Diagnosis of antithrombin deficiency, acquired or congenital
Monitoring treatment of antithrombin deficiency disorders, including
Chromogenic Assay
Antithrombin Activity
AT3 Activity/Functional
AT III Activity/Functional
Anti-Thrombin III
Plasma Na Cit
Coagulation testing is highly complex, often requiring the performance of multiple assays and correlation with clinical information. For that reason, consider ordering AATHR / Thrombophilia Profile, Plasma and Whole Blood.
Specimen Type: Platelet-poor plasma
Collection Container/Tube: Light-blue top (3.2% sodium citrate)
Submission Container/Tube: Plastic vial
Specimen Volume: 1 mL
Collection Instructions:
1. For complete instructions, see Coagulation Guidelines for Specimen Handling and Processing.
2. Centrifuge, transfer all plasma into a plastic vial, and centrifuge plasma again.
3. Aliquot plasma into a plastic vial leaving 0.25 mL in the bottom of centrifuged vial.
4. Freeze plasma immediately (no longer than 4 hours after collection) at -20 degrees C or, ideally at -40 degrees C or below.
Additional Information:
1. A double-centrifuged specimen is critical for accurate results as platelet contamination may cause spurious results.
2. Each coagulation assay requested should have its own vial.
3. Heparin treatment may lower plasma antithrombin.
If not ordering electronically, complete, print, and send a Coagulation Test Request (T753) with the specimen.
0.5 mL
| Gross hemolysis | Reject |
| Gross lipemia | Reject |
| Gross icterus | Reject |
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Plasma Na Cit | Frozen | 14 days |
Diagnosis of antithrombin deficiency, acquired or congenital
Monitoring treatment of antithrombin deficiency disorders, including
Antithrombin is a member of the serine protease inhibitor (serpin) superfamily. It is the principal plasma anticoagulant serpin mediating inactivation of serine protease procoagulant enzymes, chiefly thrombin and coagulation factors Xa and IXa.(1) Heparin and certain other naturally occurring glycosaminoglycans markedly enhance the anticoagulant activity of antithrombins (approximately 1000-fold) by providing a template to catalyze formation of covalently bonded, inactive complexes of serine protease and antithrombin that are subsequently cleared from circulation. Antithrombin is the mediator of anticoagulant activity of heparin.
The antithrombin gene on chromosome 1 encodes a glycoprotein with a molecular weight of approximately 58,000 Da that is synthesized in the liver and is present in a relatively high plasma concentration (approximately 2.3 mcmol/L). The biological half-life of antithrombin is 2 to 3 days.
Hereditary antithrombin deficiency, a relatively rare autosomal dominant disorder, produces a thrombotic diathesis (thrombophilia). Individuals with hereditary antithrombin deficiency are usually heterozygous with plasma antithrombin activity results of approximately 40% to 70%. These patients primarily manifest with venous thromboembolism (deep vein thrombosis and pulmonary embolism) with the potential of development as early as adolescence or younger adulthood. More than 100 different genetic alterations have been identified throughout the gene producing either the more common type I defects (low antithrombin activity and antigen) or the rarer type II defects (dysfunctional protein with low activity and normal antigen).(2) Homozygous antithrombin deficiency appears to be incompatible with life.
The incidence of hereditary antithrombin deficiency is approximately 1:2000 to 1:3000 in general populations, although minor deficiency (antithrombin activity =70%-75%) may be more frequent (approximately 1:350-650). In populations with venous thrombophilia, approximately 1% to 2% of individuals have antithrombin deficiency. Among the recognized hereditary thrombophilic disorders (including deficiencies of proteins C and S, as well as activated protein C -resistance [factor V Leiden variant]), antithrombin deficiency may have the highest phenotypic penetrance (greater risk of venous thromboembolism). Arterial thrombosis (eg, stroke, myocardial infarction) has occasionally been reported in association with hereditary antithrombin deficiency.
Hereditary deficiency of antithrombin activity can also occur because of defective glycosylation of this protein in individuals with carbohydrate-deficient glycoprotein syndromes (CDGS).(3) Antithrombin activity assessment may be useful as an adjunct in the diagnosis and management of CDGS.
Acquired deficiency of antithrombin is much more common than hereditary deficiency. Acquired deficiency can occur due to:
-Heparin therapy (catalysis of antithrombin consumption)
-Intravascular coagulation and fibrinolysis, disseminated intravascular coagulation, or other consumptive coagulopathies
-Liver disease (decreased synthesis and/or increased consumption) or with nephritic syndrome (urinary protein loss)
-L-asparaginase chemotherapy (decreased synthesis)
-Other conditions(1)
In general, the clinical implications (thrombotic risk) of antithrombin deficiency in these disorders are not well defined, although antithrombin replacement in severe disseminated intravascular coagulation/intravascular coagulation and fibrinolysis is being evaluated.(4) Assay of antithrombin activity may be of diagnostic or prognostic value in some acquired deficiency states.
