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Cheat Sheet for June, 2012

How Long Does HIT Ab Remain? (June 4, 2012)

Jack” asked, “Has any research been done on how long a patient with a positive HIT test stay positive before turning negative?” George replied that the HIT antibody remains 50–80 days after it is first detected, and provides two references to HIT expert Ted Warkentin MD publications on this topic.

PTT Reagent Selection (June 4, 2012)

George referenced our article, Fritsma GA, Dembitzer FR, Randhawa A, Marques MB, Van Cott EM, Adcock-Funk D, Peerschke EI. Recommendations for appropriate activated partial thromboplastin time reagent selection and utilization. AJCP 2012 137:904–8. It appears that some of us are using lupus anticoagulant-sensitive PTT reagents for our routine coagulopathy screening or heparin monitoring.
Chris Ferrell (Seattle) added this comment: Your recommendations were thought provoking. I remember back to the 70s and 80s when we had quite a selection of high- and low-LA responsive PTT reagents in the marketplace. It was confusing to the smaller labs as to which PTT reagent to use. Many of them were using an inappropriate reagent for their patient population, sometimes because their purchasing department wanted them to use the cheapest and not necessarily the best reagent. That practice still goes on today. When I worked for Sigma Diagnostics, I got to meet the research scientist who invented Innovin, Pamela Harker. She was the grand dame of coagulation reagents. She told me something that I’ve always remembered: there are only three things that go into making a PTT reagent. One controls the factor sensitivity, another controls the lupus sensitivity and the third controls the heparin sensitivity. If you change one of the three, it always changes the other two. So, no matter how hard you try, you can’t make the perfect PTT reagent.

Correlating ACT from the i-STAT and Hemochron (June 4, 2012)

Sue Allen asked about a previous post that discussed the correlation between the Abbott i-STAT ACT, ITC Hemochron 401 ACT, and the Hemochron Jr. ACT. She wondered if we ever received any responses. She is currently comparing instruments and the methods do quite well at the lower ranges but at the 300–350 second levels they differ by as much as 100 seconds.

George indicates that the longer ranges of the ACT are important to anesthetists in cardiac surgery for monitoring heparin. We’ve received no additional responses as of July 11, and the topic remains open.

Standard Mixing Study Calculation (June 4, 2012)

Axnzak:” wants to learn what calculation you use to determine mixing study results, both PT and PTT, when comparing results to patient reference ranges. George linked the questioner to a recent post, “Mixing Studies: 4:1?“  and a Quick Question. George advocates for the Rosner Index as being the most consistent and scientifically defensible approach.

Who Does D-dimer on Destiny Max? (June 14, 2012)

Crystal Azavedo is looking for Destiny Max users who run the quantitative D-dimer. She’s considering adding it, but hasn’t heard from any northeast US users that have put DD onboard. George invites all Destiny Max operators to respond to this open question.

Normalized DRVVT Ratio? (June 14, 2012)

Frequent contributor Dave McGlasson asks about normalizing the DRVVT ratio using the laboratory’s MRI in accordance with a Zhang reference that states, “The normalized ratio is recommended to correct for differences in instrument-reagent combinations and to improve discrimination between normal and low-positive LA samples.”

Dr. Emmanuel Favaloro (New South Wales) responds: “We have always used normalised ratios. It doesn’t make sense to me not to, since the baseline values for the screen and confirm are invariably different. Moreover, they will change slightly with different batches of reagents and different normal pools. On the other hand, if you have established your normal ranges based on non-normalised data you might be OK.”

George asks participants, “Do you know about normalization of the DRVVT ratio, do you use it, do you advocate for it, and what advantages does the ratio provide?”

Vanessa Chan (Toronto) responds that her group is aware of the DRVVT normalization ratio and the recommendations to use it, however, she currently is not. There are a couple of reasons. When they validated cut-offs, they used about 40–50 normals and calculated them using the 99th percentile. When they switch lot numbers of PPP, lupus sensitive PTT, and DRVVT reagents; they found that the QC ranges do not shift very much and so they have always kept the same cut-offs to date.

