Total complement activity

Total complement activity, often denoted as CH50 or total hemolytic complement, measures the functional capacity of the classical complement pathway in serum by determining the dilution required to achieve 50% lysis of antibody-sensitized sheep red blood cells.^[1] This assay serves as a primary screening tool to evaluate the overall activity of complement proteins C1 through C9, which are essential for the pathway's role in innate immunity.^[2] Low levels indicate potential deficiencies or excessive consumption of these proteins, though reference ranges can vary by laboratory.^[3] The complement system itself comprises more than 30 soluble and cell-bound proteins that form a proteolytic cascade, amplifying immune responses by promoting opsonization, inflammation, and direct lysis of pathogens.^[4] Activated through classical, alternative, or lectin pathways, it bridges innate and adaptive immunity, clearing immune complexes, damaged cells, and microbes while regulating processes like B-cell activation and tolerance.^[5] Dysregulation or deficiency in this system can lead to increased susceptibility to infections, autoimmune diseases, or hereditary conditions such as systemic lupus erythematosus (SLE) and meningococcal disease.^[3] In clinical practice, total complement activity testing is indicated for diagnosing complement deficiencies, monitoring immune complex-mediated disorders, and assessing therapeutic responses in conditions like SLE or cryoglobulinemia.^[3] The CH50 assay, performed via spectrophotometric measurement of hemoglobin release after incubation, provides a functional rather than quantitative assessment, distinguishing it from individual protein immunoassays.^[1] Complementary tests like AH50 evaluate the alternative pathway, and together they guide targeted investigations into pathway-specific defects.^[3] Limitations include variability due to sample handling, acute-phase reactant influences, and insensitivity to certain isolated deficiencies, necessitating confirmatory testing.^[1]

Overview and Background

Definition and Purpose

Total complement activity refers to the overall functional efficiency of the complement cascade, a key component of the innate immune system that amplifies antibody-mediated responses and promotes pathogen clearance. It is quantified through hemolytic assays that measure the serum dilution required to achieve 50% lysis of antibody-sensitized sheep red blood cells, with the CH50 assay specifically evaluating the classical pathway's capacity involving components C1 through C9.^[6][1] This approach assesses the integrated activity of multiple complement proteins rather than their individual concentrations, providing a broad indicator of the system's operational integrity.^[7] The primary purpose of measuring total complement activity is to screen for deficiencies in complement components, excessive consumption due to immune complex formation in autoimmune diseases, or potential hyperactivity in certain inflammatory conditions. Introduced as a diagnostic tool in mid-20th-century immunology, it enables clinicians to identify disruptions in complement function that may underlie susceptibility to infections, autoimmune disorders, or hereditary conditions.^[8][9] Historically, the hemolytic assay for total complement activity was first formalized in the 1950s through foundational work on complement-mediated hemolysis, with key developments including Rice et al. (1952) and further standardization in the 1960s, distinct from earlier methods that focused on isolated protein quantifications.^[10][11][12] Pioneered in experimental immunochemistry, this assay shifted emphasis toward functional evaluation, allowing for the detection of pathway defects even when protein levels appear normal. By integrating the sequential activation of complement proteins—such as the recognition, initiation, amplification, and membrane attack phases—it offers a practical means to gauge the system's health without dissecting each element individually.^[2]

