Johns Hopkins Pathology: Blood Disorders (Special Coagulation Laboratory)

Blood Disorders (Special Coagulation Laboratory)

The Special Coagulation Laboratory is one of the nation's foremost resources for special coagulation studies. State-of-the-art tests performed here enhance diagnostic capabilities for congenital and acquired bleeding disorders, hyper coagulable evaluations, platelet disorders, and autoimmune coagulation disorders.

We advise physicians and others seeking help with diagnoses and patient care and provide services to other reference laboratories and support clinical trials. We have extensive experience advising on and processing data for large clinical trials, including some with thousands of patients. We also provide services for those conducting animal studies. We offer specialized testing for supporting trials in anticoagulation.

Experience

The Division of Special Coagulation continues a distinguished research tradition. Pioneering discoveries in coagulation made at the Johns Hopkins Medical Institutions include the discovery of heparin, the elucidation of the role of platelets in hemostasis, and the lupus anticoagulant. Coagulation research continues today both in Hopkins research laboratories and clinics. This permits new research discoveries to be applied to studying causes of thrombosis or bleeding in individual patients or in supporting large multicenter clinical trials.

Expertise

Expert Consultation
Director of the Special Coagulation Laboratory, Dr. Thomas S. Kickler is interested in platelet disorders, hemostasis, and thrombosis. Providing medical consultation and interpretation of test results is Dr. Michael Streiff, Assistant Professor of Medicine. Dr. Edward Weir is an authority on flow cytometry and also provides interpretation of coagulation panels.

Special capabilities and services
Our fully automated lab, with four comprehensive analyzers, allows us to handle more than 500 samples a day. We are the only reference lab in this region, and one of the few nationally, able to do quantitative platelet analysis with whole blood aggregation including both molecular DNA-based tests and platelet aggregation studies. Our testing facilities also include automated testing assays, molecular diagnosis capabilities, PCR equipment, and flow cytometry. Of interest to veterinarians and those conducting animal studies, we are equipped to perform the full range of animal coagulation testing. We maintain internal relational databases on all accounts, and can store and manage large amounts of data for clinical trials. We have special interest in antiphospholipid antibody testing and drug induced thrombocytopenia, including heparin antibody testing.

Timely Results

Most test results can be supplied in one or two days, or within hours if needed. Results can be provided by phone, fax, or e-mail. A hard copy of the finished report is sent to requesting physicians and entered into our central laboratory computer system.

Faculty

Thomas S. Kickler, M.D.

Phone:	410-955-6315
Fax:	410-502-1493
E-mail:	tkickler@jhmi.edu

Director of Hematology and Coagulation Laboratory, Director of Core Laboratory
Directs Platelet Immunology Laboratory
Attending Physician, Department of Medicine/Hematology Service

Education and Training

M.D., University of West Virginia
Intern in Medicine, University of Wisconsin Hospital
Residency in Clinical Pathology, Fellow in Pathology, The Johns Hopkins University School of Medicine
Residency in Internal Medicine, Fellow in Internal Medicine Mayo Graduate School of Medicine, Fellow in Hematology, University of Rochester School of Medicine

Professional Interests
Evaluation and development of new test procedures to evaluate hemostasis disorders using molecular, immunologic and biochemical approaches. Development of new technology to reduce the expense of coagulation testing. Evaluation of the sensitivity and specificity of hemostatic parameters in different diagnostic groups. Development of critical pathways to diagnose and treat bleeding and thrombotic disorders. Study of the role of coagulation proteins and platelets in acute and chronic transplantation rejection.

Michael B. Streiff, M.D.

Phone:	410-614-0727
Fax:	410-614-8601
E-mail:	mstreif@jhmi.edu

Medical Director of the Special Coagulation Laboratory
Medical Consultant, Johns Hopkins Hemophilia Treatment Center
Attending Physician, Department of Medicine/Hematology Service

Education and Training

M.D., Johns Hopkins University
Intern in Medicine, University of Florida
Residency in Internal Medicine, University of Florida
Fellowship in Hematology and Oncology, Johns Hopkins University

Professional Interests
Clinical and laboratory investigation of thrombophilia associated with malignancy. Application of novel coagulation assays to explore the pathogenesis of thrombosis. Development of strategies to enhance the clinical management of antithrombotic agents.

Tests

To order, call Customer Service at 1-800-997-5475 between 8:00 a.m. and 11:00 p.m.

