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The document describes several assays used to measure markers related to platelet function and fibrinolysis. It discusses immunoassays for antibodies against platelet factor 4, assays for platelet activation markers like beta-thromboglobulin and PF4, the Bethesda assay for anti-factor VIII inhibitors, assays for fibrin degradation products and D-dimer, and chromogenic substrate assays to measure enzymes involved in fibrinolysis like plasminogen.
The document describes several assays used to measure markers related to platelet function and fibrinolysis. It discusses immunoassays for antibodies against platelet factor 4, assays for platelet activation markers like beta-thromboglobulin and PF4, the Bethesda assay for anti-factor VIII inhibitors, assays for fibrin degradation products and D-dimer, and chromogenic substrate assays to measure enzymes involved in fibrinolysis like plasminogen.
The document describes several assays used to measure markers related to platelet function and fibrinolysis. It discusses immunoassays for antibodies against platelet factor 4, assays for platelet activation markers like beta-thromboglobulin and PF4, the Bethesda assay for anti-factor VIII inhibitors, assays for fibrin degradation products and D-dimer, and chromogenic substrate assays to measure enzymes involved in fibrinolysis like plasminogen.
Page 1 of 31 IMMUNOASSAY FOR THE ANTI-PLATELET FACTOR 4 (HEPARIN-INDUCED THROMBOCYTOPENIA) ANTIBODY • Patient plasma is incubated in microtiter plate wells
that are coated with a soli-phase complex of
purified PF4 and polysulfonate, aplastic molecule integral to plate construction that resemble heparin • Heparin dependent anti PF4 antibodies bind the
Page 2 of 31 IMMUNOASSAY FOR THE ANTI-PLATELET FACTOR 4 (HEPARIN-INDUCED THROMBOCYTOPENIA) ANTIBODY • Bound antibodies are detected using enzyme- conjugated anti-human immunoglobulin G (IgG), IgA, and IgM antibodies and a substrate chromophore. • Detects Ab early in the development of HIT • Other immunoassay kits uses PF4-heparin
Page 4 of 31 ASSAYS • IMMUNOASSAYS of urine 11- dehydrothromboxane B2 are employed to characterize in vivo platelet activation. • Can be performed randomly • Used to monitor aspirin therapy and to identify cases of therapy failure or aspirin resistance
Page 5 of 31 BETHESDA TITER FOR ANTI- FACTOR VIII INHIBITOR • Used to confirm the presence of and quantify an anti factor VIII inhibitor • Which is an IgG4-class immunoglobulin • Uses 200uL of patient PPP • Control specimen; 200uL of imidazole buffer at pH 7.4 mixed with 200uL of rgt normal plasma • One bethesda unit of activity is the amount of Activity in the mixture
Page 7 of 31 Physiology of FDPs and D-dimers • -During coagulation, fibrin polymers become cross- linked by factor XIIIa and binds plasma plasminogen and tissue plasminogen activator • Bound TPA activates plasminogen to plasmin • Bound plasmin cleaves fibrin and yields FDPs D, E, X and Y and D-dimer • FDPs and D-dimer normal conc- less than 2ng/mL
Page 8 of 31 Physiology of FDPs and D-dimers • Fibrinolysis yields FDPs and D-dimer at conc greater than 200ng/mL • Increased FDPs and D-dimer-acute and chronic DIC, systemic fibrinolysis, deep vein thrombosis and pulmonary embolism • FDPs and D-dimer-detected in plasma after thrombolytic therapy
Page 9 of 31 Principle of the Quantitative D- Dimer Assay • Microlatex particles in buffered saline are coated with monoclonal anti D-dimer antibodies • Coated particles are agglutinated by patient plasma D-dimer • Resultant turbidity is measured using turbidometric or nephelometric technology • Most mtds detect conc as low as 10ng/mL
Page 11 of 31 Qualitative D-dimer Assay • SimpliRED D-dimer assay is a manual method that uses visible latex particles coated with monoclonal antibody • Suited to low-volume or near-patient (point of care) applications • Clin sensitivity for pulmonary embolus (94%)
Page 12 of 31 Principle of Plasminogen Chromogenic Substrate assay • Chromogenic substrate employ synthetic oligopeptides whose amino acid sequences are designed to be specific for their chosen enzymes • Plasmin hydrolyzes a bond in the oligopeptide sequence valine-leucine-lysine • Fluorophore or a chromophore such as para- nitoaniline is covalently bound to carboxyl terminus of the oligopeptide and maybe released on digestion
Page 13 of 31 Principle of Plasminogen Chromogenic Substrate assay • Streptokinase is a plasminogen activator derived from cultures of ß-hemolytic streptococci • Streptokinase is added to PPP where it binds and activates plasminogen • Streptokinase-plasmin complex reacts with chromogenic substrate such as S-2251 to release color whose intensity is proportional to the plasminogen concentration.
