Download PDF
Semin Thromb Hemost 2023; 49(06): 641-650
DOI: 10.1055/s-0043-1764468
Review Article

Laboratory Evaluation of Antithrombin, Protein C, and Protein S

Richard A. Marlar
1   Department of Pathology, University of New Mexico, TriCore Reference Laboratories, Albuquerque, New Mexico
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Thrombophilia is a complex disease process, clinically manifesting in various forms of venous thromboembolism. Although both genetic and acquired (or environmental) risks factors have been reported, the presence of a genetic defect (antithrombin [AT], protein C [PC], protein S [PS]) is considered three of the major contributing factors of thrombophilia. The presence of each of these risk factors can be established by clinical laboratory analysis; however, the clinical provider and laboratory personnel must understand the testing limitations and shortcomings associated with the assays for these factors to be able to ensure an accurate diagnosis. This article will describe the major pre-analytical, analytical, and post-analytical issues associated with the various types of assays and discuss evidence-based algorithms for analyzing AT, PC, and PS in plasma.

Keywords

thrombophilia - thrombosis - assay - testing methods


Publication History

Article published online:
20 March 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Christiansen SC, Cannegieter SC, Koster T, Vandenbroucke JP, Rosendaal FR. Thrombophilia, clinical factors, and recurrent venous thrombotic events. JAMA 2005; 293 (19) 2352-2361
    CrossrefPubMedSearch in Google Scholar
  • 2 Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrøm J. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 2007; 5 (04) 692-699
    CrossrefPubMedSearch in Google Scholar
  • 3 Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res 2016; 118 (09) 1340-1347
    CrossrefPubMedSearch in Google Scholar
  • 4 Heit JA, Ashrani A, Crusan DJ, McBane RD, Petterson TM, Bailey KR. Reasons for the persistent incidence of venous thromboembolism. Thromb Haemost 2017; 117 (02) 390-400
    Thieme ConnectPubMedSearch in Google Scholar
  • 5 Eby C. . Laboratory diagnosis of inherited thrombophilia. In: Kottke-Marchant K, ed. An Algorithmic Approach to Hemostasis Testing. Northfield, IL: College of American pathologists; 2008:267–277
  • 6 Baglin T, Gray E, Greaves M. et al; British Committee for Standards in Haematology. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol 2010; 149 (02) 209-220
    CrossrefPubMedSearch in Google Scholar
  • 7 Johnson NV, Khor B, Van Cott EM. Advances in laboratory testing for thrombophilia. Am J Hematol 2012; 87 (Suppl (Suppl. 01) S108-S112
    CrossrefPubMedSearch in Google Scholar
  • 8 Coppens M, Reijnders JH, Middeldorp S, Doggen CJ, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost 2008; 6 (09) 1474-1477
    CrossrefPubMedSearch in Google Scholar
  • 9 Moll S. . New insights into treatment of venous thromboembolism. Hematology 2014. American Society of Hematology Education Program: American Society of Hematology, American Society of Hematology; 2014:297–305
  • 10 Martinelli I, De Stefano V, Mannucci PM. Inherited risk factors for venous thromboembolism. Nat Rev Cardiol 2014; 11 (03) 140-156
    CrossrefPubMedSearch in Google Scholar
  • 11 Dahlbäck B. Advances in understanding pathogenic mechanisms of thrombophilic disorders. Blood 2008; 112 (01) 19-27
    CrossrefPubMedSearch in Google Scholar
  • 12 Franchini M, Veneri D, Salvagno GL, Manzato F, Lippi G. Inherited thrombophilia. Crit Rev Clin Lab Sci 2006; 43 (03) 249-290
    CrossrefPubMedSearch in Google Scholar
  • 13 Ye Z, Liu EH, Higgins JP. et al. Seven haemostatic gene polymorphisms in coronary disease: meta-analysis of 66,155 cases and 91,307 controls. Lancet 2006; 367 (9511): 651-658
    CrossrefPubMedSearch in Google Scholar