Normal values: 80-130%
Normal, full-term newborn infants have lower levels (> or =35-40%) that reach normal values by age 90 days. Premature infants (30-36 weeks gestation) have lower levels that reach normal values by age 180 days.
Antithrombin deficiencies due to inherited causes are much less common than those due to acquired causes (see Clinical Information). Diagnosis of hereditary deficiency requires clinical correlation, with the prospect of repeat testing (including antithrombin antigen assay), and family studies (with appropriate counseling). DNA-based diagnostic testing may be helpful, see GNANT / Antithrombin Deficiency, SERPINC1 Gene, Next-Generation Sequencing, Varies.
The clinical significance (thrombotic risk) of acquired antithrombin deficiency is not well established, but accumulating information suggests possible benefit of antithrombin replacement therapy in carefully selected situations.(4)
Antithrombin deficiency, acquired or congenital, may contribute to the phenomenon of "heparin therapy resistance" (requirement of larger heparin doses than expected for achievement of therapeutic anticoagulation responses). However, it may more often have other pathophysiology, such as "acute-phase" elevation of coagulation factor VIII or plasma heparin-binding proteins.
Increased antithrombin activity is of unknown hemostatic significance. Direct factor Xa inhibitors, rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa) may falsely elevate the antithrombin activity and mask a diagnosis of antithrombin deficiency.
Antithrombin functional result is affected by:
-Heparin (unfractionated or low-molecular-weight) >4 U/mL
-Alpha-1-antitrypsin >4 mg/mL
-Alpha-2-macroglobulin >10 mg/mL
-Heparin cofactor II >4 U/mL
-Hemoglobin >500 mg/dL
-Bilirubin >40 mg/dL
-Triglycerides >2300 mg/dL
Heparin therapy may temporarily decrease plasma antithrombin activity into the abnormal range.
Antithrombin activity in serum specimens may be significantly lower than in plasma.
1. Lane DA, Olds RJ, Thein SL. Antithrombin and its deficiency. In: Bloom AL, Forbes CD, Thomas DP, eds. Haemostasis and Thrombosis. 3rd ed. Churchill Livingstone; 1994:655-670
2. Lane DA, Bayston T, Olds RJ, et al. Antithrombin mutation database: 2nd (1997) update. For the Plasma Coagulation Inhibitors Subcommittee of the Scientific and Standardization Committee of the International Society on Thrombosis and Haesmostasis. Thromb Haemost. 1997;77(1):197-211
3. Young G, Dricsoll MC. Coagulation abnormalities in the carbohydrate-deficient glycoprotein syndrome: case report and review of the literature. Am J Hematol. 1999;60(1):66-69. doi:10.1002/(sici)1096-8652(199901)60:1<66:aid-ajh11>3.0.co;2-d
4. Mammen EF. Antithrombin: its physiological importance and role in DIC. Semin Thromb Haemost. 1998;24(1):19-25. doi:10.1055/s-2007-995819
5. Yohe S, Olson J. Thrombophilia: Assays and Interpretation. In: Kottke-Marchant Wiley K, ed. Laboratory Hematology Practice. Blackwell Publishing; 2012:492-508
6. Favaloro EJ and Lippi G. eds. Hemostasis and Thrombosis: Methods and Protocols. 1st ed. Humana Press; 2017
Patient plasma, containing antithrombin, is mixed and incubated with reagent containing factor Xa and excess heparin. Factor Xa activity in the reagent is rapidly inhibited by antithrombin. Residual factor Xa activity is then measured using an amidolytic activity assay. This occurs when residual factor Xa lyses chromogenic substrate N-alpha-benzyloxycarbonyl-D-arginyl-L-glycyl-L-arginine-p-nitroaniline-dihydrochloride and subsequently releases p-nitroaniline (detected at 405 nm) in a level that is inversely proportional to the amount of antithrombin in the sample. This method is based on inhibition of factor Xa and, therefore, only higher amounts of heparin cofactor II, alpha-2-macroglobulin, or alpha-1-antitrypsin will influence the assay.(Package insert: HemosIL Liquid Antithrombin. Instrumentation Laboratory Comp; 06/2017)
Monday through Saturday
This test has been modified from the manufacturer's instructions. Its performance characteristics were determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.
85300
| Test Id | Test Order Name | Order LOINC Value |
|---|---|---|
| ATTF | Antithrombin Activity, P | 27811-9 |
| Result Id | Test Result Name |
Result LOINC Value
Applies only to results expressed in units of measure originally reported by the performing laboratory. These values do not apply to results that are converted to other units of measure.
|
|---|---|---|
| ATTF | Antithrombin Activity, P | 27811-9 |