Coagulation Testing: Comparison Of Portable (CoaguChek

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Veterinary World, EISSN: 2231-0916Available at fRESEARCH ARTICLEOpen AccessCoagulation testing: Comparison of portable (CoaguChek XS) andautomated coagulation analyzer in healthy catsSireeporn Tonthongand Jetsada RungpupraditDepartment of Small Domestic Animal and Radiology, Faculty of Veterinary Medicine, Mahanakorn University ofTechnology, Bangkok, Thailand.Corresponding author: Jetsada Rungpupradit, e-mail: [email protected]: ST: pam [email protected]: 25-06-2020, Accepted: 19-10-2020, Published online: 27-11-2020doi: How to cite this article: Tonthong S, Rungpupradit J (2020)Coagulation testing: Comparison of portable (CoaguChek XS) and automated coagulation analyzer in healthy cats,Veterinary World, 13(11): 2541-2545.AbstractBackground and Aim: The CoaguChek XS (CCX) is a portable coagulation analyzer that is widely used to monitorprothrombin time (PT) in human patients taking oral anticoagulants. It can also be reliably used for screening dogs whenPT is in the normal range. Efficacy of the portable CCX coagulation analyzer was evaluated for testing PT in healthy catsand the normal range was established. Materials and Methods: Blood samples of 82 cats were collected from the jugular vein and PT was measured using both theCCX and an automated coagulation analyzer (ACA). Spearman’s correlation was used to measure the strength and directionof association between the two analyzers, while limits of agreement were assessed utilizing Bland-Altman analysis.Results: Range of PT using the CCX was 10.1-14.1 s. Correlation between the two analyzers was moderate but significant(r 0.3465, p 0.0014). Mean difference between CCX-PT and ACA-PT was 1.624 s and standard deviation was 0.890 with95.1% of the samples falling within the limits of agreement.Conclusion: The CCX is a portable, easy to use coagulation analyzer that requires a small volume of blood and gives resultswithin 1 min. Results showed moderate correlation and good agreement with a standard automated laboratory analyzer. TheCCX can be used for screening coagulation testing when PT is in the normal range for cats. However, testing accuracy ofthe CCX in abnormal PT cats should be further investigated before diagnostic coagulopathy applications.Keywords: cats, CoaguChek XS, coagulation testing, point-of-care testing, prothrombin time.IntroductionCoagulopathies in cats can occur from inheritedcongenital coagulation factor deficiencies, rodenticidetoxicity, hepatic failure, and disseminated intravascularcoagulation [1-7]. Coagulation profile testing is necessary to evaluate these deficits [8]. Testing before anoperation is recommended to reduce the risk of uncontrolled bleeding [9]. Automated coagulation analyzers(ACAs) are the standard laboratory method for measuring coagulation profiles. In an ACA, a mixture ofthromboplastin and calcium is added to citrated plasmaand time taken until clot formation is recorded. Whenthe clot is formed, changing turbidity by solutioneffects alters the light intensity and this can be detectedby the scattered light detection method. The ACA converts light intensity to an electrical signal and reportsthe result as seconds (s) or international normalizedratio (INR) [10,11]. The INR is typically used in humanmedicine but not in veterinary practice [12]. One disadvantage of the ACA method is that the PT result hasCopyright: Tonthong and Rungpupradit. Open Access. Thisarticle is distributed under the terms of the Creative CommonsAttribution 4.0 International License (, which permits unrestricted use, distribution,and reproduction in any medium, provided you give appropriatecredit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.The Creative Commons Public Domain Dedication waiver ) applies to the datamade available in this article, unless otherwise stated.Veterinary World, EISSN: 2231-0916 a long turnaround time [13] and this could be problematic for emergency veterinary surgery where laboratories cannot provide this service immediately [14].Portable point-of-care (POC) coagulation analyzersare widely available and popular in human medicinefor timeous evaluation of coagulation profiles [12,15].Portable analyzers are easy to use, require a small volume of blood, and provide immediate results [15,16].Many studies have evaluated the efficacy