PROTHROMBIN TIME WHY USE LOW ISI (HIGH SENSITIVITY)

PROTHROMBIN TIME WHY USE LOW ISI (HIGH SENSITIVITY)

PROTHROMBIN TIME DEFINITION The Prothrombin time is the functional determination of the extrinsic coagulation pathway. It is a widely used laboratory assay for the detection of inherited or acquired coagulation defects related to the extrinsic pathway.

TERMS INR INTERNATIONAL NORMALIZED RATIO WHO WORLD HEALTH ORGANISATION ISI INTERNATIONAL SENSITIVITY INDEX IRP INTERNATIONAL REFERENCE PREPARATION

INR INTERNATIONAL NORMALIZED RATIO Ever wondered why you obtain different results for different company PT reagents? different lots of the same companies PT reagents? PT REAGENTS ARE MADE FROM TISSUE FACTORS BEING BIOLOGICAL PRODUCTS IT EXHIBITS A LOT OF VARIABILITY WHO expert committee report on Biological Standardization, Report 34

ISI INTERNATIONAL SENSITIVITY INDEX ISI is a correction factor developed to correlate the sensitivity of commercial Thromboplastins to the 1 st IRP. (International Reference Preparation). IRP A very responsive batch of human brain extract was designated as the 1 st International Reference Preparation (IRP).

ISI International Sensitivity Index The ISI of the 1 st IRP was 1.0 The INR actually compares the prothrombin ratio measurement to the 1 st IRP. The INR represents the prothrombin time that would have been obtained if the IRP had been used as the reagent. Responsive PT reagents have lower ISI values. Analytical precision is improved with reagents with low ISI. Reagents with low ISI discriminates normal and warfarin treated patients better.

LOW ISI VS HIGH ISI LOW ISI HIGH ISI Called Clld as High sensitivity iii Called Clld as Low sensitivity iii assay assay The reagent is highly sensitive to even small The reagent is NOT sensitive to changes in PT changes in the PT Accommodates Factor deficiency DOES NOT accommodate Factor deficiency Higher levels of precision Poor precision Better global commutability with PT assays Shift towards low ISI assays globally Poor Commutability Shift away from High ISI kits globally

SAMPLES AND THEIR ROLE MOST OF THE PROBLEMS CAUSED IN PT TESTING IS BECAUSE OF SAMPLING.

SAMPLES AND THEIR ROLE ANTICOAGULANT Whole blood should be collected with 3.2% Sodium Citrate t As the anticoagulant. DO NOT USE 3.8% SODIUM CITRATE. Effect of 3.2% vs 3.8% sodium citrate concentration on routine coagulation testing, Adcock et al., Am J Clin Path 1997 Jan; 107 (1):105-10

SAMPLES AND THEIR ROLE PREPARATION OF SAMPLES Collect whole blood 9 volumes with 1 volume of 3.2% Sodium Citrate Collect samples in a plastic tube DO NOT USE GLASS VESSELS Mix whole blood and Sodium Citrate well Centrifuge at 2500 rpm for 15 minutes. The tube now has a clear area of Citrated plasma and a sediment plug. PERFORM TESTS WITHIN 1-2 HOURS AFTER SPINNING Clinically relevant differences in PT and INR values related to Blood sample Collection in Plastic VS Glass Tubes Eberhard W. Fiebig et al; Am J Clin Path; 2005; 124(6) 902-909

SAMPLES AND THEIR ROLE STORAGE OF SAMPLES Remove citrated plasma from the centrifuged sediment Place the same in a plastic container Refrigerate DO NOT FREEZE. (freezing prolongs clotting time). Stored samples must be mixed well before use. Effect of freezing method and storage at -20oC and -70oC on PT, aptt and Plasma Fibrinogen levels Sonja Alesci et al; Thrombosis Research; Vol 124, Issue 1, May 2009.

INR INTERNATIONAL NORMALIZED RATIO WHO introduced d INR in the early 80 s as a means of Standardizing PT results. INR = Patient PT Mean Normal PT ISI ISI = (Prothrombin Ratio) WHO and International Committee on Thromobosis and Haemostasis Expert committee reports

MEAN NORMAL PT FACTS Each lab must establish Mean Normal PT for the reagent and the instrument used Do not use Mean Normal PT derived from one company reagent with the other. Procedures for Validation of INR and Local Calibration of PT/INR systems; Approved Guidelines CLSI;Vol 25 No.23.

