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Laboratory assessment of Activated Protein C Resistance/Factor V-Leiden and performance characteristics of a new quantitative assay. Transfus Apher Sci 2017; 56:906-913. [PMID: 29162399 DOI: 10.1016/j.transci.2017.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Activated Protein C Resistance is mainly associated to a factor V mutation (RQ506), which induces a deficient inactivation of activated factor V by activated protein C, and is associated to an increased risk of venous and arterial thrombosis in affected individuals, caused by the prolonged activated factor V survival. Its prevalence is mainly in Caucasians (about 5%), and this mutation is absent in Africans and Asians. Presence of Factor V-Leiden is usually evidenced with clotting methods, using a two-step APTT assay performed without or with APC: prolongation of blood coagulation time is decreased if this factor is present. The R506Q Factor V-Leiden mutation is now usually characterized using molecular biology, and this technique tends to become the first intention assay for characterization of patients. Both techniques are qualitative, and allow classifying tested individuals as heterozygotes or homozygotes for the mutation, when present. A new quantitative assay for Factor V-Leiden, using a one-step clotting method, has been developed, and designed with highly purified human coagulation proteins. Clotting is triggered with human Factor Xa, in presence of calcium and phospholipids (mixture which favours APC action over clotting process). Diluted tested plasma, is supplemented with a clotting mixture containing human fibrinogen, prothrombin, and protein S at a constant concentration. APC is added, and clotting is initiated with calcium. Calibration is performed with a pool of plasmas from patients carrying the R506Q Factor V mutation, and its mixtures with normal plasma. Homozygous patients have clotting times of about <40sec; heterozygous patients have clotting times of about 40-60sec and normal individuals yield clotting times >70sec. Factor V-Leiden concentration is usually >75% in homozygous patients, 30-60% in heterozygous patients and below 5% in normal. The assay is insensitive to clotting factor deficiencies (II, VII, VIII: C, IX, X), dicoumarol or heparin therapies, and has no interference with lupus anticoagulant (LA). This new assay for Factor V-Leiden can be easily used in any coagulation laboratory, is performed as a single test, and is quantitative. This assay has a high robustness, is accurate and presents a good intra- (<3%) and inter-assay (<5%) variability. It contributes solving most of the laboratory issues faced when testing factor V-Leiden. Quantitation of Factor V-L could contribute to a better assessment of thrombotic risk in affected patients, as this complication is first associated to and caused by the presence of a defined amount of FVa.
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El-Azhary RA, Patzelt MT, McBane RD, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW, McCarthy JT. Calciphylaxis: A Disease of Pannicular Thrombosis. Mayo Clin Proc 2016; 91:1395-1402. [PMID: 27712638 DOI: 10.1016/j.mayocp.2016.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify coagulation risk factors in patients with calciphylaxis and the relationship between anticoagulation use and overall survival. PATIENTS AND METHODS Study subjects were 101 patients with calciphylaxis seen at Mayo Clinic from 1999 to September 2014. Data including thrombophilia profiles were extracted from the medical records of each patient. Survival status was determined using patient registration data and the Social Security Death Index. Survival was estimated using the Kaplan-Meier method, and associations were evaluated using Cox proportional hazards models. RESULTS Sixty-four of the 101 patients underwent thrombophilia testing. Of these, a complete test panel was performed in 55 and a partial panel in 9. Severe thrombophilias observed in 60% (33 of 55) of the patients included antiphospholipid antibody syndrome protein C, protein S, or antithrombin deficiencies or combined thrombophilias. Of the 55 patients, severe thrombophilia (85%, 23 of 27) was noted in patients who were not on warfarin at the time of testing (27). Nonsevere thrombophilias included heterozygous factor V Leiden (n=2) and plasminogen deficiency (n=1). For the comparison of survival, patients were divided into 3 treatment categories: Warfarin (n=63), other anticoagulants (n=20), and no anticoagulants (n=18). There was no statistically significant survival difference between treatment groups. CONCLUSION Laboratory testing reveals a strikingly high prevalence of severe thrombophilias in patients with calciphylaxis, underscoring the importance of congenital and acquired thrombotic propensity potentially contributing to the pathogenesis of this disease. These findings may have therapeutic implications; however, to date, survival differences did not vary by therapeutic choice.
