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Adcock DM, Moore GW, Montalvão SDL, Kershaw G, Gosselin RC. Activated Partial Thromboplastin Time and Prothrombin Time Mixing Studies: Current State of the Art. Semin Thromb Hemost 2023; 49:571-579. [PMID: 36055261 DOI: 10.1055/s-0042-1756196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Mixing studies have long been in the clinical laboratory armamentarium for investigating unexpected, prolonged activated partial thromboplastin time (aPTT) or prothrombin time (PT). The purpose of the mixing study is to identify whether the aPTT/PT prolongation is secondary to a factor deficiency versus an inhibitor, which would present as a "corrected" and "noncorrected" mixing study, respectively. The differentiation between a factor deficiency and inhibitor may likely further direct clinical decisions, including additional diagnostic testing or factor replacement therapy. While aPTT/PT mixing studies are simple tests to perform, there is a lack of standardization for both the testing protocol and the interpretation of what is considered to be a corrected or noncorrected mixing study result. This review will describe the common indications for the mixing test, preanalytic variables that may affect mixing study performance, and describe several methods for interpreting the results of aPTT and PT mixing tests.
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Affiliation(s)
| | - Gary W Moore
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University London, London, United Kingdom
| | - Silmara de Lima Montalvão
- Laboratory Hemostasis, Hematology and Hemotherapy Center, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Robert C Gosselin
- Davis Health System, Hemostasis and Thrombosis Center, University of California, Sacramento, California
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2
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Kong Y, Kershaw G, Fu YKS, Passam F. Multiple Electrode Aggregometry (Multiplate): Functional Assay for Vaccine-Induced (Immune) Thrombotic Thrombocytopenia (VITT). Methods Mol Biol 2023; 2663:429-440. [PMID: 37204728 DOI: 10.1007/978-1-0716-3175-1_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) was first described in 2021 and represents an adverse reaction to adenoviral vector COVID-19 vaccines AstraZeneca ChAdOx1 nCoV-19 (AZD1222) and Johnson & Johnson Ad26.COV2.S vaccine. VITT is a severe immune platelet activation syndrome with an incidence of 1-2 per 100,000 vaccinations. The features of VITT include thrombocytopenia and thrombosis within 4-42 days of first dose of vaccine. Affected individuals develop platelet-activating antibodies against platelet factor 4 (PF4). The International Society on Thrombosis and Haemostasis recommends both an antigen-binding assay (enzyme-linked immunosorbent assay, ELISA) and a functional platelet activation assay for the diagnostic workup of VITT. Here, the application of multiple electrode aggregometry (Multiplate) is presented as a functional assay for VITT.
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Affiliation(s)
- Yvonne Kong
- Haematology Department, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey Kershaw
- Haematology Department, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Yuet Kee Suki Fu
- Haematology Department, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Freda Passam
- Haematology Department, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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3
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Kershaw G, Dix C. Measuring Emicizumab Levels in the Hemostasis Laboratory. Methods Mol Biol 2023; 2663:589-595. [PMID: 37204738 DOI: 10.1007/978-1-0716-3175-1_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Emicizumab is a bi-specific antibody that in recent years has been introduced in many countries as a prophylactic agent for bleed prevention in cases of severe hemophilia A, and in some cases of moderate HA. It can be used in individuals with HA with and without FVIII inhibitors, because the drug is not a target for these inhibitors. Emicizumab was developed as a fixed weight-based dose and does not normally need laboratory monitoring, but in some circumstances such as a treated HA patient with unexpected bleeding episodes, a laboratory assay is justified. This chapter describes to performance of a one-stage clotting assay to measure emicizumab.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
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Favaloro EJ, Clifford J, Leitinger E, Parker M, Sung P, Chunilal S, Tran H, Kershaw G, Fu S, Passam F, Ahuja M, Ho SJ, Duncan E, Yacoub O, Tan CW, Kaminskis L, Modica N, Pepperell D, Ballard L, Clarke L, Lee CSM, Gardiner EE, Young-Ill Choi P, Tohidi-Esfahani I, Bird R, Brighton T, Chen VM. Assessment of immunological anti-platelet factor 4 antibodies for vaccine-induced thrombotic thrombocytopenia (VITT) in a large Australian cohort: A multicenter study comprising 1284 patients. J Thromb Haemost 2022; 20:2896-2908. [PMID: 36107495 PMCID: PMC9828670 DOI: 10.1111/jth.15881] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare complication of adenovirus-based vaccines aimed to prevent and minimize COVID-19 and related pathophysiology. OBJECTIVES To describe patterns of testing for anti-platelet factor 4 (PF4) antibodies using various ELISA assays in a large Australian cohort and comparative functional platelet activation assays in a subset. PATIENTS/METHODS Asserachrom HPIA IgG ELISA was performed in 1284 patients over a period of 12 months, supplemented in select cohorts by comparative ELISA using three other methods (n = 78-179), three different functional assays (flow cytometry, serotonin release assay, and/or Multiplate; n = 476), and rapid immunological chemiluminescence anti-PF4 assay (n = 460), in a multicenter study. RESULTS For first episode presentations, 190/1284 (14.8%) ELISA tests were positive. Conversely, most (445/460; 96.7%) chemiluminescence anti-PF4 test results were negative. All functional assays showed associations of higher median ELISA optical density with functional positivity and with high rates of ELISA positivity (64.0% to 85.2%). Data also identified functional positivity in 14.8%-36.0% of ELISA negative samples, suggesting false negative VITT by HPIA IgG ELISA in upward of one third of assessable cases. CONCLUSION To our knowledge, this is the largest multicenter evaluation of anti-PF4 testing for investigation of VITT. Discrepancies in test results (ELISA vs. ELISA or ELISA vs. functional assay) in some patients highlighted limitations in relying on single methods (ELISA and functional) for PF4 antibody detection in VITT, and also highlights the variability in phenotypic test presentation and pathomechanism of VITT.