MEAN NORMAL PT FACTS Each lab must establish Mean Normal PT for the reagent and the instrument used Do not use Mean Normal PT derived from one company reagent with the other. Procedures for Validation of INR and Local Calibration of PT/INR systems; Approved Guidelines CLSI;Vol 25 No.23.

MEAN NORMAL PT MEASUREMENT Collect 10-20 fresh samples (apparently normal) Measure clotting times for PT using BIOREXFARS PT reagent Assuming that the values obtained are: 14 seconds, 12.1, 11.9, 16.2, 12, 12.5, 17.6, 12.3, 16.2, 17.5. Choose 3 samples with the lowest clotting time 12.1, 11.9, 12 secs Pools these samples together. Mix them well. Measure clotting time for this pool using BIOREXFARS PT Reagent. The value obtained is close to 12.0 seconds. Label this pool 100% Sample. A 100% sample denotes that all clotting factors are ok and 100% clotting has occurred.

MEAN NORMAL PT Preparation of 50% and 25% pools 50% pool is prepared by diluting 1 volume of 100% pool with 1 volume of physiological saline. 25% pool is prepared by diluting i 1 volume of 100% pool with 3 volumes of physiological saline. Measure clotting times for the 50% and25% pools with BIOREXFARS PT reagent. Let us assume that the results were 14.8 seconds for 50% and 26.7 seconds for the 25% pool. Construct a graph on a semi log graph paper using the Clotting times obtained for the 100%, 50% and 25% pools.

MEAN NORMAL PT 25% 1/Activity 50% 100% 12 secs 14.8 secs 26.7 secs Time in seconds 25% Competitor 1 BIOREX FARS Competitor 2 Typical graph with 100%, 50% And 25% pools 1/Activity 50% 100% 12 secs 14.8 secs 26.7 secs Time in seconds Typical graph of 3 different company s PT rgts

READING THE INR TABLE PATIENT RESULTS Let us assume that the Clotting time for a patient sample is 14.1 secs. ISI VALUE OF THE KIT = 1.22 MEAN NORMAL PT = 12.0 SECS INR = Patient PT Mean Normal PT = (Prothrombin Ratio) ISI INR = (14.1/12.0) 1.22 (1.17) 17) 1.22 INR = 1.26