Complement System Fundamentals

The complement system comprises approximately 30 soluble and membrane-bound proteins primarily circulating in plasma, functioning as a key component of innate immunity by enhancing pathogen clearance through opsonization, inflammation, and direct cell lysis via proteolytic cascades.^[13] These proteins, mostly synthesized by hepatocytes in the liver, interact in a tightly regulated manner to amplify immune responses, bridging innate and adaptive immunity while preventing excessive damage to host tissues.^[14] Levels of complement proteins can vary due to genetic factors, such as hereditary deficiencies, as well as age-related changes and inflammatory states, which influence their production and activity.^[15] The system is activated through three primary pathways: the classical pathway, triggered by antibody-antigen complexes or direct C1q binding to pathogen surfaces; the alternative pathway, initiated spontaneously by low-level hydrolysis of C3 on foreign surfaces; and the lectin pathway, activated by mannose-binding lectin recognizing microbial carbohydrates.^[16] All pathways converge at the formation of C3 convertase enzymes, which cleave C3 into C3a (an anaphylatoxin promoting inflammation) and C3b (facilitating opsonization and further amplification).^[17] Terminal activation involves the assembly of C5b-9 into the membrane attack complex (MAC), a pore-forming structure that lyses target cells; deficiencies in components C1 through C9 can impair this process and reduce overall complement activity.^[18] In biological contexts, the complement system mediates innate defense against infections, clears apoptotic cells and immune complexes, and modulates adaptive immunity by enhancing antigen presentation.^[19] Dysregulation, such as overactivation or deficiencies, is associated with heightened susceptibility to infections or autoimmune conditions, underscoring its dual role in protection and potential pathology.^[20] Total complement activity assays, such as CH50 for the classical pathway and AH50 for the alternative pathway, quantify functional integrity by measuring hemolytic capacity.^[17]

Assay Methods

CH50 Assay (Classical Pathway)

The CH50 assay measures the functional activity of the classical complement pathway by quantifying the serum dilution that results in 50% lysis of antibody-sensitized sheep erythrocytes. This hemolytic assay evaluates the coordinated action of all nine complement components (C1 through C9) in the classical pathway, initiated by antigen-antibody complexes. Sheep red blood cells (RBCs) are sensitized with rabbit anti-sheep RBC IgM (hemolysin), which binds to the RBC surface and activates C1q to trigger the cascade, culminating in the formation of the membrane attack complex (MAC) and cell lysis. The degree of hemolysis is determined spectrophotometrically by measuring released hemoglobin absorbance at 412 nm or 540 nm after incubation and centrifugation.^[1] The assay requires the full complement of classical pathway proteins, including the recognition complex C1 (C1q, C1r, C1s), activators C4 and C2, central component C3, and terminal components C5 through C9. Standardized sheep RBCs serve as the target cells, providing a consistent substrate for hemolysis, while the IgM hemolysin ensures specific antibody-mediated initiation that bypasses the alternative pathway. Complement activity is expressed in hemolytic units (CH50 U/mL), representing the volume of serum needed to lyse 50% of a standard RBC suspension under defined conditions. This setup assesses the functional synergy of components rather than individual protein levels, making it sensitive to inherited or acquired deficiencies across the pathway.^[1][21] From a technical standpoint, the antibody-dependent activation in the CH50 assay distinguishes it from antibody-independent methods, highlighting defects in early recognition (C1-C4) or lytic phases (C5-C9) through reduced hemolytic efficiency. Serial dilutions of patient serum are mixed with sensitized RBCs in veronal-buffered saline containing calcium and magnesium ions, essential for cascade initiation and amplification. Post-incubation, unlysed cells are pelleted, and supernatant absorbance correlates with lysis percentage, plotted against dilution to identify the 50% endpoint. The assay's sensitivity to pathway defects arises from the requirement for stoichiometric interactions among components, where even partial reductions can impair overall activity.^[2][1] Standardization of the CH50 assay involves calibration against a reference serum with known activity, reporting results as a titer (reciprocal dilution) or percentage hemolysis relative to the control. Normal adult ranges vary by laboratory but are typically 41–90 U/mL, reflecting full pathway functionality. Values are calculated using the dilution achieving 50% lysis, ensuring reproducibility across assays.^[22][23] The key equation for determining the CH50 titer is the reciprocal of the serum dilution factor at which 50% hemolysis occurs. For instance, if 50% lysis is achieved at a 1:100 dilution, the titer is 100 U/mL. $$\text{CH50 titer (U/mL)} = \frac{1}{\text{dilution factor at 50\% lysis}}$$CH50 titer (U/mL)=dilution factor at 50% lysis1​