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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, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Emma Leitinger
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Michael Parker
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Pauline Sung
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | | | - Huyen Tran
- Clinical Haematology Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Suki Fu
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Freda Passam
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Monica Ahuja
- Haematology, NSW Health Pathology, St George Hospital, Kogarah, New South Wales, Australia
| | - Shir Jing Ho
- Haematology, NSW Health Pathology, St George Hospital, Kogarah, New South Wales, Australia
| | - Elizabeth Duncan
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Olivia Yacoub
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chee Wee Tan
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa Kaminskis
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Natasha Modica
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Dominic Pepperell
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Leanne Ballard
- Haematology, Qld Pathology, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - Lisa Clarke
- Haematology, NSW Health Pathology, Concord Hospital, Concord, New South Wales, Australia
- Australian Red Cross Lifeblood, Sydney, New South Wales, Australia
| | - Christine S M Lee
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
| | - Elizabeth E Gardiner
- John Curtin School of Medical Research, Division of Genome Sciences and Cancer, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Philip Young-Ill Choi
- John Curtin School of Medical Research, Division of Genome Sciences and Cancer, The Australian National University, Canberra, Australian Capital Territory, Australia
- Haematology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Ibrahim Tohidi-Esfahani
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
| | - Robert Bird
- Division of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Timothy Brighton
- Haematology, NSW Health Pathology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Vivien M Chen
- Haematology, NSW Health Pathology, Concord Hospital, Concord, New South Wales, Australia
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
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5
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Favaloro EJ, Mohammed S, Vong R, Chapman K, Kershaw G, Just S, Connelly L, Ryan M, Zebeljan D, Brighton T, Pasalic L. Harmonizing platelet function analyzer testing and reporting in a large laboratory network. Int J Lab Hematol 2022; 44:934-944. [PMID: 35754202 PMCID: PMC9545980 DOI: 10.1111/ijlh.13907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The platelet function analyzer (PFA) is a popular platelet function screening instrument, highly sensitive to von Willebrand disease (VWD) and to aspirin therapy, with moderate sensitivity to defects in platelet function and/or deficiencies in platelet number. There are two models, the original PFA-100 and the contemporary PFA-200. Normal reference ranges (NRRs) provided by the manufacturer are the same for both models, instead being based on the type of test cartridge, for which there are two main ones: collagen/epinephrine (C/Epi) and collagen/adenosine diphosphate (C/ADP). METHODS Comparative evaluations of PFA testing and reporting in six different sites of a large pathology network, aiming to harmonize NRRs and test reporting across all network sites. A separate comparative study of testing a range of samples (n > 150) on a PFA-100 versus that on a PFA-200. Review of contemporary literature. RESULTS Each site was identified to have a different reporting NRR, which after consolidating data permitted establishment of an agreed harmonized NRR for use across the network (C/Epi: 90-160; C/ADP: 70-124; based on n > 180). Similarly, each site reported and interpreted results in different ways, and after discussion and consolidation, a harmonized approach to interpretation and reporting was achieved. The separate comparative study of PFA-100 versus PFA-200 testing confirmed instrument equivalence. CONCLUSION We achieved harmonized NRRs and reporting for PFA testing across a large pathology network. Our approach may be useful for other laboratory networks wishing to harmonize PFA testing.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ronny Vong
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kent Chapman
- Haematology, NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Sarah Just
- Haematology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Lynne Connelly
- Haematology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael Ryan
- Haematology, NSW Health Pathology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Diane Zebeljan
- Haematology, NSW Health Pathology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy Brighton
- Haematology, NSW Health Pathology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Leonardo Pasalic
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
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6
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Favaloro EJ, Mohammed S, Vong R, Chapman K, Swanepoel P, Kershaw G, Cai N, Just S, Connelly L, Brighton T, Pasalic L. A multi-laboratory assessment of lupus anticoagulant assays performed on the ACL TOP 50 family for harmonized testing in a large laboratory network. Int J Lab Hematol 2022; 44:654-665. [PMID: 35234361 PMCID: PMC9311435 DOI: 10.1111/ijlh.13818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/17/2022] [Indexed: 12/23/2022]
Abstract
