Activated seven lupus anticoagulant (ASLA) assay

Lupus anticoagulants (LA) are classified as antiphospholipid antibodies (APA), although they are in fact directed against phospholipid-binding proteins, in particular, β2 glycoprotein I and prothrombin. The presence of persistent LA has a greater association with thrombosis, pregnancy morbidity and recurrence than the criteria antibodies detected in solid-phase assays (aCL & aβ2GPI). LA are a heterogeneous group of autoantibodies that are detected by inference based on their behaviour in phospholipid-dependent coagulation assays after other possible causes of elevated clotting times have been excluded. LA detection involves use of screening, confirmatory and mixing tests.

Screening tests commonly employ dilute phospholipid to accentuate the in vitro anticoagulant effect of LA, which if present, will prolong the clotting time. Screening tests can be prolonged for reasons other than LA, (i.e. factor deficiencies, anticoagulant therapy), so all elevated screening tests receive follow-up analyses to help define the nature of any abnormality. The confirm test generally involves performing the screening test in an identical fashion except that the phospholipid concentration is markedly increased. This has the effect of partially or completely overwhelming the LA and thus leads to a shorter clotting time than the screening test, thereby evidencing phospholipid dependence. Clotting times are converted to ratios to mitigate for issues of analytical variability. Correction of the screen ratio by the confirm ratio by ≥10% is considered consistent with the presence of a LA, providing that other causes of elevated clotting times are excluded. Diagnostic specificity is improved by performing the screen and confirmatory tests on 1:1 mixtures of test and normal plasma to evidence inhibition and reduce interferences, although the inevitable dilution effect can compromise this aspect of analysis.

Antibody heterogeneity and reagent variability necessitate use of at least two assays, of different analytical principle, to achieve acceptable detection rates. First-line assays are dilute Russell's viper venom time (dRVVT) and LA-responsive APTT yet a small proportion of LA will not react in either of these tests. One of the supplementary tests employed in our laboratories is the activated seven lupus anticoagulant (ASLA) assay, an 'extrinsic pathway' -based assay developed in these laboratories which utilises recombinant FVIIa to activate FX in vitro. Activation of FX leads to assembly of the prothrombinase complex, thrombin generation and clot formation. ASLA testing involves application of the screen, confirm amd mixing test medley and is reported with a full interpretation of the results. ASLA is not performed routinely and should be requested as an additional test.