| |

Received: 1 July 2020    Revised: 2 September 2020    Accepted: 7 September 2020

DOI: 10.1111/ijlh.13349

REVIEW

Standardization of Prothrombin Time/International Normalized

Ratio (PT/INR)

Akbar Dorgalaleh1  | Emmanuel J. Favaloro2  | Mehran Bahraini1  | Fariba Rad3,4

1
Department of Hematology and Blood
Transfusion, School of Allied Medicine, Iran Abstract
University of Medical Sciences, Tehran, Iran The prothrombin time (PT) represents the most commonly used coagulation test
2
Department of Haematology, Sydney
in clinical laboratories. The PT is mathematically converted to the international
Centres for Thrombosis and Haemostasis,
Institute of Clinical Pathology and Medical normalized ratio (INR) for use in monitoring anticoagulant therapy with vitamin K
Research, NSW Health Pathology,
antagonists such as warfarin in order to provide test results that are adjusted for
Westmead Hospital, Westmead, NSW,
Australia thromboplastin and instrument used. The INR is created using two major PT ‘correc-
3
Cellular and Molecular Research Center, tion factors’, namely the mean normal PT (MNPT) and the international sensitivity
Yasuj University of Medical Sciences, Yasuj,
Iran
index (ISI). Manufacturers of reagents and coagulometers have made some efforts
4
Blood Transfusion Research Center, High to harmonizing INRs, for example, by tailoring reagents to specific coagulometers
Institute for Research and Education in and provide associated ISI values. Thus, two types of ISIs may be generated, with
Transfusion Medicine, Tehran, Iran
one being a ‘general’ or ‘generic’ ISI and others being reagent/coagulometer-specific
Correspondence ISI values. Although these play a crucial role in improving INR results between labo-
Fariba Rad, Cellular and Molecular Research
Center, Yasuj University of Medical Sciences, ratories, these laboratories reported INR values are known to still differ, even when
Yasuj, Iran. laboratories use the same thromboplastin reagent and coagulometer. Moreover, ISI
Email: [email protected]
values for a specific thromboplastin can vary among different models of coagulom-
Funding information eters from a manufacturer using the same method for clot identification. All these
Yasuj University of Medical Sciences
factors can be sources of error for INR reporting, which in turn can significantly af-
fect patient management. In this narrative review, we provide some guidance to ap-
propriate ISI verification/validation, which may help decrease the variability in cross
laboratory reporting of INRs.

KEYWORDS

coagulation factors, harmonization, hemostasis, INR, prothrombin time, standardization

1 |  I NTRO D U C TI O N by the coagulation cascade, was first proposed scientifically in the
1960’s, and divided into two pathways, one reflected by tissue factor
The prothrombin time (PT) represents the most commonly used co- activation of FVII (PT), and the other reflecting activation of the con-
agulation test and was first introduced into use by Dr Armand Quick tact pathway (APTT, activated partial thromboplastin time). These
and colleagues in 1935.1 The PT is a single-stage screening test used pathways converge to a common pathway, becoming linked through
to evaluate the tissue factor (TF) and common coagulation path- the production of thrombin by prothrombinase complex and the
ways, and thus is affected by the activity of coagulation factors II conversion of fibrinogen to fibrin by thrombin. 2-4
2
(FII), V (FV), VII (FVII), X (FX), and fibrinogen. The test measures the Recent studies indicate that the TF pathway reflects the major
time (in seconds) required for clot formation after thromboplastin re- driver of in vivo coagulation. 2,5-7 A prolonged PT might be due to one
agent (a mixture of TF, lipids, and calcium chloride) is added to plate- or more coagulation factor defects in the TF or common pathways,
let-poor plasma (PPP). The classic model of coagulation, as reflected or might indicate the presence of inhibitors against these factors. 2,8

Int. J. Lab. Hematol.. 2020;00:1–8. wileyonlinelibrary.com/journal/ijlh© 2020 John Wiley & Sons Ltd     1 |
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2       DORGALALEH et al.