READING THE INR TABLE ISI 1.22 Choose this column to correlate the patient values for INR / Ratio or %. MEAN PATIENT (MNP) AND PATIENT RESULTS % R INR 10.0 10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0 100. 0 1.00 1.00 9.0 9.5 9.9 10.4 10.8 11.3 11.7 12.2 12.6 13.1 13.5 111. 9 0.90 0.88 9.5 10.0 10.5 10.9 11.4 11.9 12.4 12.8 13.3 13.8 14.3 98.9 0.95 0.94 10.0 10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0 100. 0 1.00 1.00 10.5 11.0 11.6 12.1 12.6 13.1 13.7 14.2 14.7 15.2 15.8 80.2 1.05 1.06 11.0 11.6 12.1 12.7 13.2 13.8 14.3 14.9 15.4 16.0 16.5 73.3 1.10 1.12 11.5 12.1 12.7 13.2 13.8 14.4 15.0 15.5 16.1 16.7 17.3 67.5 1.15 1.19 12.0 12.6 13.2 13.8 14.4 15.0 15.6 16.2 16.8 17.4 18.0 62.6 1.20 1.25 12.5 13.1 13.8 14.4 15.0 15.6 16.3 16.9 17.5 18.1 18.8 58.3 1.25 1.31 13.0 13.7 14.3 15.0 15.6 16.3 16.9 17.6 18.2 18.9 19.5 54.6 1.30 1.38 13.5 14.2 14.9 15.5 16.2 16.9 17.6 18.2 18.9 19.6 20.3 51.3 1.35 1.44 14.0 14.7 15.4 16.1 16.8 17.5 18.2 18.9 19.6 20.3 21.0 48.4 1.40 1.51 14.5 15.2 16.0 16.7 17.4 18.1 18.9 19.6 20.3 21.0 21.8 45.8 1.45 1.57 15.0 15.8 16.5 17.3 18.0 18.8 19.5 20.3 21.0 21.8 22.5 43.4 1.50 1.64 15.5 16.3 17.1 17.8 18.6 19.4 20.2 20.9 21.7 22.5 23.3 41.3 1.55 1.71 16.0 16.8 17.6 18.4 19.2 20.0 20.8 21.6 22.4 23.2 24.0 39.4 1.60 1.77 16.5 17.3 18.2 19.0 19.8 20.6 21.5 22.3 23.1 23.9 24.8 37.7 1.65 1.84 17.0 17.9 18.7 19.6 20.4 21.3 22.1 23.0 23.8 24.7 25.5 36.1 1.70 1.91 17.5 18.4 19.3 20.1 21.0 21.9 22.8 23.6 24.5 25.4 26.3 34.6 1.75 1.98 18.0 18.9 19.8 20.7 21.6 22.5 23.4 24.3 25.2 26.1 27.0 33.3 1.80 2.05 18.5 19.4 20.4 21.3 22.2 23.1 24.1 25.0 25.9 26.8 27.8 32.0 1.85 2.12 19.0 20.0 20.9 21.9 22.8 23.8 24.7 25.7 26.6 27.6 28.5 30.8 1.90 2.19 19.5 20.5 21.5 22.4 23.4 24.4 25.4 26.3 27.3 28.3 29.3 29.8 1.95 2.26 20.0 21.0 22.0 23.0 24.0 25.0 26.0 27.0 28.0 29.0 30.0 28.8 2.00 2.33 20.5 21.5 22.6 23.6 24.6 25.6 26.7 27.7 28.7 29.7 30.8 27.8 2.05 2.40 21.0 22.1 23.1 24.2 25.2 26.3 27.3 28.4 29.4 30.5 31.5 26.9 2.10 2.47 21.5 22.6 23.7 24.7 25.8 26.9 28.3 29.0 30.1 31.2 32.3 26.1 2.15 2.54 This row denotes the mean normal PTvalues derived by running the pooled samples. (eg: 12.0 secs)

SETTING ISI FOR PT REAGENTS ISI FOR PT REAGENTS CAN BE SET IN TWO WAYS BY assaying known INR values which are traceable to WHO RBT 05. BY using reference or traceable samples and assaying them in duplicates and plotting them as logarithms. The ISI is then calculated using the slope of the line that is drawn as a best fit line between these sets of log values.

SETTING ISI FOR PT REAGENTS BIOREXFARSFARS METHOD FOR SETTING ISI BY assaying known INR values which are traceable to WHO RBT 05. In BIOREXFARSFARS Diagnostics we use the AK Calibrant, which is a commercially available calibration material for setting ISI values. The advantages of using the AK Calibrant are: -4 levels - Known INR values - Traceable to WHO RBT 05

HOW IS IT DONE? USE OF AK CALIBRANT 1. Reconstitute lyophilised material supplied. 2. Ensure homogeneity. 3. Choose the reagent to be ISI assigned. 4. Incubate the PT reagent till it reaches 37 o C. 5. Assay all the 4 calibration material with the PT. SECONDS ISI VALUE Calibration curve drawn From the seconds derived For the lyophilised calibrators Point 5 in the next slide INR VALUE

HOW IS IT DONE? CALIBRATION CURVE 1. Note down the seconds after assaying the cal samples. 2. In the graph provided, plot the seconds vs the INR values. 3. Draw a line thru the seconds that have been plotted. 4. The line can be extended to the ISI area of the Y2 axis. 5. Drop a line from the first value (seconds) to the X axis. 6. Construct a line from this point (that meets the x axis) to to the Y2 axis. 7. Read the ISI value off this line.

CHECKING THE ISI VALUE? ISI VALUE CHECKS 1. Run controls with known INR values. 2. Note the seconds for these controls. 3. With the MNPT values for the PT Reagent, calculate l the INR for the control. 4. Compare the INR values derived from the PT reagent with the prescribed INR values of the control. 5. The deviation should not be more than 10%. 6. Run as many levels as possible, preferably normal and elevated INRs.