International Sensitivity Index [ISI] & The International Normalised Ratio [INR] Introduction

The Prothrombin Time (PT) in an individual with one or more deficiencies of a clotting factor will vary with the type of thromboplastin (e.g. rabbit, human, bovine etc) used in the assay. This difference in sensitivities is known as the sensitivity index. Individual thromboplastins can be calibrated against an international WHO reference thromboplastin (International Reference Preparation or IRP) to assign them an International sensitivity index or ISI. The first WHO reference thromboplastin was assigned an ISI of 1.0 and it is against this (and subsequent reference preparations) that all other thromboplastins are calibrated. The first WHO IRP was a human brain extract to which adsorbed bovine plasma was added to optimise the content of the non-vitamin K dependent coagulation factors. Subsequent WHO IRPs contain no adsorbed bovine plasma.

Principles & Methodology 1. Calculating the ISI

The calibration of a test thromboplastin must be against a reference thromboplastin of the same species e.g. human against human, rabbit against rabbit etc. Prothrombin Times are performed in duplicate for each thromboplastin and the mean for each pair of tests derived. Tests are historically performed on 20 normal donors not on anticoagulants and 60 patients who have been on oral anticoagulant treatment for at least 6 weeks. If

there is more than a 10% difference in the clotting times between duplicate samples, the tests on that plasma sample should be repeated. The mean of each pair of of PT results are plotted on double-log paper with the reference sample on the Y axis and the test plasma on the Xaxis. The use of the double-log paper removes the necessity to derive the log for each PT result. A line of best fit is drawn and the slope of this line is the ISI.

The ISI can be calculated in (at least) two ways:

Deriving the ISI The preferred method The PTs of all the plasma samples are converted to the corresponding logarithms, an orthogonal regression line is calculated and from which the ISI can be derived. For more information relating to the derivation of the ISI - see References. A best fit line is drawn with points above the highest recorded PT and the lowest PT (see figure above). The slope of the line is calculated and this represents the ISI. In the example shown above -

The simpler method

Distance A to C = 125mm and distance B to C = 110mm

So the ISI of the test thromboplastin is calculated from the formula:

So if the ISI of the Reference Thromboplastin is 1.1 and the ISI derived from the slope is 1.14, the ISI of the Test Thromboplastin is 1.1 x 1.14 = 1.25. Thromboplastins should be chosen with an ISI close to 1.0. Thromboplastins with high ISIs are less sensitive to small changes in the PT. The table below under INR illustrates this. Using a thromboplastin with an ISI of 1.0 the PT can range from 15s - 35s but the INR is still in the therapeutic range. In contrast if the ISI of the thromboplastin is 2.0 an increase in the PT from 15s to 30s results in an INR outwith the therapeutic range.

Local Calibration

Whilst the development of an International Reference Thromboplastin resulted in significant improvements in the standardisation of anticoagulant control, the use of different coagulometers for the PT and the differing methods of end-point detection can lead to significant variations in PT. For these reasons, a local calibration of thromboplastins is recommended. This involves testing a set of plasma samples with known INRs with the a laboratory-specific thromboplastin and on the coagulometers which will be used to derive the PT.

2. The International Normalised Ratio [INR]

The International Normalised Ratio (INR) is the PT ratio of a test sample compared to a normal PT (derived from the log mean normal prothrombin time (LMNPT) of 20 normal donors) corrected for the sensitivity of the thromboplastin used in the test. It is the value for the Prothrombin Time Ratio which has been obtained using the first WHO Reference Thromboplastin with an ISI of 1.0.

or as below:

So for a patient on warfarin with a PT of 23 seconds and a mean normal PT of 12 seconds using a thromboplastin with an ISI of 1.2, the INR is 2.18:

The table below illustrates a number of patients with varying PTs and in whom the INR was calculated using three thromboplastins with varying ISIs. The Geometric Mean Normal Prothrombin Time (GMNPT) for a group of 20 normal donors not on anticoagulants was 12.1s.
Patient PT [s] 15 20 25 30 35 Thromboplastin 1 [ISI 1.0] 1.25 1.67 2.08 2.5 2.91 Thromboplastin 2 [ISI 1.5] 1.39 2.15 3.00 3.95 4.98 Thromboplastin 3 [ISI 2.0] 1.54 2.78 4.3 6.25 8.51

The simplest way to calculate the INRs is to use an electronic calculator! A nomogram for correcting prothrombin time ratios to INR can be used for any thromboplastin where the ISI is known. This LINK will take to a publication which demonstrates the nomogram.

