1
|
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.
Collapse
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
| |
Collapse
|
2
|
Machado Alba JE, Wilches-Gutierrez JD, Arias-Osorio DR, Reyes JM, Nakandakari ML, Ospina-Arzuaga HD, Gaviria-Mendoza A, Castaño-Gamboa N, Valladales-Restrepo LF, Machado-Duque ME. The frequency of complications in a cohort of patients diagnosed with hemophilia A and hemophilia B receiving prophylactic treatment in Colombia: A retrospective noninterventional study. PLoS One 2023; 18:e0286187. [PMID: 38011251 PMCID: PMC10681305 DOI: 10.1371/journal.pone.0286187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/11/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Hemophilia A and B are disorders associated with the deficit of coagulation factors VIII and IX. OBJECTIVE Was to determine the incidence of complications in a cohort of patients diagnosed with moderate and severe hemophilia A or B under treatment in a specialized institution. METHODS A retrospective study of a cohort of patients with replacement therapy for hemophilia A or B, evaluating treatment and complications between January/2012 and July/2019. Sociodemographic, clinical and disease management-related variables were extracted from the medical records. Time to inhibitor development and rate associated with bleeding and hospitalizations were evaluated. RESULTS A total of 159 male patients were identified with hemophilia A (n = 140; 88.1%) and B (n = 19; 11.9%) with a mean follow-up of 5.9±2.3 years. The mean age was 23.6±16.1 years, hemophilia was reported as severe in 125 patients in hemophilia A (89.3%) and 13 patients in hemophilia B (68.4%). Primary prophylaxis was registered in 17.0% of patients, 44.7% secondary, and 38.3% tertiary, with recombinant factors (n = 84; 52.8%) followed by plasma derived factors (n = 75; 47.2%). The incidence of inhibitor development was 0.3 per 100 patients/year, with mean time to event of 509 days. The incidence of bleeding was 192 per 100 patients/year, especially at the joint (n = 99; 62.3%) and muscle (n = 25; 15.7%) level. The incidence of hospitalization was 3.7 per 100 patients/year. CONCLUSIONS The most common complication was joint bleeding which was expected in this type of patients. Low proportion of patients developed factor inhibitors during the follow up.
Collapse
Affiliation(s)
- Jorge E. Machado Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | | | | | | | | | - Harrison David Ospina-Arzuaga
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Andres Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | | | - Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Manuel E. Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Yan L, Wang T, Qiu J, Zhang X, Peng J, Fang Y, Sheng Z. Identification of a novel mutation in the factor XIII A subunit in a patient with inherited factor XIII deficiency. Int J Hematol 2023:10.1007/s12185-023-03594-y. [PMID: 37059930 DOI: 10.1007/s12185-023-03594-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/16/2023]
Abstract
Inherited factor XIII (FXIII) deficiency is an extremely rare and under-diagnosed autosomal recessive inherited coagulopathy, which is caused by genetic defects in the F13A1 or F13B gene. More than 200 genetic mutations have been identified since the first case of inherited FXIII deficiency was reported. This study aimed to identify underlying gene mutations in a patient with inherited FXIII deficiency who presented with recurrent intracerebral hemorrhage. Levels of plasma FXIII-A antigen were measured, F13A1 and F13B genes were sequenced, mutation information was analyzed, and the mutated protein structure was predicted using bioinformatics methods. Molecular genetic analysis identified four mutations of FXIII-related genes in the proband, including three previously reported mutations inherited from his parents (c.631G>A, p.Gly210Arg and c.1687G>A, p.Gly562Arg of F13A1 gene and c.344G>A, p.Arg115His of F13B gene) and a novel spontaneous mutation of F13A1 gene (c.2063C>G, p.Ser687Cys). Molecular structural modeling demonstrated that the novel Ser687Cys mutation may cause changes in the spatial structure of FXIII-A and increase its instability. In conclusion, we identified a novel and likely pathogenic mutation of the F13A1 gene, which enriched the gene mutation spectrum of inherited FXIII deficiency. The findings may provide promising targets for diagnosis and treatment of inherited FXIII deficiency.
Collapse
Affiliation(s)
- Lijie Yan
- Department of Hematology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, Jinan, China
| | - Tiantian Wang
- Shandong Blood Center, Shandong Hemophilia Treatment Center, No. 22, Shanshi East Road, Jinan, China
| | - Jihua Qiu
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xinsheng Zhang
- Shandong Blood Center, Shandong Hemophilia Treatment Center, No. 22, Shanshi East Road, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, Jinan, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yunhai Fang
- Shandong Blood Center, Shandong Hemophilia Treatment Center, No. 22, Shanshi East Road, Jinan, China.
| | - Zi Sheng
- Department of Hematology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, Jinan, China.
