Functions of Clotting Factors Pathway : Extrinsic

Activator : Factor III (tissue factor)

Hemostasis is the body’s mechanism to stop blood loss. It is made Actions : Activates Factor X which works with other factors to
up of several mechanisms with the coagulation phase involving convert prothrombin into thrombin.
the clotting factors and the formation of a blood clot. The series of
reactions whereby one clotting factor activates the next is known Factor VIII
as the coagulation cascade. The clotting factors eventually
convert fibrinogen to fibrin which then forms a mesh network at Name : Anti-hemoplytic factor / Antihemophilic factor (AHF) or
the site of injury. This traps blood cells and other components to globulin (AHG) / antihemophilic factor A
form a firm blood clot and thereby completely stop blood loss. Source : Endothelium lining blood vessel and platelets (plug)
Therefore the function of clotting factors are to trigger the Pathway : Intrinsic
formation of a blood clot and stabilize it for as long as necessary. Activator : Thrombin
Clotting factors are therefore known as procoagulants. Actions : Works with Factor IX and calcium to activate Factor X.
Deficiency : Hemophilia A
List of Clotting Factors
Factor IX
Factor I
Name : Christmas factor / Plasma thromboplastin component
Name : Fibrinogen (PTC) / Antihemophilic factor B
Source : Liver Source : Liver
Pathway : Both extrinsic and intrinsic Pathway : Intrinsic
Activator : Thrombin Activator : Factor XI and calcium
Actions : When fibrinogen is converted into fibrin by thrombin, it Actions : Works with Factor VIII and calcium to activate Factor X.
forms long strands that compose the mesh network for clot Deficiency : Hemophilia B
formation.
Factor X
Factor II
Name : Stuart Prower factor / Stuart factor
Name : Prothrombin Source : Liver
Source : Liver Pathway : Extrinsic and intrinsic
Pathway : Both extrinsic and intrinsic Activator : Factor VII (extrinsic) / Factor IX + Factor VIII + calcium
Activator : Prothrombin activator (intrinsic)
Actions : Prothrombin is converted into thrombin which then Actions : Works with platelet phospholipids to convert
activated fibrinogen into fibrin. prothrombin into thrombin. This reaction is made faster by
activated Factor V.
Factor III
Factor XI
Name : Thromboplastin / Tissue factor
Source : Platelets (intrinsic) and damaged endothelium (cells) Name : Plasma thromboplastin antecedent (PTA) / antihemophilic
lining the blood vessel (extrinsic). factor C
Pathway : Both extrinsic and intrinsic Source : Liver
Activator : Injury to blood vessel Pathway : Intrinsic
Action : Activates factor VII (VIIa). Activator : Factor XII + prekallikrein and kininogen
Actions : Works with calcium to activate Factor IX.
Factor IV Deficiency : Hemophilia C
Name : Calcium Factor XII
Source : Bone and absorption from food in gastrointestinal tract
Pathway : Both extrinsic and intrinsic Name : Hageman factor
Action : Works with many clotting factors for activation of the Source : Liver
other clotting factors. These are called calcium-dependent steps. Pathway : Intrinsic
Activator : Contact with collagen in the torn wall of blood vessels
Actions : Works with prekallikrein and kininogen to activate Factor
XI. Also activates plasmin which degrades clots.

Factor V Factor XIII

Name : Proaccerin / Labile factor / Ac-globulin (Ac-G) Name : Fibrin stabilizing factor
Source : Liver and platelets Source : Liver
Pathway : Both extrinsic and intrinsic Activator : Thrombin and calcium
Activator : Thrombin Actions : Stabilizes the fibrin mesh network of a blood clot by
Action : Works with Factor X to activate prothrombin helping fibrin strands to link to each other. Therefore it also helps
(prothrombin activator). to prevent fibrin breakdown (fibrinolysis).

