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Kim MJ, Salazar E, Philips B, Rice L, Castillo B, Leveque C, Chen J. Interpreting coagulation mixing study results in the era of direct oral anticoagulants. Blood Coagul Fibrinolysis 2024; 35:23-26. [PMID: 37994629 DOI: 10.1097/mbc.0000000000001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Interpretation of coagulation mixing studies is complicated by interference arising from direct oral anticoagulants (DOACs), which are increasingly prescribed. In this retrospective study, we reviewed 1035 consecutive coagulation mixing studies performed from 2017 to 2021. Three hundred and ninety-nine cases with normal prothrombin time (PT) and activated partial thromboplastin time (aPTT) were excluded. aPTT mixing studies were performed at time 0 and after 60 min of incubation. We confirmed the presence of interfering factors with additional laboratory testing, medication records, and medical history. Mixing corrected most prolonged PT samples (93%), but 32 cases showed incomplete correction. Of these 32 cases, 18 were confounded by DOAC use, and 3 by factor V (FV) inhibitor. We observed an unusual pattern of prolongation of aPTT after incubation, which was previously considered a characteristic of specific factor inhibitors, most commonly FVIII inhibitor. However, we found that lupus anticoagulant (28%) and DOAC (25%) contributed to this pattern similarly as specific factor inhibitors (28%). Coagulation laboratories should be aware of interference arising from DOACs and other factors in PT/aPTT mixing studies, especially in some unusual correction patterns.
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Affiliation(s)
- Moon Joo Kim
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio
| | - Bonnie Philips
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston
| | - Lawrence Rice
- Department of Medicine and Cancer Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Brian Castillo
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston
| | - Christopher Leveque
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston
| | - Jian Chen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston
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Bang HI, Lee JY, Kim HY, Shin S, Nam MH, Kim IS, Kim JM, Yoon JH, Shin MG, Hwang SM, Kong SY. Coagulation Testing in Real-World Setting: Insights From a Comprehensive Survey. Clin Appl Thromb Hemost 2024; 30:10760296241228239. [PMID: 38321776 PMCID: PMC10851719 DOI: 10.1177/10760296241228239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/18/2023] [Accepted: 01/07/2024] [Indexed: 02/08/2024] Open
Abstract
The objective of this survey was to gain a real-world perspective on coagulation testing by evaluating the availability of various coagulation laboratory tests, assessing specific analytic and postanalytic steps in clinical laboratories in Korea.Participants were surveyed using a 65-question questionnaire specifically focused on their coagulation testing practices related to prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma-mixing studies, lupus anticoagulant (LA) tests, platelet function tests, coagulation factor assays, and the composition of hemostasis and thrombosis test panels. The survey was performed between July and September 2022.The survey achieved a 77.9% (81 of 104) response rate. PT or aPTT tests were performed directly at all participating institutions, followed by D-dimer and fibrinogen tests, platelet function test, and plasma-mixing studies in order of frequency. Variations existed in the performance of mixing test and LA assessment. Patterns of coagulating testing differed depending on the size of the hospital. The survey revealed that most laboratories conducted coagulation tests following the international guidelines such as Clinical Laboratory Standards Institute guidelines and the Korean Laboratory Certification system. However, some coagulation tests, including mixing test and LA tests, are yet to be standardized in Korea.Continuous education on coagulation test methods and internal and external quality control are required to encourage laboratories to enhance the performance of coagulation testing.