Reference Ranges
The INR reference value for a patient not taking a vitamin K antagonist is 1.0. The therapeutic range for anticoagulation varies according to the precise indication - see BCSH Guidelines and ACCP Guidelines.

Data Interpretation
Click HERE to go to the Data Interpretation Exercises. COMMENTS 1. The INR is used for monitoring patients on warfarin and whilst it is frequently used in other areas e.g. for assessing the severity of liver dysfunction this is incorrect and the PT should be used for this.

2. The INR is widely used in various models for end-stage-liver-disease e.g. the MELD score [Model for End-stage LiverDisease] or the the Child-Pugh score - and is a mathematical score that is used to prioritise patients for liver transplantation. Amongst the variables included in this score is the INR. The INR in this score was used to minimise any variation in PT that might result from using thromboplastins with varying reagents and therefore patients from different centres could be prioritised. However, the INR evolved to monitor patients on oral anticoagulants and not with liver disease and the variables that affect the INR in patients with liver disease are different from those that affect the INR in patients on drugs such as warfarin. For these reasons it has been proposed that thromboplastins be calibrated to establish their ISILiverand that this ISILiver is then used to convert PT into INR. This alternative thromboplastin calibration using plasmas from patients with cirrhosis instead of from patients on vitamin K antagonists may resolve the variability of these scores in prioritising patients for transplantation. REFERENCES 1. Hermans, J., et al., A collaborative calibration study of reference materials for thromboplastins. Thromb Haemost, 1983. 50(3): p. 712-7. 2. Kovacs MJ, Wong A, MacKinnon K, Weir K, Keeney M, Boyle E, et al. Assessment of the validity of the INR system for patients with liver impairment Thromb Haemost. 1994;71(6):727-30. 3. Kitchen S, Walker ID, Woods TA, Preston FE. Thromboplastin related differences in the determination of international normalised ratio: a cause for concern? Steering Committee of the UK National External Quality Assessment Scheme in Blood Coagulation. Thromb Haemost. 1994 Sep;72(3):426-9. 4. Thomson, J.M., J.A. Tomenson, and L. Poller, The calibration of the second primary international reference preparation for thromboplastin (thromboplastin, human, plain, coded BCT/253). Thromb Haemost, 1984. 52(3): 336-42. 5. Kirkwood, T.B., Calibration of reference thromboplastins and standardisation of the prothrombin time ratio. Thromb Haemost, 1983. 49(3): 238-44.

6. Tripodi, A., et al., International collaborative study for the calibration of a proposed reference preparation for thromboplastin, human recombinant, plain. On behalf of the Subcommittee on Control of Anticoagulation. Thromb Haemost, 1998. 79(2): 439-43. 7. Tripodi, A., et al., A simplified procedure for thromboplastin calibration--the usefulness of lyophilized plasmas assessed in a collaborative study. Thromb Haemost, 1996. 75(2): 309-12. 8. Poller L. International Normalized Ratio (INR): the first 20 years. J Thromb Haemost 2004;2:849-860. 9. Floden A, Castedal M, Friman S, Olausson M, Backman L. Calculation and comparison of the model for end-stage liver disease (MELD) score in patients accepted for liver transplantation in 1999 and 2004. Transplant Proc. 2007 Mar;39(2):385-6. 10. Londono MC, Cardenas A, Guevara M, Quinto L, de Las Heras D, Navasa M, et al. MELD score and serum sodium in the prediction of survival of patients with cirrhosis awaiting liver transplantation. Gut. 2007 Sep;56(9):1283-90. 10. Baglin et al. Guidelines on oral anticoagulation (warfarin): third edition - 2005 update. Brit J Haem 2005;132(3):277-285. 11. BCSH Website 12. ACCP Guidelines

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Interpretation: Miscellaneous Tests

Introduction
This section covers many of the tests that were outlined in the section on 'Miscellaneous tests' - some questions do cross over into some of the other sections.