  • 14 Louridas GE, Lourida KG. Conceptual foundations of systems biology explaining complex cardiac diseases. Healthcare (Basel) 2017; 5 (01) 10-28
    CrossrefPubMedSearch in Google Scholar
  • 15 Heit JA, Phelps MA, Ward SA, Slusser JP, Petterson TM, De Andrade M. Familial segregation of venous thromboembolism. J Thromb Haemost 2004; 2 (05) 731-736
    CrossrefPubMedSearch in Google Scholar
  • 16 Koster T, Rosendaal FR, Briët E. et al. Protein C deficiency in a controlled series of unselected outpatients: an infrequent but clear risk factor for venous thrombosis (Leiden Thrombophilia Study). Blood 1995; 85 (10) 2756-2761
    CrossrefPubMedSearch in Google Scholar
  • 17 Marlar RA. Are the laboratory results (phenotype) indicative of a true genotype abnormality?. Am J Clin Pathol 2012; 137 (02) 173-175
    CrossrefPubMedSearch in Google Scholar
  • 18 Stevens SM, Woller SC, Bauer KA. et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis 2016; 41 (01) 154-164
    CrossrefPubMedSearch in Google Scholar
  • 19 Marlar RA. The protein C system -- How complex is it?. Thromb Haemost 2001; 85 (05) 756-757
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Lindström S, Wang L, Smith EN. et al; Million Veteran Program; CHARGE Hemostasis Working Group. Genomic and transcriptomic association studies identify 16 novel susceptibility loci for venous thromboembolism. Blood 2019; 134 (19) 1645-1657
    CrossrefPubMedSearch in Google Scholar
  • 21 Franchini M, Martinelli I, Mannucci PM. Uncertain thrombophilia markers. Thromb Haemost 2016; 115 (01) 25-30
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Kyrle PA, Minar E, Hirschl M. et al. High plasma levels of factor VIII and the risk of recurrent venous thromboembolism. N Engl J Med 2000; 343 (07) 457-462
    CrossrefPubMedSearch in Google Scholar
  • 23 Meijers JCM, Tekelenburg WLH, Bouma BN, Bertina RM, Rosendaal FR. High levels of coagulation factor XI as a risk factor for venous thrombosis. N Engl J Med 2000; 342 (10) 696-701
    CrossrefPubMedSearch in Google Scholar
  • 24 Frischmuth T, Hindberg K, Aukrust P. et al. Elevated plasma levels of plasminogen activator inhibitor-1 are associated with risk of future incident venous thromboembolism. J Thromb Haemost 2022; 20 (07) 1618-1626
    CrossrefPubMedSearch in Google Scholar
  • 25 Middeldorp S. . Anticoagulation in pregnancy complications. American Society of Hematology Education Program. Hematology 2014. American Society of Hematology Education Program: American Society of Hematology, Washington, DC; 2014:393–399
  • 26 Le Gal G, Kovacs MJ, Carrier M. et al. Risk of recurrent venous thromboembolism after a first oestrogen-associated episode. Data from the REVERSE cohort study. Thromb Haemost 2010; 104 (03) 498-503
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Aldrighi JM, De Campos LS, Eluf Gebara OC, Petta CA, Bahamondes L. Effect of a combined oral contraceptive containing 20 microg ethinyl estradiol and 75 microg gestodene on hemostatic parameters. Gynecol Endocrinol 2006; 22 (01) 1-4
    CrossrefPubMedSearch in Google Scholar
  • 28 Braekkan SK, Siegerink B, Lijfering WM, Hansen JB, Cannegieter SC, Rosendaal FR. Role of obesity in the etiology of deep vein thrombosis and pulmonary embolism: current epidemiological insights. Semin Thromb Hemost 2013; 39 (05) 533-540
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Smith TW, Pi D, Hudoba M, Lee AY. Reducing inpatient heritable thrombophilia testing using a clinical decision-making tool. J Clin Pathol 2014; 67 (04) 345-349
    CrossrefPubMedSearch in Google Scholar
  • 30 Schneider-MacRae N, Jackson SC, Valentine KA, Lockyer J, Poon MC. A study of thrombophilia testing and counseling practices of family physicians using the script concordance method in Calgary, Canada. Clin Appl Thromb Hemost 2012; 18 (04) 403-408
    CrossrefPubMedSearch in Google Scholar
