Lab Guide
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Test ID: APCR
Activated Protein C Resistance
Useful For

Useful in the evaluation of thrombophilia .

Method name and description

Turbidimetric
Test is performed using Sysmex CS5100 analyzer. When activated Protein C (APC) is added to plasma and an APTT is performed, there is normally a prolongation of the clotting time as a result of factor V and factor VIII degradation. The sample is prediluted with factor V deficient plasma to overcome possible deficiency of other coagulation factors. Presence of factor V Leiden will lead to shortening of the clotting time.     

Reporting name

APCR

Clinical information

Protein C is a part of the natural anticoagulant system and it is a vitamin K-dependent protein zymogen that is synthesized in the liver and circulates at a plasma concentration of approximately 5 mcg/mL. Protein C is activated to activated protein C (APC) via proteolytic cleavage by thrombin bound to thrombomodulin, an endothelial cell surface membrane protein. APC downregulates the procoagulant system by proteolytically inactivating procoagulant factors Va and VIIIa. Protein S, another vitamin K-dependent coagulation protein, catalyzes APC inactivation of factors Va and VIIIa. APC interacts with and proteolysis factors V/Va and VIII/VIIIa at specific APC binding and cleavage sites, respectively. Resistance to activated protein C (APC resistance) is a term used to describe abnormal resistance of human plasma to the anticoagulant effects of human APC. APC resistance is characterized by a reduced anticoagulant response of patient plasma after adding a standard amount of APC.  This generally indicate the presence of FV Leiden  which is an abnormal version of factor V that is resistant to the proteolytic action  action of APC.

Specimen type / Specimen volume / Specimen container

Plasma Na Cit. Plasma poor platelets 
Specimen Volume: 2.7ml. 
Container/Tube: Light Blue top (3.2% Sodium Citrate)

Collection instructions / Special Precautions / Timing of collection

1-    Sample collected in  HMC facilities/others and transported to the lab within 1hour :
•    Collect sample into light blue-top (sodium citrate).
•    Tubes must be filled to within +/- 10% of their proper volume, to provide a 9:1 ratio of blood to citrate.
2-    Samples collected in  HMC facilities  / others  and which are   expected not to reach the lab within  1hour:

•    Centrifuge the whole blood and carefully remove the plasma by pipette not by decanting   and send the plasma  in a temperature-controlled environment (18-25ºC ) within one hour of centrifugation. 
•     If the transportation of  the plasma can’t be within a maximum of  2hour , prepare platelet-poor plasma  as follow:
A:    Re-centrifuge plasma again.
B:    Remove the top portion of plasma leaving approximately 250 mcL in the bottom to discard.
C:    The double-centrifuged plasma should be aliquoted (0.5 to 1 mL per aliquot) into labeled plastic tubes. The number of tests ordered will determine the aliquots needed.
D:    Freeze immediately at -20 ºC or below  .
E:    Specimens must arrive frozen.
3-    Sample for Platelets function studies (Platelets function assay) , Citrated whole blood should reach HMC within a maximum of 1-2 hours of collection.
4-     For heparin monitoring, follow the above mentioned steps.
5-    Consider patient HCT %. , if HCT is >55%, the volume of anticoagulant in the tube must  be adjusted by the referring  lab, as per  the below table shows the volume of citrate (µL) to be removed from common sizes of coagulation specimen tubes prior to specimen collection. After removal of the specified volume of citrate, enough blood is added to fill the tube to the ideal volume.             

Hematocrit % Volume to be removed, µL
2.7 ml Tube 1.0 ml Tube
56 50 20
57 50 20
58 60 20
59 60 20
60 70 30
61 70 30
62 80 30
63 80 30
64 90 30
65 90 30
66 100 40
67 100 40
68 110 40
69 110 40
70 120 40
71 120 40
72 130 50
73 130 50
74 140 50
75 140 50
76 150 50
77 150 60
78 160 60
79 160 60
80 170 60
Relevant clinical information to be provided

Patient/family history of thrombotic disorder.

History of chronic diseases .                              

Patients suspected with the FV Leiden mutation will show APC resistance by this test.

Further testing by molecular genetics will detect the mutation if present.

Storage and transport instructions

Ambient

Specimen Rejection Criteria

Specimens with no label or missing required identification
Broken, leaking or contaminated specimen
Clotted samples 
Under-filled or overfilled sample tubes.
Wrong sample container sample received
Improper specimen transport temperature (e.g. like specimens which are  needed to be sent on ice)
Old specimen (test-dependent) 
Grossly Hemolyzed sample (test-dependent)                                          

Biological reference intervals and clinical decision values

Normalized Ratio: 0.91– 1.19 %.  .                                                                                                                 
With the currently used reagent, a cut-off of 0.7 for normalized ratio has a sensitivity of 98% for FV Leiden and a specificity of 99%.

Factors affecting test performance and result interpretation

No interference up to:
Triglycerides 1077 mg/dL
Hemoglobin  1000 mg/dL
Bilirubin 60 mg/dL 

Turnaround time / Days and times test performed / Specimen retention time

 3 working days/Daily/NA.