Introduction Lupus anticoagulant (LA) testing is commonly performed within hemostasis laboratories, and the ACL TOP 50 family of instruments represent a new “single platform” of hemostasis instrumentation. Our aim was to evaluate these instruments and manufacturer reagents or alternatives for utility in LA testing. Methods Comparative evaluations of LA testing using newly installed ACL TOPs 550 and 750 as well as comparative assessments with existing “reference,” predominantly Stago, instrumentation, and reagents. Evaluations comprised both dilute Russell viper venom time (dRVVT) and activated partial thromboplastin time (APTT)‐based assays. Establishment of normal reference ranges (NRR). Results The HemosIL dRVVT‐based assays showed good comparability with the existing Stago reference method (R > 0.9) and could be considered as verified as fit for purpose. A variety of APTT assays was additionally evaluated for LA utility, and we identified from the assessment good utility of a non‐Werfen solution in Hyphen BioMed Cephen reagents. NRR were established based on ≥120 normal individual plasma samples. Conclusion This evaluation of LA reagents on ACL TOP 50 Family instruments identified overall acceptable performance of both dRVVT (Werfen solution) and APTT (non‐Werfen solution) to enable harmonization of LA testing in our large network.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ronny Vong
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kent Chapman
- Haematology, NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Priscilla Swanepoel
- Haematology, NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Nancy Cai
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Sarah Just
- Haematology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Lynne Connelly
- Haematology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Timothy Brighton
- Haematology, NSW Health Pathology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Leonardo Pasalic
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,University of Sydney, Westmead, New South Wales, Australia
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7
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Nederlof A, Kitchen S, Meijer P, Cnossen M, Ali Pour N, Kershaw G, Jennings I, Walker I, de Maat MPM. Performance of factor IX extended half-life product measurements in external quality control assessment programs. J Thromb Haemost 2020; 18:1874-1883. [PMID: 32311825 PMCID: PMC7496271 DOI: 10.1111/jth.14847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patients with hemophilia B are increasingly treated with extended half-life (EHL) factor IX (FIX) concentrates. For the laboratory, introduction of these EHL concentrates presents a major challenge. To understand the variation in FIX activity levels, all available diagnostic assays need to be directly compared. METHODS The ECAT, UKNEQAS, and RCPAQAP have collaboratively performed a global survey to evaluate the quality of FIX measurements using FIX deficient plasma samples spiked with recombinant FIX (rFIX), rFIXFP, rFIXFc, and N9-GP to levels at typical FIX trough (6 IU/dL) and peak levels (60 IU/dL). Participants were asked to use their routine protocols, using one-stage assays (OSA) or chromogenic assays (CA). RESULTS In samples spiked with 6 IU/dL product, median (25%-75% range) FIX activity levels (OSA), were 8.0 IU/dL (7.0-9.2) for rFIX, 6.0 IU/dL (4.0-7.1) for rFIXFP, 6.6 IU/dL (5.5-8.0) for rFIXFc, and 4.9 IU/dL (3.5-8.4) for N9-GP. In samples spiked with 60 IU/dL, FIX activity levels measured (using OSA) was 63.0 IU/dL (59.9-67.0) for rFIX, 42.5 IU/dL (28.2-47.0) for rFIXFP, 50.0 IU/dL (45.0-55.0) for rFIXFc, and 34.0 IU/dL (24.8-67.5) for N9-GP. Considerable differences were observed between reagents for all samples. With CA, there was also quite some variation, but no differences between reagents. CONCLUSION Large variation is observed in the measurement of FIX activity levels after administration of rFIX and EHL FIX products. For N9-GP, most silica-based assays show especially high levels. It is essential to standardize and improve reliability of measurements of these concentrates as diagnosis and treatment monitoring is based on these results.
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Affiliation(s)
- Angelique Nederlof
- Department of HaematologyErasmus University Medical Centre RotterdamRotterdamthe Netherlands
- Department of Paediatric HaematologyErasmus University Medical CentreSophia Children’s HospitalRotterdamthe Netherlands
| | | | | | - Marjon Cnossen
- Department of Paediatric HaematologyErasmus University Medical CentreSophia Children’s HospitalRotterdamthe Netherlands
| | | | - Geoffrey Kershaw
- Institute of HaematologyRoyal Prince Alfred HospitalSydneyAustralia
| | | | | | - Moniek P. M. de Maat
- Department of HaematologyErasmus University Medical Centre RotterdamRotterdamthe Netherlands
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8
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Khoo L, Matthews S, Kershaw G, Pidcock M, Phipps A, Kiialainen A, Chang T. Case report of a fatal rectal haemorrhage in a person with severe haemophilia A receiving emicizumab and high-dose bypassing agents in the HAVEN 1 study. Haemophilia 2020; 26:e340-e342. [PMID: 32700348 DOI: 10.1111/hae.14110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Liane Khoo
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Stephen Matthews
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Alex Phipps
- F. Hoffmann-La Roche Ltd, Welwyn Garden City, UK
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9
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Kershaw G, Chen VM, Cai N, Khoo TL. Australian comparative field study evaluating the activity of recombinant factor VIII Fc fusion protein (Eloctate®). Haemophilia 2020; 26:e226-e229. [PMID: 32530128 DOI: 10.1111/hae.14038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 04/05/2020] [Accepted: 04/28/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Anzac Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Vivien M Chen
- Anzac Research Institute, University of Sydney, Sydney, NSW, Australia.,Haematology Department, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Nancy Cai
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Teh-Liane Khoo
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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10
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Motum P, Just S, Zebeljan D, Nicholls C, Kershaw G, Oliver S, Mohammed S, Favaloro EJ. A diagnosis of von Willebrand disease despite normal test results for factor VIII and von Willebrand factor antigen and activity. Am J Hematol 2019; 94:1425-1432. [PMID: 31423628 DOI: 10.1002/ajh.25618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/08/2019] [Accepted: 08/13/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Penelope Motum
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Sarah Just
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Diane Zebeljan
- Haematology, NSW Health Pathology Liverpool Hospital New South Wales Australia
