THROMBOSIS RESEARCH 65; 785790,1992

0049-3848/92 $5.00 + .OOPrinted in the USA.

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DIAGNOSTIC EFFICACY OF THE D-DIMER ASSAY

IN DISSEMINATED INTRAVASCULAR

COAGULATION (DIC).

RODGER L. BICK

AND

WILLIAM F. BAKER

REGIONAL CANCER ANDBLOOD DISEASE CENTER OF KERN

AND
DEPARTMENT OF MEDICINE, DIVISION OF HEMATOLOGY ONCOLOGY
UCLA CENTER FOR THE HEALTH SCIENCES,
LOS ANGELES AND BAKERSFIELD, CALIFORNIA, USA

(Received 10.1.1991; accepted in revised form 13.11.1991 by Editor M.W. Mosesson)

(Received in final form by Executive Editorial Office 24.1.1992)

ABSTRACT
The D-Dimer (D-D) assay for measuring cross-linked fibrin
degradation products is now available for the clinical laboratory.
We combined this assay with other tests to assess patients with
diagnosed or suspected DIC. Also, a small group of patients (20)
with deep venous thrombosis (DVT) were studied. The D-D test,
antithrombin-Ill assay, FDP titer, fibrinopeptide-A level, protamine
sulfate test, fibrinogen, prothrombin time, and activated partial
thromboplastin time were used. The D-D test was abnormal in
93.7%, the AT-III level was abnormal in 87.5%, the fibrinopeptide-A
level was abnormal in 89.5%, and the FDP titer was elevated in
83.7% of patients with DIC. When assessing patients found not to
have confirmed DIC the D-D assay was abnormal in 20%, the AT-III
level was abnormal in 8%, and the fibrinopeptide-A level was
elevated in 13%. We conclude the D-Dimer assay to be a useful
molecular marker of hemostasis in diagnosing DIC and this test will
often discriminate between those patients with or without DIC,
especially when used with the AT-III and fibrinopeptide-A assays.
Of the battery of tests used in this study, the most useful, in
descending order of efficacy, appear to be the D-dimer assay
(93.7% abnormal), the fibrinopeptide-A titer (89.5% abnormal), the
AT-III level (87.5% abnormal), and the FDP titer (83.7% abnormal).

Key words: D-Dimer, DIC

785
786 D-DIMER ASSAY Vol. 65, No. 6

Of the global tests, the diagnostic efficacy of the prothrombin time

activated partial thromboplastin time, and protamine sulfate test
were no greater than chance and appear to be of little use in aiding
in a diagnosis of DIC. Also, the D-Dimer assay is similar in cost to
the FDP titer and is cost effective for the routine clinical laboratory.

INTRODUCTION
Disseminated Intravascular Coagulation (DIC) is a common and complex
problem from both the clinical and laboratory diagnostic stand-point, with many
available laboratory tests being purported to be of diagnostic significance.l-4 D-
dimer is a neo-antigen formed when thrombin initiates the transformation of
fibrinogen to fibrin and also activates factor XIII to cross-link the fibrin thus
formed; this neo-antigen is formed because of plasmin digestion of cross-linked
fibrin.596 The D-dimer assay is, therefore, thought to be specific for fibrin
degradation products, whereas the formation of fibrinolytic degradation
products (FDP’s), the X, Y, D, and E fragments, may be either fibrinogen or
fibrin derived following plasmin digestion. The presence of D-dimer implies the
generation of both plasmin and thrombin, the generation of thrombin being
implied by thrombin-induced activation of factor XIII to factor Xllla which then
cross-links D fragment, giving the dimeric form.7 Monoclonal antibodies have
been harvested against the D-dimer neo-antigen DD-3B6/22 and these
antibodies are specific for cross-linked fibrin derivatives containing the D-dimer
configuration.899 Following the harvesting of these monoclonal antibodies,
latex agglutination procedures using latex particles coated with anti-DD-3B6/22
antibody have been developed into commercially available kits. The latex
agglutination assay appears equivalent to the monoclonal antibody test, done
by enzyme immunoassay,le~tf making the latex agglutination test applicable for
measuring D-dimer in plasma, resulting in a clinically applicable and easily
performed test. The D-dimer assay is available to potentially aid in the
diagnosis of disseminated intravascular coagulation by confirming the
generation of plasmin and thrombin and presence of fibrin degradation
products. We have used this test as part of a battery of DIC tests to assess its
potential efficacy in diagnosing patients with suspected DIC. Other tests done
in conjunction with the latex agglutination assay for D-dimer were the
antithrombin-Ill level, FDP titer, flbrinopeptide-A level, protamine sulfate test,
prothrombin time, activated partial thromboplastin time and fibrinogen level.
Also, these assays were done, for comparative purposes in a population of 20
patients with documented Deep Vein Thrombosis (DVT). The results of these
findings are herein reported.