In order to differentiate between coagulation factor deficiency and DOACs are also taken orally, but unlike VKAs, DOACs generally do
the presence of inhibitors, a mixing study is performed. If the PT not require regular laboratory monitoring of anticoagulation, and
is corrected after the addition of normal plasma, congenital, or ac- thus reflecting one of their main strengths.17,18 DOACs include fac-
quired coagulation factor(s) deficiency is implied, whereas, if the PT tor Xa inhibitors (eg, apixaban, edoxaban, and rivaroxaban) and di-
remains prolonged after the addition of normal plasma raises the rect thrombin inhibitors (dabigatran).19,20 Although various studies
8
possibility of inhibitors. Acquired defects of coagulation factors indicate general acceptance of these drugs, VKAs remain widely
prolonging the PT are commonly observed in people with vitamin used, in part due to lack of experience in, and knowledge of, the
K deficiency.9 Alternatively, vitamin K antagonists (VKAs) such as newer drugs. In addition, some patients may not be good candidates
warfarin, as prescribed to prevent thromboembolic events, hamper for DOACs,17,20,21 and also because in some countries DOACs are
gamma-carboxylation of vitamin K-dependent coagulation factors seen as prohibitory expensive compared to VKAs. Nevertheless, due
(VKDCFs) and thus reduce their activity and also prolong PT.9,10 to differences in the preparation, source, and constituents of throm-
However, in the case of VKAs, prolongation of the PT into a ther- boplastin reagents, their sensitivity to monitoring and controlling
apeutic range is desired. Given that the synthesis of most coagula- VKAs - particularly warfarin - varies greatly. This difference can be
tion factors is restricted to the liver, disorders of this organ can be large enough to require a change in patient management. Significant
associated with a decrease of most coagulation factors, resulting in increases or decreases of VKA dose can increase the risk of throm-
prolonged PT and/or APTT. Prolonged PT may also occur in patients bosis or bleeding if not appropriate to the situation.1,8,22
with acquired FX deficiency due to amyloidosis, especially amyloid Initial efforts to standardize PT test results by reporting PT re-
10,11
light-chain (AL) amyloidosis. sults as PT ratios were unable to completely resolve the issue of vari-
Thromboplastin reagent is an essential component of the PT ability.13 The PT ratio, which is the patient's PT over a mean normal
test. Thromboplastin reagent is a combination of TF, in complex with PT ratio, did not fully eliminate discrepancies between results: the
lipid surface of procoagulant membrane and calcium chloride ions. test was still affected by variations in thromboplastin and could not
Thromboplastin reagents may be derived from human or animal be used to harmonize results for patients receiving VKAs.13 The INR
tissues (brain or placenta), or through the production of recombi- instead reflects a mathematical calculation using a PT ratio as fur-
nant human TF within phospholipid vesicles.12,13 Use of different TF ther adjusted with a correction factor called the international sen-
sources leads to variation in PT results reported by different labora- sitivity index (ISI).1
tories. The significance of this emerged when North American coun-
tries used rabbit thromboplastin to monitor anticoagulation; this
[ ]ISI
Patient PT
International Normalized Ratio =
was less sensitive than the human thromboplastin reagents used in Mean Normal PT
the UK and elsewhere.13,14 Due to the lower sensitivity of the rabbit
thromboplastin, North American physicians prescribed higher doses According to WHO standards, an acceptable ISI value for throm-
of VKAs than the UK, as based on PT testing. However, the number boplastin reagents for manual methods is between 0.9 and 1.7. 20
of patients with bleeding in North American countries was about 5 However, due to a more severe decrease in FVII levels than other
times that in Britain.13,14 For this reason, attempts to better stan- vitamin K-dependent coagulation factors, INR is not an appropriate
dardize results of PT testing began in 1962, leading to the introduc- index to evaluate the patient's condition at the onset of anticoagu-
tion of British Comparative Thromboplastin (BCT) as the reference lation with VKAs. 23 Although INR is recommended for patients on
15
thromboplastin in 1969. Following the standardization process, VKAs, it is cannot harmonize PT results in patients with chronic liver
the World Health Organization (WHO) introduced the International disease. A modified INR, called INRliver is suggested by some authors
16
Normalized Ratio System (INR) in 1983. This standardization sys- for this purpose. In INRliver, plasma from patients with cirrhosis is
tem provides a simple way to interpret PT results independently of used to calculate ISI of thromboplastin used. 24
the thromboplastin used. Although the INR tries to harmonize PT results according to
process differences, the INR value is also influenced by other fac-
tors, including the type of coagulometer used and the value of the
1.1 | International normalized ratio (INR) mean normal PT (MNPT) or geometric mean normal PT (GMNPT).
Manufacturers of reagents and coagulometers have made some
Over the past few decades, anticoagulation has seen tremendous efforts to improve standardization, tailoring reagents to specific
and undeniable developments. Decades ago, patients in need of coagulometers. The reagents may designate two types of ISIs, the
anticoagulant therapy had only a few options, including VKAs, and general (or ‘generic’) ISI and the reagent/coagulometer-specific ISI. 25
unfractionated heparin (UFH) to help manage and prevent throm- Commercial thromboplastins should be assessed and calibrated
bosis.17 Nowadays, there are much broader options for improving by their manufacturers against the WHO thromboplastin interna-
treatment and quality of life in these patients. A variety of low mo- tional reference preparation (IRP). For this purpose, manual-tilt PT
lecular weight heparins (LMWHs), heparin analogs and heparin-like is typically performed, using a new or manufactured thromboplas-
compounds are available. In addition, direct oral anticoagulants tin and the reference thromboplastin, on 20 healthy subjects and
(DOACs) have now been marketed for nearly a decade. Like VKAs, 60 patients with stable conditions undergoing VKA therapy. 26 An
DORGALALEH et al. |
      3