Vanessa continues, “We took a look retrospectively at 200 samples and calculated a normalized ratio for each step of our testing: Lupus sensitive PTT, DRVVT screen and if applicable, DRVVT screen and confirm ratio. The normalized ratio cut-offs were calculated based on our initial validation samples. We found only one sample where, using the ratio, we would have continued on with a confirmatory step. On the other hand, there were a lot of samples where the mixing corrected and we did not continue with confirmation testing.

The value of the normalized ratio would be that it does correct for slight differences in PPP and reagent lots but at the same time, it also adds an extra calculation or two or three which increases the chance of error and adds to workload.

Do You Use Anti-Xa for Heparin? (June 20, 2012)

Marisa B. Marques, MD, who directs the transfusion service and special coagulation laboratory at the University of Alabama at Birmingham (UAB) Hospital asked George to find out what medical centers are using anti-Xa instead of PTT to monitor unfractionated heparin. She would like to hear their input and experiences in terms of patient care. We have no responses as of July 11, the topic is still open, although George was able to put her in touch with Paul Riley, PhD at Diagnostica Stago, who maintains such a list.

Heme Binds Factor VIII (June 20, 2012)

George points out a thought-provoking article: Repesse Y, Dimitrov JD, Peyron I, et al. Heme binds to factor VIII and inhibits its interaction with activated factor IX. J Thromb Haemostas 2012;10:1062–71. The authors do not speculate on in vitro specimen hemolysis, however their findings could provide additional support for rejecting hemolyzed specimens.

QQ: Anti-Xa Heparin Assay (June 20, 2012)

George provides a summary of our June, 2012 Quick Question:
To perform the chromogenic anti-Xa heparin assay, how many separate reference curves do you maintain for unfractionated (UFH), low molecular weight (LMWH) heparin and fondaparinux?
a. One hybrid curve for UFH and LMWH, same curve (computed) for fonda: 7 (16%)
b. One hybrid curve for UFH and LMWH, a separate curve for fonda: 11 (25%)
c. One reference curve for each heparin: UFH, LMWH, and fonda: 22 (50%)
d. We don’t perform the chromogenic anti-Xa heparin assay: 4 (9%)

Most of us have chosen to stay with three curves rather than take advantage of the various manufacturers’ combined (hybrid) curve that may be used to measure either UFH or LMWH. George asks whether those who do not use the hybrid curve find it necessary to confirm the type of heparin being used before running the assay.

New QQ: VWF Activity Assays (June 24, 2012)

George references a definitive article by Favaloro, et al, in the June, 2012 JTH that describes the three methods currently available to assay von Willebrand factor activity: ristocetin cofactor (VWF:RCo), collagen binding (VWF:CB), and a monoclonal antibody-based immunoassay (VWF:Act). Based on this article, this month’s Quick Question asks which VWF activity assay method you use in your laboratory. The list does not include the standard VWF concentration immunoassay that is based on polyclonal antibodies, von Willebrand factor antigen (VWF:Ag) nor does it include the factor VIII (FVIIIC) activity assay. Also, the ristocetin cofactor assay (VWF:RCo) is divided between the more traditional platelet aggregometry-based assay and the automated assay.

George asks that if you use two VWF activity assays, for instance, if you may run concurrent VWF:RCo and VWF:CB for confirmation, please comment. This topic remains open for your response.

New ACs in AF (June 24, 2012)

George comments that guidelines for Coumadin, aspirin, dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) are changing rapidly, favoring the new oral anticoagulants in most cases of atrial fibrillation and provides a link to conference presentations.

UFH Infusion: Max Dose? (June 25, 2012)

Marisa Marques, MD from UAB forwarded this question: “One of our pharmacists asked if there was a maximum dose for the heparin bolus or infusion rate for obese patients since our current recommendations are based on body weight. I haven’t been able to find a recommendation to cap dosing for these patients.”