  • 31 Wu O, Robertson L, Twaddle S. et al. Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study. Health Technol Assess 2006; 10 (11) 1-110
    PubMedSearch in Google Scholar
  • 32 Monagle P, Barnes C, Ignjatovic V. et al. Developmental haemostasis. Impact for clinical haemostasis laboratories. Thromb Haemost 2006; 95 (02) 362-372
    Thieme ConnectPubMedSearch in Google Scholar
  • 33 Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L. Maturation of the hemostatic system during childhood. Blood 1992; 80 (08) 1998-2005
    CrossrefPubMedSearch in Google Scholar
  • 34 Nowak-Göttl U, van Ommen H, Kenet G. Thrombophilia testing in children: What and when should be tested?. Thromb Res 2018; 164: 75-78
    CrossrefPubMedSearch in Google Scholar
  • 35 Van Cott EM, Orlando C, Moore GW, Cooper PC, Meijer P, Marlar R. Subcommittee on Plasma Coagulation Inhibitors. Recommendations for clinical laboratory testing for antithrombin deficiency; communication from the SSC of the ISTH. J Thromb Haemost 2020; 18 (01) 17-22
    CrossrefPubMedSearch in Google Scholar
  • 36 Cooper PC, Pavlova A, Moore GW, Hickey KP, Marlar RA. Recommendations for clinical laboratory testing for protein C deficiency, for the subcommittee on plasma coagulation inhibitors of the ISTH. J Thromb Haemost 2020; 18 (02) 271-277
    CrossrefPubMedSearch in Google Scholar
  • 37 Marlar RA, Gausman JN, Tsuda H, Rollin-Raval M, Brinkman HJ. Guidance for clinical laboratory testing for protein S deficiency. J Thromb Hemostas 2021; 19: 68-74
    PubMedSearch in Google Scholar
  • 38 Gosselin RC, Marlar RA. Pre-analytical variables in coagulation testing: setting the stage for accurate results. Semin Thromb Hemost 2019; 45 (05) 433-448
    Thieme ConnectPubMedSearch in Google Scholar
  • 39 Kitchen S, Adcock DM, Dauer R. et al. International Council for Standardisation in Haematology (ICSH) recommendations for collection of blood samples for coagulation testing. Int J Lab Hematol 2021; 43 (04) 571-580
    Search in Google Scholar
  • 40 Kitchen S, Adcock DM, Dauer R. et al. International Council for Standardization in Haematology (ICSH) recommendations for processing of blood samples for coagulation testing. Int J Lab Hematol 2021; 43 (06) 1272-1283
    Search in Google Scholar
  • 41 Adcock DM. . Sample integrity and preanalytical variables. In: Kitchen S, Olson JD, Preston FE, eds. Quality in Laboratory Hemostasis and Thrombosis. Chichester, UK: Wiley-Blackwell; 2009:31–42
  • 42 CLSI. . Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory; Approved Guideline, 3rd ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2008; C28–A3
  • 43 Marlar RA. . Hemostasis test validation, performance and reference intervals. In: Olson J, Kitchen S, Preston E, eds. Quality in Laboratory Hemostasis and Thrombosis, 2nd edn. Hoboken, NJ: Blackwell Publishers; 2013:12–21
  • 44 Marlar RA, Gausman JN. Protein S abnormalities: a diagnostic nightmare. Am J Hematol 2011; 86 (05) 418-421
    CrossrefPubMedSearch in Google Scholar
  • 45 Garcia-Horton A, Kovacs MJ, Abdulrehman J, Taylor JE, Sharma S, Lazo-Langner A. Impact of thrombophilia screening on venous thromboembolism management practices. Thromb Res 2017; 149: 76-80
    CrossrefPubMedSearch in Google Scholar
  • 46 Moore GW, Van Cott EM, Cutler JA, Mitchell MJ, Adcock DM. Subcommittee on Plasma Coagulation Inhibitors. Recommendations for clinical laboratory testing of activated protein C resistance; communication from the SSC of the ISTH. J Thromb Haemost 2019; 17 (09) 1555-1561
    CrossrefPubMedSearch in Google Scholar
  • 47 Devreese KM, Pierangeli SS, de Laat B, Tripodi A, Atsumi T, Ortel TL. Subcommittee on Lupus Anticoagulant/Phospholipid/Dependent Antibodies. Testing for antiphospholipid antibodies with solid phase assays: guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12 (05) 792-795
    CrossrefPubMedSearch in Google Scholar
  • 48 Devreese KM. Antiphospholipid antibody testing and standardization. Int J Lab Hematol 2014; 36 (03) 352-363