individual is considered to be therapeutically stable when treated Although determination of reagent/coagulometer-specific ISI
27
with VKAs for at least 6 weeks. The values obtained from the man- has played a large role in improving INR standardization, INR val-
ufactured thromboplastin are plotted on the X-axis and the values ues reported by two laboratories may differ even with the same
from the reference thromboplastin on the Y-axis. The logarithm of thromboplastin reagent and coagulometer. Moreover, the ISI value
these values is calculated and a line drawn with the best fit of the of a specific thromboplastin can vary among the different models of
points obtained. The slope of the orthogonal regression line pro- coagulometers of a particular manufacturer using the same method
vides the ISI value (Figure 1). for clot identification.36,37 All these factors comprise sources of
In vitro monitoring of VKAs is required for many reasons, and the error for INR reporting, which in turn can significantly affect patient
aim is to keep the INR in the range of 2-3 for most patients. However, management.38 However, proper ISI verification and validation can
a higher INR range may be required (eg, 2.5-3.5) for some patients decrease the rate of errors.
at high risk of venous thromboembolism (VTE), and patients with
mechanical heart valves. For this reason, clinically stable patients are
usually monitored every 4-6 weeks and patients with unstable sta- 2 | TH RO M B O PL A S TI N S W ITH A
tus are monitored by PT/INR tests at shorter time intervals - every ‘ G E N E R A L’ I S I VA LU E
week or every few days. 28,29
A general (or ‘generic’) ISI refers to an ISI value that is not specific to
a particular coagulometer. This type of ISI is usually used identified
1.2 | Problems with monitoring of vitamin K for manual methods or coagulometers that use the same end-point
antagonists clot detection method, for example, a manufactured thromboplastin
for optical-based coagulometers or mechanical clot detection meth-
As mentioned earlier, a significant decrease in INR can increase the ods.39 Use of this type of ISI may lead to greater variability than rea-
risk of thrombosis, mandating higher doses of VKAs. In contrast, a gent/coagulometer-specific ISI values because even coagulometers
significant increase in INR represents an increased risk of bleeding, that use the same clot detection method do not necessarily use the
thus potentially indicating a reduction in the dose, temporarily dis- same principles (eg, differing mathematical algorithms). The error
continuing the drug, or if associated to very high bleeding risk (eg, scale of the generic ISI, if not validated in the laboratory, is typically
30
INR > 10), reversing its effect by use of an antidote. This issue, and higher than that of reagent/coagulometer-specific ISIs. General ISI
the need for regular drug monitoring, is among the accepted limita- values should never be used clinically without prior validation in the
tions in the use and administration of VKAs. However, one less ap- laboratory.39-42
preciated, but important, issue is the accuracy or inaccuracy of the
INR as reported by laboratories.31,32
Success or failure of treatment with warfarin is sometimes de- 3 | TH RO M B O PL A S TI N S W ITH R E AG E NT/
termined by estimating the “time in therapeutic range” or TTR. The COAG U LO M E TE R-S PEC I FI C I S I VA LU E S
TTR index determines how clinically stable a patient is when receiv-
ing such anticoagulants, and thus could approximately determine This type of ISI value is thromboplastin/coagulometer-specific, with
whether VKAs are appropriate for any given patient.33-35 reagents having individual ISI values for different coagulometer
models. The ISI may differ more significantly between coagulom-
eters with different clot detection methods. Sometimes this differ-
2 ence can be noted across a company's coagulometers, even with the
Log-PT with international standard

