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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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Gonzalez-Salido J, Barron-Cervantes NM, Colado-Martinez J, Arechavala Lopez SF, Mosqueda-Larrauri VL, Ortiz-Herrera JL, Piña-Rosales E, Martinez-Bautista J. Ischemic Stroke as an Initial Manifestation of Antiphospholipid Syndrome in an Adolescent: A Case Report. Cureus 2024; 16:e55579. [PMID: 38576686 PMCID: PMC10994399 DOI: 10.7759/cureus.55579] [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] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
Cerebrovascular diseases in pediatric patients are relatively rare. Ischemic stroke in adolescents is associated with a poor prognosis. The most common causes include systemic diseases, such as heart disease and hypercoagulation disorders. It is important to mention that one of the most common acquired hypercoagulation states is the antiphospholipid syndrome (APS). Patients with this disease may present stroke as the first clinical manifestation, which not only increases morbidity in these patients but presents a diagnostic challenge. This case presents one example of how APS can present as a pediatric stroke. The diagnostic approach should always be through the presence of specific antibodies accompanied by the presence of a thromboembolic episode proven by catheterization or an imaging study. In the brain, the preferred imaging study is magnetic resonance imaging. Management is based on anticoagulation therapy and continuous monitoring in the intensive care unit.
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Mangion K, Vella K, Gatt A, Vella AM, Borg M, Borg-Aquilina D, Douxfils J, Camilleri L, Riva N. A comparative in vitro study of the anticoagulant effect of branded versus generic rivaroxaban. Thromb Res 2024; 235:41-51. [PMID: 38295600 DOI: 10.1016/j.thromres.2024.01.017] [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: 04/01/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Several generic formulations of rivaroxaban were recently marketed to be used interchangeably with their branded equivalent. However, there have been no previously published studies that directly compared the in vitro anticoagulant effect of branded vs. generic rivaroxaban. The aim of this in vitro study was to compare the effects of three raw rivaroxaban materials, obtained from the branded (Xarelto®) and two generic (Rivarolto® and Rivaroxaban Sandoz®) rivaroxaban formulations on an array of coagulation assays. METHODS A pool of normal plasma was spiked with several concentrations of the three rivaroxaban (range 50-750 ng/ml). The concentrations were assessed with a rivaroxaban calibrated anti-Xa assay and confirmed by ultra-high-performance liquid chromatography-mass spectrometry coupled with tandem mass spectrometry (UHPLC-MS/MS). The following assays were performed: Prothrombin time (PT), activated Partial Thromboplastin time (aPTT), Diluted Russell's Viper Venom Test (dRVVT), Thrombin time (TT), Clauss Fibrinogen, Factor VII, VIII and IX assays, and thromboelastography. RESULTS The results obtained by the three rivaroxaban at similar concentrations were comparable. Increasing concentrations of the three rivaroxaban showed a strong positive correlation with the PT, aPTT and dRVVT assays (r > 0.95, p < 0.01 for all), and a strong negative correlation with the Factors assays (r < -0.95, p < 0.01 for all). TT and Clauss Fibrinogen were not affected by rivaroxaban. No significant difference was identified in the mean assays' results obtained by the three rivaroxaban. CONCLUSION This study showed that the branded and generic rivaroxaban exert an identical in vitro anticoagulant effect across a wide range of concentrations.
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Affiliation(s)
- Karl Mangion
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.
| | - Kevin Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Alex Gatt
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta; Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Amy Marie Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Marica Borg
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Denise Borg-Aquilina
- National Blood Transfusion Service & Mater Dei Hospital Blood Bank, Msida, Malta.
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium; Qualiblood s.a., Qualiclinics, Namur, Belgium.
| | - Liberato Camilleri
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta.