| | - Catherine Nicholls
- Department of Genetic Pathology SA Pathology Adelaide South Australia Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology Royal Prince Alfred Hospital New South Wales Australia
| | - Susan Oliver
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
| | - Soma Mohammed
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
| | - Emmanuel J. Favaloro
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital Westmead New South Wales Australia
- Department of Haematology Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
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11
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Favaloro EJ, Kershaw G, Mohammed S, Lippi G. How to Optimize Activated Partial Thromboplastin Time (APTT) Testing: Solutions to Establishing and Verifying Normal Reference Intervals and Assessing APTT Reagents for Sensitivity to Heparin, Lupus Anticoagulant, and Clotting Factors. Semin Thromb Hemost 2019; 45:22-35. [PMID: 30630206 DOI: 10.1055/s-0038-1677018] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The activated partial thromboplastin time (APTT) assay is a very common coagulation test, used for several reasons. The test is conventionally used for assessing the contact factor (intrinsic) pathway of blood coagulation, and thus for screening deficiencies in this pathway, most typically factors VIII, IX, and XI. The APTT is also sensitive to contact factor deficiencies, including factor XII, prekallikrein, and high-molecular-weight kininogen. The APTT may also be elevated in a variety of conditions, including liver disease, vitamin K deficiency, and disseminated intravascular coagulation. The APTT can also be used for monitoring unfractionated heparin (UFH) therapy, as well as for screening lupus anticoagulant (LA) or for assessing thrombosis risk. Which of these separate uses is important to a given laboratory or clinician depends on the laboratory and the clinical context. For example, UFH sensitivity is important in hospital-based laboratories, where UFH therapy is used, but not in hospital-based laboratories where low-molecular-weight heparin (LMWH) is largely employed or where UFH may be assessed by anti-factor Xa testing, or in private/community laboratories not associated with a hospital system. High sensitivity to (low levels of) factors VIII, IX, and XI is generally preferred, as their deficiencies are clinically significant. Also preferred, but not usually achieved, is low sensitivity to factor XII and other contact factors, as these deficiencies are usually asymptomatic. Nevertheless, a good knowledge of factor sensitivity is usually needed, if only to help explain the reasons for a prolonged APTT in a given patient, or whether factor testing or other investigation is required. A good working knowledge of reagents sensitivity to LA is also advisable, especially when the reagent is used as part of a LA test panel, or else as a "general-purpose screening reagent." The current report is aimed at providing some guidance around these questions, and is intended as a kind of "how to" guide, that will enable laboratories to assess APTT reagents in regard to their sensitivity to heparin, LA, and clotting factors. The report also provides some advice on generation of normal reference ranges, as well as solutions for troubleshooting prolonged APTTs, when performing factor testing or searching for inhibitors.
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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, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia
| | - Geoffrey Kershaw
- Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia
| | - Soma Mohammed
- Diagnostic Haemostasis Laboratory, Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Giuseppe Lippi
- Department of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Section of Clinical Biochemistry, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
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12
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Vanguru VR, Kershaw G, Konda M, Chen VM. Laboratory monitoring issues in recombinant porcine FVIII replacement in acquired haemophilia A. Haemophilia 2018; 24:e70-e74. [PMID: 29418045 DOI: 10.1111/hae.13426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2017] [Indexed: 11/29/2022]
Affiliation(s)
- V R Vanguru
- Haematology, Concord Hospital, Sydney, NSW, Australia
| | - G Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,ANZAC Research Institute, Concord, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - M Konda
- Haematology, Concord Hospital, Sydney, NSW, Australia
| | - V M Chen
- Haematology, Concord Hospital, Sydney, NSW, Australia.,ANZAC Research Institute, Concord, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
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13
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Abstract
Mixing tests in coagulation studies allow the laboratory to correctly differentiate factor deficiency from inhibitors as the cause of a prolonged clotting time. This is important in terms of subsequent laboratory follow-up and clinical patient management. In this chapter, a suggested method of performing mixing tests is given, with procedures applying two different formulas for interpretation, the percent correction and the index of circulating anticoagulant.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.
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14
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Kershaw G. Performance of Activated Partial Thromboplastin Time (APTT): Determining Reagent Sensitivity to Factor Deficiencies, Heparin, and Lupus Anticoagulants. Methods Mol Biol 2017; 1646:75-83. [PMID: 28804819 DOI: 10.1007/978-1-4939-7196-1_5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The activated partial thromboplastin time (APTT) is a useful global assay for the assessment of the contact factor pathway of hemostasis and its inhibitors. The test is usually performed on fully automated analyzers using commercially prepared reagents. The three main clinical areas of interest are detection of factor deficiencies, detection of lupus anticoagulants and in the monitoring of therapy with unfractionated heparin. Methods are described here for assessing APTT reagents for their sensitivity to clotting time prolongation in each of these areas of interest.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.
