The evaluation of clotting times in the laboratory detection of lupus anticoagulants

Practical Considerations and Testing Nuances for the Detection of Lupus Anticoagulant: Do Low Phospholipid Screen Results, Assay Type, and Test Ratio Matter?

OBJECTIVES

Lupus anticoagulant (LA) detection requires (1) prolongation of a phospholipid (PL)-dependent clot-based screening assay, (2) noncorrection upon adding normal pooled plasma, and (3) a confirmatory PL dependency test. Paired LA assays run screening and confirmatory tests simultaneously, with their test ratio (TR) or differences used to evaluate test results. We evaluated patients whose paired testing demonstrated PL dependence suggestive of LA, yet the low PL screen was not prolonged.

METHODS

Clinical and laboratory parameters are compared across (1) true positive (screen prolonged, TR positive) vs borderline (screen not prolonged, TR positive); (2) low-, moderate-, and high-TR subgroups; and (3) dilute Russell viper venom time (dRVVT) vs silica clotting time (SCT).

RESULTS

Borderline samples are not statistically different from true positives in their rate of repeat LA positivity or association with other anti-PL antibodies. Compared with true positives, borderline dRVVT is more frequent in pregnancy, women, and younger age. Elevated activated partial thromboplastin time is more frequent in true-positive dRVVT and SCT vs borderline and with an increasing dRVVT TR. LA persistence is more frequent with an increasing SCT TR. In addition, dRVVT true positivity is more frequent with thromboembolic events, while SCT is more frequent with autoimmunity and pregnancy complications.

CONCLUSIONS

Negative low-PL screens may not necessarily lack LA. A reevaluation of the laboratory criteria for LA detection may be needed.

The enigmas of the lupus anticoagulant: mechanisms, diagnosis, and management

Lupus anticoagulant (LA) is a laboratory abnormality associated with the antiphospholipid syndrome. It is a paradoxical phenomenon in which one or more in vitro diagnostic clotting tests are prolonged and thus seem due to an anticoagulant, whereas the antiphospholipid syndrome is manifest clinically as inappropriate or excessive thrombosis. LA should be suspected when thrombosis, recurrent fetal loss, or a prolonged phospholipid (PL)-dependent clotting test is present without other identifiable causes. Despite the heterogeneity of LA antibodies, a consensus has evolved to identify the LA. Four conditions must be met for this laboratory diagnosis: 1) prolongation of a PL-based clotting test, 2) confirmation of an inhibitor-like pattern in the clotting test, 3) confirmation of PL dependence in coagulation tests, and 4) exclusion of a specific factor inhibitor. Even with an extensive armamentarium for LA diagnosis and treatment, it is still a formidable task.

Further evidence of false negative screening for lupus anticoagulants

INTRODUCTION

Accurate and timely detection of lupus anticoagulants (LA) is of diagnostic and prognostic importance due to the association of persistent LA with thrombotic disease. Antibody heterogeneity and assay variability complicate LA detection and weak antibodies can go undetected.

METHODS

Screen and confirm assays on equal volume mixing studies were performed on known LA using dilute Russell's viper venom time (DRVVT), dilute activated partial thromboplastin time (DAPTT) and activated seven lupus anticoagulant (ASLA) assay. Two established calculations for phospholipid dependence were applied to ascertain whether any antibodies diluted to within screening test reference ranges maintained a significant difference between screen and confirm results sufficient to imply LA activity. We then performed confirmatory tests on neat plasma samples from patients with thrombotic disease whose screening tests were within reference ranges.

RESULTS

Forty nine of 155 DRVVT positive LA were conventionally positive in the mixing studies and 8 of the 106 negative mixing studies showed significant screen and confirm test discordance. This was the case for 21 of 56 negative DAPTT mixing studies and 2 of 39 negative ASLA mixing studies. Performance of confirm assays on the neat plasma samples with screen results within reference ranges revealed possible LA activity in 19 of 166 DRVVT results, 63 of 184 DAPTT results and 9 of 117 ASLA results.

CONCLUSIONS

LA activity can be demonstrated by assessment of screen and confirm data irrespective of screening test elevation above a reference range. Other workers have demonstrated this phenomenon in APTT using different study designs and it may be that standard interpretation criteria warrant re-assessment.

Lupus anticoagulant is significantly associated with inflammatory reactions in patients with suspected deep vein thrombosis

OBJECTIVE

Lupus anticoagulant (LA) and antiphospholipid antibodies (aPL) are suggested as risk factors for development of deep vein thrombosis (DVT) among patients without systemic lupus erythematosus (SLE). Other conditions, e.g. inflammation, are reported to induce LA and it is uncertain whether the association between LA and DVT is causal. In this study the associations between aPL, LA and inflammation were investigated in 170 consecutive patients without SLE, but with a tentative diagnosis of DVT.