    CrossrefPubMedSearch in Google Scholar
  • 49 Seligsohn U, Lubetsky A. Genetic susceptibility to venous thrombosis. N Engl J Med 2001; 344 (16) 1222-1231
    CrossrefPubMedSearch in Google Scholar
  • 50 Lijfering WM, Brouwer JL, Veeger NJ. et al. Selective testing for thrombophilia in patients with first venous thrombosis: results from a retrospective family cohort study on absolute thrombotic risk for currently known thrombophilic defects in 2479 relatives. Blood 2009; 113 (21) 5314-5322
    CrossrefPubMedSearch in Google Scholar
  • 51 Marlar RA, Adcock DM, Madden RM. Hereditary dysfunctional protein C molecules (Type II): assay characterization and proposed classification. Thromb Haemost 1990; 63 (03) 375-379
    Thieme ConnectPubMedSearch in Google Scholar
  • 52 Mahmoodi BK, Brouwer JLP, Veeger NJ, van der Meer J. Hereditary deficiency of protein C or protein S confers increased risk of arterial thromboembolic events at a young age: results from a large family cohort study. Circulation 2008; 118 (16) 1659-1667
    CrossrefPubMedSearch in Google Scholar
  • 53 ten Kate MK, van der Meer J. Protein S deficiency: a clinical perspective. Haemophilia 2008; 14 (06) 1222-1228
    CrossrefPubMedSearch in Google Scholar
  • 54 Ioannou HV, Mitsis M, Eleftheriou A. et al. The prevalence of factor V Leiden as a risk factor for venous thromboembolism in the population of North-Western Greece. Int Angiol 2000; 19 (04) 314-318
    PubMedSearch in Google Scholar
  • 55 Kim RJ, Becker RC. Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies. Am Heart J 2003; 146 (06) 948-957
    CrossrefPubMedSearch in Google Scholar
  • 56 Egeberg O. Inherited antithrombin deficiency causing thrombophilia. Thromb Diath Haemorrh 1965; 13: 516-530
    PubMedSearch in Google Scholar
  • 57 Tait RC, Walker ID, Perry DJ. et al. Prevalence of antithrombin deficiency in the healthy population. Br J Haematol 1994; 87 (01) 106-112
    CrossrefPubMedSearch in Google Scholar
  • 58 Kovács B, Bereczky Z, Oláh Z. et al. The superiority of anti-FXa assay over anti-FIIa assay in detecting heparin-binding site antithrombin deficiency. Am J Clin Pathol 2013; 140 (05) 675-679
    CrossrefPubMedSearch in Google Scholar
  • 59 Khor B, Van Cott EM. Laboratory tests for antithrombin deficiency. Am J Hematol 2010; 85 (12) 947-950
    CrossrefPubMedSearch in Google Scholar
  • 60 Marlar RA, Gausman JN. Laboratory testing issues for protein C, protein S, and antithrombin. Int J Lab Hematol 2014; 36 (03) 289-295
    CrossrefPubMedSearch in Google Scholar
  • 61 Duebgen S, Kauke T, Marschall C. et al. Genotype and laboratory and clinical phenotypes of protein s deficiency. Am J Clin Pathol 2012; 137 (02) 178-184
    CrossrefPubMedSearch in Google Scholar
  • 62 Comp PC, Esmon CT. Recurrent venous thromboembolism in patients with a partial deficiency of protein S. N Engl J Med 1984; 311 (24) 1525-1528
    CrossrefPubMedSearch in Google Scholar
  • 63 Brinkman HJM, Ahnström J, Castoldi E, Dahlbäck B, Marlar RA. Pleiotropic anticoagulant functions of protein S, consequences for the clinical laboratory. J Thromb Hemost 2021; 19: 281-286
    CrossrefPubMedSearch in Google Scholar
  • 64 Johnston AM, Aboud M, Morel-Kopp MC, Coyle L, Ward CM. Use of a functional assay to diagnose protein S deficiency; inappropriate testing yields equivocal results. Intern Med J 2007; 37 (06) 409-411
    CrossrefPubMedSearch in Google Scholar
  • 65 Dahlbäck B. Vitamin K-dependent protein S: beyond the protein C pathway. Semin Thromb Hemost 2018; 44 (02) 176-184
    Thieme ConnectPubMedSearch in Google Scholar
  • 66 Toulon P, Berruyer M, Brionne-François M. et al. Age dependency for coagulation parameters in paediatric populations. Results of a multicentre study aimed at defining the age-specific reference ranges. Thromb Haemost 2016; 116 (01) 9-16
    PubMedSearch in Google Scholar