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Test Code DRVI4 Dilute Russell Viper Venom Time (DRVVT) Interpretation


Specimen Required


Only orderable as a part of a profile. For more information see DRVI1 / Dilute Russell Viper Venom Time (DRVVT), with Reflex, Plasma.


Secondary ID

603310

Useful For

Interpreting mixing and confirmation assays for lupus anticoagulants (LA)

Method Name

Only orderable as a part of a profile. For more information see DRVI1 / Dilute Russell Viper Venom Time (DRVVT), with Reflex, Plasma.

 

Medical Interpretation

Reporting Name

DRVVT Interpretation

Specimen Type

Plasma Na Cit

Specimen Minimum Volume

Only orderable as a part of a profile. For more information see DRVI1 / Dilute Russell Viper Venom Time (DRVVT), with Reflex, Plasma.

Specimen Stability Information

Specimen Type Temperature Time Special Container
Plasma Na Cit Frozen 14 days

Clinical Information

Lupus anticoagulants (LA) are immunoglobulins (IgG, IgM, IgA, or a combination of these) of autoimmune type that are specifically directed against antigenic complexes of negatively charged phospholipids (such as phosphatidylserine or phosphatidylethanolamine) and coagulation-related proteins such as beta-2-glycoprotein I (beta-2-GPI) or clotting factors including prothrombin (factor II) or factor X, and which cause prolongation of phospholipid-dependent clotting time tests due to inhibition.

 

LA are functionally and clinically distinct members of a broader group of antiphospholipid autoantibodies (APA) that includes immunologically detectable anticardiolipin antibodies or antibodies against other phospholipid-protein complexes. LA interfere with specific coagulation factor-phospholipid interactions, typically causing prolongation of 1 or more phospholipid-dependent clotting time tests (eg, activated partial thromboplastin time: APTT, dilute Russell viper venom time: DRVVT) due to inhibition. This characteristic in vitro inhibition can be overcome by addition of excess phospholipid.

 

Because of the heterogeneous nature of LA antibodies, no single coagulation test can identify or exclude all LA. Currently, the International Society on Thrombosis and Haemostasis and the Clinical and Laboratory Standards Institute recommend testing for LA with at least 2 phospholipid-dependent clotting time assays based on different coagulation pathways and principles (eg, lupus-sensitive APTT and DRVVT).

 

In addition, given the potential for false-positive results in patients on anticoagulants, a profile or panel of coagulation tests is performed, including the prothrombin time (PT), APTT, thrombin time (TT) and DRVVT. If the PT, APTT, or DRVVT are prolonged, additional testing may include mixing tests with normal plasma (to evaluate for inhibition) and the use of excess phospholipid in appropriate assay systems to evaluate for phospholipid-dependent inhibition. Additional reflexive testing helps determine presence or absence of anticoagulants and inhibitors to other factors.

 

The diagnosis of LA requires performance and interpretation of complex coagulation testing, as well as correlation with available clinical information, including evidence of persistence of LA over time (≥12 weeks).

 

The venom obtained from Russell's viper (Vipera russelli) contains enzymes that directly activate coagulation factors V and X, bypassing the activation of factors VII, VIII, IX, XI, and XII, and therefore, the effect of deficiencies or inhibitors of these factors. Diluting the phospholipid necessary for the clotting factor interactions increases the sensitivity to LA and the likelihood of identifying a phospholipid-dependent inhibitor that may not be detected by other coagulation tests with higher phospholipid content (eg, LA-insensitive APTT reagents).

 

The DRVVT screen ratio test is one of several available in vitro tests that may be used to screen and confirm for presence of LA or to help exclude LA. DRVVT testing is used in conjunction with other appropriate coagulation tests (reflexive testing panels) to assist in detection and confirmation of LA, or to help exclude their presence.

 

The DRVVT may be abnormally prolonged (DRVVT Screen Ratio ≥1.20) by LA as well as coagulation factor deficiencies, anticoagulant effects, or other types of coagulation factor inhibitors.

 

Specimens with abnormal results (DRVVT screen ratio ≥1.20) are subjected to reflexive testing. With a reflexive testing algorithm, the sensitivity of DRVVT testing for LA diagnosis is approximately 65% to 70% and the specificity is 95% or higher.

 

It is advisable to use the DRVVT screen, mix and confirm ratio results in conjunction with other appropriate coagulation tests (reflexive testing panels) to diagnose or exclude LA.

 

Although LA cause prolonged clotting times in vitro, there is a strong association with thrombosis risk. However, not all patients with persisting LA develop thrombosis.

Reference Values

Only orderable as a part of a profile. For more information see DRVI1 / Dilute Russell Viper Venom Time (DRVVT), with Reflex, Plasma.