MATERIAL AND METHODS

DVT was diagnosed in 64 patients. LA was determined according to the criteria of the International Society of Thrombosis and Haemostasis. The concentration of anticardiolipin (aCL) and beta(2)-glycoprotein I (anti-beta(2)-GPI) antibodies as well as C-reactive protein (CRP) was determined with sensitive and precise methods.

RESULTS

LA was demonstrated in 8 patients with DVT and in 10 patients without DVT, relative risk 1.33 (CI: 0.55-3.18). No significant association was observed between aCL or anti-beta(2)-GPI and DVT. Patients suffering from DVT had significantly higher concentrations of CRP than patients without DVT. However, CRP was also significantly higher in patients positive for LA than in patients without LA irrespective of the presence of DVT (p<0.001).

CONCLUSIONS

The present study supports a strong association between inflammatory reactions and development of LA in patients with suspected DVT, whereas no significant association was demonstrated between LA or aPL and DVT.

Evaluation of a new silica clotting time in the diagnosis of lupus anticoagulants

INTRODUCTION

A new commercial silica clotting time (SCT), the HemosIL SCT assay (Instrumentation Laboratory, Milan, Italy) was evaluated in the laboratory diagnosis of lupus anticoagulants (LAC). This integrated test system for screening and confirmation was compared with the frequently used aPTT-based PTT-LA and Staclot-LA (Diagnostica Stago, Asnières, France) in a patient population investigated for LAC and in a subpopulation who met the clinical criteria for antiphospholipid syndrome (APS).

MATERIALS AND METHODS

201 samples were analysed with the HemosIL SCT assay. Own reference values were calculated. Results are expressed as measured clotting times in seconds or as normalised ratios.

RESULTS

SCT screen and PTT-LA had a sensitivity of, 61.1% and 63.8%, respectively. Normalising the results gained sensitivity up to 72.2% and 90%, respectively. The confirmation SCT and the Staclot-LA had a sensitivity of 30.6% and 63.9% with a specificity of 86.7% and 100%, respectively. Sensitivity of SCT for detecting LAC in clinical criteria positive patients was lower compared to aPTT and dRVVT (45.8% versus 66.7% and 65%). Combination of SCT/dRVVT and aPTT/dRVVT gave a sensitivity of 51.2% and 63.6%, with a specificity of 50.0% and 52.3%, respectively.

CONCLUSIONS

In comparison with PTT-LA as screening test, the SCT screen shows an acceptable sensitivity. However, the HemosIL SCT assay including the confirmation step, has a much lower sensitivity in the diagnosis of LAC in comparison with the Staclot-LA test. Combining the HemosIL SCT assay with dRVVT results in a better sensitivity, although lower than the combined aPTT/dRVVT based method as usually performed in our lab.

Interpretation of normal plasma mixing studies in the laboratory diagnosis of lupus anticoagulants

INTRODUCTION

Mixing studies are part of the laboratory diagnosis of lupus anticoagulants (LA). They are used to determine the evidence of an inhibitor by demonstrating persistence of an abnormal clotting time by mixing patient plasma with normal plasma. Since there is no standardised interpretation of results of mixing studies, percent correction formulas are proposed. The sensitivity of mixing studies strongly depends on the interpretation of the results.

MATERIALS AND METHODS

A retrospective analysis was performed on 361 samples, 75 LA-positive and 286 LA-negative samples. For all the LA-positive samples and for 181/286 LA-negative samples mixing tests on one or more screening tests were performed. A percent correction formula and the Rosner index were calculated for all mixing tests on aPTT and dPT.

RESULTS

The <70% correction formula for the mixing tests on aPTT showed the highest sensitivity (95%). The Rosner index had a sensitivity (93%) comparable with the <70% correction formula. dPT is shown to be less sensitive in the detection for LA and, even when the screening test is prolonged, interpretation of the mixing test by the percent correction formula misclassifies many samples. Rosner index in the interpretation of mixing tests for dPT is more sensitive than the percent correction formula, 49% and 57%, respectively.

CONCLUSIONS

This study demonstrates that the Rosner index and the percent correction formulas for interpretation of mixing studies are complementary and can help to reduce misclassification of LA-positive or LA-negative samples.

International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)

New clinical, laboratory and experimental insights, since the 1999 publication of the Sapporo preliminary classification criteria for antiphospholipid syndrome (APS), had been addressed at a workshop in Sydney, Australia, before the Eleventh International Congress on antiphospholipid antibodies. In this document, we appraise the existing evidence on clinical and laboratory features of APS addressed during the forum. Based on this, we propose amendments to the Sapporo criteria. We also provide definitions on features of APS that were not included in the updated criteria.