Factor VII Prekallikrein

Name : Proconvertin / Serum prothrombin conversion accelerator Source : Liver

(SPCA) / stable factor Pathway : Intrinsic
Source : Liver Actions : Works with kininogen and Factor XII to activate Factor XI.
Kininogen
Source : Liver
Pathway : Intrinsic
Actions : Works with prekallikrein and Factor XII to activate Factor
XI.
Proteins involved in Blood Coagulation
The information on 21 proteins involved in blood coagulation
pathway is as follows:
Fibrinogen (factor I) consists of three polypeptide chains -
alpha, beta and gamma. It is converted to fibrin (factor Ia) by
thrombin (factor IIa). Fibrin forms a mesh around the wound
ultimately leading to blood clot. The inherited disorders caused
due to mutations in fibrinogen include afibrinogenemia
(complete lack of fibrinogen), hypofibrinogenemia (reduced
levels of fibrinogen) and hyperfibrinogenemia (dysfunctional
fibrinogen). These individuals suffer from thromboembolism.
The gene for factor I is located on the fourth chromosome.
Prothrombin (factor II) is a vitamin K-dependent serine
protease. It is enzymatically cleaved to thrombin by activated
factor X (FXa). Thrombin converts soluble fibrinogen into
insoluble fibrin. It also activates factors V, VIII, XI and XIII.
Thrombin along with thrombomodulin present on endothelial
cell surfaces form a complex that converts protein C to
activated protein C (APC). Individuals with prothrombin
deficiency have hemorrhagic diathesis. Patients may also
suffer from dysprothrombinemia or hypoprothrombinemia.
Female patients may suffer from menorrhagia.
The gene for thrombin is located on the eleventh chromosome
(11p11-q12).
Tissue factor (factor III) is also called as platelet tissue factor. It
is found on the outside of blood vessels and is not exposed to
the bloodstream. It initiates the extrinsic pathway at the site of
injury. It functions as a high-affinity receptor for factor VII. It
acts as a cofactor in the factor VIIa-catalyzed activation of
factor X to FXa.
The gene for tissue factor is located on the first chromosome.
Factor V is also referred to as proaccelerin or labile factor. It is
enzymatically inactive and acts as a cofactor to the serine
protease FXa, which in the presence of calcium ions and an
appropriate phospholipid (PL) membrane surface enhances the
activation of prothrombin to thrombin. Factor V Leiden
mutation causes factor V deficiency or parahemophilia, which
is a rare bleeding disorder. It may also lead to myocardial
infarction and deep vein thrombosis.
The gene for factor V is located on the first chromosome (1q21-
q25).
Factor VII is vitamin K-dependent serine protease. It initiates
coagulation by activating factors IX and X simultaneously with
tissue factor in the extrinsic pathway. Its deficiency may lead
to epitaxis, menorrhagia, hematomas, hemarthrosis, digestive
tract or cerebral haemorrhages.
The gene for factor VII is located on the thirteenth chromosome
(13q34-qter).
Factor VIII is also known as anti-hemophilic factor (AHF). It is a
cofactor in the activation of factor X to FXa, which is catalyzed
by factor IXa in the presence of calcium and phospholipids.
Mutations in the factor VIII gene results in hemophilia A. It is
also called classical hemophilia, an X-linked recessive
coagulation disorder. It is the most common type of
hemophilia. Pateints suffer from clinical manifestations in their
early childhood; spontaneous and traumatic bleeds continue
throughout their life.
The gene for factor VIII is located on the long arm of X
chromosome (Xq28).
Factor IX is also known as Christmas factor. It is a proenzyme
serine protease, which in the presence of calcium activates
factor X. Its deficiency cause hemophilia B or Christmas
disease. Although, the clinical symptoms of hemophilia A and B
are similar, hemophilia B is less severe than hemophilia A. High
antigen or activity levels of factor IX is associated with an
increased risk of thromboembolism.
The gene for factor IX is located on the X chromosome (Xq27.1-
q27.2).
Factor X is also known as Stuart-Prower factor. In the presence
of calcium and phospholipid, it functions in both intrinsic and
extrinsic pathway of blood coagulation. Factor X is activated to
FXa by factors IX and VII. It is the first member of the common
pathway of blood coagulation. FXa cleaves prothrombin to
thrombin. Its deficiency may cause bleeding diathesis and
hemorrhages. Patients commonly suffer from epitaxis,
gastrointestinal bleeds and hemarthrosis. Women with factor
X deficiency may be susceptible to miscarriages.
The gene for factor X is located on the thirteenth chromosome
(13q32-qter).
Factor XI is also known as plasma thromboplastin antecedent.
It is a serine protease zymogen which is activated to factor XIa
by factor XIIa. Deficiency in factor XI causes injury-related
bleeding. The disorder is sometimes referred to as hemophilia
C. Individuals with severe deficiency do not show excessive
bleeding conditions and hemorrhage normally occurs after
trauma or surgery. Female patients may experience
menorrhagia and prolonged bleeding after childbirth.
The gene for factor XI is located on the distal end on the long
arm of fourth chromosome (4q35).
Factor XII is a plasma protein, also known as Hageman factor.
It is the zymogen form of factor XIIa, which activates factor XI
and prekallikrein. Its deficiency does not cause excessive
hemorrhage due to lack of involvement of factor XIIa in
thrombin formation. However, it may increase the risk of
thrombosis, due to inadequate activation of the fibrinolytic
pathway.
The gene for factor XII is located on the tip of the long arm of
the fifth chromosome (5q33-qter).
Factor XIII or fibrin stabilizing factor is the proenzyme form of
plasma transglutaminase. It is composed of two subunits-
alpha (A) and beta (B). It is activated by thrombin into factor
XIIIa in presence of calcium. It forms ε-(γ-glutamyl)-lysyl bonds
between the fibrin chains and stabilizes the blood clot. Thus, it
reduces the sensitivity of the clot to degradation by proteases.
Genetic defects in the factor XIII gene leads to lifelong bleeding
diathesis. Patients may also suffer from intercranial bleeding
and death.
The gene for F13A is located on the sixth chromosome (6p24-
25). The F13B gene is located on the long arm of first
chromosome (1q32-32.1).
Antithrombin is also termed antithrombin III. It is an important
natural inhibitor of the activated serine proteases of the
coagulation system. It majorly inhibits factors Xa, IXa and
thrombin. It also has inhibitory effects on factors XIIa, XIa and
the complex of factor VIIa and tissue factor. Its activity is
accelerated in the presence of heparin. Based on the
functional and immunological assays, there are two types of
antithrombin deficiency: type I and type II. Type I deficiency is
characterized by reduction in the levels of antithrombin
available to inactivate the coagulation factors. In case of type II
deficiency, the amount of antithrombin present is normal, but
it does not function properly. Patients suffer from recurrent
venous thrombosis and pulmonary embolism.
The gene for antithrombin is located on the first chromosome
(1q23-25).
Plasminogen is a glycoprotein which circulates as proenzyme.
It is converted to plasmin by tissue plasminogen activator (tPA
or PLAT) in the presence of a fibrin clot. The main function of
plasmin is to dissolve the fibrin of blood clots. Plasminogen
plays important role in wound healing and the maintenance of
liver homeostasis. Deficiency in plasmin may lead to
thrombosis, as clots are not degraded adequately.
The PLG gene for plasminogen is located on sixth chromosome.
The PLAT gene for tPA is located on the eighth chromosome.
Heparin cofactor II is a serine protease inhibitor. It inhibits
thrombin and factor X. It is a cofactor for heparin and
dermatan sulphate. Mutations in this gene are associated with
heparin cofactor II deficiency, which can lead to increased
thrombin generation and a hypercoagulable state.
The gene SERPIND1 for HC-II is located on chromosome 22
(22q11).
Kallikrein is a serine protease. It exists in an inactive form
called prekallikrein, which is converted to kallikrein by factor
XIIa. Kallikrein cleaves kininogen releasing brandykinin.

