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Laboratory Investigation of Thrombophilia Laboratorijsko Ispitivanje Trombofilija

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Laboratory Investigation of Thrombophilia Laboratorijsko Ispitivanje Trombofilija J Med Biochem 2014; 33 (1) DOI: 10.2478/jomb-2013-0041 UDK 577.1 : 61 ISSN 1452-8258 J Med Biochem 33: 28–46, 2014 Review article Pregledni ~lanak LABORATORY INVESTIGATION OF THROMBOPHILIA LABORATORIJSKO ISPITIVANJE TROMBOFILIJA Sandra Margeti} Department of Laboratory Hematology and Coagulation, Clinical Institute of Chemistry, Medical School University Hospital »Sestre milosrdnice«, Zagreb, Croatia Summary: Laboratory investigation of thrombophilia is Sa`etak: Cilj laboratorijskog ispitivanja trombofilije je otkri- aimed at detecting the well-established hereditary and vanje ve} ustanovljenih naslednih i ste~enih uzroka venskog acquired causes of venous thromboembolism, including acti- tromboembolizma, me|u kojima su aktivirana rezistencija na vated protein C resistance/factor V Leiden mutation, pro- protein C/mutacija faktora V Leiden, mutacija protrombina thrombin G20210A mutation, deficiencies of the physio - G20210A, deficijencija fiziolo{kih antikoagulanasa antitrom- logical anticoagulants antithrombin, protein C and protein S, bina, proteina C i proteina S, prisustvo antifosfolipidnih the presence of antiphospholipid antibodies and increased antitela i povi{enih nivoa homocisteina i faktora koagulacije plasma levels of homocysteine and coagulation factor VIII. In VIII u plazmi. Nasuprot tome, ispitivanje disfibrinogenemije, contrast, investigation of dysfibrinogenemia, a very rare veoma retkog faktora rizika za trombofiliju, treba uzeti u raz- thrombophilic risk factor, should only be considered in a matranje samo kod pacijenata kod kojih postoje dokazi o patient with evidence of familial or recurrent thrombosis in porodi~noj ili rekurentnoj trombozi uz odsustvo svih nave- the absence of all evaluated risk factors mentioned above. At denih faktora rizika. U ovom trenutku, ispitivanje trombofilije this time, thrombophilia investigation is not recommended se ne preporu~uje za ostale potencijalne nasledne ili ste~ene for other potential hereditary or acquired risk factors whose faktore rizika, ~ija povezanost sa pove}anim rizikom za trom- association with increased risk for thrombosis has not been bozu jo{ nije nedvosmisleno dokazana. Kako bi se obezbedi- proven sufficiently to date. In order to ensure clinical rele- la klini~ka relevantnost testiranja i izbeglo pogre{no vance of testing and to avoid any misinterpretation of results, tuma~enje rezultata, laboratorijsko ispitivanje trombofilije tre- laboratory investigation of thrombophilia should always be balo bi uvek vr{iti u skladu s preporukama za testiranje koje performed in accordance with the recommended guidelines se odnose na pa`ljiv odabir pacijenata, vreme testiranja i on testing regarding the careful selection of patients, time of testove i metode koji se koriste. Cilj ovog preglednog ~lanka testing and assays and assay methods used. The aim of this je da se ukratko predstave najva`niji aspekti testiranja trom- review is to summarize the most important aspects on throm- bofilije, izme|u ostalog, koga i kada testirati, koje testove i bophilia testing, including whom and when to test, what metode upotrebiti i koje sve varijable treba uzeti u obzir pri- assays and assay methods to use and all other variables that likom laboratorijskog ispitivanja trombofilije. should be considered when performing laboratory investiga- Klju~ne rije~i: ste~eni faktori rizika, nasledni faktori rizika, tion of thrombophilia. laboratorijsko ispitivanje trombofilije, venski tromboembo - Keywords: acquired risk factors, hereditary risk factors, lizam laboratory investigation of thrombophilia, venous throm- boembolism List of abbreviations: ACL, anticardiolipin antibodies; anti-b2GP1, anti-b2 glycoprotein-1 antibodies; APC, activated protein C; APCR, activated protein C resistance; aPLAs, antiphospholipid antibodies; APLS, antiphospholipid syndrome; APTT, activated partial thromboplastin time; AT, antithrombin; C4B-BP, C4B- binding protein; CRP, C-reactive protein; CBS, cystathionine-b- Address for correspondence: synthetase; DIC, disseminated intravascular coagulation; dRVVT, dilute Russell’s viper venom time; ELISA, enzyme-linked Ph. D. Sandra Margeti} immunosorbent assay; FII, factor II; FIIG20210A, prothrombin Department of Laboratory Haematology and Coagulation G20210A mutation; FVL, factor V Leiden; FVIII, factor VIII; FXa, Clinical Institute of Chemistry activated factor X; HC, homocysteine; HHC, hyperhomocys- Medical School University Hospital Sestre milosrdnice teinemia; HCII, heparin cofactor II; HBS, heparin binding site Vinogradska 29 mutation; HRT, hormone replacement therapy; LA, lupus antico- 10 000 Zagreb, Croatia agulants; MTHFR, methylenetetrahydrofolate