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Favaloro EJ, Pasalic L, Selby R. Testing for the lupus anticoagulant: the good, the bad, and the ugly. Res Pract Thromb Haemost 2024; 8:102385. [PMID: 38623474 PMCID: PMC11017341 DOI: 10.1016/j.rpth.2024.102385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024] Open
Abstract
Lupus anticoagulant (LA) represents 1 of the laboratory criteria for classification of patients as having definite antiphospholipid syndrome (APS). The other 2 laboratory criteria are anticardiolipin antibodies and anti-beta2-glycoprotein I antibodies. At least 1 of these antiphospholipid antibody (aPL) tests need to be positive, with evidence of persistence, together with evidence of at least 1 clinical criterion for APS, before a patient can be classified as having definite APS. LA and other aPL assays are also important for diagnosis or exclusion of APS, as well as for risk stratification, with triple-positive patients carrying the greatest risk. Whereas LA is identified through "uncalibrated" clot-based assays, the other aPL assays (anticardiolipin and anti-beta2-glycoprotein I antibodies) represent immunological assays, identified using calibrated solid-phase methods. Because LA is identified using clot-based assays, it is subject to considerable preanalytical and analytical issues that challenge accurate detection or exclusion of LA. In this narrative review, we take a look at the good, the bad, and the ugly of LA testing, primarily focusing on the last 10 years. Although harmonization of LA testing as a result of International Society on Thrombosis and Haemostasis guidance documents and other international activities has led to improvements in LA detection, many challenges remain. In particular, several anticoagulants, especially direct oral anticoagulants and also vitamin K antagonists, given as therapy to treat the pathophysiological consequences of aPL, especially thrombosis, interfere with LA assays and can generate false-positive or false-negative LA findings. Overcoming these diagnostic errors will require a multifaceted approach with clinicians and laboratories working together.
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Affiliation(s)
- Emmanuel J. Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | - Leonardo Pasalic
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Rita Selby
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Efthymiou M, Bertolaccini ML, Cohen H. Viewpoint: Lupus anticoagulant detection and interpretation in antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI54-SI63. [PMID: 38320587 DOI: 10.1093/rheumatology/kead623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 02/08/2024] Open
Abstract
Lupus anticoagulant (LA) is a well-established risk factor for the clinical manifestations of antiphospholipid syndrome (APS). Accurate LA detection is an essential prerequisite for optimal diagnosis and management of patients with APS or aPL carriers. Variability remains a challenge in LA testing, with reliable detection influenced by multiple factors, including pre-analytical conditions, anticoagulation treatment, choice of tests and procedures performed, as well as interpretation of results, that can lead to false-positives or negatives. A standardised approach to LA testing, following current guidance, based on published data and international consensus, and with attention to detail, is required to underpin accurate detection of LA. Future work should focus on better characterisation of the nature of LA, which may ultimately lead to improved diagnosis and management of patients with APS and aPL carriers. This article reviews current practice and challenges, providing an overview on detection of LA.
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Affiliation(s)
- Maria Efthymiou
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
| | - Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Moore GW, Foxton E, Platton S, Yartey N, White D, MacDonald SG. Triple-positive antiphospholipid syndrome does not guarantee positivity in each lupus anticoagulant assay. J Thromb Haemost 2023; 21:3539-3546. [PMID: 37597725 DOI: 10.1016/j.jtha.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Triple positivity for all 3 criteria antiphospholipid antibodies confers high risk of symptom development in carriers, and recurrence in antiphospholipid syndrome (APS). Most triple-positivity studies report lupus anticoagulant (LA) testing as positive without distinguishing between positivity with dilute Russell's viper venom time (dRVVT) and activated partial thromboplastin time (APTT) and single-assay positivity or only perform dRVVT. Single LA assay repertoires remain in use in some centers, which risks missing some triple positives. Positivity with both assays may identify higher risk. OBJECTIVES The aim of this study is to investigate the frequency of single LA assay positivity in triple-positive patients. METHODS Three hundred forty-two triple-positive profiles from nonanticoagulated patients (237 APS, 45 systemic lupus erythematosus without APS symptoms, and 60 nonclinical criteria) were identified from laboratory databases and assessed for LA positivity by dRVVT and/or APTT. RESULTS Seventy-three of 237 (30.8%) APS samples were LA-positive with 1 assay, 40/237 (16.9%) by dRVVT only, and 33/237 (13.9%) with APTT only. Nineteen of 45 (42.2%) were LA-positive with 1 assay in the systemic lupus erythematosus cohort; 12/45 (26.7%) with dRVVT only and 7/45 (15.5%) with APTT only. Thirty-three of 60 (55.0%) were LA-positive with 1 assay in the nonclinical criteria cohort; 24/60 (40.0%) with dRVVT only and 9/60 (15.0%) with APTT only. The most common solid-phase assay profile was elevated immunoglobulin G aCL and aβ2GPI. CONCLUSION Up to 55.0% of triple-positive samples were positive in 1 LA assay, representing significant potential for misdiagnosis and inappropriate management via single LA assay repertoires.