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Abstract
ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) is also called von Willebrand factor (VWF) cleaving protease (VWFCP). ADAMTS13 acts to cleave VWF multimers and thus reduce plasma VWF activity. In the absence of ADAMTS13 (i.e., in thrombotic thrombocytopenia purpura, TTP), plasma VWF can accumulate, in particular as "ultra-large" VWF multimers, and this can lead to thrombosis. Relative deficiencies in ADAMTS13 can also occur in a variety of other conditions, including secondary thrombotic microangiopathies (TMA). Of contemporary interest, COVID-19 (coronavirus disease 2019) may also be associated with relative reduction of ADAMTS13 and also pathological accumulation of VWF, with this likely contributing to the thrombosis risk seen in affected patients. Laboratory testing for ADAMTS13 can assist in the diagnosis of these disorders (i.e., TTP, TMA), as well as in their management, and can be achieved using a variety of assays. This chapter therefore provides an overview of laboratory testing for ADAMTS13 and the value of such testing to assist the diagnosis and management of associated disorders.
Collapse
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
| |
Collapse
|
7
|
Favaloro EJ, Chapman K, Mohammed S, Vong R, Pasalic L. Identification of ADAMTS13 Inhibitors in Acquired TTP. Methods Mol Biol 2023; 2663:505-521. [PMID: 37204733 DOI: 10.1007/978-1-0716-3175-1_33] [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
Thrombotic thrombocytopenic purpura (TTP) is a prothrombotic condition caused by a deficiency of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). In turn, ADAMTS13 (also called von Willebrand factor (VWF) cleaving protease (VWFCP)) acts to cleave VWF multimers and thus reduce plasma VWF activity. In the absence of ADAMTS13 (i.e., in TTP), plasma VWF accumulates, in particular as "ultra-large" VWF multimers, and this leads to thrombosis. In most patients with confirmed TTP, ADAMTS13 deficiency is an acquired disorder due to the development of antibodies against ADAMTS13, which either promote clearance of ADAMTS13 from circulation or cause inhibition of ADAMTS13 activity. The current report describes a protocol for assessment of ADAMTS13 inhibitors, being antibodies that inhibit ADAMTS13 activity. The protocol reflects the technical steps that help identify inhibitors to ADAMTS13, whereby mixtures of patient plasma and normal plasma are then tested for residual ADAMTS13 activity in a Bethesda-like assay. The residual ADAMTS13 activity can be assessed by a variety of assays, with a rapid test able to be performed within 35 minutes on the AcuStar instrument (Werfen/Instrumentation Laboratory) used as an example in this protocol.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.
- Sydney Centres for Thrombosis and Haemostasis, 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, NSW, Australia.
| | - Kent Chapman
- Haematology Department, John Hunter Hospital, NSW Health Pathology, Newcastle, NSW, Australia
| | - Soma Mohammed
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Leonardo Pasalic
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, 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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Cacciotti C, Chan A, Bhatt M. Oral Corticosteroid Therapy as an Adjuvant Treatment for Acute Bleeding in Hemophilia Patients With High Titer Inhibitors. J Pediatr Hematol Oncol 2021; 43:e237-e239. [PMID: 31688638 DOI: 10.1097/mph.0000000000001639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/16/2019] [Indexed: 11/26/2022]
Abstract
Treatment options exist for patients with severe hemophilia and high titer factor VIII inhibitors but is often inadequate. Few studies have been conducted to evaluate the utility of short-term corticosteroid therapy for improvement in bleeding complications and temporary or sustained resolution of inhibitors in these patients. We describe 2 patients with acute muscular hematomas successfully treated with 4 to 5 days of oral adjuvant corticosteroid therapy resulting in improvement in their acute bleeds and temporary reduction of inhibitors. Thus, the addition of corticosteroids to traditional therapy of hemophilia with inhibitors may be beneficial in some patients. In those with impending compartment syndrome steroids may improve edema and bleeding symptoms preventing the need for surgical interventions.
