Laboratory Testing and Identification of Antiphospholipid Antibodies and the Antiphospholipid Syndrome: A Potpourri of Problems, a Compilation of Possible Solutions

Emmanuel J. Favaloro; Richard C. W. Wong

doi:10.1055/s-0028-1085482

Seminars in Thrombosis and Hemostasis, Table of Contents

Semin Thromb Hemost 2008; 34(4): 389-410
DOI: 10.1055/s-0028-1085482

Laboratory Testing and Identification of Antiphospholipid Antibodies and the Antiphospholipid Syndrome: A Potpourri of Problems, a Compilation of Possible Solutions

Emmanuel J. Favaloro¹ , Richard C.W Wong²

¹Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, NSW, Australia
²Division of Immunology, Pathology Queensland, Royal Brisbane and Womens Hospital, Herston, Queensland, Australia

Abstract

ABSTRACT

The antiphospholipid syndrome (APS) is an autoimmune condition characterized by vascular thromboses and/or pregnancy morbidity, and its diagnosis currently requires laboratory evidence of the presence of antiphospholipid antibodies (aPL). aPL are in turn identified using a large number of laboratory procedures based on one of two distinct test processes, namely solid-phase assays and liquid-phase assays. The former includes anticardiolipin antibodies and anti-β2 glycoprotein I antibodies, and the latter are centered on clot-based tests that are used to identify the so-called lupus anticoagulant. The current article provides an overview of the laboratory testing and identification of aPL, and in particular the limitations, standardization, and clinical utility of such testing. We also review preanalytical, analytical, and postanalytical issues that compromise the clinical utility of these tests. Finally, we provide a list of recommendations aimed to foster broader international cooperation to assist in the preparation of integrated guidelines, for both solid-phase and liquid-phase assays, and for laboratory testing, clinical ordering, and interpretation.

KEYWORDS

Antiphospholipid antibodies - aPL - antiphospholipid syndrome - APS - lupus anticoagulant - LA - anticardiolipin antibody - aCL - anti-β2 glycoprotein I antibodies - anti-β2GPI - laboratory testing - criteria - standardization - analytical variables - preanalytical variables - postanalytical variables - extraanalytical variables