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
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4
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Exner T, Dangol M, Favaloro EJ. Simplified Method for Removing Direct Oral Anticoagulant Interference in Mechanical Coagulation Test Systems-A Proof of Concept. J Clin Med 2024; 13:1042. [PMID: 38398355 PMCID: PMC10889288 DOI: 10.3390/jcm13041042] [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: 12/26/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) cause unwanted interference in various hemostasis assays, including lupus anticoagulant (LA) testing, where false positive and false negative identification may occur. DOAC Stop (DS) is an activated charcoal (AC) product used to specifically and effectively adsorb DOACs from test plasma. This process normally requires plasma treatment, centrifugation and plasma separation prior to tests, but inexperienced operators may also inadvertently transfer residual AC particles, thereby potentially adversely affecting clot detection. METHODS We hypothesized that residual DS might not be problematic for mechanical clot detection. We therefore investigated the potential impact of DS and a new DS liquid (DS-L) product on clotting tests using a mechanical clot detection system. Varying concentrations of DS were added to normal and abnormal plasmas with and without DOAC presence. Clotting tests including PT, APTT and dRVVT were performed directly in the analyzer without plasma/DS centrifugation. RESULTS DS up to double the recommended treatment level had only minor effects on all test results, despite completely obscuring visibility in the plasma/reagent mix. This confirms that the centrifugation step may be able to be omitted when using mechanical detection systems. CONCLUSIONS Should DS carryover into treated plasmas occur, this should not cause issues with testing performed on mechanical clot-sensing devices. Moreover, we hypothesize that DS can be used directly in these systems, without the need for centrifugation, thereby simplifying its many potential applications.
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Affiliation(s)
- Thomas Exner
- Haematex Research Pty Ltd., Sydney, NSW 2077, Australia; (T.E.); (M.D.)
| | - Manita Dangol
- Haematex Research Pty Ltd., Sydney, NSW 2077, Australia; (T.E.); (M.D.)
| | - Emmanuel J. Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Sydney, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, NSW 2650, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
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5
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Efthymiou M, Bertolaccini ML, Cohen H. Viewpoint: Lupus anticoagulant detection and interpretation in antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI54-SI63. [PMID: 38320587 DOI: 10.1093/rheumatology/kead623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024] Open
Abstract
Lupus anticoagulant (LA) is a well-established risk factor for the clinical manifestations of antiphospholipid syndrome (APS). Accurate LA detection is an essential prerequisite for optimal diagnosis and management of patients with APS or aPL carriers. Variability remains a challenge in LA testing, with reliable detection influenced by multiple factors, including pre-analytical conditions, anticoagulation treatment, choice of tests and procedures performed, as well as interpretation of results, that can lead to false-positives or negatives. A standardised approach to LA testing, following current guidance, based on published data and international consensus, and with attention to detail, is required to underpin accurate detection of LA. Future work should focus on better characterisation of the nature of LA, which may ultimately lead to improved diagnosis and management of patients with APS and aPL carriers. This article reviews current practice and challenges, providing an overview on detection of LA.
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Affiliation(s)
- Maria Efthymiou
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Ballif M, Vazquez SR, Saunders J, Witt DM. Prevalence of antiphospholipid antibody syndrome misclassification in an academic health system. Thromb Res 2023; 232:163-167. [PMID: 36446659 DOI: 10.1016/j.thromres.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/12/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Antiphospholipid Antibody Syndrome (APS) is a complex autoimmune disorder that includes a combination of laboratory criteria and clinical events (thrombosis, pregnancy complications). Accurate classification is essential, as APS patients may have limited oral anticoagulant options and requires indefinite anticoagulation. The prevalence of inaccurate APS misclassification is unknown. This study sought to determine the proportion of patients in an academic health-system who formally met APS criteria. METHODS This retrospective cohort study included any patient within the University of Utah Health system who had an International Classification of Diseases-10 code for APS, between January 1, 2016 and June 30, 2020. Manual chart review was performed to assess the appropriateness of the APS classification by laboratory and clinical criteria. RESULTS Of the 184 patients identified, 59 (32.1 %) formally met APS criteria, while 69 (37.5 %) did not meet criteria. The remaining 56 (30.4 %) patients lacked enough information in their medical records to decide on appropriateness of APS classification. The most prevalent reason for inappropriate APS classification in the 69 patients identified was incorrect interpretation of lab values as positive (62; 89.9 %), followed by lack of repeat confirmation testing (32; 46.4 %). CONCLUSION The results of this single-center study indicate that only one-third of patients with presumed APS met classification criteria. This was predominantly due to incorrect collection or interpretation of APS laboratory data. One-third had insufficient medical record data to determine APS classification, which impairs clinical decision-making. This suggests more education or implementation of anticoagulation stewardship is needed to ensure accurate APS classification and proper management of anticoagulation therapy.