Page 15 of 31 Chromogenic Substrate Method for Plasma Plasminogen • Reagent streptokinase activates plsaminogen to form plasmin • R-pNA designates a chromogenic substrate, where R indicates one of the several choices of peptide sequence • pNA (para nitro aniline) is the chromophore • In the case of plasminogen, R reperesents peptide sequence valine-leucine-lysine • Plasmin recognizes the Val-Leu-Lys amide sequence as its enzymatic cleavage site, releasing pNA, which generates yellow color
Page 17 of 31 Tissue Plasminogen Activator (TPA) • 2 physiologic human plasminogen activators : TPA and Urokinase • Are serine protease that form ternnary complexes w/bound plasminogen at the fibrin surface activating the plasminogen and initiating thrombus degradation • TPA –synthesized by vascular endothelial cells;half life in the circulation -3 minutes and its plasma concentration averages 5ng/mL • Urokinase- produced in the kidney and vascular endothelial cells; half life -7 minutes and con is 2- 4ng/mL
Page 18 of 31 Clinical Significance of Tissue Plasminogen Activator • Reference upper limit for TPA – 1.1 units/mL • Upper limit for TPA antigen is 14 ng/mL • TPA is mediator of fibrinolysis • Decreased TPA levels- Myocardial Infarction, stroke, deep vein thrombosis • TPA deficiency or PAI-1 (plasminogen activator inhibitor-1) excess is associated with deep vein thrombosis and MI
Page 19 of 31 Levels of coagulation automation Level Description examples Manual All reagents & specimens are transferred Tilt tubes manually by the operator wireloop Temperature is maintained by water bath or heat block;external measuremant of the operator is required End point is determined visually by the operator
Page 20 of 31 Levels of coagulation automation Level Description examples Semiautomated All reagents and specimens are transferred Fibrometer manually by the operator. Start 4 Instrument usually contains a device for Cascade M and M-4 maintaining constant 37oC temperature BFT-II Analyzer may internally monitor the KC1 and KCA temperature. Instrument has mechanism to initiate timing device automatically on addition of final reagent and mechanism for detecting clot formation and stopping the timer
Page 21 of 31 Levels of coagulation automation Level Description examples Automated All reagents are ACL TOP automatically pipetted by STA-R Evolution the instrument. STA Compact and Specimens may or may not Compact CT be automatically pipetted. Sysmex CA-530, CA-560, Analyzers contain CA-620, CA-660, CA- monitoring devices and 1500,CA-7000 internal mechanism to BCS XP maintain and monitor Coal AB constant 37oC temperature throughout testing sequence Timers are initiated and clot formation is detected automatically
Page 22 of 31 Mechanical end-point detection • Electromechanical clot detection system measure a change in conductivity between two metal electrodes in plasma • Fibrometer-probe has stationary and moving electrode • Magnetic sensor-monitors the movement of a steel ball within the test plasma • Principles: electromagnetic field detects oscillation of still ball w/in plasma reagent solution • Steel ball is positioned in inclined well, its position is detected by magnetic sensor. As the well rotates, the ball remains inclined position.When fibrin forms, the ball is swept out of position. As it moves away from the sensor, there is a break from the circuit
Page 23 of 31 Viscosimetric (electromechanical)clot detection • A steel ball oscillates in an arc from one side of the cuvette to the other • Movement is monitored continuously with magnetic field • As the sample clots, viscosity rises and movement of the steel ball is impeded • Variation in the amplitude stops the timer and the interval is the clotting
Page 24 of 31 Photo optical End point Detection (turbidometric) • Photo-optical coagulometers detect a change in plasma optical density (OD, light transmittance) during clotting • Polychromatic light is focused by a collimator and filtered to transmit a selected wavelenght. • Monchromatic light is transmitted by filter optics and focused on the reaction cuvette • As fibrin forms, opacity increases and the intensity of light reaching the sensor decreases
Page 25 of 31 Nephelometric end-point detection • Modification of photo-optical end point • Measures 90 degree or forward-angle light scatter • Light found below passes through the sample in a cuvette to the detector located above. As fibrin, polymerizes, light is deflected and is detected at an angle from the optical path
Page 26 of 31 Chromogenic end point detection • Employs a synthetic oligopeptide substrate conjugated to a chromophore, para-nitoaniline • Measures specific coagulation factor because it exploits the factor’s enzymatic properties • Direct chromogenic measurement- • OD is proportional to the activity of the substance being measured • ex. Protein C activity is measured by a synthetic chromogenic substrate specific for protein C
Page 27 of 31 • Indirect chromogenic measurement- • the CHON or analyte being measured inhibits a target enzyme. • It is the target enzyme that has the activity directed toward the synthetic chromogenic substance. • The change in the OD is inversely proportional to the concentration of the activity of the substrate being measured- • ex. Heparin in the anti-factor Xa assay
Page 28 of 31 IMMUNOLOGIC LIGHT ABSORBANCE END_POINT • Based on Ag-Ab reactions • Latex microparticles are coated with Abs directed against the selected analyte (antigen) • The increase in the light absorbance is proportional to the antigen level
Page 29 of 31 Platelet Function Analyzers • PFA-100 • Rapid, automated and sensitive to quantitative and qualitative platelet abnormalities • Detects vWD and aspirin therapy • Test cartridges contain membranes coated with collagen/epinephrine or collagen/ADP to stimulate platelet aggregation
Page 30 of 31 Molecular Coagulation Testing • Used for patients with thrombophilia • Gene mutations of factor V (FV Leiden) and prothrombin (prothrombin G20210A) • Test Methylene-tetrahydrofolate reductase • PCR-accurate detection of both point mutations and single nucleotide polymorphism