Full Text

References

REFERENCES

1 Miyakis S, Lockshin M D, Atsumi T et al.. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006; 4 295-306
2 Wong R CW, Favaloro E J. Preface. Semin Thromb Hemost. 2008; 34 213-218
3 Favaloro E J, Wong R CW. Preface. Semin Thromb Hemost. 2008; 34 309-312
4 Hughes G. Hughes syndrome. The antiphospholipid syndrome—a clinical overview. Clin Rev Allergy Immunol. 2007; 32 3-11
5 Wong R CW, Favaloro E J. Clinical features, diagnosis and management of antiphospholipid antibodies and the antiphospholipid syndrome. Semin Thromb Hemost. 2008; 34 295-304
6 Andreoli L, Rizzini S, Allegri F, Meroni P, Tincani A. Are the current attempts at standardization of antiphospholipid antibodies still useful? Emerging technologies signal a shift in direction. Semin Thromb Hemost. 2008; 34 356-360
7 Galli M. Clinical utility of laboratory tests used to identify antiphospholipid antibodies and to diagnose the antiphospholipid syndrome. Semin Thromb Hemost. 2008; 34 329-334
8 Galli M, Luciani D, Bertolini G, Barbui T. Antib2-glycoprotein I, antiprothrombin antibodies and the risk of thrombosis in the antiphospholipid syndrome. Blood. 2003; 102 2717-2723
9 Galli M, Luciani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors of thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood. 2003; 101 1827-1832
10 Galli M, Barbui T. Antiphospholipid syndrome: clinical and diagnostic utility of laboratory tests. Semin Thromb Hemost. 2005; 31 17-24
11 Oku K, Atsumi T, Amengual O, Koike T. Antiprothrombin antibody testing: detection and clinical utility. Semin Thromb Hemost. 2008; 34 335-339
12 Pierangeli S S, Harris E N. A quarter of a century in anticardiolipin antibody testing and attempted standardization has led us to here, which is?. Semin Thromb Hemost. 2008; 34 313-328
13 Wilson W A, Gharavi A E, Koike T et al.. International consensus statement on preliminary classification for definite antiphospholipid syndrome. Arthritis Rheum. 1999; 42 1309-1311
14 de Groot P G, Derksen R HWM, de Laat B. Twenty-two years of failure to set up undisputed assays to detect patients with the antiphospholipid syndrome. Semin Thromb Hemost. 2008; 34 347-355
15 Reber G, Boehlen F, de Moerloose P. Technical aspects in laboratory testing for antiphospholipid antibodies: is standardization an impossible dream?. Semin Thromb Hemost. 2008; 34 340-346
16 Tincani A, Allegri F, Sanmarco M et al.. Anticardiolipin antibody assay: a methodological analysis for a better consensus in routine determinations—a cooperative project of the European Antiphospholipid Forum. Thromb Haemost. 2001; 86 575-583
17 Tincani A, Allegri F, Balestrieri G et al.. Minimal requirements for antiphospholipid antibodies ELISAs proposed by the European Forum on antiphospholipid antibodies. Thromb Res. 2004; 114 553-558
18 Wong R CW, Gillis D, Adelstein S et al.. Consensus guidelines on anti-cardiolipin antibody testing and reporting. Pathology. 2004; 361 63-68
19 Wong R C, Favaloro E J, Adelstein S et al.. Consensus guidelines on anti-beta2 glycoprotein I testing and reporting. Pathology. 2008; 40 58-63
20 Green D, Hougie C, Kazmier F J et al.. Report of the Working Party on Acquired Inhibitors of Coagulation: studies of the “lupus” anticoagulant. Thromb Haemost. 1983; 49 144-146
21 Exner T, Triplett D A, Taberner D, Machin S J. Guidelines for testing and revised criteria for lupus anticoagulants. SSC Subcommittee for the Standardization of Lupus Anticoagulants. Thromb Haemost. 1991; 65 320-322
22 Brandt J T, Triplett D A, Alving B, Scharrer I. Criteria for the diagnosis of lupus anticoagulants: an update. On behalf of the Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibody of the Scientific and Standardization Committee of the ISTH. Thromb Haemost. 1995; 74 1185-1190
23 Greaves M, Cohen H, Machin S J, Mackie I. Guidelines on the investigation and management of the antiphospholipid syndrome. Br J Haematol. 2000; 109 704-715
24 Wong R CW, Favaloro E J. A consensus approach to the standardization of laboratory testing and reporting of antiphospholipid antibody assays. Semin Thromb Hemost. 2008; 34 361-372
