Test Catalog

Test Id : RAVUM

Ravulizumab Complement Blockage Monitoring, Serum

Useful For
Suggests clinical disorders or settings where the test may be helpful

Monitoring of complement blockage by ravulizumab

 

Investigation of suspected alternative pathway complement deficiency, atypical hemolytic uremic syndrome, C3 glomerulonephritis, dense-deposit disease

Highlights

Ravulizumab is a new complement C5 inhibitor therapeutic monoclonal antibody with a longer half-life than eculizumab. Monitoring complete complement blockade by eculizumab has allowed personalized therapy in specific settings. Similar action is expected with ravulizumab. Ravulizumab has 4 different amino acids from eculizumab, which allow greater affinity for the FcRn immunoglobulin receptor and change the affinity of the molecule for C5.

Method Name
A short description of the method used to perform the test

Enzyme-Linked Immunosorbent Assay (ELISA)

NY State Available
Indicates the status of NY State approval and if the test is orderable for NY State clients.

No

Reporting Name
Lists a shorter or abbreviated version of the Published Name for a test

Ravulizumab Complement Blockage, S

Aliases
Lists additional common names for a test, as an aid in searching

aHUS

Alternate Pathway Complement

Alternative Pathway

Functional Complement

Specimen Type
Describes the specimen type validated for testing

Serum Red

Ordering Guidance

To measure therapeutic concentrations of ravulizumab, order RAVU / Ravulizumab, Serum.

Specimen Required
Defines the optimal specimen required to perform the test and the preferred volume to complete testing

Patient Preparation: Fasting preferred.

Supplies: Sarstedt 5 mL Aliquot Tube (T914)

Collection Container/Tube: Red top

Submission Container/Tube: Plastic vial

Specimen Volume: 1 mL

Collection Instructions:

1. Immediately after specimen collection, place the tube on wet ice.

2. Centrifuge at 4 degrees C and aliquot serum into 5 mL plastic vial.

3. Freeze specimen within 30 minutes.

Forms

Specimen Minimum Volume
Defines the amount of sample necessary to provide a clinically relevant result as determined by the Testing Laboratory

0.2 mL

Reject Due To
Identifies specimen types and conditions that may cause the specimen to be rejected

Gross hemolysis OK
Gross lipemia OK
Gross icterus OK

Specimen Stability Information
Provides a description of the temperatures required to transport a specimen to the performing laboratory, alternate acceptable temperatures are also included

Specimen Type Temperature Time Special Container
Serum Red Frozen (preferred) 14 days

Useful For
Suggests clinical disorders or settings where the test may be helpful

Monitoring of complement blockage by ravulizumab

 

Investigation of suspected alternative pathway complement deficiency, atypical hemolytic uremic syndrome, C3 glomerulonephritis, dense-deposit disease

Clinical Information
Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

Ravulizumab (Ultomiris, Alexion Pharmaceuticals) is a humanized hybrid monoclonal antibody (IgG2/IgG4) that blocks complement C5 cleavage, thereby preventing the activation of the proinflammatory effects of C5a and the cytolytic effects of the membrane attack complex (MAC) formed by C5b-C9. It is FDA-approved for atypical hemolytic uremic syndrome,(1) and paroxysmal nocturnal hemoglobinuria.(2)

 

Compared to its predecessor eculizumab, ravulizumab is a longer-acting therapeutic monoclonal antibody. There are 4 amino acid changes in ravulizumab’s heavy chain in comparison to eculizumab. These changes resulted in more affinity for the FcRn receptor which recycles immunoglobulins instead of degrading them, and changes in the variable region of the heavy chain made it possible for C5 to be released from ravulizumab molecule, so that C5 is left alone inside the endosome to be degraded. The dosing regimen for ravulizumab is weight-based, and after a loading dose schedule, the maintenance therapy requires administration intravenously every 8 weeks. Therapy efficacy may be monitored by measuring efficiency of complement blockade. Ravulizumab will affect complement function assays that rely on the formation of the MAC to generate cell lysis. Validation studies performed by the Mayo Clinic show that the alternative pathway (AH50) enzyme-linked immunosorbent assay  is the most helpful of the complement tests to monitor efficacy of the complement blockage by ravulizumab. Ravulizumab serum concentrations greater than 200 mcg/mL inhibited the AH50 activity completely, and 0% activity was detected at all subsequent tested concentrations up to 1000 mcg/mL.

Reference Values
Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.

> or =46% normal

Interpretation
Provides information to assist in interpretation of the test results

In clinical trials for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome, therapeutic concentrations of ravulizumab were established as greater than 175 mcg/mL.

 

For the complement blockage monitoring of ravulizumab:

-When ravulizumab is present in serum at concentrations around 50 mcg/mL, the results range from 20% to 29% of normal.

-When ravulizumab concentrations are around 100 mcg/mL, the results range from 8% to13% of normal.

-When ravulizumab concentrations are greater than 200 mcg/mL, the results are below the limit of quantitation of the assay (<10% of normal).

Cautions
Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances

This assay is a functional test and is dependent on correct sampling, storage, and shipping conditions. Both degradation by temperature and consumption of complement components will lead to false low function results. These are difficult to differentiate from real complement dysregulation.

 

While pre-analytic handling can lead to false positive results, it is far less likely that it would lead to false normal results. If more than one component is measured as low, it is important to look for technical errors. 

 

Complement testing may be ordered in several circumstances where standard treatment includes plasmapheresis or plasma exchange. The procedure itself, if traumatic, may activate complement so may not reflect what is going on with the patient’s complement system. The recommendation is to collect blood prior to the plasma exchange whenever possible.

