Laboratory Diagnostics in Thrombophilia

Abstract

A thrombophilic disorder is a hereditary or acquired condition that increases the risk of thrombosis. The most common hereditary thrombophilias that predispose to venous thrombosis in the Caucasian population are the heterozygous forms of the factor V Leiden and prothrombin G20210A mutation that are generally detected by direct DNA genotyping. Immunologic antigen assays and chromogenic or clot-based activity assays are used to identify deficiencies in the natural coagulation inhibitors antithrombin, protein C and protein S. Because pre-analytical errors and acquired causes of low antithrombin, protein C or protein S levels are considerably more common than hereditary deficiencies, all potential conditions that may lower activity levels of the natural coagulation inhibitors (e.g. concomitant liver disease, pregnancy, anticoagulant therapy) must be considered and excluded before the diagnosis of an inhibitor deficiency can be made. To avoid misclassification, the diagnosis should not be made based on a single abnormal test result. Thus, repetitive testing when the patient is not on anticoagulant therapy is mandatory to confirm the diagnosis. Screening for antiphospholipid syndrome (APS) comprises testing for lupus anticoagulants (LAs) and the presence of IgG or IgM antibodies directed against phospholipids and phospholipid-binding proteins such as β-2-glycoprotein-I. A combination of clot-based assays has been recommended to demonstrate LA activity, whereas solid-phase immunoassays allow the detection of anti-cardiolipin and anti-β-2-glycoprotein-I antibodies. The diagnosis of APS requires the persistence of antiphospholipid antibodies for at least 12 weeks together with thrombotic and/or obstetric features of APS.

Zusammenfassung

Thrombophilie bezeichnet eine genetisch bedingte oder erworbene Thromboseneigung. Bei Europäern sind Faktor V Leiden und die Prothrombin-G20210A-Mutation in jeweils heterozygoter Form die häufigsten Genvarianten, die zu venösen Thrombosen prädisponieren. Beide Mutationen werden durch direkte DNA-Genotypisierung nachgewiesen. Für den Nachweis von Mangelzuständen der physiologischen Gerinnungsinhibitoren Antithrombin, Protein C und Protein S finden immunologische Antigen-Assays und chromogene bzw. gerinnungs-basierte Aktivitäts-Assays Anwendung. Bevor die Diagnose eines Inhibitormangels gestellt wird, sind die häufiger vorkommenden sekundären Ursachen (z.B. Lebererkrankung, Schwangerschaft, Antikoagulanzientherapie) auszuschließen. Da auch präanalytische Fehler vorkommen können, ist eine Diagnose nie auf Basis einer einzigen Bestimmung zu stellen, sondern erfordert die Bestätigung durch wiederholte Testung. Die Suche nach Antiphospholipid-Antikörpern erfolgt über den Nachweis von Lupusantikoagulans und die Testung auf Cardiolipin- und β-2-Glykoprotein-I-Antikörper vom IgG- und IgM-Typ. Für den Nachweis von Lupusantikoagulans-Aktivität werden mindestens zwei unterschiedliche gerinnungs-basierte Testverfahren eingesetzt, während spezifische Immunoassays anti-Cardiolipin- und anti-β-2-Glykoprotein-I-Antikörper nachweisen. Die Diagnose eines Antiphospholipid-Syndroms erfordert die Persistenz von Antiphospholipid-Antikörpern über mindestens 12 Wochen in zeitlichem Zusammenhang mit dem Auftreten von vaskulären Thrombosen und/oder Schwangerschaftskomplikationen.

Keywords

thrombophilia - factor V Leiden mutation - prothrombin - natural coagulation inhibitor - antiphospholipid antibodies

Schlüsselwörter

Thrombophilie - Faktor-V-Leiden-Mutation - Prothrombin-Mutation - physiologische Gerinnungsinhibitoren - Antiphospholipid-Antikörper

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