Paroxysmal Nocturnal Hemoglobinuria Testing

Preferred test for initial diagnosis of PNH and quantification of PNH clones

Includes high-sensitivity WBC and RBC analysis

Indications for Ordering

Diagnose PNH in patients with

  • Unexplained hemoglobinuria
  • Coombs-negative hemolytic anemia
  • Unusual thrombotic sites (eg, Budd-Chiari, cerebral)
  • Thrombosis combined with intravascular hemolysis or cytopenias
  • Aplastic or hypoplastic anemia

Monitor individuals with confirmed PNH

Related Tests

Monitor subclinical PNH and eculizumab treatment

Quantify or monitor PNH clone

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disorder caused by nonmalignant clonal expansion of one or more stem cell lines due to an acquired mutation in the PIGA gene. PNH is associated with intravascular hemolysis, thrombotic complications, and bone marrow failure. 

Typical Testing Strategy

  • Initial testing includes:
    • Complete blood count with peripheral smear
    • Reticulocyte count
    • Direct Coombs test
    • Serum lactate dehydrogenase
    • Indirect bilirubin
    • Serum haptoglobin
  • Diagnostic testing (if suspicion exists based on primary tests) should include flow cytometry of both white blood cells (WBCs) and red blood cells (RBCs)
  • Flow cytometry testing of WBCs and/or RBCs may be used in therapeutic monitoring
    • Ham and sugar water tests are no longer used; do not order

Disease Overview

Incidence

1.3/million 

Symptoms 

  • Hemolysis
    • Symptoms include dysphagia, lethargy, renal failure, anemia, hemoglobinuria, male impotence, pulmonary hypertension
  • Thrombophilia
    • Potentially life-threatening
    • Thromboses located at unusual sites (eg, hepatic portal)
  • Bone marrow (BM) failure
    • May present as severe aplastic anemia

Physiology

  • PNH is caused by a somatic mutation of PIGA gene which results in deficiency or absence of glycosylphosphatidylinositol (GPI)-anchored cell membrane proteins on progeny of affected stem cells 
    • Lack of CD55 and CD59 causes RBC sensitivity to complement lysis
    • Pathophysiology of thrombophilia and bone marrow failure in PNH is unknown
  • Percentage of RBCs or WBCs that entirely or partially lack GPI-linked antigens is referred to as PNH clone size  
    • WBC testing is most accurate in the determination of PNH clone size
    • RBC testing is most appropriate for detection of cells only partially lacking GPI-linked antigens
      • Type I: normal levels of CD59
      • Type II: reduced levels of CD59
      • Type III:  absent levels of CD59

Test Interpretation

Analytical Sensitivity

Limits of detection:

  • RBCs: 0.005%
  • Polymorphonuclear neutrophils (PMNs or granulocytes): 0.005%
  • Monocytes: 0.020%

Results

Results Cells Detected Interpretation

Positive

PNH cells: ≥1% in RBCs and WBCs

Indicates PNH

RBC PNH cells: ≥0.005% to <1%

WBC (PMN) PNH cells: ≥0.005% to <1%

Monocyte PNH cells: ≥0.020% to <1%

Indicates subclinical PNH

 

Often associated with symptoms of bone marrow failure

Negative

PNH cells: not detected

Reduces, but does not eliminate the probability of PNH

Limitations

  • Conditions that may compromise accuracy include significant neutropenia, gross hemolysis, and specimens that lack expression of CD15, CD64, or glycophorin A
  • Recent RBC transfusions may decrease percentage of PNH cells measured in RBCs

 

References 
  1. Borowitz MJ, Craig FE, Digiuseppe JA, Illingworth AJ, Rosse W, Sutherland R, Wittwer CT, Richards SJ, Clinical Cytometry Society. Guidelines for the diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria and related disorders by flow cytometry. Cytometry B Clin Cytom. 2010; 78(4): 211-30. PubMed
  2. Sutherland DR, Acton E, Keeney M, Davis BH, Illingworth A. Use of CD157 in FLAER-based assays for high-sensitivity PNH granulocyte and PNH monocyte detection. Cytometry B Clin Cytom. 2014; 86(1): 44-55. PubMed

Last Update: August 2019