MATERIALS AND METHODS

The D-dimer latex agglutination assay was obtained from American
Diagnostica and performed according to manufacturer’s instructions. The
fibrinopeptide-A assay was obtained from Mallinckrodt immunoassay systems
and performed by RIA according to instructions. The protamine sulfate and FDP
assays were obtained from American Dade and performed according to
manufacturer’s directions. The antithrombin-Ill assay was obtained from KABI
(Coatest), using the chromogenic substrate S-2236 and was performed
Vol. 65, No. 6 D-DIMER ASSAY 787

according to manufacturer’s instructions on a multistat Ill (Instrumentation

Laboratories) analyzer. The prothrombin time and activated partial
thromboplastin time were both obtained from Helena Laboratories and
performed according to manufacturer’s instructions.
Patients studied were those routinely seen in our consultative
hematology/oncology medical practice. Sixty-three patients with suspected DIC
were seen and evaluated during this study. A diagnosis of DIC was based upon
clinical and laboratory evidence as previously describedl* and consisted of
finding the appropriate types(s) of hemorrhage / thrombosis in the appropriate
clinical setting in association with characteristic abnormal laboratory findings. It
was found that forty-eight patients with suspected DIC had the diagnosis
confirmed based upon clinical and laboratory findings and fifteen patients
initially suspected to have DIC were found to have a different hemorrhagic or
thrombotic disorder based upon further clinical and laboratory evaluation. Also,
twenty patients with documented deep venous thrombosis (ascending contrast
venography or technetium thromboscintograms) were studied for comparative
purposes with this same battery of procedures.

iDi
In patients with documented DIC it was found that the D-dimer assay was
abnormally elevated (> 200 ug/dl) in 93.7%, with the mean D-dimer level being
1982 ug/dl; in those patients in whom DIC was ruled out, the D-dimer assay was
abnormal in 20% with the mean level being 293 ug/dl. These differences were
of significance (p = 0.040). In patients with confirmed DIC, the antithrombin-Ill
level was abnormal (< 85% normal human plasma [NHP]) in 87.5% of patients,
with the mean antithrombin-Ill level being 81.9% of NHP. In patients with
suspected but not confirmed DIC, the mean antithrombin-III level was 105% of
NHP. These differences were of significance (p < 0.0001). The FDP titer was
abnormally elevated (> 40 ug/dl) in 83.7% of patients with confirmed DIC, with
the mean titer being 211.9 ug/dl; in those patients with suspected, but not
confirmed DIC, the FDP level was elevated in 40% and the mean FDP titer was
32.6 ug/dl. The fibrinopeptide-A titer was abnormal (> 9 ng/dl) in 89.5% of
patients with confirmed DIC, with the mean level being 24.8 ng/dl, and the
fibtinopeptide-A titer was abnormal in 13% of the non-confirmed DIC patients,
with the mean titer being 11.6 ng/dl. The differences in FDP level and
fibrinopeptide-A levels between those with or without DIC were not of statistical
significance (p = 0.56 and 0.07 respectively). The protamine sulfate test was
abnormal (positive) in 26% of patients with confirmed DIC and was abnormal in
13% of patients with suspected but non-confirmed DIC. In the non-confirmed
patients, never were the D-dimer, antithrombin-HI, and fibrinopeptide-A results
all abnormal. Of significance, in the patients who had non-confirmed DIC, only
one patient had a D-dimer level of 2000 ug/dl and all other patients in this
group were under 1000 ug/d. The prothrombin time and activated partial
thromboplastin time were abnormal in 20% and 48% of patients with confirmed
DIC. The mean D-dimer results, antithrombin-Ill results, FDP assay results, and
the fibrinopeptide-A results for all three categories of patients studied
(confirmed DIC, non-confirmed DIC, and DVT) are summarized in the table.
788 D-DIMER ASSAY Vol. 85, No. 6