Question 1

You are provided with prothrombin times using two different thromboplastins on a number of patients stably anticoagulated on warfarin as well as several normal healthy individuals. One thromboplastin is the WHO rabbit reference material and the other is an 'in-house' rabbit material you have prepared in your laboratory. Plasma Sample PT [s] WHO Reference Preparation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 32 46 50 46 15 43 13 45 32 13 55 48 13 14 55 55 29 PT [s] In-House Preparation 15.5 16 19.5 16 12 16 12 18.5 15.5 11 18 17 11 12 18 20 15

A. What is the ISI of the home made material? B. Would you use this thromboplastin in your laboratory? If not, why not?

Question 2

From the data shown in the attached graph derive the ISI (roughly) for thromboplastin. If you click HERE you can open graph in a new window. The WHO Reference thromboplastin has an ISI of 1.0. Points A, B and C are designed to help you.

Question 3
A 20-year-old woman is 32/40 weeks pregnant. She attends the antenatal clinic for a routine check up. You are asked to see her because of the following results: Test Hb WCC Platelets MPV Patient 10.1g/dL 6.2 x 109/L 80 x 109/L 13.1 fL Reference Range 11.5-13.5 g/dL 6 - 10 x 109/L 150-400 x 109/L 7.5-9.2 fL

1. What would you do immediately and what investigations would you request? 2. What are the possible diagnoses? Click here for Part 2

Click here for Part 3

Question 4
A 23-year-old man is investigated for a possible bleeding disorder whilst living in Paris. He has a bleeding time performed and this is found to be significantly prolonged at 26 minutes (NR: <10 minutes). He returns to the UK and seeks your advice as to the significance of the prolonged Bleeding Time. a. Briefly outline the principles of the bleeding time b. What abnormalities would explain the prolonged bleeding time? c. What additional tests would you request? d. Is this test still commonly performed? Click here for Part 2

Question 5

Briefly explain the principles of the Activated Clotting Time and the Thrombin Time 1. What factors can affect the ACT? 2. What factors can affect the thrombin time? 2. Why do we use the ACT and not the thrombin time to monitor patients on cardio-pulmonary bypass?

Question 6
A 64-year-old man undergoes an aortic valve replacement. Prior to coming off bypass he is given protamine sulphate to reverse the unfractionated heparin. His BP falls and he becomes profoundly hypotensive. 1. What is protamine sulphate and how does it work? 2. What do you think might have happened?

Question 7
A 56-year-old man with a long history of COPD is admitted for surgery. His pre-operative investigations show a Hb of 19g/dL and an Hct of 0.58 . Test PT APTT Patient 20s 47s Reference Range 11-14s 23-35s

1. What might explain these findings and what would you do next?

Question 8
Outline the mechanism of action of tranexamic acid and DDAVP.

Question 9

A 45-year-old female presents with a spontaneous proximal DVT. She is anticoagulated with initially a low molecular weight heparin and subsequently warfarin with a target INR of 2.5. Shortly after starting warfarin she complains of bruising and presents 5 weeks later to Accident and Emergency with a large haematoma in her right calf. Her investigations on admission are shown below:

Test INR APTT Fibrinogen (Clauss) Haemoglobin Platelets

Patient 2.3 117s 3.9 g/dL 12.2g/dl 298 x 109/L

Reference Range 1.0 28-34.5s 2-4 g/dL 13.5-16.2 g/L 150-400 x 109/L

1. What additional tests might you request and why? Click here for Part 2

Click here for Part 3

Question 10
A 67-year-old man with no previous history of note requires an aortic valve replacement. He has a pre-operative screen performed and this shows the following: Test PT APTT Fibrinogen (Clauss) Thrombin Time Platelets 1. What would you do next? Click here for Part 2 Patient 13s >120s 3.9 g/dL 14s 358 x 109/L Reference Range 11-14s 28-34.5s 2-4 g/L 11.5-13.5s 150-400 x 109/L