 

Functional results inconsistent with the clinical history should be verified with a new blood draw.

 

Specimens should be frozen immediately after collection.

 

Long term stability is optimal when the sample is kept at -70 degrees Celsius or lower prior to testing. 

Clinical Reference
Recommendations for in-depth reading of a clinical nature

1. Frazer-Abel A, Sepiashvili L, Mbughuni MM, Willrich MA: Overview of laboratory testing and clinical presentations of complement deficiencies and dysregulation. Adv Clin Chem. 2016;77:1-75 doi: 10.1016/bs.acc.2016.06.001

2. Go RS, Winters JL, Leung N, et al: Thrombotic microangiopathy care pathway: A consensus statement for the Mayo Clinic Complement Alternative Pathway-Thrombotic Microangiopathy (CAP-TMA) Disease-Oriented Group. Mayo Clin Proc. 2016;91(9):1189-1211 doi: 10.1016/j.mayocp.2016.05.015

3. Willrich MAV, Andreguetto BD, Sridharan M, et al: The impact of eculizumab on routine complement assays. J Immunol Methods. 2018;460:63-71 doi: 10.1016/j.jim.2018.06.010.

4. Ardissino G, Tel F, Sgarbanti M, et al: Complement functional tests for monitoring eculizumab treatment in patients with atypical hemolytic uremic syndrome: an update. Pediatr Nephrol. 2018;33(3):457-461

5. Volokhina EB, van de Kar NC, Bergseth G, et al: Sensitive, reliable and easy-performed laboratory monitoring of eculizumab therapy in atypical hemolytic uremic syndrome. Clin Immunol. 2015 Oct;160(2):237-243

6. Sridharan M, Willrich MA, Go RS: Personalized Dosing of Eculizumab Using C5 Functional Activity and Eculizumab Level in Complement-mediated Thrombotic Microangiopathy: A Safe and Cost-saving Approach. XXVIII Congress of the International Society on Thrombosis and Haemostasis. Virtual ISTH 2020; July 12-14, 2020.

7. Cataland S, Ariceta G, Chen P, et al: Discordance between free C5 and CH50 complement assays in measuring complement C5 inhibition in patients with aHUS treated with ravulizumab. Blood. 2019;134(Supplement_1):1099

Method Description
Describes how the test is performed and provides a method-specific reference

The Wieslab enzyme-linked immunosorbent assay (ELISA) complement assay for the alternative pathway combines principles of the hemolytic assay for complement activation with the use of labeled antibodies specific for neoantigens produced as a result of complement activation. The microtiter plate strips are coated with lipopolysaccharide. Patient serum is diluted in diluent containing specific blocker to ensure that only the alternative pathway is activated. During the first incubation, the diluted patient serum in the wells is activated by the coating. The wells are then washed and C5b-9 (membrane attack complex: MAC) is detected with a specific alkaline phosphatase labeled antibody to the neoantigen expressed during MAC formation. After a final wash, an alkaline phosphatase substrate is added. The amount of alternative pathway complement activity correlates with the color intensity of the solution and is measured in terms of absorbance (optical density).(Nordin JG, Truedsson L, Sjoholm A: New procedure for detection of complement deficiency by ELISA. Analysis of activation pathways and circumvention of rheumatoid factor influence. J Immunol Methods. 1993 Dec 3;166(2):263-270; Frazer-Abel A, Sepiashvili L, Mbughuni MM, Willrich MA: Overview of laboratory testing and clinical presentations of complement deficiencies and dysregulation. Adv Clin Chem. 2016;77:1-75. doi: 10.1016/bs.acc.2016.06.001)

PDF Report
Indicates whether the report includes an additional document with charts, images or other enriched information

No

Day(s) Performed
Outlines the days the test is performed. This field reflects the day that the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time before the test is performed. Some tests are listed as continuously performed, which means that assays are performed multiple times during the day.

Varies

Report Available
The interval of time (receipt of sample at Mayo Clinic Laboratories to results available) taking into account standard setup days and weekends. The first day is the time that it typically takes for a result to be available. The last day is the time it might take, accounting for any necessary repeated testing.

1 to 7 days

Specimen Retention Time
Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded

14 days

Performing Laboratory Location
Indicates the location of the laboratory that performs the test

Rochester

Fees
Several factors determine the fee charged to perform a test. Contact your U.S. or International Regional Manager for information about establishing a fee schedule or to learn more about resources to optimize test selection.

  • Authorized users can sign in to Test Prices for detailed fee information.
  • Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
  • Prospective clients should contact their Regional Manager. For assistance, contact Customer Service.

Test Classification
Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR) product.

This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information
Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Clinic Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.

CPT codes are provided by the performing laboratory.

86161

LOINC® Information
Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the order and results codes of this test. LOINC values are provided by the performing laboratory.

Test Id Test Order Name Order LOINC Value
RAVUM Ravulizumab Complement Blockage, S 74520-8
Result Id Test Result Name Result LOINC Value
Applies only to results expressed in units of measure originally reported by the performing laboratory. These values do not apply to results that are converted to other units of measure.
609500 Ravulizumab Complement Blockage, S 74520-8

Test Setup Resources

Setup Files
Test setup information contains test file definition details to support order and result interfacing between Mayo Clinic Laboratories and your Laboratory Information System.

Excel | Pdf

Sample Reports
Normal and Abnormal sample reports are provided as references for report appearance.

Normal Reports | Abnormal Reports

SI Sample Reports
International System (SI) of Unit reports are provided for a limited number of tests. These reports are intended for international account use and are only available through MayoLINK accounts that have been defined to receive them.

SI Normal Reports | SI Abnormal Reports