1.8 On VKA
same clot detection method.42-44 Thus, different laboratories using
identical reagents and coagulometers may identify significant differ-
1.6
ences in reporting INR values. For this reason, if the same sample is
1.4 sent to different laboratories, different INR values will be reported.
Normal
Although the difference in INR value is less than the PT value, even
1.2 ISI = slope of the existing level of variation in INR value can affect the physician's
regression line
1 decision to change the treatment dose.44-46
If the thromboplastin manufacturer does not designate a re-
0.8
0.8 1 1.2 1.4 1.6 1.8 2 agent/coagulometer-specific ISI for the model used in a laboratory,
Log-PT with working thromboplastin the laboratory should not permit use of that specific thromboplastin
for its own coagulometer without determination and verification of
F I G U R E 1   Calibration of the working thromboplastin solution
the instrument-specific ISI. In addition, each laboratory is obligated
(X-axis) against the international standard thromboplastin (Y-axis).
Each dot represents the mean PT results (normal individuals and to verify even the asserted reagent/coagulometer-specific ISI of the
patients on VKA) interpolated on logarithmic paper. The slope of manufacturer before using the PT reagent for clinical tests. In each
the regression line represents the ISI value case, if the verification process cannot confirm the asserted ISI, the
 |
4       DORGALALEH et al.

reagent cannot be used for patient testing without ISI calibration 4.2.1 | Method of laboratory ISI calculation
26,42
and verification of calibrated ISI.
This is a modification to the WHO-recommended method, and can
be used in most laboratories.50 The PT value of each certified plasma
4 |  L A B O R ATO RY I S I C A LI B R ATI O N is determined according to the reagent and the coagulometer in the
laboratory and plotted on logarithmic paper against the determined
4.1 | World Health Organization (WHO) INR for each citrated plasma. The slope of the regression line is used
recommended method to determine the laboratory ISI. Orthogonal regression is the appro-
priate regression analysis.50,51
The World Health Organization (WHO) recommends this method
for estimating ISI and GMNPT values for a new PT reagent by using
a reference thromboplastin. To determine ISI and GMNPT of a new 4.2.2 | Recommended method of the European
PT reagent, the laboratory should test the plasma of at least 20 Concerted Action on Anticoagulation (ECAA)
healthy subjects and 60 patients undergoing VKA therapy with sta-
ble clinical conditions.47 To determine MNPT, the plasma PT value Another method is to use commercial plasma with a specified INR
of 20 to 40 normal individuals is determined and its geometric mean value. In this procedure, the INR of several commercial plasma sam-
is calculated (ie, GMNPT).48 As in Figure 2, the logarithm of these ples is determined by the recommended WHO method or other, al-
numbers is plotted against the logarithm of the new PT results. The ternative methods.52 These commercial plasmas can sometimes be
ISI is calculated as 1/slope of the regression line. Alternatively, one used to determine the ISI, and perhaps even the GMNPT, for the
can replace the X- and Y-axes and then calculate the ISI based on the new reagent/coagulometer combination, or to verify or reject a man-
slope of the regression line.49 ufacturer's asserted ISI. One alternative that is also approved by the
FDA is that recommended by the ECAA Committee - the simplified
WHO method.32 In this procedure, 27 artificially reduced lyophilized
4.2 | Laboratory calibration of test system using plasmas, including 20 factor-deficient plasmas and 7 normal plasmas
certified plasma were suggested. Indeed, because of the unavailability of stabilized
patients under treatment with VKAs, the number of plasmas used
Laboratory calibration can be performed using certified plasmas one in this procedure is greater than in other methods that use these
of two different methods: patients for commercial plasma preparation. This is one of the limita-
tions of the ECAA's proposed method, which is performed manu-
1. Calculation of laboratory ISI ally with only one type of recombinant thromboplastin and a WHO
2. Direct determination of INR (calculation of PT/INR calibration human reference thromboplastin, and which may not to be suitable
line) for all PT methods or all laboratories. In addition, one of the most
important considerations when using certified or commercial plasma
Proper use of either of these methods can improve the accuracy is that one should read the plasma guidelines before purchase to
of the INR report. ensure that plasmas are suitable for the coagulometer and reagent
used in the desired laboratory. Accordingly, the certified plasma
specifies which commercial plasmas are usable for which devices.
Moreover, if a laboratory uses recombinant human thromboplastin,
1/slope = 0.92 = calculated
ISI. (Manufactured ISI = it should ensure that certified commercial plasma is also verified for
use with this type of thromboplastin.32,53
In this procedure, similarly to the WHO-recommended method,
Clinically stable patients the logarithm of the INR values obtained by commercial calibrant
on VKA therapy, n ≥ 60
plasma is plotted against the PT values obtained by the reagent/co-
Normal samples
n ≥ 20, MNPT = 12.8
agulometer combination. The ISI is calculated as 1/slope of the re-
gression line, as in the WHO method. The MNPT value is calculated
as antilog of the y value.52,53
An alternative way to calculate ISI is by using the slope of the
F I G U R E 2   How to achieve the ISI and MNPT values for a new regression line, which can be used when replacing the X- and Y-axes
reagent, based on the WHO method. The MNPT value is obtained is possible (Figure 3).
by calculating the geometric mean of at least 20 normal individuals'
This alternative is also applicable and can be used in laborato-
plasma PT results. In this example, MNPT value is 12.8. The INR
numbers are calculated by reference thromboplastin and are used ries, but it should be considered that the accuracy of this method
for deriving reference INR. The ISI value is calculated by the slope depends on the accuracy of the INR values set for commercial cali-
of regression line, which in this example is 0.92 brators by the manufacturers.
DORGALALEH et al. |
      5