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Affiliation(s)
- Madison Ballif
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Sara R Vazquez
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America.
| | - John Saunders
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America
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Zlatković-Švenda M, Ovuka M, Ogrič M, Čučnik S, Žigon P, Radivčev A, Zdravković M, Radunović G. Antiphospholipid Antibodies and Vascular Thrombosis in Patients with Severe Forms of COVID-19. Biomedicines 2023; 11:3117. [PMID: 38137338 PMCID: PMC10741207 DOI: 10.3390/biomedicines11123117] [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: 08/10/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 12/24/2023] Open
Abstract
Antiphospholipid antibodies (aPLA) are a laboratory criterion for the classification of antiphospholipid syndrome (APS) and are known to cause clinical symptoms such as vascular thrombosis or obstetric complications. It is suggested that aPLA may be associated with thromboembolism in severe COVID-19 cases. Therefore, we aimed to combine clinical data with laboratory findings of aPLA at four time points (admission, worsening, discharge, and 3-month follow-up) in patients hospitalized with COVID-19 pneumonia. In 111 patients with COVID-19 pneumonia, current and past history of thrombosis and pregnancy complications were recorded. Nine types of aPLA were determined at four time points: anticardiolipin (aCL), anti-β2-glycoprotein I (anti- β2GPI), and antiphosphatidylserine/prothrombin (aPS/PT) of the IgM, IgG, or IgA isotypes. During hospitalization, seven patients died, three of them due to pulmonary artery thromboembolism (none were aPLA positive). Only one of the five who developed pulmonary artery thrombosis was aPLA positive. Out of 9/101 patients with a history of thrombosis, five had arterial thrombosis and none were aPLA positive at admission and follow-up; four had venous thrombosis, and one was aPLA positive at all time points (newly diagnosed APS). Of these 9/101 patients, 55.6% were transiently aPLA positive at discharge only, compared to 26.1% without a history of thrombosis (p = 0.041). Patients with severe forms of COVID-19 and positive aPLA should receive the same dose and anticoagulant medication regimen as those with negative aPLA because those antibodies are mostly transiently positive and not linked to thrombosis and fatal outcomes.
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Affiliation(s)
- Mirjana Zlatković-Švenda
- Institute of Rheumatology Belgrade, 11000 Belgrade, Serbia; (G.R.); (A.R.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Faculty of Medicine Foča, University of East Sarajevo, 73300 Foča, Bosnia and Herzegovina
| | - Milica Ovuka
- Clinical Hospital Center Pančevo, 26101 Pancevo, Serbia;
- Institute for Cardiovascular Diseases Dedinje, 11000 Belgrade, Serbia
| | - Manca Ogrič
- Department of Rheumatology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (S.Č.); (P.Ž.)
| | - Saša Čučnik
- Department of Rheumatology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (S.Č.); (P.Ž.)
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Polona Žigon
- Department of Rheumatology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (S.Č.); (P.Ž.)