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15
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Abstract
Specific coagulation factor inhibitors, most notably to coagulation factor VIII, can develop in patients with hemophilia after exposure to replacement factor or as an acquired (autoimmune) event. Such inhibitors can be detected by a combination of prolonged coagulation screening tests, such as the activated partial thromboplastin time, plus a non-correcting mixing test. Non-correction may only be evident, or else may be extenuated, with incubation at 37 °C. The Bethesda assay for quantitation of inhibitor strength is based on a combination of mixing tests followed by specific factor assays.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.
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16
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Kitchen S, Kershaw G, Tiefenbacher S. Recombinant to modified factor VIII and factor IX - chromogenic and one-stage assays issues. Haemophilia 2016; 22 Suppl 5:72-7. [DOI: 10.1111/hae.13012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 01/26/2023]
Affiliation(s)
- S. Kitchen
- Sheffield Haemophilia and Thrombosis Centre; Sheffield UK
| | - G. Kershaw
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney NSW Australia
| | - S. Tiefenbacher
- Laboratory Corporation of America; Colorado Coagulation; Denver CO USA
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17
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Williams P, Yang K, Kershaw G, Wong G, Dunkley S, Kam PCA. The effects of haemodilution with hydroxyethyl starch 130/0.4 solution on coagulation as assessed by thromboelastography and platelet receptor function studies in vitro. Anaesth Intensive Care 2016; 43:734-9. [PMID: 26603798 DOI: 10.1177/0310057x1504300611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the effects of haemodilution with either 6% hydroxyethyl starch (HES) 130/0.4 (Voluven(®)) or 0.9% normal saline (NS) on blood coagulation in vitro. Haemodilution with 6% HES 130/0.4 impaired coagulation, as indicated by the changes in thromboelastographic parameters k-time, α-angle and maximum amplitude. Light transmission aggregometry and multiple electrode aggregometry demonstrated that impaired platelet receptor function occurred only at high levels of haemodilution (40%) with both fluids, but there was no significant difference between the two fluids (P=0.05). The thromboelastographic functional fibrinogen assay showed that the fibrinogen component of clot strength was significantly impaired with haemodilution with HES 130/0.4 compared with haemodilution with NS (whole blood [14.4 ± 4.6 mm] versus 40% HES dilution [3.7 ± 1.9], [P=0.001]; versus 40% NS dilution [10.4 ± 4.6], [P=0.129]). These findings suggest that there is little difference between HES or NS in relation to coagulation or platelet function during minor or moderate haemodilution, but at high levels of haemodilution with HES, fibrinogen activity is more impaired compared with NS.
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Affiliation(s)
- P Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P C A Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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18
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Pathirana S, Wong G, Williams P, Yang K, Kershaw G, Dunkley S, Kam PCA. The Effects of Haemodilution with Albumin on Coagulation in Vitro as Assessed by Rotational Thromboelastometry. Anaesth Intensive Care 2015; 43:187-92. [DOI: 10.1177/0310057x1504300207] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM® (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. There was no significant difference in fibrinogen concentration at equivalent haemodilutions with normal saline and 4% albumin solutions. Forty percent haemodilution with albumin significantly prolonged coagulation time (EXTEM P=0.007, FIBTEM P=0.0001) and significantly decreased lysis index (FIBTEM P=0.009) compared with NS. A significant decrease in maximum clot firmness from undiluted measurements ( P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
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Affiliation(s)
- S. Pathirana
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K. Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S. Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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19
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Bouchard J, Ghannoum M, Bernier-Jean A, Williamson D, Kershaw G, Weatherburn C, Eris JM, Tran H, Patel JP, Roberts DM. Comparison of intermittent and continuous extracorporeal treatments for the enhanced elimination of dabigatran. Clin Toxicol (Phila) 2015; 53:156-63. [PMID: 25661675 DOI: 10.3109/15563650.2015.1004580] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CONTEXT Severe bleeding associated with dabigatran frequently requires intensive care management. An antidote is currently unavailable and data reporting the effect of dialysis on elimination of dabigatran are encouraging, but limited. Objective. To report the effect of intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) at enhancing elimination of dabigatran. MATERIALS AND METHODS Patients were identified by existing collaborative networks. Pre-filter dabigatran plasma concentrations were measured in all patients, and in dialysate of three patients. RESULTS Seven patients received dialysis, five with active bleeding and two requiring emergent surgery. Five received IHD and two received CRRT. The plasma elimination half-life of dabigatran was 1.5-4.9 h during IHD, and 14.0-27.5 h during CRRT. Mean dabigatran plasma clearance during IHD was 85-169 mL/min in three patients. Time to obtain a subtherapeutic dabigatran concentration depended on the initial concentration, being 8-18 h for IHD in three patients while 4 h was insufficient in a supratherapeutic case. A 38% rebound in dabigatran levels occurred after one case during IHD, and thrombin time increased after IHD in another, but not after 144 h CRRT or 17 h IHD in two others; data were incomplete in three cases. The amount removed during IHD was proportional to the pre-IHD concentration and clearance, but was consistently low at 3.3-17.4 mg in three patients where this was determined. Moderate bleeding occurred while obtaining vascular access in one patient. Two patients died from intracerebral bleeding, and the influence of treatments could not be determined in these cases. DISCUSSION AND CONCLUSIONS IHD enhanced elimination of dabigatran more efficiently than CRRT, but their net effect remains poorly defined. Dialysis decisions, including modality and duration, must be individualized based on a risk-benefit assessment.