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Affiliation(s)
| | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Medicine, Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Wysokinska EM, Wysokinski WE, Ketha S, Litin S, Daniels P, Slusser J, Hodge DO, Heit JA, McBane RD. Periprocedural Anticoagulation Management of Patients with Thrombophilia. Am J Med 2016; 129:986-92. [PMID: 27235004 DOI: 10.1016/j.amjmed.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Appropriate periprocedural management of the chronically anticoagulated patient with an inherited or acquired thrombophilia is uncertain. The objective of this study was to test "thrombophilia" as a potential predictor of the 3-month cumulative incidence of thromboembolism and major bleeding among chronically anticoagulated patients undergoing an invasive procedure. METHODS In a prospective cohort study, consecutive chronically anticoagulated patients referred to the Mayo Thrombophilia Center for standardized periprocedural anticoagulation management who had venous thromboembolism and complete thrombophilia testing were categorized as "severe," "non-severe," or "no identifiable" thrombophilia. The 3-month cumulative incidence rates of thromboembolism, bleeding, and death were estimated using the Kaplan-Meier product limit method. RESULTS Among 362 patients with complete thrombophilia testing, 165 (46%) had a defined thrombophilia; 76 patients had severe thrombophilia, mainly due to antiphospholipid syndrome (66%). Half of the patients in each of the 3 groups received pre- and postprocedure heparin. During follow-up, there were no thromboembolic events, rare major bleeding events (1% for each group), and 4 deaths. Due to the very low event rates for each of these outcomes, Cox proportional hazard modeling could not be performed. CONCLUSIONS Periprocedural event rates were low irrespective of thrombophilia status. Inherited or acquired thrombophilia was not a predictor of thromboembolism, major bleeding, or mortality after temporary interruption of chronic anticoagulation for an invasive procedure.
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Affiliation(s)
- Ewa M Wysokinska
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Waldemar E Wysokinski
- Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Siva Ketha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Scott Litin
- Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Paul Daniels
- Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Joshua Slusser
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - David O Hodge
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - John A Heit
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minn; Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Robert D McBane
- Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Mayo Clinic, Rochester, Minn.
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Sutkowska E, McBane RD, Tafur AJ, Sutkowski K, Grill DE, Slusser JP, Wysokinski WE. Thrombophilia differences in splanchnic vein thrombosis and lower extremity deep venous thrombosis in North America. J Gastroenterol 2013; 48:1111-8. [PMID: 23247829 DOI: 10.1007/s00535-012-0728-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 11/23/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND The utility of thrombophilia testing in patients with splanchnic vein thrombosis (SpVT) has not previously been rigorously evaluated. The purpose of this study was to characterize differences in the prevalence of thrombophilia in patients with SpVT involving portal (PVT), mesenteric (MVT), splenic (SVT), or hepatic (HVT) veins in isolation or with multisegmental (M-SpVT) involvement compared to patients with lower extremity deep vein thrombosis (DVT). METHODS An inception cohort of patients with incident SpVT was identified for whom comprehensive thrombophilia testing was performed between 1995 and 2005 and compared to DVT controls. RESULTS 341 patients with SpVT (mean age 50 ± 16 years, 53 % women) including isolated PVT (n = 112), MVT (n = 67), HVT (n = 22), SVT (n = 11), and M-SpVT (n = 129) involvement and 3621 DVT controls (mean age 55 ± 16 years, 56 % women) had comprehensive thrombophilia testing. The prevalence of abnormal results was similar for SpVT (24.6 %) and DVT (25.9 %) patients. "Strong" thrombophilias were more prevalent among SpVT patients (12.3 vs. 8.5 %, p = 0.0168). Patients with splenic (45.5 %) and mesenteric (41.8 %) thrombosis had the highest thrombophilia prevalence. Protein S deficiency was more common in SpVT patients (3.5 vs. 0.9 %, p < 0.001). In contrast, FV Leiden was more prevalent among DVT patients (15.8 vs. 10.9 %, p = 0.0497). CONCLUSION The prevalence of selected thrombophilia factors differ comparing SpVT and DVT patients. The prevalence is particularly high for patients with splenic and mesenteric vein thrombosis. Whereby the finding of strong thrombophilia impacts duration of anticoagulant therapy, such testing is warranted in the evaluation of patients with unprovoked SpVT.