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Affiliation(s)
- Hae In Bang
- Department of Laboratory Medicine, Soonchunhyang University Seoul Hospital, Seoul, The Republic of Korea
| | - Ja Young Lee
- Department of Laboratory Medicine, Inje University Busan Paik Hospital, Busan, The Republic of Korea
| | - Hyun-Young Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
| | - Saeam Shin
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, The Republic of Korea
| | - Myung Hyun Nam
- Department of Laboratory Medicine, Korea University Anam Hospital, Seoul, The Republic of Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, The Republic of Korea
| | - Ji Myung Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, The Republic of Korea
| | - Jong-Hyun Yoon
- Department of Laboratory Medicine, Seoul National University Boramae Medical Center, Seoul, The Republic of Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, The Republic of Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, The Republic of Korea
| | - Sun-Young Kong
- Department of Laboratory Medicine, National Cancer Center Hospital, Goyang, The Republic of Korea
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Adcock DM, Moore GW, Montalvão SDL, Kershaw G, Gosselin RC. Activated Partial Thromboplastin Time and Prothrombin Time Mixing Studies: Current State of the Art. Semin Thromb Hemost 2023; 49:571-579. [PMID: 36055261 DOI: 10.1055/s-0042-1756196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Mixing studies have long been in the clinical laboratory armamentarium for investigating unexpected, prolonged activated partial thromboplastin time (aPTT) or prothrombin time (PT). The purpose of the mixing study is to identify whether the aPTT/PT prolongation is secondary to a factor deficiency versus an inhibitor, which would present as a "corrected" and "noncorrected" mixing study, respectively. The differentiation between a factor deficiency and inhibitor may likely further direct clinical decisions, including additional diagnostic testing or factor replacement therapy. While aPTT/PT mixing studies are simple tests to perform, there is a lack of standardization for both the testing protocol and the interpretation of what is considered to be a corrected or noncorrected mixing study result. This review will describe the common indications for the mixing test, preanalytic variables that may affect mixing study performance, and describe several methods for interpreting the results of aPTT and PT mixing tests.
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Affiliation(s)
| | - Gary W Moore
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University London, London, United Kingdom
| | - Silmara de Lima Montalvão
- Laboratory Hemostasis, Hematology and Hemotherapy Center, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Robert C Gosselin
- Davis Health System, Hemostasis and Thrombosis Center, University of California, Sacramento, California
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Santoro RC, Molinari AC, Leotta M, Martini T. Isolated Prolongation of Activated Partial Thromboplastin Time: Not Just Bleeding Risk! MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1169. [PMID: 37374373 DOI: 10.3390/medicina59061169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
Activated partial thromboplastin time (aPTT) is a fundamental screening test for coagulation disturbances. An increased aPTT ratio is quite common in clinical practice. How the detection of prolonged activated aPTT with a normal prothrombin time is interpreted is therefore very important. In daily practice, the detection of this abnormality often leads to delayed surgery and emotional stress for patients and their families and may be associated with increased costs due to re-testing and coagulation factor assessment. An isolated, prolonged aPTT is seen in (a) patients with congenital or acquired deficiencies of specific coagulation factors, (b) patients receiving treatment with anticoagulants, mainly heparin, and (c) individuals/patients with circulating anticoagulants. We summarize here what may cause an isolated prolonged aPTT and evaluate the preanalytical interferences. The identification of the cause of an isolated prolonged aPTT is of the utmost importance in ensuring the correct diagnostic workup and therapeutic choices.