- Faculty of Mathematics, Natural Sciences and Information Technologies, University of Primorska, 6000 Koper, Slovenia
| | | | - Marija Zdravković
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Clinical Hospital Bežanijska Kosa, 11000 Belgrade, Serbia
| | - Goran Radunović
- Institute of Rheumatology Belgrade, 11000 Belgrade, Serbia; (G.R.); (A.R.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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Favaloro EJ, Dean E, Arunachalam S. Variable Performance of Lupus Anticoagulant Testing: The Australasian/Asia-Pacific Experience. Semin Thromb Hemost 2023. [PMID: 37967835 DOI: 10.1055/s-0043-1776406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Lupus anticoagulant (LA) is one of three tests identified as laboratory criteria for definite antiphospholipid syndrome (APS). The other two tests are anticardiolipin antibody (aCL) and anti-β2-glycoprotein I (aβ2GPI) antibody. The presence of LA is assessed using clot-based tests, while the presence of aCL and aβ2GPI is assessed by immunological assays. Since no test can be considered 100% sensitive or specific for LA, current guidelines recommend using two different clot-based assays reflecting different principles, with the dilute Russell viper venom time (dRVVT) and activated partial thromboplastin time (aPTT) recommended. Initially, LA-sensitive reagents are used to screen for LA, and then, in "screen-positive" samples, LA-"insensitive" reagents are used to confirm LA. Because LA assays are based on clot detection, anything that can interfere with fibrin clot development may affect test results. In particular, in addition to LA, the tests are also sensitive to the presence of a wide range of clinical anticoagulants, reflecting preanalytical issues for testing. We provide updated findings for LA testing in our geographic region, using recent data from the Royal College of Pathologists of Australasia Quality Assurance Programs, an international external quality assessment program with approximately 120 participants. Data show a wide variety of assays in use, especially for aPTT testing, and variable outcomes in reported numerical values with these assays when assessing proficiency samples. dRVVT testing mostly comprised reagents from three main manufacturing suppliers, which also showed differences in numerical values for the same homogeneous tested samples. Nevertheless, despite the use of different test reagents and processes, >98% of participants correctly identified LA-negative samples as LA-negative and LA-positive samples as LA positive. We hope our findings, reflecting on the heterogeneity of test processes and test data, help improve diagnostic testing for LA in the future.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | - Elysse Dean
- RCPA QAP Haematology, St Leonards, NSW, Australia
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Pontara E, Bison E, Cattini MG, Tonello M, Denas G, Pengo V. Close link between antiphosphatidylserine/prothrombin antibodies, lupus anticoagulant, and activated protein C resistance in tetra antiphospholipid antibody-positive subjects. J Thromb Haemost 2023; 21:3138-3144. [PMID: 37422199 DOI: 10.1016/j.jtha.2023.06.033] [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: 04/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Most of the carriers/patients triple-positive for antiphospholipid antibodies (lupus anticoagulant [LAC], immunoglobulin G [IgG]/immunoglobulin M [IgM] anticardiolipin, and anti-β2-glycoprotein I antibodies) are tetra-positive, being positive for antiphosphatidylserine/prothrombin (aPS/PT) antibodies. The relationship between aPS/PT titer, LAC potency, and resistance to activated protein C (aPC-R) has not been investigated. OBJECTIVES The aim of this study was to clarify the mutual interdependence of these parameters in tetra-positive subjects. METHODS Twenty-three carriers and 30 patients with antiphospholipid syndrome, none of whom were being treated with anticoagulants, and 30 age- and sex-matched controls were studied. Detection of aPS/PT, LAC, and aPC-R in each individual was performed with established methods in our laboratory. Carriers and patients were positive for IgG or IgM aPS/PT or for both isotypes without significant difference. Since both IgG and IgM aPS/PT have anticoagulant activity, we used the sum of their titers (total aPS/PT) for the correlation studies. RESULTS Total aPS/PT in all individuals studied exceeded that in controls. There was no difference in total aPS/PT titers (P = .72), LAC potency (P = .56), and aPC-R (P = .82) between antiphospholipid antibody-carriers and patients with antiphospholipid syndrome. There was a significant correlation between total aPS/PT and LAC potency (r = 0.78; P < .0001) and between total aPS/PT titers and aPC-R (r = 0.80; P < .0001). LAC potency also was correlated significantly with aPC-R (r = 0.72; P < .0001). CONCLUSION This study shows that there is interdependence between aPS/PT, LAC potency, and aPC-R.
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Affiliation(s)
- Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Marta Tonello
- Department of Medicine, Rheumatology Section, University of Padua, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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10
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Molinari AC, Martini T, Banov L, Ierardi A, Leotta M, Strangio A, Santoro RC. Lupus Anticoagulant Detection under the Magnifying Glass. J Clin Med 2023; 12:6654. [PMID: 37892792 PMCID: PMC10607820 DOI: 10.3390/jcm12206654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Lupus anticoagulant (LA) is one of the three laboratory parameters (the others being antibodies to either cardiolipin or β2-glycoprotein I) that defines this rare but potentially devastating condition. For the search for aCL and aβ2-GP-I, traditionally measured with immunological solid-phase assays (ELISA), several different assays and detection techniques are currently available, thus making these tests relatively reliable and widespread. On the other hand, LA detection is based on functional coagulation procedures that are characterized by poor standardization, difficulties in interpreting the results, and interference by several drugs commonly used in the clinical settings in which LA search is appropriate. This article aims to review the current state of the art and the challenges that clinicians and laboratories incur in the detection of LA.