Collapse
Affiliation(s)
- Chantel Cacciotti
- Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON
| | | | | |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Favaloro EJ. Coagulation mixing studies: Utility, algorithmic strategies and limitations for lupus anticoagulant testing or follow up of abnormal coagulation tests. Am J Hematol 2020; 95:117-128. [PMID: 31674066 DOI: 10.1002/ajh.25669] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 01/08/2023]
Abstract
Coagulation testing underpins the investigation of hemostasis and/or monitoring of anticoagulation therapy for prevention and/or treatment of thrombosis related pathology. Assessment of coagulation results requires comparison against a normal reference range or interval (NRR/NRI). Results flagged as "abnormal" (ie, above the NRR/NRI for patients not on anticoagulant therapy), typically require further evaluation. eg, follow up or reflexive testing is used to identify the reason for prolongation, especially when supported by clinical context (eg, bleeding). Mixing tests may have utility to help identify the pathway of follow-up testing (ie, towards investigation of factor deficiencies, or else inhibitors), and are also useful for investigation of lupus anticoagulants (LA). In general, mixing tests that "correct" tend to suggest the presence of factor deficiencies, where as those that do not correct suggest the presence of "inhibitors". Various approaches can be used to identify correction/non-correction, and all have strengths and limitations. Furthermore, eventual identification of causal factor deficiencies or even "inhibitors" may (eg, factor VIII or IX deficiencies or inhibitors) or may not (eg, factor XII deficiency) be clinically important. Ultimately, mixing studies performed in view of appropriate clinical scenarios (eg, bleeding patient) and for LA investigations in symptomatic patients will have best utility.
Collapse
Affiliation(s)
- Emmanuel J. Favaloro
- Department of HaematologyInstitute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
| |
Collapse
|
12
|
Lippi G, Favaloro EJ. Emicizumab (ACE910): Clinical background and laboratory assessment of hemophilia A. Adv Clin Chem 2018; 88:151-167. [PMID: 30612605 DOI: 10.1016/bs.acc.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Congenital hemophilia A, a relatively common and sometimes life-threatening bleeding disorder, is caused by inherited deficiency of clotting factor (F) VIII. The adoption of an appropriate medical and environmental prophylaxis is critical for long-term management of hemophilia because it will considerably reduce the number of both mild and severe bleeding episodes. Among the many therapeutic options that have become available over the past decades, ACE910 (also known as emicizumab) is a bispecific immunoglobulin G antibody characterized by its unique ability to bind FIX or FIXa on one arm and FX on the other, thus abrogating FVIII activity in vivo. Several phase I to III clinical trials have now been published, confirming the clinical efficacy and relative safety of this new agent for long-term prophylaxis of hemophilia A, especially those patients having FVIII inhibitors. The recent regulatory clearance of ACE910 in many countries will hence impose additional challenges to clinical laboratories because the panel of available tests will need to address the emerging issue of monitoring patients treated with this novel anti-hemophilic agent by using conventional as well as innovative approaches. Therefore, this article is aimed to provide an update on clinical background and challenges of laboratory assessment in hemophilia A patients undergoing ACE910 administration.
Collapse
Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy.
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres fosr Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| |
Collapse
|
13
|
Favaloro EJ, Mohammed S, Lippi G. Postanalytical considerations that may improve the diagnosis or exclusion of haemophilia and von Willebrand disease. Haemophilia 2018; 24:849-861. [PMID: 30024638 DOI: 10.1111/hae.13587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/17/2018] [Indexed: 01/07/2023]
Abstract
von Willebrand disease (VWD) and haemophilia represent the most common inherited or acquired bleeding disorders. However, many laboratories and clinicians may be challenged by their accurate diagnosis or exclusion. Difficulties in diagnosis/exclusion may include analytical issues, where assays occasionally generate an incorrect result (ie representing an analytical error) or have limitations in their measurement range of and/or low analytical sensitivity. Also increasingly recognized is the influence of preanalytical issues on the diagnosis of VWD or haemophilia. Unfortunately, postanalytical considerations are often not well considered in the diagnostic process. Therefore, this narrative review aims to provide an overview of some important postanalytical considerations that may help improve the diagnosis of VWD and haemophilia. This review primarily discusses aspects around reporting of test results. However, we also discuss other less well-recognized postanalytical considerations, including the use of assay ratios to help identify differential diagnoses and then guide further investigation.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Diagnostic Haemostasis Laboratory, 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, NSW, Australia
| | - Soma Mohammed
- Diagnostic Haemostasis Laboratory, Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| |
Collapse
|
14
|
Farhat E, Tegg E, Mohammed S, Grzechnik E, Favaloro EJ. Not as sweet as honey: A rare case of an apparent factor V "inhibitor" in association with bee sting anaphylaxis. Am J Hematol 2018; 93:965-970. [PMID: 29675861 DOI: 10.1002/ajh.25121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Elisabeth Farhat
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Elizabeth Tegg
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Elzbieta Grzechnik
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital; Westmead NSW Australia
| | - Emmanuel J. Favaloro
- Haematology, 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
| |
Collapse
|