Internal quality control and external quality assurance in testing for antiphospholipid antibodies: part II–lupus anticoagulant
Open accessAbstract
In addition to the presence of appropriate clinical features, the diagnosis of the antiphospholipid antibody syndrome (APS) fundamentally requires the finding of positive antiphospholipid antibody (aPL) test result(s), with these comprising clot-based assays for the identification of lupus anticoagulant (LA) and immunologic ("solid-phase") assays such as anticardiolipin antibodies (aCL) and anti-β2-glycoprotein I antibodies (aβ2GPI). This article is the second of two that review the process for, and provide recommendations to improve, internal quality control (IQC) and external quality assurance (EQA; or proficiency testing) for aPL assays. These processes are critical for ensuring the quality of laboratory test results, and thence the appropriate clinical diagnosis and management of APS. This article covers LA testing. We provide some updated findings from the Royal College of Pathologists of Australasia Haematology Quality Assurance Program, and cover testing results for the past 3 years (2009 to 2011 inclusive). In brief: (1) essentially all laboratories currently perform LA testing using activated partial thromboplastin time (APTT) and dilute Russell viper venom time (dRVVT) methods, and about one-third also employ the kaolin clotting time (KCT); (2) KCT usage has dropped slightly, from around 50% of laboratories in 2009, to around 35% in 2011, presumably reflecting take up of the latest consensus recommendations; (3) other methodologies such as silica clotting time (SCT) and the platelet neutralization procedure (PNP) are only used by <5% of laboratories; (4) interlaboratory coefficients of variation (CVs) are in general moderate, and substantially better than those reported for solid-phase assays such as aCL and aβ2GPI, with median (range) values being 11.6% (9.2 to 25.5%) for APTT ratios, 16.7% (10.1 to 19.2%) for KCT ratios, and 11.7% (5.7 to 17.4%) for dRVVT ratios; (5) CVs increase slightly with increasing LA positivity; (6) most laboratories correctly interpreted test findings for LA, reporting normal samples as normal, and LA-positive samples as positive (albeit with varying gradings of positivity); and (7) however, some laboratories found interpretation to be challenging for some samples, namely a weak LA sample (which was reported as normal by around 50% of laboratories) and a very strong LA sample (which was reported as normal by around 10% of laboratories, primarily those that did not perform mixing studies).
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External quality assessment exercises continue to show high rates of false-positive or false-negative LA results.
“External quality assessment exercises still show high rates of false-positive or false-negative results.10,11”
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“67 It has also been demonstrated that test and reagent type can in fl uence the diagnostic ef fi cacy of mixing tests.”
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“generally used by laboratories, as, for example, recently reported using data from the RCPA (Royal College of Pathologists of Australasia) Haematology QAP (Quality Assurance Program) [12] (Figure 1).”
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“The CVs in our EQA (Table I) therefore seem to be much lower, and similar to those of other specialized assays such as lupus anticoagulant, factor assays, and factor inhibitor assays (15,16) but well below those of some other specialized assays such as anti-cardiolipin and antiB2-glycoprotein-I (17).”
ResultSelf-citationThe Russell viper venom time (RVVT) test for investigation of lupus anticoagulant (LA)
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“2 often identifies a cut-off value for LA positivity.(16)”
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Self-citationAbility of Polyphosphate and Nucleic Acids to Trigger Blood Clotting: Some Observations and Caveats
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Testing for the lupus anticoagulant: the good, the bad, and the ugly
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“Asanexample,thelatestreportfromtheRCPAQAPhasrecently beenpublished[10],ashavepriorreportsfromtheRCPAQAPandother EQA providers/surveys of practice [44 – 52].”
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“This can be illustrated by Figures 1B and 1C, again using data from the RCPA QAP [10] .”
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“10 As already noted, some contemporary fi ndings replicate those we reported at that time, including the “ generic ” or “ default ” cut off of 1.2 for dRVVT screen/con fi rm to identify LA positivity.”
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Quality in Hemostasis and Thrombosis — Part III
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“The dRVVT /SCT test results are also highly dependent on methodology with inter-laboratory variation affected by the determination of reference intervals, particularly problematic for classifying samples with weak LACs [17].”
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“Secondly, there is a stronger association of LA than anticardiolipin antibodies with adverse events such as thrombosis [8].”
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“This property makes ecarin time an optimal con fi rmatory test [6,15,16]. textarin sensitive to LAC [6,12,13].”
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Self-citationMisdiagnosis of high thrombotic risk triple-positive antiphospholipid antibodies
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“20 was chosen as another cutoff for the integrated test.(15) Five different cutoffs were used to designate positive results:”
MethodAssessment of anti-prothrombin antibodies in thrombosis complicating inflammatory bowel diseases
Saibeni, S., Etchevers, M. J., Tàssies, D., Panés, J., Reverter, J. C., Danese, S., Pique, J. M., Bruno, S., Vecchi, M. L., Gasbarrini, A., et al. (2013) · International Journal of Colorectal Disease · doi:10.1007/s00384-013-1696-7
“The diagnosis of the antiphospholipid antibody syndrome, in addition to the presence of appropriate clinical features, fundamentally requires the finding of positive antiphospholipid antibody (aPL) test result(s), with these comprising clot-based assays for the identification of lupus anticoagulant (LAC) and immunolog…”
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- Authors
- Favaloro, E., Bonar, R., & Marsden, K.
- Affiliations
- Westmead Hospital (AU)
- Royal College of Pathologists of Australasia (AU)
- Royal Hobart Hospital (AU)
- ORCID
- Favaloro, Emmanuel
- Venue
- Seminars in Thrombosis and Hemostasis
- Publisher
- Georg Thieme Verlag KG
- Published
- 2012-05-07
- Volume
- 38
- Issue
- 04
- Pages
- 404-411
- ISSN
- 0094-6176 (ISSN-L)
- 1098-9064
- OpenAlex
- W1970271209
- Cited by
- 49
- References
- 25
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2023: 6 · 2022: 2 · 2021: 4 · 2020: 3 · 2019: 7 · 2018: 2 · 2017: 3 · 2016: 4 · 2015: 3 · 2014: 6 · 2013: 5 · 2012: 1
- FWCI
- 3.68
- Type
- journal article
- Language
- en
- Open access
- green
- figshare.com
- Licence
- cc-by
- Locations
- Seminars in Thrombosis and Hemostasis (publishedVersion)
- PubMed (publishedVersion)
- eCite Digital Repository (University of Tasmania) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Funders
- Royal College of Pathologists of Australasia
- Topics
- Health Sciences › Medicine › Rheumatology › Systemic Lupus Erythematosus Research
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Health Sciences › Medicine › Hematology › Blood Coagulation and Thrombosis Mechanisms
- Keywords
- lupus anticoagulant, antiphospholipid syndrome, internal quality control, external quality assurance, proficiency testing, activated partial thromboplastin time, dilute Russell viper venom time, kaolin clotting time, inter-laboratory variability, test result interpretation, anticardiolipin antibodies
- MeSH terms
- Female, Humans, Pregnancy, Pregnancy Complications, Quality Assurance, Health Care, Quality Control, Lupus Coagulation Inhibitor, Antibodies, Antiphospholipid
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