Protein C is a serine protease enzyme. Its function is to
inactivate factors Va and VIIIa. It is activated by thrombin to
activated protein C (APC). APC along with protein S degrades
factors Va and VIIIa. Protein C deficiency is a rare genetic
disorder that causes venous thrombosis. There are two types
of protein C deficiency: type I and type II. Type I deficiency
results from an inadequate amount of protein C whereas type
II deficiency is characterized by defective protein C molecules.
Patients may suffer from arterial and venous thrombosis.
The PROC gene is located on the second chromosome (2q13-
q14).
The gene for plasma kallikrein is located on the fourth
chromosome (4q34-q35).
High-molecular-weight kininogen (HMWK) is also called as the
Williams-Fitzgerald-Flaujeac factor. It is enzymatically inactive
and functions as a cofactor for the activation of kallikrein and
factor XII. Kinins such as brandykinin are released from
kininogen upon activation of plasma kallikrein.
The gene for HMWK is located on the third chromosome
(3q26).

Protein S is a vitamin K-dependent plasma glycoprotein. It acts

as a cofactor to protein C, thus enhancing the inactivation of
factors Va and VIIIa. Mutations in the PROS1 gene can lead to
protein S deficiency which increases the risk of thrombosis.
There are three types of protein S deficiency: type I, type II and
type III. Type I deficiency is characterized by inadequate
amount of both free and total protein S levels. Type II
deficiency is characterized by normal protein S levels but
reduction in functional activity of protein S. Type III deficiency
is characterized by low amount of free protein S.