25 Asherson R A. The primary, secondary, catastrophic and seronegative variants of the antiphospholipid syndrome: a personal history long in the making. Semin Thromb Hemost. 2008; 34 227-235
26 Galli M, Reber G, De Moerloose P, deGroot P G. Invitation to a debate on the serological criteria that define the antiphospholipid syndrome. J Thromb Haemost. 2008; 6 399-401
27 Helbert M, Bodger S, Cavenagh J et al.. Optimising testing for phospholipids antibodies. J Clin Pathol. 2001; 54 693-698
28 Wong R CW, Adelstein S, Gillis D, Favaloro E J. Development of consensus guidelines for anticardiolipin and lupus anticoagulant testing. Semin Thromb Hemost. 2005; 31 39-48
29 Bland J M, Altman D G. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986; 1 307-310
30 Favaloro E J. Standardization, regulation, quality assurance and emerging technologies in hemostasis: issues, controversies, benefits and limitations. Semin Thromb Hemost. 2007; 33 290-297
31 Ichikawa K, Tsutsumi A, Atsumi T et al.. A chimeric antibody with the human gamma1 constant region as a putative standard for assays to detect IgG beta2-glycoprotein I-dependent anticardiolipin and anti-beta2-glycoprotein I antibodies. Arthritis Rheum. 1999; 42 2461-2470
32 Reber G, Tincani A, Sanmarco M, de Moerloose P, Boffa M C. European Forum on Antiphospholipid Antibodies Standardization Group . Variability of anti-beta2 glycoprotein I antibodies measurement by commercial assays. Thromb Haemost. 2005; 94 665-672
33 Lewis D A, Pound M L, Ortel T L. The reactivity of paired plasma and serum samples are comparable in the anticardiolipin and anti-b2-glycoprotein-1 ELISAs. J Thromb Haemost. 2006; 4 265-267
34 Lewis D A, Pound M L, Ortel T L. The reactivity of paired plasma and serum samples are comparable in the anticardiolipin and anti-b2-glycoprotein-1 ELISAs. Reply to a rebuttal. J Thromb Haemost. 2006; 4 1435-1437
35 Manoussakis M N, Tzioufas A G, Silis M P, Pange P J, Goudevenos J, Moutsopoulos H M. High prevalence of anti-cardiolipin and other autoantibodies in a healthy elderly population. Clin Exp Immunol. 1987; 69 557-565
36 El-Roeiy A, Gleicher N. Definition of normal autoantibody levels in an apparently healthy population. Obstet Gynecol. 1988; 72 596-602
37 Shi W, Krilis S A, Chong B H, Gordon S, Chesterman C N. Prevalence of lupus anticoagulant and anticardiolipin antibodies in a healthy population. Aust N Z J Med. 1990; 20 231-236
38 Wong R CW, Wilson R J, Pollock W, Steele R H, Gillis D. Anti-cardiolipin antibody testing and reporting practices among laboratories participating in a large external quality assurance program. Pathology. 2004; 36 174-181
39 Hunt B J. Paediatric antiphospholipid antibodies and antiphospholipid syndrome. Semin Thromb Hemost. 2008; 34 274-281
40 Ledford-Kraemer M R. Laboratory testing for lupus anticoagulants: pre-examination variables, mixing studies and diagnostic criteria. Semin Thromb Hemost. 2008; 34 380-388
41 Tripodi A. Laboratory testing for lupus anticoagulants: diagnostic criteria and use of screening, mixing and confirmatory studies. Semin Thromb Hemost. 2008; 34 373-379
42 Clinical Laboratory Standards Institute .Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays: Approved Guideline. Fifth ed. Wayne, PA; Clinical Laboratory Standards Institute 2007 Document H21–A5
43 Favaloro E J. Preanalytical variables in coagulation testing. Blood Coagul Fibrinolysis. 2007; 18 86-89
44 Watson H G, Greaves M. Can we predict bleeding?. Semin Thromb Hemost. 2008; 34 97-103
45 Chee Y L, Crawford J C, Watson H G, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008; 140 496-504
46 Favaloro E J, Bonar R, Duncan E et al.. (on behalf of the RCPA QAP in Haematology Haemostasis Committee). Identification of factor inhibitors by diagnostic haemostasis laboratories: a large multicenter evaluation. Thromb Haemost. 2006; 96 73-78
47 Favaloro E J, Bonar R, Duncan E et al.. (on behalf of the RCPA QAP in Haematology Haemostasis Committee). Misidentification of factor inhibitors by diagnostic haemostasis laboratories: recognition of pitfalls and elucidation of strategies. A follow up to a large multicentre evaluation. Pathology. 2007; 39 504-511
