Challenges for complement functional assays in the clinical laboratory: From test validation to clinical interpretation

Abstract

Complement functional assays are essential first-tier tests for a gamut of disorders spanning from inborn errors of the immune system which lead to recurrent severe infections, to angioedema attacks, presentation of autoimmune disease, thrombotic microangiopathies and rare kidney disorders. These assays evaluate the activity of the three complement pathways and specific complement components, which helps in differential diagnosis and monitoring disease progression. The rising use of complement inhibitors for treating complement-mediated thrombotic microangiopathies has heightened the demand for personalized treatment plans and laboratory assessment of complement blockage. However, conducting these assays is challenging due to the labile nature of complement proteins, which necessitates strict handling protocols—prompt processing, cold centrifugation, and preferable storage at −80 °C. Currently, the only FDA-approved complement functional test is the classical pathway activity assay while other tests are categorized as laboratory developed tests (LDTs). Validation of LDTs requires thorough evaluation of precision, accuracy, reference intervals, clinical reportable ranges, analytical sensitivity, and specificity. Achieving harmonization across laboratories is critical but heavily relies on the methodologies and calibrators used. This article discusses the various challenges and limitations associated with complement functional assays, highlighting the need for standardization and improved practices in clinical laboratories.