The PROS1 gene for protein S is located on the third

chromosome.

Protein Z plays a role in the degradation of factor Xa.

The PROZ gene is located on the thirteenth chromosome

(13q34).

von Willebrand factor (vWF) is a multimeric glycoprotein

involved in hemostasis. It supports binding of platelets to the
site of injury by forming a bridge between collagen matrix and
platelet-surface receptor complex. Hereditary or acquired
defects of vWF lead to von Willebrand disease. Patients may
suffer from bleeding diathesis, menorrhagia and
gastrointestinal bleeding.

The gene for vWF is located on short arm of the twelfth

chromosome.
PECIMEN REQUIREMENTS/CONTAINERS
Laboratory test results are dependent on the quality of the
specimen submitted. If there is any doubt or question regarding
the type of specimen that should be collected, it is imperative that
the laboratory is called to clarify the order and specimen
requirements.
Most laboratory tests are performed on serum, anticoagulated
plasma or whole blood. Please see the individual test directory
listings for specific requirements.
Plasma: Plasma: Draw a sufficient amount of blood with the
indicated anticoagulant to yield the necessary plasma volume.
Gently mix the blood collection tube by inverting 8-10 times
immediately after collection. The majority of samples require
separation of plasma from cells within two hours of
collection. However, there are few tests that require separation
within 15-30 minutes. Please refer to our laboratory test
directory for additional information. All specimens must be
delivered to the laboratory within 4 hours of collection.
Serum: Draw a sufficient amount of blood to yield the necessary
serum volume. Invert tube 5-10 times to activate clotting. Allow
blood to clot at room temperature for 30 minutes. NOTE: Avoid
hemolysis.
Whole Blood: Draw a sufficient amount of blood with the
indicated anticoagulant. Gently mix the blood collection tube by
inverting 8-10 times immediately after collection. NOTE: Tubes
intended for whole blood analyses are not to be centrifuged and
separated.
All patient specimens must be place in biohazard bags for
transport to the laboratory.
Specimen Collection Tubes
 Gold-top serum separator tube (SST)
This tube contains a clot activator and serum gel
separator – used for various chemistry, serology, and
immunology tests. If the specimen requirement for a
test is red-top tube(s), do not use gold-top/SST tube(s).
NOTE: Invert the tube to activate the clotting; let stand
for 20-30 minutes before centrifuging for 10 minutes. If
frozen serum is required, pour off serum into plastic vial
and freeze. Do not freeze Vacutainer® tubes.
 Red-top tube, plastic
This tube is a plastic Vacutainer containing a clot
activator but no anticoagulants, preservatives, or
separator material. It is used for collection of serum for
selected laboratory tests as indicated. If the specimen
requirement for a test is red-top tube(s), do not
use gold-top/SST® tube(s), as the gel separator may
interfere with analysis.
 Red-top tube, glass
This tube is a plain glass Vacutainer® containing no clot
activators, anticoagulants, preservatives or separator
material. These tubes can be used for Blood Bank tests.
 Pink-top tube (EDTA)
This tube contains EDTA as an anticoagulant. These
tubes are preferred for blood bank tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
 Light green-top tube (lithium heparin)
This tube contains lithium heparin and gel separator
used for the collection of heparinized plasma for routine
chemistry tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
 Dark green-top tube (sodium heparin)
This tube contains sodium heparin used for the
collection of heparinized plasma or whole blood for
special tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
 Grey-top tube (potassium oxalate/sodium fluoride)
This tube contains potassium oxalate as an
anticoagulant and sodium fluoride as a preservative –
used to preserve glucose in whole blood and for some
special chemistry tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
 Lavender-top tube (EDTA)
This tube contains EDTA as an anticoagulant - used for
most hematological procedures. These tubes are
preferred for molecular tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.To
avoid RBC shrinkage due to excess EDTA (with resulting
changes in HCT and RBC indices values) and possible
dilutional effect, the tubes should be filled with the
proper amount of blood for the size of tube used. Tubes
with various draw volumes are available (2.0 mL, 3.0 mL,
5.0 mL and 0.75 mL microvettes); to assure proper ratio
of EDTA to blood, it is recommended that the tubes
contain no less than one-half of the stated volume.
 Royal blue-top tube
There are two types of royal blue-top Monoject® tubes –
one with the anticoagulant EDTA and the other
plain. These are used in the collection of whole blood or
serum for trace element analysis. Refer to the individual
metals in the individual test listing to determine the
tube type necessary.
 Yellow-top tube (ACD)
This tube contains ACD, which is used for the collection
of whole blood for special tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
 Pearl white-top tube plasma preparation tube (PPT)
This tube contains EDTA and a special polyester material
- used for the collection of plasma for molecular (PCR)
tests.
NOTE: After the tube has been filled with blood,
immediately invert the tube 8-10 times to mix and
ensure adequate anticoagulation of the specimen.
Special Collection Tubes: Some tests require specific tubes for
proper analysis. Please contact the laboratory prior to patient
draw to obtain the correct tubes for metal analysis or other tests
as identified in the individual test listings. Urine Collection