AH50 Assay (Alternative Pathway)

The AH50 assay evaluates the functional integrity of the alternative complement pathway by quantifying the serum dilution necessary to lyse 50% of unsensitized rabbit erythrocytes, which serve as activators due to their surface properties that promote spontaneous pathway initiation.^[24] This antibody-independent hemolytic assay measures total alternative pathway activity, providing a screening tool for deficiencies in this cascade.^[25] Unlike the classical pathway, activation begins with the spontaneous hydrolysis of C3 (known as "tick-over"), generating C3(H2O) that binds factor B in the presence of factor D, forming an initial C3 convertase; this is amplified on the erythrocyte surface by factors B, D, and properdin to deposit C3b and proceed through the terminal components.^[26] The assay requires intact alternative pathway initiators—factors B, D, and properdin—along with shared downstream components C3 through C9 for membrane attack complex formation and cell lysis.^[27] Technical execution involves a magnesium-EGTA buffer to chelate calcium ions, selectively blocking classical and lectin pathway activation while enabling magnesium-dependent alternative pathway function; rabbit erythrocytes are used as targets because they more readily support alternative pathway amplification compared to human cells.^[28] This setup enhances sensitivity to disruptions in C3 or terminal components (C5-C9), as the alternative pathway's feedback amplification loop magnifies even partial deficiencies, allowing distinction from classical pathway defects (as assessed in the CH50 assay).^[29] Standardization of the AH50 expresses results in units per milliliter (U/mL), where one unit represents the reciprocal of the serum dilution achieving 50% lysis under defined conditions (e.g., 1.5 × 10^7 rabbit erythrocytes per mL reaction volume).^[28] The titer is calculated as follows: \text{AH50 (U/mL)} = \frac{1}{\text{dilution factor at 50% lysis}} For instance, a dilution of 1:80 yielding 50% hemolysis corresponds to 80 U/mL.^[24] Normal reference ranges vary by laboratory due to lack of full harmonization but are commonly 77-159 U/mL in healthy adults.^[30]

Procedures and Protocols

CH50 Procedure

The CH50 procedure is a hemolytic assay that quantifies total complement activity through the classical pathway by measuring the dilution of serum required to achieve 50% lysis of antibody-sensitized sheep red blood cells (EA cells).^[31] This method relies on the formation of the membrane attack complex initiated by antigen-antibody complexes on the cell surface, leading to hemoglobin release measurable by spectrophotometry.^[1]

Materials

Key reagents include sheep red blood cells (SRBC) sensitized with rabbit anti-sheep erythrocyte IgM (hemolysin) to form EA cells at a concentration of approximately 1 × 10^8 to 5 × 10^8 cells/mL, gelatin-veronal buffer (GVB or VBS) supplemented with Ca^{2+} and Mg^{2+} (typically 0.15 mM CaCl_2 and 0.5 mM MgCl_2, pH 7.3-7.5), and serial dilutions of patient serum ranging from 1:2 to 1:1024 in the buffer.^[31][1] Additional items encompass complement reference standards (positive and negative sera with known CH50 values), distilled water for total lysis controls, and equipment such as test tubes or 96-well plates, a 37°C incubator or water bath, centrifuge, and spectrophotometer.^[32]

Procedure Steps

1. Prepare serial twofold dilutions of the test serum in GVB, starting from 1:2 up to 1:1024 (e.g., 100 µL serum in 100 µL buffer per well or tube, transferring 100 µL successively).^[1]
2. Add an equal volume of sensitized EA cells (e.g., 100-200 µL containing 5 × 10^7 cells) to each dilution.^[31]
3. Incubate the mixtures at 37°C for 60 minutes, with gentle mixing every 10-15 minutes to ensure uniform reaction.^[31]
4. Stop the reaction by adding EDTA (10 mM final concentration) to chelate divalent cations and halt complement activation, or use a commercial stop solution in kit-based protocols.^[32]
5. Centrifuge samples at 400-1,500 × g for 5-10 minutes to pellet unlysed cells, then transfer 100 µL of supernatant to a new plate or cuvette.^[1]
6. Measure absorbance of the supernatant at 412-541 nm to quantify released hemoglobin, with 415 nm common in microplate formats.^[32][31]