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Affiliation(s)
- Edyta Sutkowska
- Division of Rehabilitation, Department and Clinic of Orthopedic and Traumatologic Surgery, Wroclaw Medical University, Wroclaw, Poland
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Hossain N, Paidas MJ. Inherited thrombophilia: diagnosis and anticoagulation treatment in pregnancy. Clin Lab Med 2013; 33:377-90. [PMID: 23702125 DOI: 10.1016/j.cll.2013.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The association between inherited thrombophilia and deep vein thrombosis is well established. Adverse pregnancy outcomes, sometimes called placenta-mediated complications, have been attributed to excessive thrombosis and inflammation at the uteroplacental interface. This linkage resulted in widespread screening for thrombophilia in women with adverse pregnancy outcome. Anticoagulant therapy was initially liberally administered for prevention of adverse pregnancy outcome. Well-designed randomized trials were initiated and the results of some of these randomized trials have provided critical evidence-based data to serve as a guide for clinicians faced with managing patients with one or more of the common obstetric complications.
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Affiliation(s)
- Nazli Hossain
- Department of Obstetrics & Gynecology, Dow University of Health Sciences, Karachi 74200, Pakistan.
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Oh H, Smith CL. Evolving methods for single nucleotide polymorphism detection: Factor V Leiden mutation detection. J Clin Lab Anal 2012; 25:259-88. [PMID: 21786330 DOI: 10.1002/jcla.20470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The many techniques used to diagnose the Factor V Leiden (FVL) mutation, the most common hereditary hypercoagulation disorder in Eurasians, and the most frequently requested genetic test reflect the evolving strategies in protein and DNA diagnosis. METHODS Here, molecular methods to diagnose the FVL mutation are discussed. RESULTS Protein-based detection assays include the conventional functional activated protein C resistance coagulation test and the recently reported antibody-mediated sensor detection; and DNA-based assays include approaches that use electrophoretic fractionation e.g., restriction fragment length polymorphism, denaturing gradient gel electrophoresis, and single-stranded conformational PCR analysis, DNA hybridization (e.g., microarrays), DNA polymerase-based assays, e.g., extension reactions, fluorescence polarization template-directed dye-terminator incorporation, PCR assays (e.g., amplification-refractory mutation system, melting curve analysis using real-time quantitative PCR, and helicase-dependent amplification), DNA sequencing (e.g., direct sequencing, pyrosequencing), cleavase-based Invader assay and ligase-based assays (e.g., oligonucleotide ligation assay and ligase-mediated rolling circle amplification). CONCLUSION The method chosen by a laboratory to diagnose FVL not only depends on the available technical expertise and equipment, but also the type, variety, and extent of other genetic disorders being diagnosed.
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Affiliation(s)
- Herin Oh
- Molecular Biotechnology Research Laboratory, Boston University, Boston, MA, USA.
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Abstract
Factor V Leiden is a genetic disorder characterized by a poor anticoagulant response to activated Protein C and an increased risk for venous thromboembolism. Deep venous thrombosis and pulmonary embolism are the most common manifestations, but thrombosis in unusual locations also occurs. The current evidence suggests that the mutation has at most a modest effect on recurrence risk after initial treatment of a first venous thromboembolism. Factor V Leiden is also associated with a 2- to 3-fold increased relative risk for pregnancy loss and possibly other obstetric complications, although the probability of a successful pregnancy outcome is high. The clinical expression of Factor V Leiden is influenced by the number of Factor V Leiden alleles, coexisting genetic and acquired thrombophilic disorders, and circumstantial risk factors. Diagnosis requires the activated Protein C resistance assay (a coagulation screening test) or DNA analysis of the F5 gene, which encodes the Factor V protein. The first acute thrombosis is treated according to standard guidelines. Decisions regarding the optimal duration of anticoagulation are based on an individualized assessment of the risks for venous thromboembolism recurrence and anticoagulant-related bleeding. In the absence of a history of thrombosis, long-term anticoagulation is not routinely recommended for asymptomatic Factor V Leiden heterozygotes, although prophylactic anticoagulation may be considered in high-risk clinical settings. In the absence of evidence that early diagnosis reduces morbidity or mortality, decisions regarding testing at-risk family members should be made on an individual basis.