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Affiliation(s)
- Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | | | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
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Matsuda M, Hoshiyama Y, Ogawa K, Emmi M, Terai S, Moriyama M. Performance characteristics of 5 numerical indexes in mixing test interpretation under coexistence of lupus anticoagulant and coagulation factor deficiency. Res Pract Thromb Haemost 2023; 7:100065. [PMID: 36891278 PMCID: PMC9986643 DOI: 10.1016/j.rpth.2023.100065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Background The mixing test is useful to investigate the cause of unexpectedly prolonged activated partial thromboplastin time (APTT). Several indexes are available for distinguishing correction from non-correction (ie, factor deficiency from inhibitors), but their performance characteristics may differ because of their different formulas. Furthermore, it is unclear how each index performs under the coexistence of factor deficiency and inhibitors. Objectives The objective of this study was to examine the differences in indexes, depending on factor VIII activity (FVIII:C) levels and lupus anticoagulant (LA) titers in test samples. Methods APTT was measured in spiked samples with various FVIII:C levels and LA titers, normal pooled plasma (NPP), and their 4:1, 1:1, and 1:4 mixtures. The following 5 indexes were calculated: index of circulating anticoagulant, mixing test normalized ratio, 4:1 and 1:1 percent corrections, and an APTT difference between the 1:1 mixture and NPP. The samples with LA, showing correction, were measured for FVIII:C in a one-stage assay to check parallelism. Results All indexes showed correction under FVIII deficiency and non-correction under higher LA titers. However, under lower LA titers, some indexes showed non-correction but others showed correction because of dilution effects and variations in formulas and/or sample mix ratios. The differences among the indexes were more pronounced under coexistent FVIII deficiency and LA, even though LA titers were equal in the tested samples; samples with lower FVIII:C showed correction, whereas those with normal FVIII:C showed non-correction. The samples tested for FVIII:C showed non-parallelism. Conclusion Each index had different performance characteristics to LA samples, which were pronounced under low FVIII:C levels in test samples.
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Affiliation(s)
- Masato Matsuda
- Department of Clinical Laboratory Sciences, School of Health Sciences, Fukushima Medical University, Fukushima, Japan.,Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,Medical Laboratory Division, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yoshiki Hoshiyama
- Medical Laboratory Division, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazuei Ogawa
- Department of Clinical Laboratory Sciences, School of Health Sciences, Fukushima Medical University, Fukushima, Japan
| | - Mari Emmi
- Product Strategy Department, Diagnostics Division, SEKISUI MEDICAL Co. Ltd., Tokyo, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,Medical Laboratory Division, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Masato Moriyama
- Department of Medical Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Jin Y, Cheng Y, Mi J, Xu J. A rare case of schizophrenia coexistence with antiphospholipid syndrome, β-thalassemia, and monoclonal gammopathy of undetermined significance. Front Psychiatry 2023; 14:1178247. [PMID: 37091711 PMCID: PMC10117972 DOI: 10.3389/fpsyt.2023.1178247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
A patient with schizophrenia who was treated with chlorpromazine developed lupus anticoagulant (LA) and antiphospholipid syndrome (APS). On protein electrophoresis, a monoclonal immunoglobulin A peak was seen in this patient, defining a condition of monoclonal gammopathy of undetermined significance. Additionally, β-thalassemia was diagnosed with the CD41-42 genotype. This condition is extremely rare, particularly in patients with schizophrenia and APS. We present a case of a patient with schizophrenia and secondary APS who had a positive LA, a significantly prolonged activated partial thromboplastin time, endogenous coagulation factor deficiency and inhibitor, no bleeding, and an unexpected finding of β-thalassemia and monoclonal IgA. Following that, a literature review on the disorders was presented.
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Affiliation(s)
- Yingming Jin
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
| | - Yiquan Cheng
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
| | - Jifeng Mi
- Department of Laboratory Medicine, Ningbo No.2 Hospital, Ningbo, China
| | - Jianfen Xu
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
- *Correspondence: Jianfen Xu,
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13
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Kornfehl A, Brock R, Staudinger T, Schellongowski P, Nagler B, Hermann A, Robak O, Schwameis M, Quehenberger P, Buchtele N. Prevalence and Impact of Lupus Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation. Clin Appl Thromb Hemost 2023; 29:10760296231207062. [PMID: 37853541 PMCID: PMC10588400 DOI: 10.1177/10760296231207062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/05/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Monitoring of blood coagulation is essential in ECMO patients. We investigated the prevalence of lupus anticoagulant (LA) and its association with coagulation testing and hemostaseologic complications in patients treated with ECMO. METHODS This is a retrospective analysis including adult patients who received ECMO at a medical intensive care unit at the Medical University of Vienna. The primary outcome was the prevalence of LA. Secondary outcomes included conditions associated with LA positivity, rates of bleeding and thromboembolic events, as well as the proportions of aPTT and antiXa measurements within the target range. RESULTS Between 2013 and 2021 193 patients received ECMO, in 62 (32%) of whom LA diagnostics were performed. Twenty-two (35%) patients tested positive. LA positive patients had more frequently received VV ECMO (77.3% vs 34.3%; p = 0.002), were more frequently diagnosed with viral respiratory infections (SARS-CoV2: 45.5% vs 20%; p = 0.041, influenza virus: 22.7% vs 0%; p = 0.003), had a longer ECMO treatment duration (25 vs 10 days; p = 0.011) and a longer ICU stay (48 vs 25 days; p = 0.022), but similar rates of bleeding and thromboembolic events.