Controls

Include a total lysis control by treating EA cells with distilled water or hypotonic buffer to achieve 100% hemolysis, a no-lysis (spontaneous release) control using buffer alone with cells, and positive/negative serum standards to validate assay performance and calculate units (CH50 U/mL as the reciprocal of the dilution yielding 50% lysis).^[1] These controls ensure the % hemolysis = (sample absorbance - blank absorbance) / (total lysis absorbance - blank absorbance) × 100, plotted against log dilution for interpolation.^[31]

Safety and Quality Considerations

Perform the assay under biosafety level 2 conditions due to handling of potentially infectious human serum and animal blood products, using gloves, eye protection, and proper waste disposal.^[1] Ensure SRBC freshness by using cells prepared within 1-2 weeks and stored at 4°C, validating new batches against reference sera for consistent sensitization (optimal hemolysin dilution yielding sharp titration curves).^[33] Automate dilutions and readings where possible using microplate systems to enhance reproducibility and reduce variability from manual pipetting.^[32] The procedure typically requires 2-3 hours, including preparation (30-45 minutes), incubation (60 minutes), and analysis (30-45 minutes), though kit-based or ELISA variants (e.g., using neoantigen detection instead of hemolysis) can shorten hands-on time to under 2 hours while maintaining functional assessment.^[31][32]

AH50 Procedure

The AH50 procedure evaluates the functional activity of the alternative complement pathway by measuring the ability of diluted human serum to lyse unsensitized rabbit red blood cells (RBCs) in a buffer that selectively inhibits the classical pathway.^[34] This hemolytic assay quantifies total alternative pathway activity through serial serum dilutions, with results expressed as the reciprocal of the dilution achieving 50% hemolysis (AH50 units).^[35]

Materials

Key reagents include unsensitized rabbit RBCs (typically at 1-3 × 10^9 cells/mL after washing in Ca²⁺/Mg²⁺-free phosphate-buffered saline), Mg-EGTA buffer (e.g., 8-10 mM EGTA and 2-5 mM MgCl₂ or MgSO₄ in veronal-buffered saline to chelate Ca²⁺ and block classical pathway activation while permitting alternative pathway function), serial dilutions of patient serum or plasma (starting from 1:2 to 1:32 or higher), EDTA solution (25 mM for stopping reactions), and lysis controls such as distilled water or hypotonic buffer for 100% hemolysis.^[34][35] Spectrophotometric measurement requires a microplate reader set to 412-415 nm to detect released hemoglobin.^[35]

Procedure Steps

1. Prepare serial twofold or custom dilutions of serum in Mg-EGTA buffer (e.g., 50 μL per well in a 96-well round-bottom microplate) to span the expected activity range.^[35]
2. Add an equal volume (e.g., 50 μL) of washed rabbit RBC suspension to each well containing diluted serum.^[34]
3. Incubate the mixture at 37°C for 30-60 minutes to allow alternative pathway-mediated hemolysis.^[35][34]
4. Terminate the reaction by adding EDTA-containing stop solution (e.g., 100-115 μL of 25 mM EDTA) to chelate ions and halt complement activation.^[34]
5. Centrifuge the plate (e.g., 400-1800 × g for 5-10 minutes) to pellet unlysed RBCs, then transfer 100 μL of supernatant to a flat-bottom microplate.^[35]
6. Measure absorbance at 412-415 nm; calculate percent hemolysis as [(sample OD - blank OD) / (100% lysis OD - blank OD)] × 100, and determine AH50 via linear regression of log(dilution) versus percent hemolysis to find the 50% point.^[35][34]