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Schöni R, Quehenberger P, Wu JR, Wilmer M. Clinical evaluation of a new functional test for detection of activated protein C resistance (Pefakit® APC-R Factor V Leiden) at two centers in Europe and the USA. Thromb Res 2007; 119:17-26. [PMID: 16934314 DOI: 10.1016/j.thromres.2006.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 05/29/2006] [Accepted: 06/23/2006] [Indexed: 11/23/2022]
Abstract
A new clotting assay, Pefakit APC-R Factor V Leiden (Pentapharm Ltd., Switzerland), for the detection of an increased resistance of coagulation factor V against degradation by activated protein C, caused mainly by the factor V Leiden mutation, was evaluated in clinical studies at two University Centers in Europe and the US. The performance was compared with the performance of the routinely used predicate device COATEST APC Resistance V (Chromogenix IL, USA). Both tests were run in parallel on a STA-R analyzer (Diagnostica Stago, France). Samples from subjects undergoing routine laboratory thrombophilia screening were examined, 187 at the Institute of Medical and Chemical Laboratory Diagnostics (IMCLD), University of Vienna, Austria, and 236 at the Duke University Medical Center (DUMC), Durham/Raleigh NC, USA. All samples were analyzed for factor V Leiden mutation and prothrombin 20210 G/A mutation using standard PCR methods. The data show that the Pefakit APC-R Factor V Leiden assay discriminates very well between healthy controls and carriers of the factor V Leiden mutation, even in patients with lupus anticoagulant or with deficiency in Protein C or Protein S. Furthermore, this new test is able to discriminate well between heterozygous and homozygous carriers of the factor V Leiden mutation. In both studies the Pefakit assay showed 100% sensitivity and 100% specificity for detection of the factor V Leiden mutation, compared to 93.1% sensitivity and 93.0% specificity for the COATEST APC Resistance V in the IMCLD study and 93.9% sensitivity and 95.6% specificity in the DUMC study. The new test has PCR-like discrimination power which will help to decrease costs by reducing the need for PCR verification of borderline cases.
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Affiliation(s)
- Reto Schöni
- Research and Development Haemostasis, Pentapharm Ltd., Engelgasse 109, 4002 Basel, Switzerland.
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Novacek G, Miehsler W, Palkovits J, Reinisch W, Waldhör T, Kapiotis S, Gangl A, Vogelsang H. Resistance to activated protein C is a risk factor for fibrostenosis in Crohn’s disease. World J Gastroenterol 2006; 12:6026-31. [PMID: 17009403 PMCID: PMC4124412 DOI: 10.3748/wjg.v12.i37.6026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of resistance to activated protein C (aPCR), the most common known inherited thrombophilic disorder, on the risk of intestinal operation of fibrostenosis in patients with Crohn’s disease (CD).
METHODS: In a previous study, we assessed the prevalence of aPCR in CD. In a retrospective case-controlled study, 8 of these CD patients with aPCR were now compared with 24 CD patients without aPCR, matched by gender, age at diagnosis and duration of disease in a 1:3 fashion. The primary end point was the occurrence of an intestinal CD-related operation with evidence of fibrostenosis in the bowel resection specimen.
RESULTS: The Kaplan-Meier analysis revealed that patients with aPCR had a lower probability of remaining free of operation with fibrostenosis than patients without aPCR (P = 0.0372; exact log-rank test) resulting in a significantly shorter median time interval from diagnosis of CD to the first operation with fibrostenosis (32 vs 160 mo). At 10 years, the likelihood of remaining free of operation with fibrostenosis was 25% for patients with aPCR and 57.8% for patients without aPCR.
CONCLUSION: CD patients with aPCR are at higher risk to undergo intestinal operation of fibrostenosis than those without aPCR. This supports our hypothesis of aPCR being a possible risk factor for fibrostenosis in CD.
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Affiliation(s)
- Gottfried Novacek
- Department of Internal Medicine IV, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna A-1090, Austria.