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Affiliation(s)
- Andrea Kornfehl
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Roman Brock
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Bernhard Nagler
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Oliver Robak
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2; Medical University of Vienna, Vienna, Austria
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14
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Pillay D, Rapiti N. The diagnosis and Management of HIV Associated Acquired Hemophilia A: A Case Series From Durban, South Africa. J Prim Care Community Health 2023; 14:21501319231194970. [PMID: 37646157 PMCID: PMC10467197 DOI: 10.1177/21501319231194970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION In acquired hemophilia A (AHA), the body produces auto-antibodies against Factor VIII. Although AHA is rare, with an incidence of 1.5 patients/1 million population/year, there is a strong association with human immunodeficiency virus (HIV) infection. The accurate interpretation of screening coagulation tests is critical to identify patients with AHA, as the mortality rate secondary to bleeding is high. METHODS This was a retrospective case series which included all newly diagnosed AHA patients that were referred to Hemophilia care unit at King Edward VIII Hospital, Durban, South Africa from January 2011 to December 2021. The clinical presentation and laboratory results were documented. RESULTS Five patients were included in this case series. All patients were females aged between 28 and 64 years of age and they were HIV seropositive. They presented with spontaneous cutaneous and intramuscular bleeding. Four patients were virologically suppressed on anti-retroviral therapy, and no patient had a family history of congenital bleeding diathesis. Laboratory investigations confirmed AHA with high Factor VIII inhibitor titers, which ranged from 41 to 900 Bethesda Units (BU). All patients were managed with bypassing agents and oral corticosteroids. The monitoring of patients after the initiation of treatment was difficult as they all defaulted treatment. CONCLUSION In view of the prevalence of HIV in sub-Saharan Africa, there is a possibility that AHA is under-diagnosed in our setting. The clinician and the laboratory have a combined critical role in identifying patients with AHA as the investigation of a prolonged APTT is mandatory. There are challenges in managing AHA patients in a resource-constrained setting.
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Affiliation(s)
- Dashini Pillay
- University of KwaZulu-Natal - Department of Hematology, National Health Laboratory Services, School of laboratory medicine, Durban, South Africa
- Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Nadine Rapiti
- University of KwaZulu-Natal - Department of Hematology, National Health Laboratory Services, School of laboratory medicine, Durban, South Africa
- Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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15
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Favaloro EJ, Pasalic L. An Overview of Laboratory Testing for Antiphospholipid Antibodies. Methods Mol Biol 2023; 2663:253-262. [PMID: 37204715 DOI: 10.1007/978-1-0716-3175-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Antiphospholipid antibodies (aPL) represent a group of autoantibodies directed against phospholipids. These antibodies may arise in a number of autoimmune conditions, of which the antiphospholipid (antibody) syndrome (APS) is best recognized. aPL can be detected by various laboratory assays, essentially comprising both solid-phase (immunological) assays and "liquid-phase" clotting assays identifying so-called lupus anticoagulants (LA). aPL are associated with various adverse pathologies, including thrombosis and placental/fetal morbidity and mortality. The type of aPL present, as well as the pattern of reactivity, is variously associated with the severity of the pathology. Thus, laboratory testing for aPL is indicated to help assess the future risk of such events, as well as representing certain "classification" criteria for APS, also used as surrogates for diagnostic criteria. The current chapter overviews the laboratory tests available to measure aPL and their potential clinical utility.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
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16
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Fortier JC, Pang SS, Amofa-Ho S, Harris NS, Zumberg M. A Case of Acquired Hemophilia A and Congenital Hemophilia B. Cureus 2022; 14:e30324. [PMID: 36407152 PMCID: PMC9662256 DOI: 10.7759/cureus.30324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Congenital hemophilia B is a rare, inherited X-linked bleeding disorder caused by a deficiency of factor IX (FIX). Acquired hemophilia A is a rare, acquired bleeding disorder which presents as new onset bleeding in older adults due to the development of autoantibodies against factor VIII (FVIII). This report describes the management of a patient with congenital hemophilia B and acquired hemophilia A. We highlight the limitations in maintaining FVIII levels using factor replacement alone and the need for escalating treatment such as rituximab and prednisone in patients with acquired hemophilia A. This case demonstrates the importance of continuing to pursue alternative diagnoses when existing ones do not explain the full clinical picture and laboratory data is inconclusive.