reductase; OC, Tel: +385 1 3787 115 oral contraceptives; PC, protein C; PS, protein S; PT, prothrom- Fax: +385 1 3768 280 bin time; RT, reptilase time; TT, thrombin time; VKA, vitamin K e-mail: margeticsandraªgmail.com antagonists; VTE, venous thromboembolism. J Med Biochem 2014; 33 (1) 29 Introduction Patients with venous thromboembolism Thrombophilia is defined as a tendency to de- Although, as already mentioned, patients with a ve lop thrombosis due to predisposing hereditary history of VTE represent the main population suitable and/or acquired risk factors. Although thrombosis for laboratory investigation of thrombophilia, it is im- may occur in both veins and arteries, the term throm- por tant to note that testing is not indicated in unse- bophilia is usually considered in the context of venous lected patients presenting with a first episode of VTE thromboembolism (VTE), since most of the well- (10). Instead, the target population of VTE patients defined thrombophilic risk factors are commonly that should be considered for testing includes those associated with thrombosis in venous blood vessels. with a confirmed VTE that fulfill at least one of the fol- Today, VTE is a serious health problem that affects lowing criteria: thrombosis prior to the age of 50 approximately 1–2 individuals per 1000 in the gener- years even in the presence of a transient predisposing al population of Western countries each year (1–3). risk factor, recurrent venous thrombosis, thrombosis During the last two decades, knowledge on the etiol- at unusual sites (portal, mesenteric, splenic, hepatic, ogy of thrombophilia has considerably increased and renal or cerebral veins) and VTE patients with a fam- various hereditary and acquired risk factors have been ily history of VTE (9, 11). When considering throm- discovered. This has led to widespread laboratory bophilia investigation, it is always important to keep in investigation of thrombophilia. Due to the lack of mind that VTE is a multifactorial disorder which global assays for thrombophilia investigation, testing means that a single hereditary or acquired risk factor requires an expensive approach by performing a does not necessarily lead to thrombosis without inter- panel of different assays for each individual patient. action with other transient predisposing risk factors However, testing is not always justified because patients are not carefully selected or the appropriate (12). Although VTE at a young age is an important time of testing is often not considered (4–6). The lab- feature of thrombophilia, the first thrombotic episode oratory investigation of thrombophilia should always may happen later in life. Also, some persons with be performed in accordance with the recommended thrombophilia do not experience a throm botic event guidelines on testing, regarding whom and when to if an additional triggering transient risk factor is not test and what assays and assay methods to use. present. Namely, besides those well-defined heredi- Inappropriate thrombophilia testing outside the rec- tary and acquired thrombophilic risk factors, which ommended guidelines may be more detrimental than will be discussed below, there are also several tran- helpful for the patient due to possibility of misinter- sient or environmental risk factors, including trauma, pretation of the test results with simultaneously huge immobilization or prolonged bed rest, surgery and waste of health-care resources. postoperative state, advancing age (>60 years), malignancy, pregnancy and postpartum period, use of The aim of this review is to summarize the most estrogen-containing OC or HRT, long distance travel important current knowledge in the laboratory diag- and obesity, that are associated with an increased risk nosis of thrombophilia including careful patient selec- for VTE (12, 13). These risk factors can predispose tion and clinical conditions to be investigated, the rec- any individual to thrombosis, but may also stimulate ommended assays and assay methods for individual thrombosis in individuals with hereditary or acquired risk factors as well as all other variables that should be thrombophilia. Interactions between hereditary or considered when employing laboratory investigation of thrombophilia. acquired thrombophilic defects and transient risk fac- tors further increase the risk of VTE (14, 15). VTE often occurs in subjects with an underlying throm- Who should be investigated? bophilic risk factor in pathophysiological conditions associated with the presence of a transient triggering The prevalence of any known risk factor for VTE risk factor, as a result of their synergistic interactions. is not sufficient to justify indiscriminate screening of Currently, VTE patients in whom thrombophilia test- the general population (7–8). The main clinical indi- ing is still debated in the literature include those
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