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Favaloro EJ, Orsag I, Bukuya M, McDonald D. A 9-year retrospective assessment of laboratory testing for activated protein C resistance: evolution of a novel approach to thrombophilia investigations. Pathology 2002; 34:348-55. [PMID: 12190294 DOI: 10.1080/003130202760120526] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS To assess international and local trends in laboratory testing for activated protein C (APC) resistance (APCR) and factor V Leiden (FVL). Also, to compare local results of FVL testing with a variety of different clot-based APCR assays to assess utility for detection of APCR both related and unrelated to FVL. METHODS Local test statistics and test result patterns were evaluated and international literature was reviewed over the past 9 years. Direct comparisons of FVL testing by DNA analysis against (a) the standard APTT-based APCR assay, with and without pre-dilution with factor V deficient (FVD) plasma, or with and without normalisation, and (b) three alternative RVVT-based procedures (most recently using a commercial RVVT-based procedure called GradiLeiden V; GLV). In total, data obtained over the past 7 years, using referred samples from over 1,000 patients, have been assessed. RESULTS The 9-year retrospective assessment has seen many changes in test-based processes. Locally, test requests for both APCR and FVL have consistently increased. We suspect this has been fuelled in part by media reports of 'economy class syndrome' (ECS) and associated general public and clinical concern. Current request patterns number around 800 APCR and 1,600 FVL per year. Interestingly, most requests are for one or either test, with joint requests comprising less than 20% of those overall. Although test requests are increasing, detection of the FVL defect as a proportion of test requests is actually falling (from a high of over 25% in 1996 to around 14% currently). Whether this suggests an increasing tendency for clinical ordering in the absence of appropriate clinical histories is a matter of concern. Consistent with previous findings, the original and commonly used APTT-based procedure was found to show the least correlation with DNA findings, with a large overlap between FVL and non-FVL individuals. The alternate-RVVT-based procedures showed much better differentiation. Thus, for the APTT-based method, in order to ensure 100% sensitivity, an APC ratio cut-off value of 3.1 was required, and this yielded only 49.1% specificity. In contrast, for the GLV RVVT-based method, in order to ensure 100% sensitivity, an APC ratio cut-off value of 1.65 was required, and this yielded 96.6% specificity. CONCLUSIONS It is important to recognise the limitation of APTT-based assays to discriminate FVL. However, a combination of RVVT- and APTT-based testing is still recommended, as this will provide excellent discriminatory power for the FVL defect, particularly negative prediction, in addition to detection of potential APCR unrelated to FVL, as well as detection of other potential haemostatic disturbances. Accordingly, we detail strategies, including a test algorithm that we are currently using to improve our detection of APCR and prediction of FVL, and use of clotting-based procedures as the first-line approach.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Western Sydney Area Health Service, NSW, Australia.
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11
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Kottke-Marchant K. Genetic polymorphisms associated with venous and arterial thrombosis: an overview. Arch Pathol Lab Med 2002; 126:295-304. [PMID: 11860303 DOI: 10.5858/2002-126-0295-gpawva] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To provide an overview of genetic polymorphisms associated with thrombotic cardiovascular disease. DATA SOURCES A literature search using the National Library of Medicine database. STUDY SELECTION The literature on genetic polymorphisms associated with venous and arterial thrombosis was reviewed. DATA EXTRACTION Based on the literature review, the clinical significance of polymorphisms in various coagulation proteins was assessed and a summary was developed. CONCLUSIONS Thrombosis is a multifactorial disorder, with both congenital and acquired risk factors. It is now clear that there are many genetic abnormalities that impart an increased risk for thrombophilia, and the presence of more than 1 abnormality results in a further increased risk of thrombosis. In hemostasis, there is a balance between procoagulant factors and natural anticoagulant proteins. The first genetic thrombotic disorders described were deficiencies of the natural anticoagulants, such as antithrombin, protein C, and protein S, but these abnormalities are rare and are caused by many different mutations. More recently, single polymorphisms that are relatively common in the general population have been described in procoagulant factors, such as factor V and prothrombin, which impart an increased risk for venous thrombosis. As more scrutiny is placed on the hemostatic system, further polymorphisms have come to light. The current challenge is to elucidate the relationship between these new polymorphisms and either venous or arterial thrombotic cardiovascular disease.