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Affiliation(s)
- Josée Bouchard
- Department of Nephrology, Hôpital du Sacré-Coeur de Montréal, University of Montreal , Montreal , Canada
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20
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Meijer P, Jennings I, Sioufi J, Bonar R, Kitchen D, Kershaw G, Lippi G, Favaloro E. Problems and Solutions in Laboratory Testing for Hemophilia. Semin Thromb Hemost 2013. [DOI: 10.1055/s-0033-1360721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Piet Meijer
- ECAT Foundation, Dobbeweg 1, Voorschoten, The Netherlands
| | | | - John Sioufi
- RCPAQAP Haematology, St Leonards, New South Wales, Australia
| | - Roslyn Bonar
- RCPAQAP Haematology, St Leonards, New South Wales, Australia
| | | | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Giuseppe Lippi
- Department of Pathology and Laboratory Medicine, Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy
| | - Emmanuel Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, Westmead Hospital, Westmead, New South Wales, Australia
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21
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Meijer P, Jennings I, Sioufi J, Bonar R, Kitchen D, Kershaw G, Lippi G, Favaloro E. Problems and Solutions in Laboratory Testing for Hemophilia. Semin Thromb Hemost 2013; 39:816-33. [PMID: 24026910 DOI: 10.1055/s-0033-1356573] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Piet Meijer
- ECAT Foundation, Dobbeweg 1, Voorschoten, The Netherlands
| | | | - John Sioufi
- RCPAQAP Haematology, St Leonards, New South Wales, Australia
| | - Roslyn Bonar
- RCPAQAP Haematology, St Leonards, New South Wales, Australia
| | - Dianne Kitchen
- ECAT Foundation, Dobbeweg 1, Voorschoten, The Netherlands
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Giuseppe Lippi
- Department of Pathology and Laboratory Medicine, Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy
| | - Emmanuel Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, Westmead Hospital, Westmead, New South Wales, Australia
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22
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Orellana D, Kershaw G. Mixing Tests: Diagnostic Aides in the Investigation of Prolonged Prothrombin Times and Activated Partial Thromboplastin Times. Semin Thromb Hemost 2013; 39:283-90. [DOI: 10.1055/s-0033-1336832] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Daniel Orellana
- Haemostasis Laboratory, Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Geoffrey Kershaw
- Haemostasis Laboratory, Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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23
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Khoo TL, Weatherburn C, Kershaw G, Reddel C, Curnow J, Dunkley S. The use of FEIBA®in the correction of coagulation abnormalities induced by dabigatran. Int J Lab Hematol 2012; 35:222-4. [DOI: 10.1111/ijlh.12005] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/08/2012] [Indexed: 11/30/2022]
Affiliation(s)
- T.-L. Khoo
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney; NSW; Australia
| | - C. Weatherburn
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney; NSW; Australia
| | - G. Kershaw
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney; NSW; Australia
| | | | | | - S. Dunkley
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney; NSW; Australia
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24
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Weinstein R, Linden J, Laplante G, Banks N, Kershaw G, Karr E. O-24 AUTOLOGOUS HEMOPOIETIC PROGENITOR CELL COLLECTION IN TANDEM WITH HEMODIALYSIS IN A PATIENT WITH MYELOMA KIDNEY. Transfus Apher Sci 2012. [DOI: 10.1016/s1473-0502(12)70025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Abstract
The main laboratory characteristic of lupus anticoagulants (LA) is their ability to prolong phospholipid-dependent clotting time in vitro. The laboratory demonstration of LA requires a systematic approach combined with an awareness of the many variables that can affect test results. The ideal testing procedures are those sensitive enough to detect weak LA and specific enough so as not to produce incorrect conclusions. International guidelines have been published to assist laboratories in applying correct testing processes. The most recently published guidelines from the International Society on Thrombosis and Haemostasis update the criteria for detecting the presence of LA that were presented in the 1995 guidelines. Some of the specific recommendations relate to the key areas of setting cut-off levels for screening, mixing, and confirmatory procedures. The more challenging aspects of testing for LA include maintaining sensitivity and specificity of the assays, especially in the presence of anticoagulant therapy.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2065, Australia.