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Affiliation(s)
- Gary W Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, UK.
| | - Eleanor Foxton
- Synnovis Haemostasis and Thrombosis Laboratory, St Thomas' Hospital, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Nada Yartey
- East and South East London NHS Pathology Partnership, Barts Health NHS Trust, London, UK
| | - Danielle White
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen G MacDonald
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Favaloro EJ, Dean E, Arunachalam S. Variable Performance of Lupus Anticoagulant Testing: The Australasian/Asia-Pacific Experience. Semin Thromb Hemost 2023. [PMID: 37967835 DOI: 10.1055/s-0043-1776406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Lupus anticoagulant (LA) is one of three tests identified as laboratory criteria for definite antiphospholipid syndrome (APS). The other two tests are anticardiolipin antibody (aCL) and anti-β2-glycoprotein I (aβ2GPI) antibody. The presence of LA is assessed using clot-based tests, while the presence of aCL and aβ2GPI is assessed by immunological assays. Since no test can be considered 100% sensitive or specific for LA, current guidelines recommend using two different clot-based assays reflecting different principles, with the dilute Russell viper venom time (dRVVT) and activated partial thromboplastin time (aPTT) recommended. Initially, LA-sensitive reagents are used to screen for LA, and then, in "screen-positive" samples, LA-"insensitive" reagents are used to confirm LA. Because LA assays are based on clot detection, anything that can interfere with fibrin clot development may affect test results. In particular, in addition to LA, the tests are also sensitive to the presence of a wide range of clinical anticoagulants, reflecting preanalytical issues for testing. We provide updated findings for LA testing in our geographic region, using recent data from the Royal College of Pathologists of Australasia Quality Assurance Programs, an international external quality assessment program with approximately 120 participants. Data show a wide variety of assays in use, especially for aPTT testing, and variable outcomes in reported numerical values with these assays when assessing proficiency samples. dRVVT testing mostly comprised reagents from three main manufacturing suppliers, which also showed differences in numerical values for the same homogeneous tested samples. Nevertheless, despite the use of different test reagents and processes, >98% of participants correctly identified LA-negative samples as LA-negative and LA-positive samples as LA positive. We hope our findings, reflecting on the heterogeneity of test processes and test data, help improve diagnostic testing for LA in the future.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | - Elysse Dean
- RCPA QAP Haematology, St Leonards, NSW, Australia
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Gkrouzman E, Willis R, Andrade D, Tektonidou MG, Pengo V, Ruiz-Irastorza G, Belmont HM, Fortin PR, Gerosa M, Signorelli F, Atsumi T, Branch DW, Nalli C, Rodriguez-Almaraz E, Petri MA, Cervera R, Knight JS, Efthymiou M, Cohen H, Bertolaccini ML, Erkan D, Roubey R. Associations Among Antiphospholipid Antibody Types, Isotypes, and Titers: An AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) Study. J Transl Med 2023; 103:100147. [PMID: 37044248 DOI: 10.1016/j.labinv.2023.100147] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/10/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Several antiphospholipid antibody (aPL) profiles ("triple" and lupus anticoagulant [LA] positivity) are associated with a higher risk for clinical manifestations of antiphospholipid syndrome (APS). Further risk is correlated with higher levels of anticardiolipin antibody (aCL) and anti-β2 glycoprotein-I antibody (aβ2GPI), and with aPL persistence. Given that the 3 aPL tests detect partially overlapping sets of antibodies, the primary goal of this study was to characterize the associations among aPL tests using AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) core laboratory data. The APS ACTION Registry includes annually followed adult patients with positive aPL based on the Revised Sapporo Classification Criteria. We analyzed baseline and prospective core laboratory data of the registry for associations among aPL tests using the Spearman rank correlation with Bonferroni-adjusted significance level for multiple comparisons. An aPL Load was calculated based on 6 tests (aCL IgG/IgM/IgA and aβ2GPI IgG/IgM/IgA); a receiver operating characteristic curve was used to evaluate the diagnostic performance of the aPL Load in predicting LA positivity. In 351 patients simultaneously tested for LA, aCL, and aβ2GPI, the frequency of moderate-to-high (≥40 U) titers of aCL and aβ2GPI IgG/IgM/IgA was higher in patients who were positive for LA vs those who were negative. An aPL Load was calculated for each patient to assess the overall aPL burden. For every 1-point increase in the aPL Load, the possibility of a positive LA test increased by 32% (odds ratio, 1.32; 95% CI, 1.2-1.5; P < .001). Based on core laboratory data from a large international registry, most aPL enzyme-linked immunosorbent assay ≥40 U and a high calculated aPL Load combining 6 aPL enzyme-linked immunosorbent assays were predictive of a positive LA. These data suggest that the combined quantitative burden of aPL may provide a mechanistic explanation of a positive LA.