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17
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Bauça JM, Ajzner É, Cadamuro J, Hillarp A, Kristoffersen AH, Meijer P. An international study on activated partial thromboplastin time prolongation. Part 1: Analytical results. Clin Chim Acta 2022; 535:167-173. [PMID: 36041550 DOI: 10.1016/j.cca.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/28/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unexpected prolongation of first-line coagulation tests, including activated partial thromboplastin time (APTT), should trigger further work-up by performing mixing tests to elucidate the underlying cause, direct further specific testing and clarify their possible clinical impact. The aim of our study was to assess whether methodological diversity has any impact on the APTT mixing test results and their interpretation. MATERIAL AND METHODS Two lyophilized plasma samples (case 1: heparin contamination [0.5 IU/mL]; case 2: factor VIII deficiency [0.13 IU/mL]) and their respective fictional clinical cases were sent to European laboratories for APTT measurement and performance of mixing tests. Participants were surveyed about the methodology (reagents, analytical platform, reference ranges), APTT results, mixing test conditions, their classification (normal, equivocal, prolonged) and categorization of the sample (factor deficiency, presence of inhibitor, anticoagulant, unknown). RESULTS A total of 269 responses were included. For case 1, all participants reported a prolonged APTT, and 91% obtained no correction in the mixing test, without differences among reagents or analytical platforms. Only 15% of them selected the presence of an anticoagulant as the single cause for the prolongation. For case 2, 99% of participants reported a prolonged APTT, while some heterogeneity in the mixing test results was found. Eighty-six percent of participants selected factor deficiency as the cause for APTT prolongation. CONCLUSIONS Most European laboratories obtained valid results for APTT and the subsequent mixing tests, despite using different methodologies. However, their classification could be improved. Therefore, more training and periodic evaluations are recommended to harmonize protocols and ensure proper result classification and categorization.
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Affiliation(s)
- Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain.
| | - Éva Ajzner
- Central Laboratory, András Jósa University Hospital, Nyíregyháza, Hungary
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Hillarp
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Piet Meijer
- ECAT Foundation (External Quality Control for Assays and Tests), Voorschoten, Netherlands
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18
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Bauça JM, Ajzner É, Cadamuro J, Hillarp A, Kristoffersen AH, Meijer P. An international study on activated partial thromboplastin time prolongation. Part 2: Interpretative commenting. Clin Chim Acta 2022; 535:174-179. [PMID: 36055391 DOI: 10.1016/j.cca.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Providing evidence-based interpretative comments (IC) is an integral task of clinical laboratory professionals. It may be of special relevance for coagulation testing, where pathological first-line tests could trigger more specialized tests. Our aim was to evaluate the quality of ICs provided to the physician in two samples with activated partial thromboplastin time (APTT) prolongation. MATERIAL AND METHODS Two lyophilized plasma samples and their respective fictional clinical cases (case 1: heparin contamination and case 2: factor VIII deficiency) were sent to European laboratories for APTT and APTT mixing test measurement, and elaboration of ICs based on their results. The quality of ICs was evaluated in terms of analytical classification, laboratory interpretation, advice to physician, clarity, length and whether the clinical question was answered. RESULTS A total of 214 laboratories were included. Classification of the analytical result was stated in 57 % of comments. Laboratory interpretation was found in 91 % of comments for case 1 and 83.3 % for case 2, among which 9.3 % and 6.5 % were considered wrong, respectively. Advice for the requesting physician was provided in 65.8 % of comments for case 1 and 61.2 % for case 2, among which 36 % and 4.7 % were considered wrong, respectively. More than 70 % of comments for both cases were evaluated as clear and of an adequate length. CONCLUSION A significant number of laboratories provide clear interpretations and helpful advice for the management of altered coagulation results. Nevertheless, the finding of several confusing and misleading comments highlights the need for recommendations on elaboration of interpretative comments.