Click here for Part 3

Question 11
A 56-year-old woman is admitted thorough Accident and Emergency having been found confused at home by her partner. Investigations show: Test PT APTT Fibrinogen (Clauss) Thrombin Time Hb Platelets WCC LDH Serum creatinine Patient 14s 35s 2.1 g/dL 14s 8.6 g/dL 23 x 109/L 11.2 x 109/L 2342 U/L 356 mol/L Reference Range 11-14s 28-34.5s 2-4 g/L 11.5-13.5s 7.3 g/dL 150-400 x 109/L 6-10 x 109/L <450 U/L 52-90 mol/L

1. What additional tests would you request? Click here for Part 2

Click here for Part 3

Click here for Part 4

Question 12

A 45-year-old woman is on treatment for pulmonary TB and develops a large abdominal haematoma. Laboratory investigations show: Test PT APTT Fibrinogen (Clauss) Thrombin Time Platelets PFA-100 [Collagen:ADP] Patient 14s 35s 4.2 g/L 13s 387 x 109/L Normal closure times Reference Range 11-14s 28-34.5s 2-4 g/L 11.5-13.5s 150-400 x 109/L

1. What additional tests would you request? Click here for Part 2

Question 13
A 67-year-old male is admitted to CCU with unstable angina. He undergoes an emergency coronary angioplasty and receives in addition to 5000 units of unfractionated heparin, Abciximab to prevent re-occlusion of the coronary artery. 3 days after the procedure he is noted to be bruising and his platelets are found to be 5 x 109/L having been 189 x 109/L at the time of his admission. i. What are you going to do ii. What do you think has happened iii. What is Abciximab

Question 14

A 23-year-old man is referred for investigation of prolonged bleeding after dental extraction. Shown below are the results of his premilinary tests. Comment upon the results of these tests and suggest other other that you think would be of value. Test PT APTT Fibrinogen (Clauss) Thrombin Time Platelets PFA-100 [Collagen:ADP] 1. What additional tests would you request? Click HERE for Part 2 Patient 11s 45s 3.8 g/L 13s 387 x 109/L 155s Reference Range 11-14s 28-34.5s 2-4 g/L 11.5-13.5s 150-400 x 109/L 60-133s

Click HERE for Part 3

Question 15

A 57-year-old man is transferred to ITU following coronary artery bypass grafting. He has a 'routine' post-operative clotting screen performed which shows:

Test PT APTT Fibrinogen (Clauss) Thrombin Time Platelets

Patient 11s 34s 2.2 g/L >120s 187 x 109/L

Reference Range 11-14s 28-34.5s 2-4 g/L 11.5-13.5s 150-400 x 109/L

1. What do you think might provide an explanation for these results and what would tests would you like to perform? Click HERE for Part 2 Click HERE for Part 3

Question 16

A 47-year-old man is see in the Emergency Department with a 2 week history of easy bruising and more recently of a prolonged epistaxis. His past medical history was unremarkable, he had not commenced any new drugs and there was no family history of note. He had a full blood count performed together with the results of some 'basic' clotting tests. Shown below are the results of his preliminary tests. Comment upon the results of these tests and suggest other investigations that you think would be of value in reaching a diagnosis. Test PT APTT Fibrinogen (Clauss) D Dimer Platelets Hb WCC Patient 15.9s 21.3s 0.6 g/L >60,000 ng/mL 14 x 109/L 7.2 g/L 276 x 109/L Reference Range 11-14s 28-34.5s 2-4 g/L 0-230 ng/mL 150-400 x 109/L 11.5 -15.5 g/dL 5-16 x 109/L

1. What additional tests would you request? Click HERE for Part 2 Comment upon the results of the blood films?

Why do patients with this particular problem bleed?

Click HERE for the Answers

Try to avoid looking at the answers until you have worked through the questions. COMMENTS 1. You will gain maximum educational value if you work through each part of each answer before you look at the second and subsequent parts or indeed the answers. 2. The answers will give you some help as to the reasoning behind

some of the questions. 3. The questions span disorders from common to exceptionally rare but interesting. REFERENCES LINKS HOME PAGE Site Map Graph Paper SEARCH THIS SITE
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