of POCcoagulation analyzers compared to the routine laboratory coagulation method [13,15-19]. The CoaguChek XS (CCX) is a portable coagulation analyzer that wasdeveloped for measuring prothrombin time (PT) inpatients taking warfarin to prevent coagulopathy aftercardiac surgery [20]. The system comprises an analyzermeter and a test strip (plastic cartridge with iron oxideparticles). Each test strip has a test area containing aprothrombin reagent (thromboplastin). When blood isapplied, the reagent is dissolved and an electrochemicalreaction takes place [12,19,20]. The chemical reactioninduces the magnetic field which activates and movesthe iron oxide particles. A laser photosensor detectsthe light reflection that occurs from the movement ofiron oxide particles until the clot is formed. The timerequired for this result is known as the PT [12,19].Accuracy of PT measurement using the CCX wasreported in human [17-19], horse [21], and dog [12].The previous studies found that the CCX was reliable2541

Available at ffor screening dogs when the PT was normal [12],while it was potentially specific and quite sensitivefor detecting abnormal hemostasis in horses [21].However, the accuracy of the CCX for PT measurement in cats and normal ranges was not evaluated.Before applying the CCX to measure PT, the efficacyand normal range need to be addressed.The aim of this study was to evaluate the correlation efficiency of the CCX compared to an ACA formeasuring PT and establish the normal range of PT inhealthy cats.Materials and MethodsEthical approvalThe study was approved by the Animal Careand Use Committee of Mahanakorn Universityof Technology, Thailand with Protocol numberACUC-MUT-2020/005.AnimalsBetween July 2018 and December 2019, 82 catswere recruited from cases presented for either routinecastration or ovariohysterectomy at the Small AnimalTeaching Hospital, Faculty of Veterinary Medicine,Mahanakorn University of Technology, Thailand.A permission form was signed by the cat owners toagree to study participation. Medical history, physical examination, and minimum blood profiles such ascomplete blood count, alanine aminotransferase, andcreatinine were evaluated. The laboratory results indicated that all 82 cats were healthy.Sample collection and PT recordingTwo milliliters of whole blood were collected fromthe jugular vein of each cat. One drop of blood was immediately used for PT measurement using the CCX portablecoagulation analyzer (Roche Diagnostics, Mannheim,Germany), while the remaining blood was mixed into a3.2% sodium citrate tube and then centrifuged at 3000g for 15 min. The plasma was harvested and stored at 20 C before testing using an ACA (Sysmex CS-2500,Siemens Healthcare Diagnostic Products GmbH,Marburg, Germany) within 24 h after collection. The PTvalues measured by the ACA (ACA-PT) and by the CCX(CCX-PT) were recorded in seconds.normal range of CCX-PT was 10.1-14.1 s (Table-1). PTresults using the portable analyzer were generally higherthan the automated analyzer (76/82 samples), except for3/82 samples that were less than the automated analyzer,while 3/82 samples were equal to the automated analyzer. Coefficients of variation of ACA-PT and CCX-PTwere 7.2% and 6.4%, respectively.The Shapiro–Wilk test showed that both ACA-PTand CCX-PT did not have normal distributions (p 0.0177and 0.0423, respectively). Spearman’s correlation testgave the correlation coefficient (r) and p-value as 0.3465and 0.0014, respectively (Figure-1). Comparison of PTbetween both methods was assessed using the BlandAltman analysis. The mean difference between PT usingportable and ACAs was 1.624 s and the standard deviation (SD) was 0.890, while limits of agreement (meandifference 2SD) ranged from 0.12 to 3.37 s. TheBland-Altman plot indicated that 95.1% (78/82) of thesamples fell within the limits of agreement (Figure-2).DiscussionEfficacy of the CCX compared to the ACA wasevaluated for measuring PT in healthy cats. Accuracywas also measured by statistical agreement.Table-1: Prothrombin time values measured using anautomated coagulation analyzer (Sysmex CS-2500System, Siemens Healthcare Diagnostic Products GmbH,Marburg, Germany) and the portable CoaguChek XS(Roche Diagnostics, Mannheim, Germany).AnalyzerNo of sampleRange (s)AutomatedPortable82829-12.910.1-14.1Statistical analysisDistribution of continuous data was assessed bythe Shapiro–Wilk test and normal