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26
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Morel-Kopp MC, Tan CW, Brighton TA, McRae S, Baker R, Tran H, Mollee P, Kershaw G, Joseph J, Ward C. Validation of whole blood impedance aggregometry as a new diagnostic tool for HIT: results of a large Australian study. Thromb Haemost 2012; 107:575-83. [PMID: 22234599 DOI: 10.1160/th11-09-0631] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 12/01/2011] [Indexed: 11/05/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) remains a challenge, with diagnosis confirmed only by functional assays. The gold standard 14C-serotonin release assay (SRA) is highly sensitive but technically challenging and unsuitable for routine use. We conducted a large study to validate whole blood impedance aggregometry (WBIA) as a suitable diagnostic tool for HIT. WBIA and SRA were used to test 181 samples positive for H-PF4 antibodies by PaGIA or ELISA. Using the same high responder donor, 77 samples were positive by WBIA (aggregation with low-dose but not high-dose heparin). Using the strict definition for SRA positivity, 72 samples were true HIT. In nine samples, serotonin release with high-dose heparin dropped by > 50% but was still >20%; these were retested after a one-half dilution and 8/9 became positive. Ten other samples were discrepant between the two assays: one strongly positive (89% release) and six weakly positive samples by SRA (average release 56%) were WBIA negative. When these samples were retested using a random donor, only two remained SRA positive. Three samples were strongly WBIA positive but SRA negative; two were retested by SRA with 0.5IU/ml heparin and one became positive. Under controlled conditions, using the same selected high-responder donor, WBIA and SRA performed similarly with slightly increased sensitivity of the WBIA when using the strict definition of SRA positivity. WBIA is easy to perform with rapid turn-around time and warrants a multi-laboratory trial to complete its validation as a confirmatory assay for platelet-activating HIT antibodies.
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Affiliation(s)
- Marie-Christine Morel-Kopp
- Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia.
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27
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Favaloro EJ, Bonar R, Zebeljan D, Kershaw G, Marsden K. Laboratory investigation of lupus anticoagulants: mixing studies are sometimes required. J Thromb Haemost 2010; 8:2828-31. [PMID: 21029364 DOI: 10.1111/j.1538-7836.2010.04090.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Kershaw G, Jayakodi D, Dunkley S. Laboratory Identification of Factor Inhibitors: The Perspective of a Large Tertiary Hemophilia Center. Semin Thromb Hemost 2010; 35:760-8. [DOI: 10.1055/s-0029-1245108] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Favaloro E, Bonar R, Kershaw G, Duncan E, Sioufi J, Marsden K. Investigations from External Quality Assurance Programs Reveal a High Degree of Variation in the Laboratory Identification of Coagulation Factor Inhibitors. Semin Thromb Hemost 2010; 35:794-805. [DOI: 10.1055/s-0029-1245112] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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Alhaliq AR, Joshua D, Kershaw G, Dunkley S. The Diamed assay has a poor positive predictive value for HIT in a tertiary hospital referral setting. ACTA ACUST UNITED AC 2007; 29:69-70. [PMID: 17224011 DOI: 10.1111/j.1365-2257.2006.00849.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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Dunkley S, Kershaw G, Young G, Warburton P, Lindeman R, Matthews S, Rennisson F. Rituximab treatment of mild haemophilia A with inhibitors: a proposed treatment protocol. Haemophilia 2006; 12:663-7. [PMID: 17083518 DOI: 10.1111/j.1365-2516.2006.01351.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inhibitors are an uncommon complication of mild haemophilia A but represent a severe disease, typically with high titre inhibitors and an associated high rate of bleeding. We present data from three patients with MHAI who were successfully treated with Rituximab alone and unequivocally prove that such inhibitors respond to this agent. A treatment protocol is suggested.
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Affiliation(s)
- S Dunkley
- Haemophilia and Thrombosis Unit, Royal Prince Alfred Hospital, Sydney, Australia.
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32
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Favaloro EJ, Bonar R, Kershaw G, Sioufi J, Hertzberg M, Street A, Lloyd J, Marsden K. Laboratory diagnosis of von Willebrand's disorder: quality and diagnostic improvements driven by peer review in a multilaboratory test process. Haemophilia 2004; 10:232-42. [PMID: 15086320 DOI: 10.1111/j.1365-2516.2004.00897.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Regular multilaboratory surveys of laboratories derived primarily from Australia, New Zealand and Southeast Asia have been conducted over the past 7 years to evaluate testing proficiency in the diagnosis of von Willebrand's disorder (VWD) and to assess changes to test practice. Participating laboratories (currently 45) are asked to perform their usual panel of tests for VWD, and then to self-interpret test results as to the likelihood (or not) of VWD, as well as to the potential subtype identified. Samples provided in the past two survey distributions (both conducted in 2003) were as follows. Survey part A/distribution 1: Normal donor plasma, plasma with borderline normal/reduced levels of VWF (x2) and plasma from an individual with type 2 A VWD. Survey part B/distribution 2 (family VWD study): Plasma from a father, mother and son with borderline normal/reduced von Willebrand factor (VWF), and a daughter with type 3 VWD. In line with previously published survey results, the interassay and within method coefficients of variation (CV) were similar for all assays (around 15-25%), although tending to be slightly higher for VWF:RCo and VWF:CB than VWF:Ag and FVIII:C. Most laboratories reported test values consistent with expected findings, and made correct interpretations or predictions regarding the nature of the samples, although discrepant assay results or interpretations are still seen in approximately 5-10% of responses (typically from laboratories using a more limited test panel or not performing the VWF:CB). Overall, problems with the non-identification of functional VWF discordance in type 2 VWD, the misidentification of functional VWF discordance in type 1 VWD, and difficulties in discriminating types 1 and 3 VWD appear to predominate. In comparison with previous surveys, performance of electro-immuno diffusion (EID) (or Laurel gel) procedures has now ceased, and a reduction in VWF:RCo and VWF:Multimer testing and an increase in latex immunoassay (LIA) testing is sustained. We conclude that laboratories are generally proficient in tests for VWD, and that diagnostic error rates are reduced when test panels are more comprehensive and include the VWF:CB.