2 CV of the laboratory. If this number exceeds the designated CV, the

1.9
test must be repeated for the certified plasma(s). The mean PT of
Log PT (new testing reagent)

1.8
each plasma is plotted on the Y-axis and the specified INR value of
1.7
1.6
each certified plasma is plotted on the X-axis of logarithmic paper.
1.5 Slope = 0.91; ISI for The reference line is then drawn. This reference line helps to obtain
1.4
new reagent = 1/slope = a patient INR based only on a patient's PT values, without the need
1.09
1.3 for ISI and MNPT values 54 (Figure 4).
1.2
Y-axis intercept at X = 0.0 is 1.0499; antilog
1.1 of intercept at X = 0.0 => MNPT = 11.2
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 6 | V E R I FI C ATI O N O F I N R R E S U LT S
Log INR (commercial calibrant plasma)

Specific reagent/coagulometer ISIs should be verified prior to clini-

F I G U R E 3   Demonstrates how to use commercial calibrators to
determine ISI and MNPT for a new PT reagent. The INR values set cal use in all laboratories using that ISI. For all laboratories using
for commercial plasma are considered as the reference INR values. a generic ISI, verification is required and laboratory calibration is
Logarithm of these values is plotted against the logarithm of the strongly recommended.42
PT number obtained by the reagent/coagulometer combination.
ISI, which is 1.09 in this example, is calculated as 1/slope of the
regression line. The MNPT is calculated as the antilog of the Y-axis
with the X value considered to be zero. In this example, with 7 | U SAG E O F C E RTI FI E D PL A S M A S FO R
INR = 1.0, the MNPT is 11.2 V E R I FI C ATI O N

It is recommended that at least three certified plasmas, covering the

100 therapeutic dose of INR ranging from 1.5 to 4.5, be used to verify
ISI. For some of these commercial certified plasmas, it is not pos-
sible to determine a single INR for all coagulometers. Before using
PT (sec)

these plasmas, one should read the instructions for these reagents
10
to check the possibility of using these plasmas for their own test sys-
tem (combined set of reagent and coagulometer). If a new laboratory
ISI is designated or a new calibration line is created for PT/INR, the
1 test system must be validated prior to reporting patient results.50,51
1 10
INR value