Controls

Include a full lysis control (e.g., RBCs in distilled water or lysis fluid for 100% hemolysis), a buffer blank (Mg-EGTA buffer alone for 0% hemolysis and baseline OD correction), and reference sera such as known high-activity normal human serum or deficient controls (e.g., heat-inactivated serum at 56°C for 30 minutes) to validate assay performance and calibrate units.^[35] These ensure reproducibility, with reference curves generated from serial dilutions of standardized plasma.^[35]

Variations

Zymosan, a yeast-derived activator, is occasionally added (e.g., 1-10 mg/mL pre-incubated with serum) to enhance alternative pathway initiation on rabbit RBCs, particularly in low-activity samples or for studying activation thresholds.^[34] Automated microplate-based kits reduce manual variability compared to traditional tube assays, enabling higher throughput while maintaining sensitivity.^[35] Chicken or guinea pig erythrocytes may substitute for rabbit RBCs in some protocols to alter surface reactivity.^[26]

Considerations

The alternative pathway components are more labile than those in the classical pathway, necessitating fresh serum processing (ideally within 1-2 hours of collection on ice, with aliquots frozen at -70°C if delayed) to prevent factor decay from spontaneous activation or proteolysis.^[25] Assays should be performed in duplicate or triplicate, with pipetting precision critical to avoid variability in hemolysis readings.^[35]

Interpretation of Results

Normal Reference Ranges

The normal reference ranges for total complement activity, as measured by CH50 and AH50 assays, are established through studies of healthy populations and vary by laboratory due to differences in assay methodologies, such as hemolytic titration or enzyme-linked immunosorbent assays.^[23][36] These ranges typically represent the central 95% confidence interval of values from unaffected donors, ensuring they capture physiological variability while excluding extremes.^[25] For the CH50 assay, which evaluates classical pathway function, adult normal values are generally 41–95 U/mL, though some labs report 38.7–89.9 U/mL depending on calibration standards.^[23][37] In pediatric populations, ranges are similar but may start lower in neonates (approximately 50% of adult levels) and approach adult norms by early childhood, with one reference indicating 30–75 U/mL across ages.^[2][38] CH50 activity shows a positive correlation with age in healthy adults, increasing gradually without significant sex-based differences.^[39] The AH50 assay, assessing alternative pathway activity, is often expressed as a percentage of a reference standard, with normal results at ≥46% activity in adults.^[36] Equivalent unit-based ranges in healthy adults are 77–159 U/mL, with pediatric values showing comparable adjustments to CH50, though specific age-stratified data are limited.^[30] Unlike CH50, AH50 levels are lower in females than males and also increase with age.^[39] Ranges for both assays can be reported as hemolytic titers (dilution achieving 50% lysis), percentage hemolysis relative to controls, or standardized units, with lab-specific protocols aligned to international references like those from the World Health Organization for consistency.^[25] In healthy individuals, CH50 and AH50 values are typically balanced at a ratio near 1:1, providing a baseline for detecting isolated pathway defects when one falls outside normal limits.^[8]

Abnormal Findings (Low and High Levels)