Abnormal PT and/or APTT Evaluation
This panel is used to evaluate the cause of an abnormal protime or activated partial thromboplastin time.
APTT
APTT Mixing Studies
Hepzyme (Test for heparin contamination)
PT (Prothrombin Time)
PT (Prothrombin Time) Mixing Studies
Platelet Neutralization

Cardiovascular Panel
Test abnormalities in this panel correlate with an increased risk of cardiovascular disorders.
Factor VII Activity
Fibrinogen Activity
Homocysteine (special collection)
Lipoprotein (a)
Plasminogen Activator Inhibitor-1 (PAI-1)
Prothrombin Fragment 1.2
Tissue Plasminogen Activator Antigen

Circulating Anticoagulant and Lupus Anticoagulant
A basic screening panel for factor deficiencies and the detection of inhibitors.
APTT
Mixing Studies (APTT)
Mixing Studies (PT)
PT (Prothrombin Time)
Platelet Neutralization
d-RVVT, with confirm
Anti-cardiolipen Antibody, IgG, IgM, IgA
Anti-B2 GP1 antibodies, IgG, IgM, IgA

DDAVP Challenge
The panel is used to evaluate the response of mild hemophilia and von Willebrand disease patients to DDAVP.
Factor VIII Activity
Ristocetin CoFactor assay
WF Antigen
HEME-8 (pre - post)

DIC Screen
The DIC screen is useful in the diagnosis and follow-up of disseminated intravascular coagulation.
APTT
D-dimer (Quantitative)
Fibrinogen
Prothrombin Time

Extrinsic Pathway Panel
Panel used to evaluate and identify the cause of an abnormal prothrombin time.
Factor VII Activity
Factor X Activity
Factor V Activity
Factor II Activity

Fibrinolysis Panel
The fibrinolysis panel may be used to monitor or diagnose acquired or congenital abnormalities of the fibrinolytic system.
alpha-2-Antiplasmin
D-dimer Quantitative
Fibrinogen Degradation Products
Plasminogen Activator Inhibitor-1 (PAI-1)
Plasminogen Activity
Tissue Plasminogen Activator Antigen

Intrinsic Pathway Panel
Panel can be used to evaluate and identify the cause of an abnormal activated partial thromboplastin time.
Factor XII Activity
Factor XI Activity
Factor IX Activity
Factor VIII Activity

Lupus Anticoagulant (Antiphospholipid Screen)
A basic screening panel for the detection of lupus-like inhibitors. The profile may also be used for patients with an unexplained prolonged prothrombin time or APTT.
Anticardiolipin Antibody (ELISA)
APTT and Mixing Studies
D-RVVT (Dilute Russell Viper Venom) and Mixing Studies
PT (Prothrombin Time) and Mixing Studies
Platelet Neutralization Test if evidence for an inhibitor

Platelet Function Panel
Panel used to identify platelet function problems.
PFA-100
Bleeding Time
Clot Retraction
Platelet Aggregation
Platelet Secretion (ATP release)
Flow cytometry studies if indicated
Prothrombin Consumption Test

Thrombotic Risk Panel - Comprehensive
The thrombotic risk panel is a comprehensive group of tests for evaluating patients with hypercoagulable states.
Activated Protein C Resistance and Factor V Leiden
Antithrombin III Activity
Dilute Russell's Viper Venom (D-RVVT)
Fibrinogen Activity, Fibrinogen Antigen
Homocysteine (special collection)
Lipoprotein (a)
Lupus Anticoagulant Screen
Plasminogen Activator Inhibitor 1 (PAI-1)
Plasminogen Activity
C Activity
Protein C Antigen
Protein S Activity Protein S Antigen Total
Thrombin Time
Tissue Plasminogen Activator Antigen
Prothrombin Gene Mutation

Thrombotic Risk Screen
A group of basic tests used to screen patients for only the most common causes of thrombosis.
Activated Protein C Resistance
Antithrombin III Activity
D-RVVT
Homocysteine (special collection)
Protein C Activity
Protein S Activity

von Willebrand Panel
This panel is for the evaluation of suspected von Willebrand disease.
APTT
Factor VIII Activity
Ristocetin Cofactor
vWF Antigen
vWF Multimers as needed

Markers of Hyper-Coagulation
Prothrombin fragment 1,2
Plasma p-Selectin
Thromboxane
Beta-Thromboglobulin
PF4

Miscellaneous Bleeding Disorders
Factor XIII Activity

Special Ordering Instructions

Collection and Processing
Tests for hemostatic evaluations are extremely sensitive to variations in sample collection and specimen processing. Test results are directly affected by the quality of the sample presented for analysis. Therefore, it is extremely important that NCCLS reference guidelines for coagulation sample collection and processing are followed.