Microtainer® tubes (pediatric bullet tubes)* Random Collection: For routine and microscopic evaluation, a
clean catch or midstream specimen is preferred.

Inpatients: The patient should void a small amount of urine, which

is discarded. Collect urine in a clean container before voiding is
completed. The container should be capped, labeled and
Microtainer® tube
refrigerated.

Outpatients and Referral Patients: After collection, the transfer of

urine into preservative tubes should happen at the collection site.
Mix the urine and peel back the protective sticker on the blue cap
LighttoGreen (amber
expose or
the cannula. Light Green
Fill the tubes in this order: (without
gray for culture
Color Gold Red Lavender
clear) gel barrier)
& sensitivity, yellow-red marble top for urinalysis and non-
additive red top . The tube is filled by pushing the tube stopper
No additive w/ gel Lithium
sideHeparin w/ gel
down onto theKexposed Lithium
cannula. Each tube hasHeparin
a line
Additive No additive 2EDTA
barrier barrier
indicating the “minimum draw.” without gel barrier

Volume 0.5 mL 0.5 mL 0.5 mL

*Microtainer is a registered trademark of Becton, Dickinson and
Company
Microbiological Collection Containers
Anaerobic Transport Media: Tube with soft agar and reducing
agents designed to maintain viability of anaerobic organisms. Fluid
can be injected through the diaphragm cap into the tube. To
transport swab specimens or tissue, remove the cap, place the
specimen into the tube (break off the swab stem if needed) and
replace and tighten cap.
Blood Culture Media: Draw 20 mL of blood and aseptically
inoculate 10 mL into each of the 2 bottles: BACTEC PLUS (blue
label) and BACTEC LYTIC (purple label). Use an alcohol prep to
clean the top of each bottle before and after inoculation.
Charcoal Amies Medium With Swab: This swab is used for the
collection and transport of specimens for Bordetella isolation. The
specimen of choice is secretions collected from the posterior
nasopharynx. Culture Swab™ must be submitted for direct
examination.
Urine Collection for0.5 mL
Chlamydia/Gonorrhea .04 mLPatient must not
PCR:
have voided for at least 2 hours. The first stream of urine is
collected and submitted for testing.
24-hour Urine Collection: UCI Pathology Services provides 24-
hour urine collection containers.
Use the following procedure for the correct specimen collection
and preparation:
1. Warn the patient of the presence of potentially
hazardous preservatives in the collection container.
Instruct the patient to discard the first morning
specimen and to record the time of voiding.
2. The patient should collect all subsequent voided urine
for the remainder of the day and night. The first-
morning specimen on day two should be collected at the
same time as noted on day one.
3. Mix well before aliquoting and provide the total volume
of the 24-hour urine collection or send the complete 24-
hour collection to the laboratory.

Chlamydia Culture Transport Medium: Use the swab provided to

collect the specimen and inoculate the transport medium. If
specimen transport is delayed, refrigerate after inoculation.

Chlamydia trachomatis, MicroTrak® Direct Stain Specimen

Collection Kit: This is used in the collection of specimens for
analysis by the MicroTrak C trachomatis direct specimen test. The
kit contains slide, swabs, cytology brush, and fixative. The
directions for use are on the package.

HSV 1, HSV 2, VZV MicroTrak Direct Stain Specimen Collection

Kit: For use in the collection of specimens for analysis by the
HSV1/HSV2 and VZV direct specimen typing test. This test is for
external lesions only. The kit contains slides, swabs, fixative and
directions for use. Collection kits are available in microbiology.

Isolator Microbial Tube (adult and pediatric): These tubes are

used for the collection of blood specimens for the isolation of
fungi and mycobacteria. Transport to the laboratory at ambient
temperature.

Viral Culturette®: This sterile swab is used for the collection and
transport of herpes and viral specimens. Transport to the
laboratory on wet ice.