Factor VII Inhibitor Profile, Comprehensive

CPT: 85230; 85335; 85610; 85611(x2); 85730
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Test Details

Synonyms

  • Bethesda Titer

Test Includes

Activated partial thromboplastin time (aPTT); factor VII activity; factor VII Bethesda titer; prothrombin time (PT); PT 1:1 mix with normal plasma; PT 1:1 mix with saline

Use

Confirmation and characterization of factor VII inhibitor

Limitations

If there is residual coagulation factor activity, it could falsely lower the Bethesda titer result. Lupus anticoagulant activity and antithrombotic agents that function as inhibitors must be ruled out prior to assaying for factor inhibitors in order to avoid factitiously positive results. Autoimmune inhibitors that demonstrate second order kinetics cannot always be accurately measured in the Bethesda titer system.

Methodology

The factor VII inhibitor (Bethesda titer) assay is performed using a prothrombin time-based system, using thromboplastin reagent.6 Serial dilutions are made of patient plasma with veronal buffered saline, then mixed with normal plasma containing close to 100% factor VII activity and are then incubated for two hours. A PT-based factor VII assay using factor VII-depleted plasma substrate is then performed on these incubated mixtures. Results are compared to those of incubated normal plasma. One Bethesda unit is defined as the amount of factor VII inhibitor that neutralized 0.5 IU of factor VII in this system. The number of serial dilutions tested is based on the anticipated level of the inhibitor.

Additional Information

Factor inhibitors (also called circulating anticoagulants or inactivators) are endogenously produced antibodies that interfere with coagulation in vivo or in vitro.6 These inhibitors are frequently specific for their respective coagulation factors. Specific factor inhibitors can be classified as neutralizing or non-neutralizing. Neutralizing inhibitors interact with the functional component of the coagulant protein and may cause clinical bleeding. Non-neutralizing antibodies react with the protein somewhere other than the functional epitopes and may be clinically silent or may result in increased clearance of the factor. Factor inhibitors are not normally present in plasma. When present, factor inhibitors are measured by Bethesda titer units (BU). Titers <5 BUs are generally classified as low responders, titers >10 BUs as high responders. Responder status influences the approach for clinical treatment. Factor inhibitor assays are ordered in response to clinical impression, and are performed periodically on individuals who have inhibitors and are receiving therapy. During therapy, periodic assays are used, both to manage the dosage and to establish whether a patient is a low or high responder. Low responders maintain titers consistently <5 BUs, while high responders may generate extremely high titers and rapid amnestic responses to therapy. Assays must also be performed repeatedly during inhibitor suppression therapy.

Specimen Requirements

Specimen

Plasma, frozen

Volume

6 mL (2 mL in each of three tubes)

Container

Blue-top (sodium citrate) tubes

Patient Preparation

The patient should not be anticoagulated. Do not draw from an arm with a heparin lock or heparinized catheter.

Collection

Citrated plasma samples should be collected by double centrifugation. Blood should be collected in a blue-top tube containing 3.2% buffered sodium citrate.1 Evacuated collection tubes must be filled to completion to ensure a proper blood to anticoagulant ratio.2,3 The sample should be mixed immediately by gentle inversion at least six times to ensure adequate mixing of the anticoagulant with the blood. A discard tube is not required prior to collection of coagulation samples, except when using a winged blood collection device (ie, "butterfly"), in which case a discard tube should be used.4,5 When noncitrate tubes are collected for other tests, collect sterile and nonadditive (red-top) tubes prior to citrate (blue-top) tubes. Any tube containing an alternate anticoagulant should be collected after the blue-top tube. Gel-barrier tubes and serum tubes with clot initiators should also be collected after the citrate tubes. Centrifuge for 10 minutes and carefully remove 2/3 of the plasma using a plastic transfer pipette, being careful not to disturb the cells. Deliver to a plastic transport tube, cap, and recentrifuge for 10 minutes. Use a second plastic pipette to remove the plasma, staying clear of the platelets at the bottom of the tube. Transfer the plasma into a LabCorp PP transpak frozen purple tube with screw cap (LabCorp N° 49482). Freeze immediately and maintain frozen until tested. To avoid delays in turnaround time when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test requested.

Please print and use the Volume Guide for Coagulation Testing to ensure proper draw volume.

Storage Instructions

Freeze. Stable at room temperature for four hours.

Clinical Information

Footnotes

1. Adcock DM, Kressin DC, Marlar RA. Effect of 3.2% vs 3.8% sodium citrate concentration on routine coagulation testing. Am J Clin Pathol. 1997 Jan; 107(1):105-110. 8980376
2. Reneke J, Etzell J, Leslie S, Ng VL, Gottfried EL. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109 mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol. 1998 Jun; 109(6):754-757. 9620035
3. National Committee for Clinical Laboratory Standardization. Collection, Transport, and Processing of Blood Specimens for Coagulation Testing and General Performance of Coagulation Assays; Approved Guideline. 5th ed. Villanova, Pa: NCCLS; 2008. Document H21-A5:28(5).
4. Gottfried EL, Adachi MM. Prothrombin time and activated partial thromboplastin time can be performed on the first tube. Am J Clin Pathol. 1997 Jun; 107(6):681-683. 9169665
5. McGlasson DL, More L, Best HA, Norris WL, Doe RH, Ray H. Drawing specimens for coagulation testing: Is a second tube necessary? Clin Lab Sci. 1999 May-Jun; 12(3):137-139. 10539100
6. Adcock DM, Bethel MA, Macy PA. Coagulation Handbook. Aurora, Colo: Esoterix−Colorado Coagulation; 2006.

References

Goodnight SH, Hathaway WE. Disorders of Hemostasis and Thrombosis: A Clinical Guide. 2nd ed. New York, NY: McGraw-Hill; 2001.
Kamikubo Y, Miyamoto S, Iwasa A, Ishii M, Okajima K. Purification and characterization of factor VII inhibitor found in a patient with life threatening bleeding. Thromb Haemost. 2000 Jan; 83(1):60-64. 10669156

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
500371 F VII Inact Assay 500372 Prothrombin Time sec 5902-2
500371 F VII Inact Assay 500373 PT 1:1 NP sec 5959-2
500371 F VII Inact Assay 500375 PT 1:1 NP 60 Inc sec 33356-7
500371 F VII Inact Assay 500376 PT 1:1 NP 60 Min Inc. control sec 33884-8
500371 F VII Inact Assay 500513 APTT sec 14979-9
500371 F VII Inact Assay 500679 Factor VII Activity % 3198-9
500371 F VII Inact Assay 500379 F VII Inact Assay Bethesda 3196-3
500371 F VII Inact Assay 501033 F VII Inact Assay N/A

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