DEEP VENOUS THROMBOSIS PATIENTS:

In assessing twenty patients with deep venous thrombosis, the D-dimer
assay was abnormally elevated in 50%, with the mean level being 525 ug/dl;
this is significantly different from DIC patients (p = 0.041). The antithrombin-Ill
level was depressed in 30% of DVT patients with the mean antithrombin-Ill level
being 84.1% of NHP. This also was significantly different from the DIC levels (p
= 0.003). The fibrinopeptide-A titer was only abnormal in lo%, with a mean
level of 13.3 ng/dl, and the FDP titer was abnormally elevated in 30%, with the
mean level being 103 ug/dl; these findings were not significantly different from
those found in DIC patients (p’ 0.05).

MEAN ASSAY VALUES

DIAGNOSIS: DIC NO DIC DVT NORMAL

# PATIENTS: [48] [15] (201

ASSAY:

D-DIMER f 982.4 293.3 525 (200 ug/dL

AT-III 61.9 105.4 84.1 > 85% NHP

F.P.-A 24.8 11.7 13.3 < 9 ugldL

FDP 210.9 32.6 103.7 < 40 ug/dL

DISCUSSION
Based upon these results, the D-dimer test done by the latex
agglutination technique appears to be a useful test for assessing the probability
of DIC in the appropriate clinical setting. Indeed, of the tests used in this study,
it appeared to be the most reliable (specific) test for probability of being
abnormal in patients with confirmed DIC. With this battery of tests, in the
appropriate clinical setting, the reliability of the tests used, in descending order
of reliability appear to be the D-dimer assay (abnormal in 93.7%), the
fibrinopeptide-A level (abnormal in 89.5%), the antithrombin-Ill assay (abnormal
in 87.5%), and the FDP titer (abnormal in 83.7%). However, only the
differences in the D-dimer and antithrombin-Ill levels, when comparing DIC to
non-DIC or DIC to DVT patients, were of statistical significance. The
prothrombin time, activated partial thromboplastin time and the protamine
sulfate test appear to be of marginal use in DIC patients. Lane and co-workers
have studied the D-dimer fragment in 9 patients with DIC and found the levels to
be elevated in 8 of the 9.13 Also, Elms and co-workers have assessed D-dimer
in DIC patients and found the levels to be elevated in all patients.14 Boisclair
and associates evaluated D-dimer and other markers of hemostasis activation in
30 patients with DIC; although measurements of fragment E antigen were more
sensitive than the D-dimer assay, the D-dimer assay was found more sensitive
than the thrombin-antithrombin (TAT) complex. 1s Carr and coworkers studied D-
dimer and FDP in 33 patients with DIC and concluded the FDP titer to be more
sensitive and the D-dimer to be the more specific of the two assays.’
Vol. 65, No. 6 D-DIMER ASSAY 789

Based upon our findings and the reports of others, it seems reasonable to
conclude that the D-dimer latex agglutination test, measuring the presence of
the neo-antigen DD-386122, is a very useful test which is easily done in a
routine clinical laboratory and should be included in the armamentarium of tests
used to confirm or rule out disseminated intravascular coagulation. Since the
D-dimer test is providing the same information as both the FDP titer and the
protamine sulfate or ethanol gelation test, it can replace both these tests in the
diagnostic work up of a patient with suspected DIC, leading to both cost
effectiveness and enhanced diagnostic efficacy.16917

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