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Affiliation(s)
- Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain.
| | - Éva Ajzner
- Central Laboratory, András Jósa University Hospital, Nyíregyháza, Hungary
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Hillarp
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Piet Meijer
- ECAT Foundation (External Quality Control for Assays and Tests), Voorschoten, Netherlands
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19
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Uchiba M, Matsuoka M. Using weighted harmonic mean for prediction of APTT in the mixing test. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Zhang J, Mu R, Chen J, Song J. Effect of different incubation times on the detection of factor VIII inhibitor in acquired hemophilia A. Clin Chem Lab Med 2022; 60:e195-e197. [PMID: 35561743 DOI: 10.1515/cclm-2022-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Jiahong Zhang
- Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, P.R. China
| | - Runqing Mu
- Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, P.R. China
| | - Junli Chen
- Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, P.R. China
| | - Jianqing Song
- Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, P.R. China
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21
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Favaloro EJ, Pasalic L. Should multiple factor dilutions be performed for all patient coagulation factor assays? Let the debate begin! Res Pract Thromb Haemost 2022; 6:e12689. [PMID: 35308100 PMCID: PMC8918913 DOI: 10.1002/rth2.12689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 11/09/2022] Open
Abstract
Laboratory assessment of blood coagulation factors may be undertaken for various reasons, including investigating the possibility of hemophilia or unexpected prolongation in routine coagulation assays (eg, prothrombin time, activated partial thromboplastin time). Several guidelines recommend performing multiple dilutions (usually 2-3) on all patient test samples to evaluate "parallelism" as a guide to the presence of potential "inhibitors," be they factor inhibitors, lupus anticoagulant, or related to the presence of anticoagulant therapy. The current Forum argues against mandating investigation of parallelism (or multiple dilutions) for all samples destined for testing, instead suggesting that a more targeted approach will likely provide better clinical utility and use of laboratory resources.
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Affiliation(s)
- Emmanuel J. Favaloro
- Department of HaematologyInstitute of Clinical Pathology and Medical Research (ICPMR)NSW Health PathologyWestmead HospitalWestmeadNew South WalesAustralia
- Sydney Centres for Thrombosis and HaemostasisWestmeadNew South WalesAustralia
- Faculty of Science and HealthCharles Sturt UniversityWagga WaggaNew South WalesAustralia
| | - Leonardo Pasalic
- Department of HaematologyInstitute of Clinical Pathology and Medical Research (ICPMR)NSW Health PathologyWestmead HospitalWestmeadNew South WalesAustralia
- Sydney Centres for Thrombosis and HaemostasisWestmeadNew South WalesAustralia
- Sydney UniversityWestmeadNew South WalesAustralia
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22
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Abstract
Remarkable changes are occurring in the diagnosis and management of individuals with hemophilia A. Genetic testing, including next-generation sequencing, enables family planning, carrier testing, and prenatal diagnosis. Musculoskeletal ultrasound examination facilitates the early detection of acute bleeds and joint disease in clinic, enabling more rapid bleed resolution and treatment planning. Novel therapies offer simpler weekly or monthly administration, some by subcutaneous injection, with better compliance and quality of life, as well as fewer bleeds. Gene therapy provides a 1-time phenotypic "cure" that is cost effective, but may be complicated by waning levels, vector immune responses, and hepatotoxicity.