Low total complement activity, as measured by CH50 or AH50 assays, typically indicates either a genetic deficiency in complement components or acquired consumption due to excessive activation. Genetic deficiencies, such as null mutations in C2 or C3, result in reduced production of functional proteins, leading to persistently low levels across affected pathways.^[8] Acquired consumption occurs when complement is depleted during immune complex-mediated processes, such as flares in autoimmune conditions like systemic lupus erythematosus (SLE).^[40] Diagnostic patterns in CH50 and AH50 results help localize defects within the complement system. An isolated low CH50 with normal AH50 suggests a deficiency in early classical pathway components (C1, C2, or C4).^[8] Conversely, a low AH50 with normal CH50 points to an issue in the early alternative pathway, such as deficiencies in factor B, factor D, or properdin.^[41] When both CH50 and AH50 are low, this pattern implicates a defect in the common or terminal pathway (C3 through C9).^[27] Serial monitoring of these assays is essential to detect trends, such as progressive decline during active disease or stabilization post-treatment.^[42] A level below 20% of predicted activity in CH50 or AH50 is often considered diagnostically significant, warranting further investigation, though repeat testing is recommended to confirm results and rule out technical artifacts.^[8] Distinguishing functional activity from antigenic protein levels is crucial; low functional activity (e.g., reduced CH50) alongside normal antigenic levels of specific components may indicate the presence of inhibitors or dysfunctional proteins rather than absolute deficiency.^[42] High total complement activity is rare and less clinically emphasized than low levels. Elevated CH50 or AH50, such as CH50 exceeding 150 U/mL in some reference systems, may reflect hyperfunction and is occasionally observed in acute inflammatory states or certain malignancies, including B-cell cancers.^[43] In these scenarios, increased complement production serves as part of the acute-phase response, though it does not typically alter management unless linked to underlying pathology.^[6]

Clinical Applications

Indications for Testing

Total complement activity testing, encompassing both CH50 (classical pathway) and AH50 (alternative pathway) assays, is primarily indicated in the evaluation of suspected complement deficiencies, particularly in patients presenting with recurrent bacterial infections such as meningococcal meningitis or infections caused by encapsulated organisms like Streptococcus pneumoniae.^[9][44] These tests serve as initial screening tools to identify functional defects in the complement pathways, guiding further component-specific investigations when levels are low.^[45] In autoimmune diseases, testing is recommended for monitoring disease activity, especially in systemic lupus erythematosus (SLE) and vasculitis, where complement consumption due to immune complex formation can lead to reduced activity levels during flares.^[46] Complement assessment is used in monitoring disease activity in SLE, particularly in guidelines for classification and specific manifestations like lupus nephritis, alongside tools like SLEDAI.^[47] Similarly, in hypocomplementemic urticarial vasculitis and other immune complex-mediated vasculitides, CH50 testing helps confirm pathway involvement.^[46] Screening is advised for individuals with a family history of hereditary complement deficiencies, as well as in cases of unexplained renal disease or glomerulonephritis, including membranoproliferative glomerulonephritis and poststreptococcal glomerulonephritis, where alternative pathway dysregulation may be implicated.^[23][9] For hereditary angioedema due to C1-inhibitor deficiency, to confirm involvement of the classical pathway alongside low C4 levels.^[6] Additional indications include post-transplant monitoring in kidney recipients to detect complement activation associated with rejection or thrombotic microangiopathy, and evaluation of immune complex disorders such as cryoglobulinemia, where low CH50 levels indicate active disease.^[48][49] Testing is typically performed at baseline for at-risk patients and repeated during clinical flares or suspected exacerbations, but is not recommended as a routine screen in general health checkups.^[46] If pathway specificity is required, both CH50 and AH50 should be assessed concurrently.^[45]