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Affiliation(s)
- Elena Gkrouzman
- Division of Rheumatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts.
| | - Rohan Willis
- University of Texas Medical Branch, Galveston, Texas
| | | | | | | | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, UPV/EHU, Bizkaia, The Basque Country, Spain
| | | | - Paul R Fortin
- CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | | | | | | | - D Ware Branch
- James R. and Jo Scott Research Chair, University of Utah and Intermountain Healthcare, Salt Lake City, Utah
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Michelle A Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ricard Cervera
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Hematology, University College London, London, United Kingdom
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Hematology, University College London, London, United Kingdom
| | | | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Robert Roubey
- University of North Carolina, Chapel Hill, North Carolina
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Devreese KM, Zuily S, Meroni PL. Role of antiphospholipid antibodies in the diagnosis of antiphospholipid syndrome. J Transl Autoimmun 2021; 4:100134. [PMID: 34816113 PMCID: PMC8592860 DOI: 10.1016/j.jtauto.2021.100134] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 01/07/2023] Open
Abstract
The diagnosis of antiphospholipid syndrome (APS) relies on the detection of antiphospholipid antibodies (aPL). Currently, lupus anticoagulant (LA), anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are included as laboratory criteria, if persistently present. LAC measurement remains a complicated procedure with many pitfalls and interfered by anticoagulant therapy. Solid-phase assays for aCL and aβ2GPI show interassay differences. These methodological issues make the laboratory diagnosis of APS challenging. In the interpretation of aPL results, antibody profiles help in identifying patients at risk. Other aPL, such as antibodies against the domain I of beta2-glycoprotein (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies have been studied in the last years and may be useful in risk stratification of APS patients. Because of the methodological shortcomings of immunological and clotting assays, these non-criteria aPL may be useful in patients with incomplete antibody profiles to confirm or exclude the increased risk profile. This manuscript will focus on the laboratory aspects, the clinical relevance of assays and interpretation of aPL results in the diagnosis of APS. The presence of antiphospholipid antibodies (aPL) define the diagnosis of the antiphospholipid syndrome (APS). Laboratory criteria are lupus anticoagulant, anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG/IgM. Lupus anticoagulant measurement, as well as solid phase assays for aCL and aβ2GPI, show methodological challenges. Antibodies against domain I of β2GPI (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies are non-criteria aPL. aDI and aPS/PT may be useful in risk stratification of APS patients.
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Affiliation(s)
- Katrien M.J. Devreese
- Coagulation Laboratory, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Corresponding author. Coagulation Laboratory, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Gent, Belgium.
| | - Stéphane Zuily
- Université de Lorraine, Inserm, DCAC, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Regional Universitaire de Nancy, 54000, Nancy, France
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano–Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
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Petri MA, Avci M, Magder LS. Evaluation of different ways to identify persistent positivity of lupus anticoagulant in systemic lupus erythematosus. Lupus Sci Med 2021; 7:7/1/e000406. [PMID: 33139453 PMCID: PMC7607609 DOI: 10.1136/lupus-2020-000406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/04/2020] [Accepted: 10/03/2020] [Indexed: 11/28/2022]
Abstract
Objective Persistent positivity for lupus anticoagulant has been associated with an increased risk of thrombosis among patients with SLE. Persistent positivity is often defined as having two positive assessments separated by more than 90 days. Our objective was to determine whether frequent repeated lupus anticoagulant testing would identify more patients with persistent positivity, and whether the additional patients identified were still at increased risk of thrombosis. Methods Using a large longitudinal cohort with frequent lupus anticoagulant testing, we compared three different hypothetical clinical strategies for identifying persistent positivity: (1) assessment of lupus anticoagulant twice more than 90 days apart; (2) assessment of lupus anticoagulant annually, with repeat testing if an annual assessment was positive; and (3) assessment of lupus anticoagulant 16 times (approximately quarterly for 4 years). The prevalence of persistent positivity was compared between the approaches and by demographic subgroups. Subgroups based on these definitions were compared with respect to the risk of thrombosis in subsequent follow-up using discrete survival analysis. Results Among the 785 patients included in our analysis, the prevalence of persistent lupus anticoagulant as defined by the first two patient assessments was 4.3%. Annual assessment resulted in a prevalence of 6.6%, and using all 16 assessments resulted in a prevalence of 10.5%. The prevalence was substantially higher in men than in women, and in Caucasians than in African-Americans (p<0.01 for all comparisons). The rate of thrombosis was significantly elevated among those with persistently positive lupus anticoagulant by any definition (HR ranging from 2.75 to 3.42) relative to those without persistently positive lupus anticoagulant. Conclusion While there are other risk factors for thrombosis (including other antiphospholipid subtypes), more frequent testing (not limited to twice over 3 months) for lupus anticoagulant would be useful for identifying more patients with SLE at elevated risk for thrombosis.