ranges (lowest tohighest value) of PT from both methods were determined. Correlation of both methods was assessed bySpearman’s correlation test with agreement evaluatedusing Bland-Altman analysis [22]. Statistical analyseswere performed using a commercial software package(NCSS, LLC, Kaysville, Utah, USA) and p 0.05 wasconsidered as statistically significant.ResultsVarious breeds were identified in the sample of 49male and 33 female cats. Ages ranged from 0.5 to 13 yearsold. The normal range of ACA-PT was 9-12.9 s and theVeterinary World, EISSN: 2231-0916 Figure-1: Comparison of prothrombin time (PT) in 82healthy cats measured using an automated coagulationanalyzer and the portable CoaguChek XS (CCX).Spearman’s correlation test showed that the CCX-PTresults had a moderate but significant correlation withthe automated coagulation analyzer-PT results in cats(r 0.3465, p 0.0014).2542

Available at fFigure-2: Bland-Altman plot to assess the agreementbetween CoaguChek XS-prothrombin time (CCX-PT) andautomated coagulation analyzer (ACA)-PT in 82 healthycats. The X-axis shows the mean (CCX-PT ACA-PT/2)values in close agreement, representing the accuracy ofthe results, while the Y-axis shows the difference (CCX-PT- ACA-PT) in values at close to zero with 95.1% of thesamples falling within the limits of agreement (1.624s 2SD).A large number of samples was sufficient todetermine an appropriate normal range of ACA-PTand CCX-PT in cats. The results showed the normalrange of ACA-PT as 9-12.9 s. Engelen et al. [23]determined PT using a STACompact ACA (StagoGermany, Düsseldorf, Germany) as 10.1-12.8 s,while Stokol et al. [24] reported 16-24 s using an STACompact (Diagnostica Stago, Parsippany, USA) inhealthy cats. Differences in the PT result from variousautomated analyzers might be influenced by the use ofdifferent reagents, especially thromboplastin [25-28].Therefore, each laboratory should establish its ownnormal range of PT for a particular test [25].The normal range of CCX-PT in this study was10.1-14.1 s as the first report that measured PT usingthe portable CCX in cats. By contrast, the normal rangeof CCX-PT in dogs was reported by Kelmer et al. [12]as 9.6-11.5 s.Our study results determined that most samplesrecorded CCX-PT higher than ACA-PT. Similarly,Newbould and Norman [29] reported that PT usingCCX (Roche Diagnostics, Indianapolis, IN) was higherthan the standard laboratory result in dogs, whileanother study in dogs that used a different type of portable coagulation analyzer showed different results,with the POC-PT giving significantly shorter timesthan results obtained in the clinical laboratory [28].The difference between CCX-PT and ACA-PT resultsmay be due to several reasons, including species, venipuncture technique, sample handling, different typesof portable coagulation analyzer, and methods of endpoint determination [12,28,30]. Consequently, resultsfrom the same sample may differ between laboratories.Veterinary World, EISSN: 2231-0916 For non-normal distribution data in this study,a correlation between PT obtained from both methods was assessed by Spearman’s correlation test. Thecorrelation coefficient was determined by the degreeof relationship as moderate but significant (p 0.01),according to Akoglu [31]. Our results were consistent with the previous studies that showed a moderatecorrelation between portable and ACAs in dogs forthe CCX (Roche Diagnostics, Mannheim, Germany)versus ACL 200 (Instrumentation Laboratory, Milano,Italy) (r 0.35) [12], while CCX (Roche Diagnostics,Indianapolis, IN) versus a laboratory model (NewZealand Veterinary Pathology, Palmerston North, NZ)showed high value of coefficient of determination oflinear regression (r2 0.99) [29].The Bland-Altman analysis and plot were usedto assess the comparability between methods bystudying the mean difference and constructing limits of agreement [22]. The previous studies also usedBland-Altman analysis to evaluate the ability of thePOC coagulation analyzer for PT measurement compared with standard laboratory methods in dogs.Kelmer et al. [12] reported that PT obtained from theCCX (Roche Diagnostics, Mannheim, Germany) provided good agreement with an ACA, while Newbouldand Norman [29] reported that PT using CCX (RocheDiagnostics, Indianapolis, IN) had an excellent agreement. In this study, mean difference was 1.624 s andSD was 0.890, with limits of agreement (mean difference 2SD) from 0.12 to 3.37 s. The Bland-Altmanplot showed that 95.1% of the samples fell within thelimits of agreement. This conformed to statistical recommendations [22] and indicated that PT obtainedfrom the CCX had good agreement with PT obtainedfrom the ACA.When considering the clinical necessity and benefits of the device, our results suggest that CCX-PTwould provide an acceptable and immediate estimation of laboratory PT in healthy cats [22]. Similar tothe previous studies, the CCX can be used reliably forscreening dogs when the PT is normal [12]. It is usefulto rule out coagulation disorder for critical decisionmaking or hemostasis profile testing before an operation. This device is useful for animal clinics in remoteareas that are not able to access a veterinary diagnostic laboratory within the required time. The shortstorage time for the coagulation test and the smallsample required for the use of the CCX-PT are alsosignificant advantages compared to the 2 mL of bloodrequired for laboratory testing. The sample requiredfor the CCX is much smaller (8 µL) and can be easier to obtain in cats. In addition, the normal range ofPT using CCX in cats was established from this studyand will allow use in clinical practice. According tothe instruction manual [20], limitations of the CCXare that the device provides an accurate result forhematocrit ranges between 25% and 55%, while thedevice is not designed to measure results lower than9.6 s. Further, a high concentration of blood bilirubin,2543

Available at ftriglycerides, heparin, and severe hemolysis can interfere with the result.The limitation of this study was that a prolongedPT group of cats was not included. Therefore, thesensitivity and specificity of CCX were not proven.Nevertheless, the previous studies reported sensitivityand specificity of this device as 92% and 56%, respectively, in dogs [12] and 50% and 74%, respectively, inhorses [21]. Thus, we do not recommend using CCXfor diagnosing coagulation abnormalities in cats. Inaddition, a recent study that assessed the accuracy ofCCX in dogs recommended further investigation ofcoagulopathy using an automated standard analyzerwhen CCX-PT was prolonged [12]. Furthermore, thisstudy did not prove that anemia and thrombocytopeniacan result in hypocoagulability and lead to false-positive results for POC analyzers in cats, similar to a previous study in canines [12]. Future investigation andclarification of the effect of anemia and thrombocytopenia on CCX-PT results from CCX are necessary.References1. CCX is easy to use, portable coagulationanalyzer that requires a small volume of blood andproduces immediate results. It can be used to evaluate PT in healthy cats in clinical practice. The resultsobtained concurred with those measured by a standardautomated analyzer. However, for prolonged CCX-PTinvestigation of coagulopathy, the use of an automatedstandard analyzer is recommended. Further investigations are required to determine the effects of anemiaand thrombocytopenia on the accuracy of CCX-PTresults and monitoring the coagulopathy in cats is necessary for more precise diagnoses.Authors’ ContributionsBoth authors designed the study. ST collectedsamples and performed the statistical analysis. Bothauthors drafted and revised the manuscript. JRapproved the final manuscript.AcknowledgmentsThe authors would like to thank Mrs. PangramPrateep na Thalang for statistical and technical assistance. We are also grateful to Asst. Prof. SakchaiRuenphet for his kindness in commenting, reading,and improving the manuscript. The authors received aportion of the funds for this study through the Master’sdegree program of the Faculty of Veterinary Medicine,Mahanakorn University of Technology, Thailand(grant number Competing InterestsThe authors declare that they have no competinginterests.16.Publisher’s NoteVeterinary World remains neutral with regardto jurisdictional claims in published institutionalaffiliation.Veterinary World, EISSN: 2231-0916 17.Brooks, M. and DeWilde, L. (2006) Feline factor XII deficiency. Compend. Contin. Educ. 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coagulation analyzer (Roche Diagnostics, Mannheim, Germany), while the remaining blood was mixed into a 3.2% sodium citrate tube and then centrifuged at 3000 g for 15 min. The plasma was harvested and stored at 20 C before testing using an ACA (Sysme