48 Job Harenberg , Wehling M. Current and future prospects for anticoagulant therapy: inhibitors of factor Xa and factor IIa. Semin Thromb Hemost. 2008; 34 39-57
49 Arnout J. Antiphospholipid syndrome: diagnostic aspects of lupus anticoagulants. Thromb Haemost. 2001; 86 83-91
50 Aboud M, Roddie C, Ward C, Coyle L. To mix with pooled normal plasma or not to mix: a comparative study of two approaches to assess lupus anticoagulant inhibitory activity in the dilute Russell Viper venom method. Clin Chem. 2007; 53 143-145
51 Thom J, Ivey L, Eikelboom J. Normal plasma mixing studies in the laboratory diagnosis of lupus anticoagulant. J Thromb Haemost. 2003; 1 2689-2691
52 Jennings I, Kitchen S, Woods T AL, Preston F E, Greaves M. Clinically important inaccuracies in testing for the lupus anticoagulant: an analysis of results from three surveys of the UK NEQAS for Blood Coagulation. Thromb Haemost. 1997; 77 934-937
53 Favaloro E J, Wong R, Silvestrini R, McEvoy R, Jovanovich S, Roberts-Thompson P. A multi-laboratory peer-assessment quality assurance program based evaluation of anti-cardiolipin antibody, and beta-2-glycoprotein-1 antibody, testing. Semin Thromb Hemost. 2005; 31 73-84
54 Favaloro E J, Wong R CW, Jovanovich S, Roberts-Thomson P. A review of beta-2-glycoprotein-I antibody testing results from a peer-driven multi-laboratory quality assurance program. Am J Clin Pathol. 2007; 127 441-448
55 Favaloro E J, Silvestrini R, Mohammed A. Clinical utility of anticardiolipin antibody assays: high inter-laboratory variation and limited consensus by participants of external quality assurance programs signals a cautious approach. Pathology. 1999; 31 142-147
56 Favaloro E J, Silvestrini R. Assessing the utility of anticardiolipin antibody assays: a cautious approach is suggested by high variation and limited consensus in multi-laboratory testing. Am J Clin Pathol. 2002; 118 548-557
57 Roussi J, Roisin J P, Goguel A. Lupus anticoagulants. First French interlaboratory Etalonorm survey. Am J Clin Pathol. 1996; 105 788-793
58 Favaloro E J, Bonar R, Sioufi J et al.. (on behalf of the RCPA QAP in Haematology). Multi-laboratory testing of thrombophilia: current and past practice in Australasia as assessed through the Royal College of Pathologists of Australasia Quality Assurance Program in Haematology. Semin Thromb Hemost. 2005; 31 49-58
59 Jennings I, Greaves M, Mackie I J, Kitchen S, Woods T A, Preston F E. UK National External Quality Assessment Scheme for Blood Coagulation. Lupus anticoagulant testing: improvements in performance in a UK NEQAS proficiency testing exercise after dissemination of national guidelines on laboratory methods. Br J Haematol. 2002; 119 364-369
60 Arnout J, Meijer P, Vermylen J. Lupus anticoagulant testing in Europe: an analysis of results from the first European Concerted Action on Thrombophilia (ECAT) survey using plasmas spiked with monoclonal antibodies against human beta2-glycoprotein I. Thromb Haemost. 1999; 81 929-934
61 Tripodi A, Biasiolo A, Chantarangkul V, Pengo V. Lupus anticoagulant (LA) testing: performance of clinical laboratories assessed by a national survey using lyophilized affinity-purified immunoglobulin with LA activity. Clin Chem. 2003; 49 1608-1614
62 Reber G, Arvieux J, Comby E et al.. Multicenter evaluation of nine commercial kits for the quantitation of anticardiolipin antibodies. The Working Group on Methodologies in Haemostasis from the GEHT (Groupe d'Etudes sur l'Hémostase et la Thrombose). Thromb Haemost. 1995; 73 444-452
63 Reber G, Schousboe I, Tincani A et al.. Inter-laboratory variability of anti-beta2-glycoprotein I measurement. A collaborative study in the frame of the European Forum on Antiphospholipid Antibodies Standardization Group. Thromb Haemost. 2002; 88 66-73
64 Harris E N, Pierangeli S S. Primary, secondary and catastrophic syndrome: what is in a name?. Semin Thromb Hemost. 2008; 34 219-226

Dr. Emmanuel J Favaloro

Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR)

Westmead Hospital, SWAHS, Westmead, NSW, 2145, Australia

Email: emmanuel.favaloro@swahs.health.nsw.gov.au