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23
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Szabó G, Antal-Szalmás P, Kerényi A, Pénzes K, Bécsi B, Kappelmayer J. Laboratory Approaches to Test the Function of Antiphospholipid Antibodies. Semin Thromb Hemost 2021; 48:132-144. [PMID: 34261151 DOI: 10.1055/s-0041-1730357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder caused by the presence of aPLs (antiphospholipid antibodies, i.e., anti-β2-glycoprotein I and anti-cardiolipin). Everyday practice in terms of laboratory diagnostics of APS includes determination of aPLs and well-known functional assays assessing for lupus anticoagulant (LA), in turn using various tests. According to recent guidelines, the recommended method for LA identification or exclusion is based on the Russell Viper Venom test and a sensitive activated partial thromboplastin time assay. Despite the fact that LA can be quantified in laboratory practice in this way, LA is still used as a binary parameter that is just one of the risk factors of thrombosis in APS. As of today, there are no other functional assays to routinely assess the risk of thrombosis in APS. It is well-known that APS patients display a wide range of clinical outcomes although they may express very similar laboratory findings. One way to solve this dilemma, could be if antibodies could be further delineated using more advanced functional tests. Therefore, we review the diagnostic approaches to test the function of aPLs. We further discuss how thrombin generation assays, and rotational thromboelastometry tests can be influenced by LA, and how experimental methods, such as flow cytometric platelet activation, surface plasmon resonance, or nano differential scanning fluorimetry can bring us closer to the puzzling interaction of aPLs with platelets as well as with their soluble protein ligand. These novel approaches may eventually enable better characterization of aPL, and also provide a better linkage to APS pathophysiology.
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Affiliation(s)
- Gábor Szabó
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Thrombosis, Haemostasis and Vascular Biology Programme, Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Adrienne Kerényi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Krisztina Pénzes
- Division of Medical Laboratory Sciences, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Bálint Bécsi
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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24
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Favaloro E. Mixing studies for lupus anticoagulant: mostly yes, sometimes no. Clin Chem Lab Med 2021; 58:487-491. [PMID: 31874094 DOI: 10.1515/cclm-2019-1240] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 12/29/2022]
Abstract
Lupus anticoagulants (LAs) represent one manifestation of the clinical condition called antiphospholipid syndrome (APS) and are associated with many adverse clinical outcomes, but primarily with thrombosis and/or pregnancy morbidity. LAs are identified by laboratory testing, principally using clot-based assays based on Russell viper venom time (RVVT) and activated partial thromboplastin time (APTT) test methods. All three of the most recent guidance documents for LA testing recommend using these tests, although they vary in regard to inclusion/exclusion of other test processes. Mixing studies form part of the process of LA identification/exclusion, since in vitro LAs act like coagulation inhibitors. Mixing studies are also supported by all three LA guidance documents, but recommendations vary in regard to relative importance and placement in the LA identification/exclusion algorithm. This Point article takes the position that mixing tests are usually indicated for appropriate identification/exclusion of LAs, but can occasionally be omitted.