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Affiliation(s)
- Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
| | - Laura Banov
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Antonella Ierardi
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Alessandra Strangio
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
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11
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Buckley GT, Murphy B, Fleming N, Crowley MP, Harte JV. Removing direct oral factor Xa inhibitor interferences from routine and specialised coagulation assays using a raw activated charcoal product. Clin Chim Acta 2023; 550:117565. [PMID: 37769932 DOI: 10.1016/j.cca.2023.117565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly prescribed for the prevention and treatment of thrombosis. However, DOACs are associated with extensive interference in coagulation assays. Herein, we evaluate raw activated charcoal (AC) as an adsorbent material, to minimise DOAC-associated interferences in routine and specialised coagulation parameters on CS-series analysers (Sysmex, Kobe, Japan). METHODS Commercial human-derived non-anticoagulated plasma materials, with or without increasing concentrations of anticoagulant, were assayed for routine and specialised coagulation parameters before and after treatment with AC. RESULTS Treatment of non-anticoagulated plasma with raw AC had minimal impact on routine and specialised coagulation parameters available on the CS-series; however, clinically relevant prolongations of certain activated partial thromboplastin time (APTT)-based assays were observed after treatment. Furthermore, in apixaban- and rivaroxaban-containing plasma material, AC efficiently adsorbed therapeutic and supratherapeutic DOAC concentrations; and, treatment with raw AC resolved DOAC-associated interferences on all affected routine and specialised coagulation parameters. CONCLUSIONS Overall, raw AC efficiently adsorbed apixaban and rivaroxaban from human-derived plasma, without significantly affecting the majority of underlying routine and specialised coagulation parameters available on CS-series analysers.
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Affiliation(s)
- Gavin T Buckley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland
| | - Ber Murphy
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Niamh Fleming
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland; Irish Network for Venous Thromboembolism Research (INViTE), Ireland
| | - James V Harte
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland.
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12
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Marco-Rico A, Marco-Vera P. Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature. Semin Thromb Hemost 2023; 49:736-743. [PMID: 36996874 DOI: 10.1055/s-0043-1767728] [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: 04/01/2023]
Abstract
Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.
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Affiliation(s)
- Ana Marco-Rico
- Department of Thrombosis and Hemostasis, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
| | - Pascual Marco-Vera
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
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13
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Amikam U, Hochberg A, Shenhav M, Haj L, Hochberg-Klein S, Hiersch L, Yogev Y. Anti-Phospholipid Antibodies in Women with Placenta-Mediated Complications Delivered at >34 Weeks of Gestation. J Clin Med 2023; 12:4516. [PMID: 37445549 DOI: 10.3390/jcm12134516] [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: 06/01/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE To determine the prevalence of positive antiphospholipid (aPL) antibodies among pregnant women with placenta-mediated complications delivered at >340/7 weeks of gestation. METHODS This was a single-center retrospective observational study conducted between 2017 and 2022. Inclusion criteria included pregnant or post-partum women, >18 years, diagnosed with any of the following placenta-mediated complications and delivered at >340/7 weeks of gestation: small-for-gestational-age neonate (SGA ≤ 5th percentile according to local birthweight charts), preeclampsia with severe features, and placental abruption. The primary outcome was the prevalence of positive aPL antibodies: Lupus anticoagulant, Anticardiolipin, or Anti-ß2glycoprotein1. RESULTS Overall, 431 women met the inclusion criteria. Of them, 378(87.7%) had an SGA neonate, 30 had preeclampsia with severe features (7%), 23 had placental abruption (5.3%), and 21 patients had multiple diagnoses(4.9%). The prevalence of aPL antibodies in the cohort was 4.9% and was comparable between the three subgroups (SGA-3.9%; PET with severe features-3.3%; and placental abruption-13% (p = 0.17)). CONCLUSION aPL antibodies prevalence in women with placenta-mediated complications > 34 weeks of gestation was 4.9%, with comparable prevalence rates among the three subgroups. Future prospective studies are needed to delineate the need for treatment in those who tested positive for aPL antibodies and do not meet Anti-Phospholipid Antibody Syndrome clinical criteria.