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Affiliation(s)
- Kandice Kottke-Marchant
- Department of Clinical Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Quenhenberger P, Handler S, Mannhalter C, Pabinger-Fasching I, Speiser W. Evaluation of a highly specific functional test for the detection of factor V Leiden. INTERNATIONAL JOURNAL OF CLINICAL & LABORATORY RESEARCH 2001; 30:113-7. [PMID: 11196068 DOI: 10.1007/s005990070009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present study, a new functional test for the detection of increased resistance of coagulation factor V to degradation by activated protein C (factor V Leiden mutation) was evaluated. The STA-STACLOT APC-R Test (Diagnostica Stago, Asnieres, France) is based on the specific activation of factor X by Crotalus viridis helleri snake venom. The results are given as clotting time in seconds of the patient's plasma in the presence of venom and activated protein C. The intra-assay coefficient of variation was 2.17% (n=20) for samples within the normal range, and 1.70% and 1.42% (n=20) for the plasma of a heterozygous or a homozygous carrier of the factor V Leiden mutation, respectively. The inter-assay coefficient of variation (n=10) was 7.75% for the plasma of a healthy donor, 5.05% for the plasma of a heterozygous carrier and 3.38% for the plasma of a homozygous individual. The normal range (5th-95th percentile) of 136.4 s-174.7 s was derived from the clotting time of the plasma of 38 healthy controls. Values below 136 s were found in every sample from patients carrying the factor V Leiden mutation (n=52), whereas no patient with protein C (n=11) or protein S deficiency (n=10) had reduced clotting times. Homozygous carriers of the factor V Leiden mutation had clotting times shorter than 66.0 s and heterozygous carriers had clotting times longer than 80.0 s. Thus, based upon the individual clotting time, patients homozygous for factor V Leiden mutation could easily be distinguished from normals or heterozygous individuals. The influence of coagulation factor X, V, or II deficiency on the STACLOT APC-R Test was evaluated and revealed prolonged clotting times at factor V activities below 50%. In the presence of lupus anticoagulant the specificity of the STA-STACLOT APC-R Test was clearly decreased. In the present study, we clearly show that the STA-STACLOT APC-R Test is able to discriminate carriers of the factor V Leiden mutation from healthy controls or patients with protein C or protein S deficiency.
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Affiliation(s)
- P Quenhenberger
- Department of Medical and Chemical Laboratory Diagnostics, University of Vienna, Austria
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Thrombopoietin induces rapid resolution of thrombocytopenia after orthotopic liver transplantation through increased platelet production. Blood 2000. [DOI: 10.1182/blood.v95.3.795.003k25_795_801] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Thrombopoietin (TPO) deficiency has been proposed as an important etiologic factor for thrombocytopenia in advanced-stage liver disease. To clarify the contributions of platelet production, platelet consumption, coagulation activation, and splenic sequestration to thrombocytopenia in liver disease, we studied TPO serum levels and markers of platelet production, platelet activation, and coagulation activation before and 14 days after orthotopic liver transplantation (OLT) in 18 patients with advanced liver cirrhosis. Thrombocytopenia before transplantation occurred with low-normal serum levels of TPO, normal levels of platelet and coagulation activation markers, and no increase in bone marrow production of platelets. TPO serum levels increased significantly on the first day after OLT, preceding the increase of reticulated platelets by 3 days and peripheral platelets by 5 days. Normalization of the peripheral platelet count occurred in most patients within 14 days of OLT, irrespective of the change in spleen size assessed by computed tomography volumetry. Normalization of platelet counts was not hampered by a certain degree of platelet activation observed during the steepest increase in the peripheral platelet count. Bone marrow production of platelets increased significantly within 2 weeks of transplantation. Low TPO serum levels with low platelet counts and without platelet consumption suggests low TPO production in end-stage liver disease. The rapid increase in TPO serum levels after transplantation induces an increase in the bone marrow production of platelets. Decreased TPO production in the cirrhotic liver is an important etiologic factor for thrombocytopenia in liver disease that is rapidly reversed by transplantation.