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Affiliation(s)
- Emmanuel Favaloro
- Department of Laboratory Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
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25
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Alqahtany FS, Algahtani FH, Alshebly MM, Albegamy TS, Alghamdi ES, Alnakhli MA, Madkhaly FM, Alharbi AA, Alqahtani NA. Factor XII deficiency in asymptomatic Saudi population: A retrospective cohort study. Saudi J Biol Sci 2021; 28:2004-2006. [PMID: 33732086 PMCID: PMC7938109 DOI: 10.1016/j.sjbs.2021.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/26/2022] Open
Abstract
Factor XII (FXII) deficiency is a rare genetic blood disorder. It can lead to a higher risk of developing deep vein thrombosis or acquired thrombotic disorders than the general population. This retrospective study evaluated patients who opted for surgery and were found to have abnormal clotting profiles and clotting factors on preoperative routine blood. Patients were included regardless of whether they were symptomatic or asymptomatic. The cohort comprised 115 patients with a mean FXII level of 128.04 ± 36.93%. Two (1.79%) patients, both of whom were women, had FXII levels <60%. The mean FXII level was 58 ± 1.41 (range, 57–59%) in this group. The present study shows the prevalence of FXII in the asymptomatic Saudi population. The results provide the normal range for FXII. The findings of our study provide the basis for diagnosing F XII deficiency in the asymptomatic Saudi population.
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Affiliation(s)
- Fatmah S Alqahtany
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Farjah H Algahtani
- Department of Medicine, Division of Oncology/Hematology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Mashael M Alshebly
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Thamer S Albegamy
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Essam S Alghamdi
- Heamatopathology & Blood Transfusion Consultant, Ministry of Health, Riyadh, Saudi Arabia
| | - Mohammed A Alnakhli
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Fatimah M Madkhaly
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf A Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
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26
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Shimonishi N, Ogiwara K, Oda Y, Kawabe T, Emmi M, Shima M, Nogami K. Inhibitor Index in the Clot Waveform Analysis-Based Mixing Test Differentiates among Hemophilia A without and with Inhibitors, and Lupus Anticoagulant. Thromb Haemost 2021; 121:792-799. [PMID: 33412612 DOI: 10.1055/s-0040-1721776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The mixing test is used to identify the pathway to follow-up testing and is also useful for the investigation of lupus anticoagulant (LA) positivity. "To completely correct" indicates clotting factor deficiency, while "to not correct" indicates the presence of a clotting factor inhibitor including LA. "Index of circulation anticoagulant" and/or "percent correction" is used to interpret the results of mixing studies, but it does not accurately differentiate factor inhibitors from LA. AIM To precisely differentiate hemophilia A (HA), HA with inhibitor (HA-inh), and LA using the clot waveform analysis (CWA)-based mixing test. METHODS Plasma samples from HA, LA, and HA-inh including acquired HA were incubated with normal plasma in 9:1, 1:1, and 1:9 mix ratios. From activated partial thromboplastin time CWA at 0-minute (immediately) and 12-minute incubation, the ratios of CWA parameters at 12 minutes/0 minute (inhibitor index) were assessed. RESULTS The inhibitor index values of CWA parameters obtained using the mixing test in a 1:1 ratio demonstrated a significant difference between HA-inh and LA but could not differentiate LA from HA-inh completely. Plasmas used for the mixing tests in 9:1 and 1:9 ratios were able to fully distinguish between HA-inh (>0.5 BU/mL) and LA. These indices significantly correlated with inhibitor titer below 40 BU/mL (r > 0.90), possibly estimating FVIII inhibitor titer from the inhibitor index. Plasmas in HA and LA could be distinguished by mixing in a 1:1 ratio at 0 minute (immediately). CONCLUSION The inhibitor index from CWA-based mixing tests with a 12-minute incubation could differentiate among HA, HA-inh, and LA quickly.
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Affiliation(s)
- Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yukio Oda
- SEKISUI MEDICAL CO., LTD., Tokyo, Japan
| | | | - Mari Emmi
- SEKISUI MEDICAL CO., LTD., Tokyo, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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27
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Exner T, Rigano J, Favaloro EJ. The effect of DOACs on laboratory tests and their removal by activated carbon to limit interference in functional assays. Int J Lab Hematol 2020; 42 Suppl 1:41-48. [DOI: 10.1111/ijlh.13196] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Joseph Rigano
- Haematology Department Alfred Hospital Melbourne Vic. Australia
| | - Emmanuel J. Favaloro
- Laboratory Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Sydney NSW Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead Hospital Sydney NSW Australia
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