George provided these doses from the 2012 American College of Chest Physicians Guidelines:

  • Venous thromboembolic disease: 80 units/kg bolus, 18 units/kg/hour
  • Acute coronary syndrome: 60–70 units/kg bolus, maximum 5000 units, 12–15 units/kg/hour, max 1000 units/kg/h
  • If given with thrombolytic agents: 60 units/kg bolus, 12 units/kg/hour, maximum 1000 units/kg/hour

The authors do not discuss a maximum dosage other than the limits given. They do recommend regular monitoring to ensure that the dosage is within the therapeutic range. Likewise, they recommend monitoring subcutaneously administered low molecular weight heparin in patients who are either obese or underweight.

Panic Value: INR or PT? (June 27, 2012)

Miquel Vélez MT (ASCP), Immuno Reference Laboratory, asks what should be considered as a panic value, a high PT value or the INR? If it is the PT value, what value should be considered as a panic?

George recommends the INR, as the PT in seconds varies in sensitivity from lot to lot. Also, it appears from our May, 2012 Quick Question survey that most choose the INR of 4.0 as their call-back value.

Low Factor VIII Reporting (June 27, 2012)

Miquel Vélez also sees some low factor VIII activity results, as low as 0.3%. In those instances he was told to dilute the sample 1:2, and retest. On those retests he gets the same results, should we report the result as it is or with a less than something value?
George maintains that operators typically perform the factor VIII assay on three or four dilutions. They prepare a primary dilution of 1:10 and further dilute by (for example) 1:2, 1:4, and 1:8, making the final dilutions 1:10, 1:20, 1:40, and 1:80. They assay all four dilutions and multiply the initial assay results by the dilution factors, 1, 2, 4, and 8, and check for parallel results. Most operators consider results that match within ±10% to be parallel. Non-parallel results indicate a plasma inhibitor, which requires follow-up. Most automated coagulometers are programmed to perform factor VIII (and other factor) assays at these or similar dilutions and to provide the necessary computations.
Further, most operators re-assay plasmas that yield results <10% or perhaps <5% for greater sensitivity, using established laboratory protocol. For the re-assay, they typically prepare a 1:5 dilution in place of the standard 1:10, then divide the initial assay result by 2 for a final result. Many instruments are programmed to do this reflexively, providing accurate results in severe hemophilia A; such results help to guide therapy. They could also conceivably perform the assay at 1:2 and divide the initial assay result by 5, though the accuracy suffers as the dilution factor rises.
Clinically, a factor VIII activity level <1% is classified as severe hemophilia A. Levels from 1–5% are moderate, and 5–30% are mild. These categories help define the treatment approach to hemophilia symptoms. There is little clinical reason for providing greater sensitivity when the result is <1%, as the treatment would be unchanged, thus most operators report 1% or <1%, but not fractional results.

This post brought three responses:
From Dave McGlasson, June 28: In 2009 George and I presented a paper, McGlasson DL, Fritsma GA. Comparison of two chromogenic FVIII activity assays to a standard clot-based FVIII activity assay. Journal of Thrombosis and Haemostasis 2009; Volume 7, Supplement 2: Abstract PP-WE-235 at ISTH in Boston where we compared results of two chromogenic and clottable results for comparing FVIII methodologies using a high curve and low curve for determining levels of FVIII. Dave quoted the abstract and concluded that, when dealing with very low levels of FVIII, using a low range curve might help quantitate low levels with more accuracy.
And then, a July 6 response from “japgi”: I’d like to get some information on this clinical situation- If a patient with an uncharacterized bleeding disorder has been transfused plasma or cryoprecipitate in an emergency setting, how soon afterwards can one do a coagulation screen to avoid the results from getting compromised by the transfused factors?
And third, also on July 6 from “mfranco”: You say there is no clinical reason for providing greater sensitivity when the result is <1%. We currently report <0.25% because our curve reads that low. Is this something we should consider changing? And, a second question if I may. When we run factor assays, we have found that 1:10, 1:20 and 1:40 show parallelism or results that do not agree within 15%. We currently re-dilute those with FVIII DP 1:2 and re-run 1:10, 1:20 and 1:40. Sometimes these results then agree with each other. Other times they agree with one of the original dilutions. We are having a hard time discerning if these are true parallelisms or poor recovery from different dilutions. Any insight?

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