Mixing test specific cut‐off is more sensitive at detecting lupus anticoagulants than index of circulating anticoagulant
Abstract
Introduction Recent guidelines for lupus anticoagulant (LA) detection recommend mixing test interpretation with either a mixing test-specific cut-off (MTC) or index of circulating anticoagulant (ICA). Few studies directly compare efficacy of these approaches. We retrospectively applied MTC and ICA assessment to raw data of 350 LA-positive plasmas from non-anticoagulated patients to compare detection rates of inhibition.Materials and methods Screen and confirm dRVVT and dilute APTT assays were performed on undiluted plasma and 1:1 mixtures with normal pooled plasma. Samples were considered LA-positive if one or both screening test ratios were elevated and corrected by ≥10% with the confirmatory test. Mixing tests were assessed against locally derived cut-offs for MTC (dRVVT >1.13, dAPTT >1.15) and ICA (dRVVT >11.9%, dAPTT >13.2%).Results 105 of 350 (30%) were positive in dRVVT and dAPTT, 109/350 (31.1%) were dRVVT positive only and 136/350 were dAPTT positive only (38.9%), from undiluted plasma results. Of the 214 dRVVT positive plasmas, 53 (24.8%) were negative for inhibition by MTC and 65 (30.4%) negative by ICA. Of the 241 dAPTT positive plasmas, 48 (19.2%) were negative by MTC and 97 (40.2%) negative by ICA.Conclusion Whilst integrated testing often detects LA without mixing tests they are diagnostically useful in certain circumstances. Thus, it is valuable to maximise mixing test interpretation as the dilution can lead to false-negative results. These data on a large cohort of LA-positive plasmas reveal that, with the reagents and equipment employed, MTC is superior to ICA in detecting the in vitro inhibition of LA.
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Interpreting mixing tests with a mixing-test-specific cutoff expressed as a normalized ratio has better sensitivity than using the index of circulating anticoagulant.
“We recommend that mixing tests should be interpreted with a mixing test-specific cutoff expressed as normalized ratio because recent studies suggest it has better sensitivity than the alternatively recommended index of circulating anticoagulant.65,66”
Cut-off values for screen, confirm, and mixing test in each additional reagent were determined from upper limits of the distribution of 50 normal samples in each reagent.
“Cut‐off values for screen, confirm, and mixing test in each additional reagent were determined from upper limits of the distribution of 50 normal samples in each reagent, and for ICA with the routinely employed LA reagents, ICA cut‐off values were previously established and used in each additional reagent.9, 21, 22, 23”
In a previous study, MTC had higher sensitivity than ICA for detecting in vitro inhibition of LA with a single dAPTT and dRVVT reagent pairing.
“We previously evidenced that MTC was superior to ICA in detecting the in vitro inhibition of LA with a single dilute APTT (activated partial thromboplastin time) and dRVVT (diluted Russell's viper venom time) pairing.”
Manifestation in mixing tests seems to be a function of more than just antibody potency; other possible contributory factors include epitope specificity, antibody avidity, and reagent composition.
“Manifestation in mixing tests seems to be a function of more than just potency, other possible contributory factors include epitope specificity, antibody avidity, and reagent composition.9”
MTC and ICA can be calculated and employed as interpretation indices for mixing tests.
“In addition, the mixing test–specific cutoff (MTC) and index of circulating anticoagulant (ICA) can be calculated and employed as interpretation indices for the mixing tests [[15], [16], [17], [18], [19]].”
From Comparison of different algorithms for lupus anticoagulant detection: a single-center experience (2024) · cites this paper as [19]
Although MTC provides greater sensitivity for the detection of LA, especially when weak LA is present, it has a greater tendency to produce false-positive results than ICA.
“Although MTC provides greater sensitivity for the detection of LA, especially when weak LA is present, it has a greater tendency to produce false-positive results than ICA [16,18,19].”
From Comparison of different algorithms for lupus anticoagulant detection: a single-center experience (2024) · cites this paper as [19]
Several studies have recommended the use of MTC over ICA as it offers greater sensitivity in detecting in vitro inhibition of LA.
“For the interpretation of the LA mixing test result, several studies have recommended the use of MTC over ICA as it offers greater sensitivity in detecting in vitro inhibition of LA [[17], [18], [19]].”
From Comparison of different algorithms for lupus anticoagulant detection: a single-center experience (2024) · cites this paper as [19]
ICA has recently been demonstrated to be less sensitive to LA than a mixing-test-specific cut-off expressed as a normalized ratio.
“Nevertheless, ICA, originally developed for LA detection and later exported to the interpretation of other mixing tests in hemostasis [56], has recently been demonstrated to be less sensitive to LA than a mixing-test-specific cut-off expressed as a normalized ratio [57,58,59].”
From Lupus Anticoagulant Detection under the Magnifying Glass (2023) · cites this paper as [58]
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- Authors
- Moore, G. W., Culhane, A. P., Daw, C. R., Noronha, C. P., & Kumano, O.
- Affiliations
- St Thomas' Hospital (GB)
- Sysmex (Japan) (JP)
- Corresponding author
- Moore, Gary W.
- Venue
- Thrombosis Research
- Publisher
- Elsevier BV
- Published
- 2016-03
- Volume
- 139
- Pages
- 98-101
- ISSN
- 0049-3848 (ISSN-L)
- OpenAlex
- W2280036456
- Cited by
- 42
- References
- 35
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 6 · 2023: 6 · 2022: 4 · 2021: 3 · 2020: 2 · 2019: 5 · 2018: 3 · 2017: 6 · 2016: 3
- FWCI
- 6.05
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Thrombosis Research (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Systemic Lupus Erythematosus Research
- Health Sciences › Medicine › Hematology › Blood Coagulation and Thrombosis Mechanisms
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Keywords
- lupus anticoagulant, mixing test, in vitro inhibition, false-negative results, anticoagulant screening, diagnostic sensitivity
- MeSH terms
- Blood Coagulation Tests, Humans, Immunoglobulins, Partial Thromboplastin Time, Lupus Coagulation Inhibitor, Antiphospholipid Syndrome
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