Associated Conditions and Diseases

Abnormal total complement activity is associated with a variety of conditions and diseases, primarily manifesting as reduced levels due to consumption or genetic deficiencies, though elevations can occur in certain inflammatory states. In systemic lupus erythematosus (SLE), low CH50 levels reflect consumption through classical pathway activation during active disease flares, frequently accompanied by reduced C4 concentrations. This pattern aids in monitoring disease activity, with hypocomplementemia observed in approximately 25-50% of active SLE cases. Post-streptococcal glomerulonephritis often presents with low C3 levels leading to decreased AH50 and CH50, resulting from alternative pathway activation by streptococcal antigens during the acute phase. Hereditary angioedema due to C1-inhibitor deficiency typically shows low CH50 during attacks, stemming from uncontrolled classical pathway initiation, while C4 remains persistently low even in remission. Inherited complement deficiencies are present in a subset of SLE cases and contribute to monitoring challenges, particularly of early classical components. Complement deficiency syndromes further link reduced total activity to increased infection susceptibility. C3 deficiency, a central component shared by all pathways, causes profoundly low CH50 and AH50 levels and predisposes individuals to recurrent pyogenic infections, such as those caused by encapsulated bacteria like Streptococcus pneumoniae, often beginning in early childhood. Defects in terminal complement components (C5-C9) impair the membrane attack complex, resulting in low activity in both assays downstream of C3 and heightened vulnerability to neisserial infections, including recurrent meningococcal disease, with recurrence rates up to 50% in affected individuals. Elevated total complement activity is less common but observed in specific contexts, such as the acute phase response where increased hepatic synthesis of complement proteins like C3 and C4 can raise CH50 levels during inflammation or infection. In ulcerative colitis, heightened complement activation and potential increases in total hemolytic activity have been noted in active disease, contributing to mucosal inflammation. Certain cancers, including lymphomas, may exhibit elevated complement components or activity as part of tumor-associated immune responses, though this varies by subtype and stage. Disease-specific patterns highlight pathway-selective abnormalities; for instance, both CH50 and AH50 are often low in severe infections or sepsis due to widespread consumption and activation across pathways. Isolated low AH50 occurs in paroxysmal nocturnal hemoglobinuria (PNH) from alternative pathway dysregulation on deficient cell surfaces and in atypical hemolytic uremic syndrome (aHUS) due to uncontrolled C3 convertase activity leading to endothelial damage. Inherited complement deficiencies collectively have a prevalence of approximately 0.03% (1 in 3,333) in the general population, with individual component deficiencies rarer, such as C2 deficiency at about 1 in 20,000. Recent therapeutic advances, including complement inhibitors like eculizumab for complement-driven complications in SLE nephritis, highlight the need for pathway-specific testing in monitoring responses as of 2023 EULAR updates.^[47]

Limitations and Advances

Factors Influencing Assay Results

Several biological factors can influence total complement activity measurements, independent of pathological conditions. Complement activity tends to increase with age, with studies showing higher classical pathway (CH50) levels in adults compared to younger individuals, as CH50 rises progressively from infancy to reach adult norms by around 6-18 months and continues to elevate modestly thereafter. In children, levels are often higher relative to newborns but stabilize or slightly exceed adult ranges by adolescence. Sex differences also exist, with females exhibiting lower alternative pathway activity than males, though classical pathway (CH50) activity shows no significant sex-based variation in healthy populations. Pregnancy elevates total complement activity, particularly in the second and third trimesters, due to increased synthesis of complement proteins like C3 and C4, leading to higher CH50 titers compared to non-pregnant states. Circadian variations are minimal or absent for CH50, with no significant rhythm observed in serum levels of total hemolytic activity, C3, or C4 across day-night cycles. Ethnic differences may contribute to variability, as East Asian populations often display lower classical pathway activity due to higher prevalence of C4A gene copy number deficiencies, which reduce overall CH50 levels compared to European or African ancestries. Pre-analytical variables are critical, as complement proteins are highly labile and prone to in vitro activation or degradation. Proper sample handling requires separation of serum within 1 hour of collection, followed by freezing at -70°C or -80°C to preserve activity; delays or storage at higher temperatures (e.g., room temperature or 4°C) can lead to rapid CH50 decline, with up to 50% loss within days. Hemolysis causes optical interference due to released hemoglobin, which increases baseline absorbance and leads to falsely elevated CH50 results, while lipemia obscures spectrophotometric readings in hemolytic assays, leading to inaccurate quantification.^[1] EDTA anticoagulation should be avoided for CH50 testing, as it chelates essential ions like Ca²⁺ and Mg²⁺, inhibiting the classical pathway more than the alternative. Physiological states and interventions can transiently alter measurements. Acute inflammation boosts hepatic synthesis of complement proteins, elevating CH50 levels as part of the acute-phase response. Certain medications suppress activity; for instance, glucocorticoids like dexamethasone inhibit complement activation by interfering with C3 convertases and reducing synthesis of components such as C2 and factor B. Technical factors introduce variability in assay outcomes. Inter-laboratory coefficients of variation (CV) for CH50 typically range from 15-20%, stemming from differences in sheep erythrocyte sensitization, reagent lots, and endpoint detection methods (e.g., hemolytic vs. liposome-based). Buffer pH is particularly sensitive, with values below 7.1 promoting spontaneous complement activation and artificially high readings, necessitating strict maintenance of optimal pH (around 7.4) with divalent cations. For borderline results, repeat testing is recommended to account for these confounders, and harmonization efforts since the 2010s, including external quality assurance programs by groups like the Complement EQA, have reduced discrepancies through standardized protocols and reference materials.