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Quehenberger P, Handler S, Mannhalter C, Kyrle PA, Speiser W. The Factor V (Leiden) test: evaluation of an assay based on dilute Russell Viper Venom Time for the detection of the Factor V Leiden mutation. Thromb Res 1999; 96:125-33. [PMID: 10574590 DOI: 10.1016/s0049-3848(99)00090-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the present study a new clotting assay for the detection of an increased resistance of coagulation factor V against degradation by activated protein C (Factor V Leiden mutation, FVLM) was evaluated. The Factor V (Leiden) Test (Gradipore, North Ryde NSW, Australia) is based on the dilute Russell Viper Venom Time (DRVVT), which is prolonged when the plasma sample is preincubated with dilute whole Agkistrodon contortrix contortrix venom for activation of protein C (PC). In contrast to the DRVVT based global assay, Protein C Pathway Test (Gradipore, North Ryde NSW, Australia) this new assay is expected to be more specific for FVLM because of optimized amounts of the venom. The test result is expressed as the ratio between the DRVVT with and without addition of the venom. The following precision values were found: intraassay coefficient of variation (CV): 5.53% (n=20) in the normal range, 4.30% (n=20) in the pathological range; interassay CV: 6.90% (n=10) and 7.64% (n=10), respectively. A normal range (5th to 95th percentile) of 2.12 to 3.08 was calculated from 50 healthy controls. A ratio below 2.12 was found in all samples from patients with FVLM (n=21), in 9 of 12 patients with PC, in 0 of 6 with protein S (PS), and in 0 of 4 with antithrombin (AT) deficiency. There was, however, a good discrimination between carriers of the FVLM (highest ratio 1.44) and patients deficient in PC (lowest ratio 1.59), in particular when samples were prediluted with factor V deficient plasma FVDP (1.16 vs. 1.96, respectively). Predilution of samples with FVDP caused a clear discrimination between controls and patients deficient in PC, PS, AT, and FVLM-positive individuals and also in patients on oral anticoagulant treatment. Our data show that the Factor V (Leiden) Test discriminates well between carriers of the FVLM and healthy controls or patients deficient in PC, PS, and AT. Individuals presenting values between the lower cutoff of controls and the range in which FVLM-positive individuals are found are highly suspicious for protein C deficiency.
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Affiliation(s)
- P Quehenberger
- The Clinical Institute of Medical and Chemical Laboratory Diagnostics, University of Vienna, Austria
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15
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Creinin MD, Lisman R, Strickler RC. Screening for factor V Leiden mutation before prescribing combination oral contraceptives. Fertil Steril 1999; 72:646-51. [PMID: 10521103 DOI: 10.1016/s0015-0282(99)00318-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of screening for factor V Leiden mutation in women in the United States who use combination oral contraceptives. DESIGN Cost-effectiveness analysis. SETTING A national research reference laboratory, a university medical center, and an academic health center managed care organization. PATIENT(S) Women of reproductive age in the United States. INTERVENTION(S) Baseline risk estimates of venous thromboembolic disease in the general population and in carriers of factor V Leiden mutation were calculated using available data. MAIN OUTCOME MEASURE(S) The number of women who would require factor V Leiden testing and the cost of identifying this cohort to prevent one death caused by venous thromboembolic disease before prescribing combination oral contraceptives. RESULT(S) To prevent one venous thromboembolic death attributable to the use of oral contraceptives in women with factor V Leiden mutation, >92,000 carriers would need to be identified and stopped from using these pills. The estimated charge to prevent this one death would exceed $300 million. If the price of testing were discounted to 34.5% of current charges, the cost still would be between $105 million and $130 million. CONCLUSION(S) Screening for factor V Leiden mutation before prescribing combination oral contraceptives is not a cost-effective use of U.S. health care dollars. The best and most cost-effective screening tool we have is taking a thorough personal and family history related to venous thromboembolic events.
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Affiliation(s)
- M D Creinin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Hospital, Pennsylvania 15213-3180, USA.
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16
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Miles AM, Monga M. Factor V Leiden mutation: the most commonly inherited risk factor for venous thromboembolism. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1068-607x(99)00014-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Novacek G, Miehsler W, Kapiotis S, Katzenschlager R, Speiser W, Vogelsang H. Thromboembolism and resistance to activated protein C in patients with inflammatory bowel disease. Am J Gastroenterol 1999; 94:685-90. [PMID: 10086652 DOI: 10.1111/j.1572-0241.1999.00937.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Thromboembolic events are serious complications in patients with inflammatory bowel disease (IBD). Resistance of factor V to degradation by activated protein C (APC) is a major cause for venous thrombosis and is found in approximately 30% of patients with thromboembolism. The aim of the present study was to assess the prevalence of APC resistance and clinical risk factors in patients with IBD. METHODS One-hundred-two patients with IBD (64 women and 38 men; median age, 35 yr; range, 17-77 yr; 77 with Crohn's disease, 25 with ulcerative colitis) and 102 gender- and age-matched healthy control subjects were investigated prospectively for the presence of APC resistance. None of the healthy controls but 16 patients with IBD had a history of thromboembolism. RESULTS Patients with IBD and thromboembolism were young, with a median age of 37 yr (range, 17-61 yr). Five (31.3%) of them had APC resistance, which was more common than in patients with IBD without thromboembolism (7%) and in controls (5.9%) (p < 0.01). Three patients had two thromboembolic events, the other 13 each had one. Deep vein thrombosis of the leg and pulmonary emboli were the most common thromboembolic complications (84.2%). Active disease, fistula, or bowel stenosis were found in 10 (52.6%) of 19 thromboembolic events; in three (15.8%) cases thromboembolism happened postoperatively. CONCLUSIONS APC resistance is not associated with IBD but, when present, increases the risk of thromboembolism. Patients with IBD and thromboembolism are mostly young and clinical risk factors can be found in one-half of cases.