F I G U R E 4   How to obtain INR directly using commercial 8 | V E R I FI C ATI O N M E TH O D

certified plasma. In this method, PT is determined for commercial
certified plasma having an INR specified by the PT reagent and the In the verification process, one can use certified or lyophilized
laboratory coagulometer. The mean PT obtained for each verified
plasma. The certified plasma INR value must be determined by the
commercial plasma is then plotted on the Y-axis on logarithmic
reagent and device used in the laboratory and by the ISI designated
paper and the assigned number corresponding to each verified
plasma is plotted on the X-axis. The reference line is then drawn. by the manufacturer.51 When certified plasma is used for verification,
For each patient, a PT test is performed, and from the Y-axis, it should be used in duplicate tests for at least 2 days.50 According
the PT number line is connected first to the reference line, then to the International Society on Thrombosis and Haemostasis (ISTH)
perpendicular to the X-axis. The number that represents the standards, the INR obtained by the laboratory system with the INR
perpendicular line on the X-axis is the patient's INR
determined by the company should not differ more than ± 15%.51
All coagulometers used, even as support for PT testing, must be
5 | D I R EC T D E TE R M I N ATI O N O F I N R verified.52

This method of determining INR, first proposed by researchers from

France, and latter modified in Clinical and Laboratory Standards 9 | R EQ U I R E D TI M E I NTE RVA L FO R
Institute (CLSI) document, 50,54 is independent of ISI and MNPT. 54 V E R I FI C ATI O N
The PT test for commercially certified plasma is performed by a lab-
oratory coagulometer and reagent.54 The verification process should be performed for each thrombo-
This should be done within 3 days or three separate runs to min- plastin with a general ISI. It is also recommended for thromboplas-
imize day-to-day and between-runs variations. The difference be- tins with reagent/coagulometer-specific ISI. The approval process
tween the PT of a certified plasma must not exceed the permissible should be re-performed following any changes to the reagent, lot
 |
6       DORGALALEH et al.

ISI of WHO reference thromboplastin

11 | I M PAC T O F G O O D L A B O R ATO RY
PR AC TI C E (G LP) O N I N R R E S U LT S

ISI verified by manufacturer Good laboratory practice (GLP) can be considered an optimal labo-
ratory performance and ensures that INR results are correct. Best
practices should also include50:
ISI verified by laboratory
< 15% > 15%
1. Ensuring that the coagulometer is maintained and used in ac-
cordance with the conditions specified by the manufacturer.

Laboratory ISI calibration

2. Ensuring that the laboratory method used to perform PT is fully
ISI is verified
controlled. It is important to make sure that the reagents used
have not expired and all reagents are from one lot. Additionally,
Verification of laboratory ISI calibration the laboratory must ensure that ISI and MNPT values have been
correctly identified and incorporated into the INR formula.
<15%
3. Ensuring that reagents are maintained, prepared, and used in ac-
New ISI accepted
cordance with company instructions.

F I G U R E 5   ISI Calibration and Verification Process in the

Laboratory (Adopted from reference 42 with some changes)
12 | CO N C LU S I O N S

Accurate reporting of PT/INR results has a direct effect on the

number, coagulometer, or any major overhaul of the coagulometer, management of patients undergoing VKAs therapy. An appropriate
all of which can change the PT, MNPT, and ISI values. If a significant standardization process, can significantly improve the accuracy of
change in quality control results, or a severe deviation is observed reported results. Verification and if necessary, calibration of rea-
during external quality control testing, and the cause of the problem gent/coagulometer-specific, and generic ISIs, prior to clinical use is
is not identified by standard and determined methods, the verifica- mandatory, and play a crucial role in improving PT/INR results.
tion process should be initiated,.42,51
C O N FL I C T O F I N T E R E S T
The authors have no competing interests.
10 | I NTE R PR E TATI O N O F V E R I FI C ATI O N
R E S U LT S A N D CO R R EC TI V E AC TI O N S AU T H O R C O N T R I B U T I O N S
A. Dorgalaleh, F. Rad, and M. Bahraini wrote the manuscript. EJ.
Corrective measures should be considered if the results obtained for Favaloro revised the manuscript. All the authors approved the
the INR by the laboratory differ from those determined by the com- submission.
mercial plasma manufacturer (actual values) by more than ± 15%
42,51,52
(Figure 5). ORCID
Firstly, one must ensure that the coagulometer is working Akbar Dorgalaleh  https://orcid.org/0000-0002-0125-9319
properly and that the verification process has been done cor- Emmanuel J. Favaloro  https://orcid.org/0000-0002-2103-1661
rectly.42,50 If the verification process was not achieved, laboratory Mehran Bahraini  https://orcid.org/0000-0001-9735-4830
calibration of PT/INR should be performed. The verified plasma Fariba Rad  https://orcid.org/0000-0003-0709-8832
used for calibration should be different from the verified plasma
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