Modern Developments and Alternatives

In recent years, enzyme-linked immunosorbent assay (ELISA)-based methods have emerged as robust alternatives to traditional hemolytic assays for assessing total complement activity, offering pathway-specific evaluation of classical, alternative, and lectin pathways. The Wieslab complement kits, developed in the early 2000s, utilize ELISA technology to measure functional complement activation through detection of terminal complement complex (C5b-9) deposition, providing qualitative and semi-quantitative results with reduced variability and faster turnaround times compared to CH50 and AH50 procedures.^[50][51] These assays address limitations of hemolytic methods by eliminating the need for sheep erythrocytes, thereby minimizing biohazards and improving reproducibility in clinical settings.^[52] Flow cytometry-based assays represent another advancement, enabling precise quantification of membrane attack complex (MAC) deposition on sensitized cells or beads, which serves as a direct indicator of complement activation. This approach, refined in the 2010s and 2020s, offers high sensitivity for detecting subtle deficiencies, particularly in rare complement disorders, and supports high-throughput screening without reliance on lysis endpoints.^[53] It has proven valuable for confirming functional impacts in patients with suspected primary immunodeficiencies, where traditional assays may lack resolution.^[54] Integration of next-generation sequencing (NGS) panels with functional complement assays has transformed diagnostics since the mid-2010s, especially for atypical hemolytic uremic syndrome (aHUS), by identifying pathogenic variants in complement genes such as CFH, CFI, and C3. Panels targeting 10-15 complement-related genes, implemented post-2015, allow rapid variant detection, with subsequent functional testing (e.g., via ELISA or flow cytometry) to classify variants of unknown significance and correlate genotypes with activity levels.^[55][56] This combined strategy enhances precision in guiding therapies like complement inhibitors. Emerging multiplex immunoassays, such as Luminex-based panels, enable simultaneous profiling of multiple complement components and activation products (e.g., C3a, C5a, sC5b-9) from a single sample, facilitating comprehensive "complementomics" analysis. These high-throughput tools, advanced in the late 2010s and 2020s, support detailed phenotyping of deficiencies and monitoring of therapeutic responses, surpassing the scope of single-pathway hemolytic tests.^[57][58] For the alternative pathway, targeted assays for factor B function provide a specific alternative to AH50, measuring hemolytic or enzymatic activity to isolate defects in early components.^[25][59] These modern methods collectively offer advantages including higher throughput, decreased reliance on animal-derived reagents, and enhanced safety profiles, making them suitable for routine clinical use and research.^[60] However, challenges persist, such as limited standardization across novel assays and the need for validated protocols in diverse populations. Ongoing research focuses on their application in monitoring complement-targeted therapeutics, like eculizumab, where functional assays track blockade efficacy and breakthrough activation to optimize dosing.^[61][62] Early explorations into AI-driven pattern recognition for integrating genetic, proteomic, and functional data show promise in predictive diagnostics, though clinical trials remain in preliminary stages as of the 2020s.^[63]