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Affiliation(s)
- Uri Amikam
- Lis Hospital for Women, Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Alyssa Hochberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva 4941492, Israel
| | - Michael Shenhav
- Lis Hospital for Women, Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Lilian Haj
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Sarit Hochberg-Klein
- Palmerston North Hospital, Te Whatu Ora Health NZ, Palmerston North 4442, New Zealand
| | - Liran Hiersch
- Lis Hospital for Women, Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Yariv Yogev
- Lis Hospital for Women, Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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14
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Vandevelde A, Gris JC, Moore GW, Musiał J, Zuily S, Wahl D, Devreese KMJ. Added value of antiphosphatidylserine/prothrombin antibodies in the workup of obstetric antiphospholipid syndrome: communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2023; 21:1981-1994. [PMID: 37061133 DOI: 10.1016/j.jtha.2023.04.001] [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: 01/16/2023] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The added value of antiphosphatidylserine/prothrombin antibodies (aPS/PT) in the diagnostic workup of antiphospholipid syndrome (APS) is unclear. Currently, diagnosis of thrombotic APS (TAPS) and obstetric APS (OAPS) requires persistent presence of lupus anticoagulant (LAC), anticardiolipin (aCL) immunoglobulin (Ig) G/IgM, or anti-β2-glycoprotein I (aβ2GPI) IgG/IgM antibodies. OBJECTIVES To evaluate the role of aPS/PT IgG and IgM in OAPS. METHODS aPS/PT IgG/IgM, aCL IgG/IgM, aβ2GPI IgG/IgM, and LAC were determined in 653 patients (OAPS, TAPS, and controls). In-house aPS/PT cut-off values were calculated, titers and prevalence were compared between OAPS, TAPS, and controls and type of pregnancy morbidity. Sensitivity, specificity, likelihood ratios, and odds ratios (OR) with 95% CI were calculated. RESULTS In OAPS, aPS/PT IgG and IgM showed an OR of 4.32 (95% CI, 2.54-7.36) and 3.37 (95% CI, 1.93-5.89), respectively, but the association was not independent of LAC. Prevalence and titers of aPS/PT IgG and IgM were lower in OAPS than in patients with TAPS. aPS/PT were more prevalent and showed higher titers in patients with late pregnancy loss than in patients with early pregnancy loss with a positivity of 86.4% and 39.3%, respectively. Higher aPS/PT titers did not increase the likelihood of having OAPS. CONCLUSION The added value of aPS/PT testing in the current diagnostic workup of OAPS seems limited compared with LAC, aCL, and aβ2GPI. aPS/PT might be useful in specific subsets of patients with OAPS. However, future multicentric studies are needed to elucidate the risk of less frequent and most severe obstetrical manifestations.