Specimens may be collected in siliconized evacuated tubes or by the two syringe technique. The specimen must not be the first tube drawn, a traumatic venipuncture or hemolyzed. When samples are collected from patients with indwelling catheters, the first 20 mls of blood should not be used for coagulation testing. If the catheter contains heparin, the first 30 mls should not be used for coagulation testing.

Citrated Plasma

Blue top collection tubes containing either 3.2% or 3.8% sodium citrate should be used. Other anticoagulants are not recommended for coagulation testing.
Fill tube to proper level by letting the vacuum fill the tube. Mix tube immediately by inverting at least 6 times. Filling the collection tube to the proper level and maintaining an anticoagulant ratio of 9:1 for whole blood to anticoagulant is critical to obtaining accurate coagulation results.
Check the tube for clots and centrifuge at 2,000 g for 10 minutes to obtain platelet poor plasma.
Using a plastic pipette remove plasma (avoid platelet layer) into a plastic tube and recentrifuge for 10 minutes. Transfer the plasma into a new plastic tube (avoiding platelets) and label the tube with patient's name, date of collection, patient identification number, and sample type (plasma or serum).
Note: Samples for lupus testing must be double spun and platelet free (<10,000/mm3).
Immediately freeze the plasma and transport frozen sample, on dry ice, to the Johns Hopkins Hospital Special Coagulation Laboratory. Samples must remain frozen during transport.
Note: The ratio of sodium citrate to blood should be adjusted for patients with hematocrits above 60% or below 20%. You may use the following formula or call 410-614-4724 for instructions.
Formula:
C = 1.85 x 103 x (100 - H) x V
C = volume of 3.8% sodium citrate in milliliters
H = Hematocrit in percent
V = Volume of whole blood in milliliters

Serum for Homocysteine Testing
Note: Improper sample collection may invalidate the result.

Collect blood in a plain red top tube. Immediately place sample on crushed ice.
Immediately transport sample to the laboratory.
Allow sample to clot (approximately 30 minutes).
Centrifuge for 10 minutes in a refrigerated centrifuge (4 C).
Transfer serum into plastic tube and cap.
Label appropriately.
Immediately freeze serum (-20 C). Send frozen specimen on dry ice to Johns Hopkins Hospital Special Coagulation Laboratory.

Serum for Heparin Induced Antibody

Collect blood in a plain 5 ml red top tube.
Allow sample to clot (approximately 30 minutes)
Centrifuge for 10 minutes.
Transfer serum into plastic tube and cap.
Label appropriately.
Immediately freeze serum. Send frozen specimen on dry ice to The Johns Hopkins Special Coagulation Laboratory.

Platelet Factor 4 and Beta Thromboglobulin
Note: Use Diatube--break the vacuum of these tubes before sample collection.

Prepare a cup of crushed ice and water to cool the specimen after collection.
Use tourniquet only for locating the vein. Discard the first 2ml of blood; then collect 5.0ml of blood into a syringe.
Add 4.5ml whole blood down the side of Diatube-H tube (keep tube refrigerated).
Cap the tube and mix by gentle inversion. Mix at least 6 times.
Allow tube to cool in ice and water for at least 15 minutes.
Within an hour of collection, centrifuge the tube at 2,500g for 30 minutes in a refrigerated centrifuge.
When centrifugation is complete, collect one-third the volume of plasma supernatant by aspirating from the middle region of the liquid portion, try not to aspirate plasma from top or bottom region of tube.
Freeze sample and send overnight on dry ice to The Johns Hopkins Hospital Special Coagulation Laboratory. (save unused Diatubes in refrigerator)

Shipping

Note: Plasma and serum specimens must be frozen prior to shipping. Purple top tubes should be sent in separate box with cold packs.

Frozen specimens must be shipped in an insulated container (preferably styrofoam)
Place samples in styrofoam container.
Add 2-4 pounds of dry ice.
Place packing material (i.e. newspaper, cardboard, etc) in the container to fill up the air space and help samples remain frozen. Include test requests in plastic bag.
Close container and seal with tape to reduce exposure to air.
Place styrofoam container in cardboard box, seal and attach a dry ice label to the side of the box before mailing.
Select overnight shipper for sample delivery.

Johns Hopkins Pathology