Detection and quantification of lupus anticoagulants in plasma from heparin treated patients, using addition of polybrene

Background

Lupus anticoagulants prolong clotting times in phospholipid-dependent coagulation tests. Lupus Ratio assays are integrated tests for lupus anticoagulants that may be based on APTT, RVVT or dPT clotting times. If a patient is being treated with unfractionated heparin, however, the heparin prolong clotting times and the diagnosis of lupus anticoagulant is invalidated. Commercial assays may have heparin neutralising agents added to their reagents. However, the type and efficacy of the heparin neutralisation is often not documented. We wanted to test the influence and efficacy of heparin neutralisers in the Lupus Ratio assay.

Methods

Several heparin neutralisers were tested, and polybrene was chosen for further testing. Unfractionated heparin and/or polybrene were added to normal plasma and to plasma from patients with or without lupus anticoagulant and clotting times compared before and after the additions. Lupus anticoagulant-positive patients were given 5000 IU i.v. of unfractionated heparin and plasma was collected just before and five minutes after the injection. Lupus Ratios were calculated after polybrene was added to the postinjection samples.

Results

The Lupus Ratio became slightly lower when polybrene was added to plasma without heparin. Plasma heparinised in vitro and plasma from patients that had received heparin, both had Lupus Ratios nearly identical to the Lupus Ratios calculated before any additions.

Conclusion

By addition of polybrene to a final concentration of 7.9 μg/ml in test plasma, Lupus Ratio may be determined in lupus anticoagulant-negative as well as positive plasmas irrespective of the presence of heparin 0.0 – 1.3 U/ml.

Predictive value of persistent versus transient antiphospholipid antibody subtypes for the risk of thrombotic events in pediatric patients with systemic lupus erythematosus

Study objectives were to determine, in children with systemic lupus erythematosus (SLE), (1) the association of antiphosholipid antibody (APLA) subtypes with thrombotic events (TEs) and (2) the predictive value of persistent versus transient antibodies for TEs. This is a cohort study of 58 SLE children in whom lupus anticoagulants (LAs), anticardiolipin antibodies (ACLAs), anti–β2-glycoprotein-I (anti–β2-GPI), and antiprothrombin (anti-PT) were assessed on at least 2 occasions (more than 3 months apart). Antibodies were classified as persistent (positive on at least 2 occasions) or transient (positive once). Outcomes were symptomatic TEs confirmed by objective radiographic tests identified retrospectively and prospectively. Seven of the 58 patients (12%) had 10 TEs; 5 patients had TEs during prospective follow-up. Persistent LAs showed the strongest association with TEs (P < .001). Persistent ACLAs (P = .003) and anti–β2-GPI (P = .002) were significantly associated with TEs; anti-PT (P = .063) showed a trend. Persistent or transient LAs and anti–β2-GPI showed similar strength of association, while ACLAs and anti-PT were no longer associated with TEs. Positivity for multiple APLA subtypes showed stronger associations with TEs than for individual APLA subtypes because of improved specificity. Lupus anticoagulant is the strongest predictor of the risk of TEs; other APLA subtypes provide no additional diagnostic value. Anticardiolipin antibodies and anti-PT require serial testing because only persistent antibodies are associated with TEs.

Effect of subcutaneous administration of dalteparin on lupus anticoagulant assays

INTRODUCTION

Treatment with unfractionated heparin (UH) is known to affect screening tests for lupus anticoagulant (LA). False positive test results are common because confirmatory steps lack sufficient specificity to distinguish between LA and the presence of heparin. In this study, we wanted to see if therapeutic levels of low-molecular weight heparin (LMWH) may cause false positive tests for LA or alter the LA test results in LA-positive patients. We also wanted to evaluate the need to include heparin-neutralizing agents in the reagents.

MATERIALS AND METHODS

Six healthy subjects without LA and six LA-positive patients were given 100 IU/kg dalteparin subcutaneously (s.c.). Samples for three in-house and two commercially available LA tests were taken before and 4 h after the injection. LA test results were calculated as normalized screening/confirm ratios or as recommended by the manufacturers.

RESULTS

With both healthy subjects and LA patients, only small and clinically unimportant differences in mean clotting times and final test results were seen 4 h after subcutaneous dalteparin injections, at anti-FXa activities within the therapeutic range.

CONCLUSIONS

Our study with dalteparin suggests that LMWH therapy with plasma concentrations within the therapeutic range does not cause false positive tests for LA when normalized screening/confirm ratios are applied; nor do test results for LA-positive patients seem to be significantly altered. Heparin-neutralizing agents did not influence test performance.