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Affiliation(s)
- Arne Vandevelde
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Jean-Christophe Gris
- Department of Hematology, CHU Nîmes, Montpellier University, Nîmes, France; Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France; UMR UA11 INSERM IDESP - Montpellier University, France; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Gary W Moore
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, United Kingdom; Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, United Kingdom
| | - Jacek Musiał
- Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Stéphane Zuily
- Université de Lorraine, Inserm, DCAC and Centre Hospitalier Regional Universitaire de Nancy, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
| | - Denis Wahl
- Université de Lorraine, Inserm, DCAC and Centre Hospitalier Regional Universitaire de Nancy, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy, France
| | - Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
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15
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Favaloro EJ, Mohammed S, Vong R, Pasalic L. Antiphospholipid Antibody Testing for Anti-cardiolipin and Anti-β2 Glycoprotein I Antibodies Using Chemiluminescence-Based Panels. Methods Mol Biol 2023; 2663:297-314. [PMID: 37204719 DOI: 10.1007/978-1-0716-3175-1_19] [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 (antibody) syndrome (APS) is a prothrombotic condition with increased risk for thrombosis and pregnancy-related morbidity. In addition to clinical criteria related to these risks, APS is characterized by the persistent presence of antiphospholipid antibodies (aPL), as detected in the laboratory using a potentially wide variety of assays. The three APS criteria-related assays are lupus anticoagulant (LA), as detected using clot-based assays, and the solid-phase assays of anti-cardiolipin antibodies (aCL) and anti-β2 glycoprotein I antibodies (aβ2GPI), with immunoglobulin subclasses of IgG and/or IgM. These tests may also be used for the diagnosis of systemic lupus erythematosus (SLE). In particular, APS diagnosis/exclusion remains challenging for clinicians and laboratories because of the heterogeneity of clinical presentations in those being evaluated and the technical application and variety of the associated tests used in laboratories. Although LA testing is affected by a wide variety of anticoagulants, which are often given to APS patients to prevent any associated clinical morbidity, detection of solid-phase aPL is not influenced by these anticoagulants, and this thus represents a potential advantage to their application. On the other hand, various technical issues challenge accurate laboratory detection or exclusion of aPL. This report describes protocols for the assessment of solid-phase aPL, specifically aCL and aβ2GPI of IgG and IgM class by means of a chemiluminescence-based assay panel. These protocols reflect tests able to be performed on the AcuStar instrument (Werfen/Instrumentation Laboratory). Certain regional approvals may also allow this testing to be performed on a BIO-FLASH instrument (Werfen/Instrumentation Laboratory).
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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.
| | - Soma Mohammed
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Leonardo Pasalic
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
- Westmead Clinical School, Sydney University, Westmead, NSW, Australia
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16
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Favaloro EJ, Gosselin RC, Pasalic L, Lippi G. Hemostasis and Thrombosis: An Overview Focusing on Associated Laboratory Testing to Diagnose and Help Manage Related Disorders. Methods Mol Biol 2023; 2663:3-38. [PMID: 37204701 DOI: 10.1007/978-1-0716-3175-1_1] [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
Hemostasis is a complex but balanced process that permit normal blood flow, without adverse events. Disruption of the balance may lead to bleeding or thrombotic events, and clinical interventions may be required. Hemostasis laboratories typically offer an array of tests, including routine coagulation and specialized hemostasis assays used to guide clinicians for diagnosing and managing patients. Routine assays may be used to screen patients for hemostasis-related disturbances but may also be used for drug monitoring, measuring efficacy of replacement or adjunctive therapy, and other indications, which may then be used to guide further patient management. Similarly, "specialized" assays are used for diagnostic purposes or may be used to monitor or measure efficacy of a given therapy. This chapter provides an overview of hemostasis and thrombosis, with a focus on laboratory testing that may be used to diagnose and help manage patients suspected of hemostasis- and thrombosis-related disorders.
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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.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, Davis Health System, University of California, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Favaloro EJ, Gosselin RC, Pasalic L, Lippi G. Post-analytical Issues in Hemostasis and Thrombosis Testing: An Update. Methods Mol Biol 2023; 2663:787-811. [PMID: 37204753 DOI: 10.1007/978-1-0716-3175-1_53] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
There are typically three phases identified as contributing to the total testing process. The preanalytical phase starts with the clinician and the patient, when laboratory testing is being considered. This phase also includes decisions about which tests to order (or not), patient identification, blood collection, blood transport, sample processing, and storage to name a few. There are many potential failures that may occur in this preanalytical phase, and these are the topic of another chapter in this book. The second phase, the analytical phase, represents the performance of the test, which is essentially covered in various protocols in this book and the previous edition. The third is the post-analytical phase, which is what occurs after sample testing, and is the topic of the current chapter. Post-analytical issues are generally related to reporting and interpretation of test results. This chapter provides a brief description of these events, as well as guidance for preventing or minimizing post-analytical issues. In particular, there are several strategies for improved post-analytical reporting of hemostasis assays, with this providing the final opportunity to prevent serious clinical errors in patient diagnosis or management.