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Affiliation(s)
- G Novacek
- Department of Internal Medicine IV, Clinical Institute of Medical and Chemical Laboratory Diagnostics, University of Vienna, Austria
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18
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Hunault M, Marsh-Scott C, Jou C, Marshall R, Scheffel C, Fiore LD, Bauer KA, Mitchell MJ. Automated Detection of the Factor V Leiden Mutation Using the LCx Microparticle Enzyme Immunoassay. Clin Chem 1999. [DOI: 10.1093/clinchem/45.1.41] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
The factor V Leiden mutation, a G→A transition at position 1691 in exon 10 of the gene that codes for factor V, produces an Arg506Gln substitution and is the most common genetic risk factor for venous thrombosis. We have developed a rapid, sensitive, and specific method to detect the factor V Leiden mutation in genomic DNA from whole blood by PCR amplification and microparticle enzyme immunoassay detection using the Abbott LCx instrument. We compared this automated method with the standard procedure using restriction endonuclease digestion of PCR products followed by gel electrophoresis in blinded experiments. In 130 patients (from Veterans Affairs medical centers) with deep venous thromboses, including 24 heterozygotes with the factor V Leiden mutation, there was complete agreement between the two methods. The assay was also able to distinguish heterozygotes from homozygotes. This method, which carries a low potential for cross-contamination of samples, should be a useful routine test for the factor V Leiden mutation in clinical laboratories with sufficient demand for molecular diagnostic assays using the LCx instrument.
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Affiliation(s)
- Mathilde Hunault
- Hematology-Oncology Section, Brockton-West Roxbury Veterans Affairs Medical Center, Brockton, MA 02410
| | - Camile Marsh-Scott
- Division of Laboratory Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215
| | - Cynthia Jou
- Abbott Laboratories, Molecular Diagnostics, Abbott Park, IL 60064
| | - Ron Marshall
- Abbott Laboratories, Molecular Diagnostics, Abbott Park, IL 60064
| | - Christi Scheffel
- Abbott Laboratories, Molecular Diagnostics, Abbott Park, IL 60064
| | - Louis D Fiore
- Hematology-Oncology Section, Boston Veterans Affairs Medical Center, Boston, MA 02130
| | - Kenneth A Bauer
- Hematology-Oncology Section, Brockton-West Roxbury Veterans Affairs Medical Center, Brockton, MA 02410
| | - Michael J Mitchell
- Division of Laboratory Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215
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Ruzicka K, Kapiotis S, Quehenberger P, Handler S, Pabinger-Fasching I, Mannhalter C, Jilma B, Speiser W. Evaluation of a new screening assay ProC Global for identification of defects in the protein C/protein S anticoagulant pathway. Thromb Res 1997; 87:501-10. [PMID: 9330432 DOI: 10.1016/s0049-3848(97)00179-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the present study a new assay, ProC Global, globally estimating the activity of the main plasma components of anticoagulant protein C/protein S pathway, was evaluated with respect to test characteristics and its sensitivity in the detection of deficiency states of protein C and protein S and of increased aPCR. In the ProC Global assay procedure protein C is activated in patient's plasma by an activator reagent (venom from agkistrodon contortrix). The extent of the prolongation of a sample's aPTT, caused by the activation of protein C, is taken as a measure for its anticoagulant capacity. Ninety-eight patients with one of the above mentioned defects were investigated. Decreased plasma protein C activity and increased aPCR were detected with a sensitivity of 1.0, while only 11 of 14 patients with decreased levels of free protein S antigen showed abnormal results in the ProC Global assay (sensitivity = 0.79). The test can be used in heparinized samples up to 1.0 anti Xa U/ml heparin (UFH and LMWH). When samples from patients on oral anticoagulant treatment are prediluted with factor V deficient plasma the test is sensitive for increased aPCR.
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Affiliation(s)
- K Ruzicka
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University of Vienna, Austria
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