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Affiliation(s)
- Michelle A Petri
- Division of Rheumatology, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA
| | - Mertcan Avci
- Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Laurence S Magder
- School of Medicine, Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, Maryland, USA
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Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking (APS ACTION): 10-Year Update. Curr Rheumatol Rep 2021; 23:45. [PMID: 33932165 PMCID: PMC8088198 DOI: 10.1007/s11926-021-01008-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
Purpose of Review APS ACTION is an international research network created to design and conduct large-scale, multicenter research in persistently antiphospholipid antibody (aPL)–positive patients. Given the expanding research activities of the network in the last decade since its creation, the purpose of this article is to review the scientific contributions of APS ACTION as well as future directions. Recent Findings APS ACTION has achieved increased international collaboration with internal and external investigators for outcome, interventional, and mechanistic antiphospholipid syndrome (APS) studies. This has been linked to substantial progress in Core laboratory work, which has demonstrated that laboratories can achieve good agreement in performance of aPL assays by use of the same reagents, analyzer type, and protocols. Summary APS ACTION will continue to identify gaps in the existing aPL/APS literature, design mechanistic studies to elucidate underlying mechanisms, and conduct prospective, large-scale clinical studies, all for the ultimate goal of early diagnosis and improved management of aPL-positive patients.
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Chighizola CB, Sciascia S, Andreoli L, Meroni PL. Beyond current concepts in anti-phospholipid syndrome: The 16th International Congress on Anti-phospholipid Antibodies (ICAPA) in Manchester. Autoimmun Rev 2020; 19:102615. [PMID: 32663623 DOI: 10.1016/j.autrev.2020.102615] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/06/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy; Unit of Allergology, Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases/Nephrology and Dialysis Unit, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, Turin, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Milan, Italy; Unit of Allergology, Immunology and Rheumatology, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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Tripodi A, Cohen H, Devreese KMJ. Lupus anticoagulant detection in anticoagulated patients. Guidance from the Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:1569-1575. [PMID: 32619349 DOI: 10.1111/jth.14846] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The laboratory detection of lupus anticoagulants (LA) in anticoagulated patients represents a challenge and there is no consensus on the types of assays/procedures to be adopted. OBJECTIVES This communication of the International Society on Thrombosis and Haemostasis (ISTH), Scientific and Standardization Committee (SSC) aims to give guidance on the procedures to be adopted. METHODS Members of the ISTH-SSC on Lupus Anticoagulant/Antiphospholipid Antibodies reviewed the literature to search for evidence on the most appropriate assays/procedures to be adopted. RESULTS Anticoagulants are able to interfere with the tests used for LA detection, giving rise to occasional false-positive or false-negative LA. Some commercial tests include in their composition heparin-neutralizers able to quench unfractionated or low molecular weight heparin up to 1.0 U/mL. LA tests are less affected by low molecular weight heparin, but caution is needed in the interpretation of results. Vitamin K antagonists (VKAs) may affect LA detection. Dilution of test plasma into pooled normal plasma is not a reliable solution as false-negative or false-positive LA may occur. Direct oral anticoagulants (DOACs) affect LA detection. Hence, it is not recommended to attempt LA detection in those patients. The use of DOAC adsorbents is a promising solution and should be further investigated on LA-positive and LA-negative patient populations. Taipan/Ecarin tests may be a solution for VKAs and anti-FXa DOACs, but independent evidence on their value and standardized kits is needed. CONCLUSIONS LA detection during anticoagulation remains a challenge, especially for VKAs. DOAC removal by in vitro addition to plasma of appropriate absorbents is promising.
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Affiliation(s)
- Armando Tripodi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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