Interpretation

Dilute Russell viper venom time (DRVVT) screen ratio (<1.20):

A normal DRVVT screen ratio (<1.20) indicates that lupus anticoagulant (LA) is not present or not detectable by this method (but might be detected with other methods). 

 

An abnormal DRVVT screen ratio (DRVVT screen ratio ≥1.20) may suggest presence of LA, however, other possibilities include:

-Deficiencies or dysfunction of factors I (fibrinogen), II, V, or X, congenital or acquired

-Inhibitors of factor V, or occasionally by inhibitors of factor VIII, or other specific or nonspecific inhibitors

-Anticoagulation therapy effects (see Cautions)

 

Further evaluation consists of performing mixing studies with an equal volume of normal pooled plasma (DRVVT 1:1 mix) to investigate the possibility of coagulation factor deficiency (suggested by DRVVT mix ratio <1.20) and to evaluate inhibition (suggested by DRVVT mix ratio ≥1.20) and mixing patient plasma with DRVVT reagent enriched in phospholipid (DRVVT confirmatory reagent) (DRVVT mix and DRVVT confirmation ratios).

 

Possible combination of results include the following: 

 

-DRVVT screen ratio ≥1.20, DRVVT mix ratio <1.20, and DRVVT confirmation ratio <1.20:

No evidence of LA. These data may reflect anticoagulation therapy effects or other (congenital or acquired) coagulopathy.

 

-DRVVT screen ratio ≥1.20, DRVVT mix ratio ≥1.20, and DRVVT confirmation ratio <1.20:

The prolonged and inhibited DRVVT (DRVVT screen and mix ratios) may reflect presence of a specific factor inhibitor (eg, factor V inhibitor), anticoagulation therapy effects or other nonspecific inhibitors as can be seen with monoclonal protein disorders, lymphoproliferative disease etc. Although LA cannot be conclusively excluded, the DRVVT confirmation ratio of ≤1.20 makes this less likely.

 

-DRVVT screen ratio ≥1.20, DRVVT mix ratio <1.20, and DRVVT confirmation ratio ≥1.20:

Although mixing study of the prolonged DRVVT screen and mix ratios provides no evidence of inhibition, additional phospholipid shortens the clotting time (DRVVT confirm ratio), suggesting presence of LA.

 

-DRVVT screen ratio ≥1.20, DRVVT mix ratio ≥1.20, and DRVVT confirmation ratio ≥1.20:

The data are consistent with presence of LA, provided anticoagulant effect can be excluded (see Cautions)

 

Because no single coagulation test can identify or exclude all LAs, and because of the complexity of testing LA, one of  the following Coagulation Consultation reflexive panel procedures are recommended if clinically indicated:

ALUPP / Lupus Anticoagulant Profile, Plasma

AATHR / Thrombophilia Profile, Plasma

APROL / Prolonged Clot Time Profile, Plasma

 

DRVVT assays ordered as a single, stand-alone test should be interpreted within patient clinical context and close attention to medication use by patient (see Cautions).

Clinical Reference

1. Proven A, Bartlett RP, Moder KG, et al: Clinical importance of positive test results for lupus anticoagulant and anticardiolipin antibodies. Mayo Clin Proc 2004 April;79(4):467-475

2. Gastineau DA, Kazmier FJ, Nichols WL, Bowie EJ: Lupus anticoagulant: an analysis of the clinical and laboratory features of 219 cases. Am J Hematol 1985 Jul;19(3):265-275

3. Brandt JT, Triplett DA, Alving B, Sharrer I: Criteria for the diagnosis of lupus anticoagulant: an update. On behalf of the Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibody of the Scientific and Standardisation Committee of the ISTH. Thromb Haemost 1995 Oct;74(4);1185-1190

4. Arnout J, Vermylen J: Current status and implications of autoimmune antiphospholipid antibodies in relation to thrombotic disease. J Thromb Haemost 2003 May;1(5):931-942

5. Pengo V, Tripodi A, Reber G, Rand JH, et al: Update of the guidelines for lupus anticoagulant detection. Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibody of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2009;7:1737-1740. doi: 10.1111/j.1538-7836.2009.03555.x

6. CLSI Laboratory Testing for Lupus Anticoagulant; Approved Guideline. CLSI document H60-A. Wayne, PA: Clinical and Laboratory Standards Institute; 2014

Day(s) and Time(s) Performed

Monday through Friday; Varies

Analytic Time

2 days

Performing Laboratory

Mayo Clinic Laboratories in Rochester

Test Classification

Not Applicable

LOINC Code Information

Test ID Test Order Name Order LOINC Value
DRVI4 DRVVT Interpretation 50008-2

 

Result ID Test Result Name Result LOINC Value
DRVI4 DRVVT Interpretation 50008-2