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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.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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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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19
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Favaloro EJ, Pasalic L, Lippi G. Autoimmune Diseases Affecting Hemostasis: A Narrative Review. Int J Mol Sci 2022; 23:ijms232314715. [PMID: 36499042 PMCID: PMC9738541 DOI: 10.3390/ijms232314715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022] Open
Abstract
Hemostasis reflects a homeostatic mechanism that aims to balance out pro-coagulant and anti-coagulant forces to maintain blood flow within the circulation. Simplistically, a relative excess of procoagulant forces can lead to thrombosis, and a relative excess of anticoagulant forces can lead to bleeding. There are a wide variety of congenital disorders associated with bleeding or thrombosis. In addition, there exist a vast array of autoimmune diseases that can also lead to either bleeding or thrombosis. For example, autoantibodies generated against clotting factors can lead to bleeding, of which acquired hemophilia A is the most common. As another example, autoimmune-mediated antibodies against phospholipids can generate a prothrombotic milieu in a condition known as antiphospholipid (antibody) syndrome (APS). Moreover, there exist various autoimmunity promoting environments that can lead to a variety of antibodies that affect hemostasis. Coronavirus disease 2019 (COVID-19) represents perhaps the contemporary example of such a state, with potential development of a kaleidoscope of such antibodies that primarily drive thrombosis, but may also lead to bleeding on rarer occasions. We provide here a narrative review to discuss the interaction between various autoimmune diseases and hemostasis.
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Affiliation(s)
- Emmanuel J. Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW 2678, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
- Correspondence: ; Tel.: +61-2-8890-6618
| | - Leonardo Pasalic
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Westmead, Sydney, NSW 2006, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, 37129 Verona, Italy
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Gosselin RC, Favaloro EJ, Douxfils J. The myths behind DOAC measurement: Analyses of prescribing information from different regulatory bodies and a call for harmonization. J Thromb Haemost 2022; 20:2494-2506. [PMID: 36111493 PMCID: PMC9828176 DOI: 10.1111/jth.15884] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/12/2023]
Abstract
For more than a decade, US laboratories have failed to implement solutions to help their clinicians in managing complex situations or patients on direct oral anticoagulants (DOACs). The problem may find different origins, among which is the position of the Food and Drug Administration, which categorized these drugs as monitoring- and measurement-free, whereas other regulatory bodies like the European Medicines Agency or the Therapeutic Goods Administration in Australia were more conservative on the principle that the absence of proof (of monitoring/measurement benefits) is not proof of an absence (of monitoring/measurement needs). Pivotal clinical studies that led to the approval of DOACs were presented as devoid of such testing, although some companies considered monitoring as a solution to improve their benefit/risk ratio. In this JTH In Clinics issue, we report more than a decade of development that has permitted the activation of smart laboratory solutions to qualify or quantify DOACs and discuss myths and misconceptions around technical and regulatory requirements that support the current reluctance of implementing these technologies in most US laboratories. Use of DOACs is ever expanding, with DOAC prescriptions now exceeding those of other anticoagulants, including vitamin K antagonists, in some geographies. As this use increases, the likely need to measure DOAC exposure will also increase. Measurement of DOACs does not represent any technical difficulty. That these laboratory tests are not available in some locations suggests disparities in patient care, and we suggest it is time to address such inequalities.
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Affiliation(s)
- Robert C. Gosselin
- Davis Health System, Hemostasis and Thrombosis CenterUniversity of CaliforniaSacramentoCaliforniaUSA
| | - Emmanuel J. Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health PathologyWestmead HospitalWestmeadNew South WalesAustralia
- School of Medical Sciences, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- School of Dentistry and Medical Sciences, Faculty of Science and HealthCharles Sturt UniversityWagga WaggaNew South WalesAustralia
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy,Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis CenterNamurBelgium
- QUALIblood s.a.Research and Development DepartmentNamurBelgium
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21
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Ong J, Bennett A. A review of laboratory considerations in thrombophilia testing. Pathology 2022; 54:835-841. [DOI: 10.1016/j.pathol.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 10/14/2022]
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