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Affiliation(s)
- E J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, NSW, Australia.
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33
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Favaloro EJ, Kershaw G, Bukuya M, Hertzberg M, Koutts J. Laboratory diagnosis of von Willebrand disorder (vWD) and monitoring of DDAVP therapy: efficacy of the PFA-100 and vWF:CBA as combined diagnostic strategies. Haemophilia 2001; 7:180-9. [PMID: 11260278 DOI: 10.1046/j.1365-2516.2001.00487.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We have coevaluated a combination of test processes for diagnosing von Willebrand disease (vWD) and monitoring deamino-delta-D-arginine vasopressin (DDAVP) therapy. Using normal controls (n = 23), closure time (CT) ranges measured by PFA-100(R) were (mean +/- 2SD): (i) collagen/ADP cartridge (C/ADP): 67-127 s (ii) collagen/epinephrine (C/Epi): 94-162 s. From a panel of 125 patients undergoing evaluation for clinical haemostatic defects, 29/30 samples from patients with vWD [17/18 type 1, 1/1 type 3, 3/3 type 2A, 7/7 type 2B and 1/1 pseudo-vWD] gave prolonged CTs using C/Epi. The C/ADP was less sensitive, being normal in 7/18 of the type 1 vWD individuals, with higher sensitivity to more severe vWD. Individuals with haemophilia (six factor VIII-deficient, one factor XI-deficient) gave normal CTs, while those with clinical thrombocytopenia (n=13) gave normal or prolonged CTs, somewhat dependent on platelet count. The PFA-100 was also evaluated as a part of the laboratory monitoring procedure in patients with either vWD or haemophilia undergoing a DDAVP trial as a therapeutic management process. For vWD, correction of an initially prolonged CT by DDAVP, accompanied by normalization of von Willebrand factor (vWF) measurable by von Willebrand factor antigen, vWF collagen binding activity and vWF ristocetin cofactor assays (vWF:Ag, vWF:CBA and vWF:RCof), was achieved in type 1 vWD (n=5). In an individual with type 2A vWD, DDAVP normalized vWF:Ag and vWF:RCof, but had no apparent effect on the baseline maximally prolonged CT. In an individual with type 2B vWD, factor VIII/vWF concentrate also normalized vWF:Ag and vWF:RCof, but similarly had no apparent effect on the baseline maximally prolonged CT. vWF:CBA did not normalize for either of these individuals, potentially suggesting that normalization of vWF:CBA might be required for normalization of CT. This concept is supported by correlation analysis undertaken between CT and various vWF parameters. Among these, vWF:CBA held the strongest relationship in our data set, which showed an inverse progressive rise in CT for falling vWF:CBA. Based on these results, we would conclude that the PFA-100 is highly sensitive to the presence of vWD, and may thus provide a valuable screening test for vWD. Furthermore, the combined utility of the PFA-100 and vWF:CBA as markers of DDAVP responsiveness may prove to be simple, quick but powerful, predictors for its clinical efficacy.
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Affiliation(s)
- E J Favaloro
- Diagnostic Haemostasis Laboratory, Department of Haematology, ICPMR, Westmead Hospital, Australia.
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Senderowicz AM, Vitetta E, Headlee D, Ghetie V, Uhr JW, Figg WD, Lush RM, Stetler-Stevenson M, Kershaw G, Kingma DW, Jaffe ES, Sausville EA. Complete sustained response of a refractory, post-transplantation, large B-cell lymphoma to an anti-CD22 immunotoxin. Ann Intern Med 1997; 126:882-5. [PMID: 9163289 DOI: 10.7326/0003-4819-126-11-199706010-00005] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- A M Senderowicz
- National Cancer Institute, National institutes of Health, Bethesda, Maryland, USA
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Mukai J, Kershaw G, Hees PS. Application of magnetic resonance imaging to physiologic and morphologic characterization of renal artery stenosis before and after angioplasty. Am J Physiol Imaging 1992; 7:220-9. [PMID: 1343219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study describes the application of dynamic gadolinium-enhanced magnetic resonance (MR) imaging and MR angiography in the diagnosis and evaluation of the physiology of renal artery stenosis (RAS) before and after angioplasty. The MR imaging findings are discussed and compared to those of renal arteriography. MR time intensity curves of the renal cortex and medulla are obtained. Dynamic gadolinium-enhanced and angiographic MR data were abnormal in the setting of RAS and improved after angioplasty. The diagnosis of RAS could be made by visual inspection of MR dynamic images or MR angiographic images alone. Dynamic MR provides cross-sectional physiologic imaging data that compliments MR angiographic data. The role of dynamic gadolinium-enhanced MR in the evaluation of renovascular hypertension requires further investigation.
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Affiliation(s)
- J Mukai
- Central Massachusetts Magnetic Imaging Center, Worcester
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