1
|
Warkentin TE. Immunologic Effects of Heparin Associated With Hemodialysis: Focus on Heparin-Induced Thrombocytopenia. Semin Nephrol 2023; 43:151479. [PMID: 38195304 DOI: 10.1016/j.semnephrol.2023.151479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Intermittent hemodialysis (HD) is almost invariably performed with heparin, and thus HD patients are at risk of developing the immune-mediated adverse effect heparin-induced thrombocytopenia (HIT), caused by anti-platelet factor 4/heparin IgG, which strongly activates platelets. HIT patients develop hypercoagulability with greatly increased risk of thrombosis, both venous and arterial. Certain HIT-associated complications are more likely to develop among HD patients, including hemofilter thrombosis despite heparin, intravascular catheter and/or arteriovenous fistula-associated thrombosis, post-heparin bolus anaphylactoid/anaphylactic reactions, and thrombotic stroke and acute limb artery thrombosis (reflecting the high frequency of underlying arteriopathy in many patients with renal failure). Management of HIT in HD usually requires use of an alternative (non-heparin) anticoagulant; for example, danaparoid sodium (outside the USA) or argatroban (USA and elsewhere). Whether heparin-grafted hemodialyzers (without systemic heparin) can be used safely in acute HIT is unknown. The HIT immune response is remarkably transient and usually not retriggered by subsequent heparin administration. Accordingly, since renal failure patients often require long-term HD, there may be the opportunity-following seroreversion (loss of platelet-activating HIT antibodies)-to restart heparin for HD, a practice that appears to have a low likelihood of retriggering HIT.
Collapse
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada; Service of Benign Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada.
| |
Collapse
|
2
|
Warkentin TE. Heparin-induced thrombocytopenia (and autoimmune heparin-induced thrombocytopenia): an illustrious review. Res Pract Thromb Haemost 2023; 7:102245. [PMID: 38193057 PMCID: PMC10772877 DOI: 10.1016/j.rpth.2023.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
3
|
Howick V JF, Harmon DM, McBane RD. 44-Year-Old Woman With Cough and Shortness of Breath. Mayo Clin Proc 2023; 98:1557-1563. [PMID: 37793730 DOI: 10.1016/j.mayocp.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 10/06/2023]
Affiliation(s)
- James F Howick V
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David M Harmon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Robert D McBane
- Advisor to residents and Consultant in Vascular Cardiology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
4
|
Simon ER, Rakholia M, McHenry ML, Mishra PK, Singh R, Javangula K, Minhaj MM, Chaney MA. Cardiac Surgery in a Patient With Antiphospholipid Syndrome and Heparin-Induced Thrombocytopenia. J Cardiothorac Vasc Anesth 2021; 36:1196-1206. [PMID: 34344598 DOI: 10.1053/j.jvca.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Eric R Simon
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Milap Rakholia
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA
| | - Marie LaPenta McHenry
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA
| | - Pankaj Kumar Mishra
- Department of Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
| | - Rajendra Singh
- Cardiac Anaesthesia and Critical Care, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
| | - Kalyana Javangula
- Department of Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
| | - Mohammed M Minhaj
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL.
| |
Collapse
|
5
|
Abstract
Purpose of Review This review will illustrate the importance of heparin-induced thrombocytopenia in the intraoperative and critical care settings. Recent Findings Heparin-induced thrombocytopenia (HIT) occurs more frequently in surgical patients compared with medical patients due to the inflammatory release of platelet factor 4 and perioperative heparin exposure. Recognition of this disease requires a high index of suspicion. Diagnostic tools and therapeutic strategies have been expanded and refined in recent years. Summary HIT is a condition where antibodies against the heparin/platelet factor 4 complex interact with platelet receptors to promote platelet activation, aggregation, and thrombus formation. Our review will focus on intraoperative and postoperative considerations related to HIT to help the clinician better manage this rare but often devastating hypercoagulable disease process.
Collapse
|
6
|
Droege CA, Ernst NE, Messinger NJ, Burns AM, Mueller EW. Evaluation of Thrombocytopenia in Critically Ill Patients Receiving Continuous Renal Replacement Therapy. Ann Pharmacother 2018; 52:1204-1210. [PMID: 29871503 DOI: 10.1177/1060028018779200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) may be associated with thrombocytopenia in critically ill patients. A confounding factor is concomitant use of unfractionated heparin (UFH) and suspicion for heparin-induced thrombocytopenia (HIT). OBJECTIVE To determine the impact of CRRT on platelet count and development of thrombocytopenia. METHODS Retrospective analyses evaluated the intrapatient change in platelet count following CRRT initiation. Critically ill adult patients who received CRRT for at least 48 hours were included. The primary outcome was intrapatient change in platelet count from CRRT initiation through the first 5 days of therapy. Secondary outcomes included thrombocytopenia incidence, identification of concomitant factors associated with thrombocytopenia, and frequency of HIT. RESULTS 80 patients were included. Median platelet count at CRRT initiation (D0) was 128000/µL (81500-212500/µL), which was higher than those on subsequent post-CRRT days (D1: 104500/µL [63000-166750/µL]; D2: 88500/µL [53500-136750/µL]; D3: 91000/µL [49000-138000/µL]; D4: 93000/µL [46000-134000/µL]; and D5: 76000/µL [45500-151000/µL]; P < 0.05 for all). Twenty-five (35%) patients had thrombocytopenia on CRRT D0 compared with D2 (56.3%), D3 (58.7%), and D5 (59.1%); P < 0.05 for all. Controlling for potential confounders, Sequential Organ Failure Assessment score at the time of CRRT initiation was the only independent factor associated with thrombocytopenia. One (1.3%) patient had confirmed HIT. Conclusion and Relevance: This study is the first to demonstrate serial decreases in platelet count across multiple days after CRRT initiation. These data may provide additional insight to thrombocytopenia development in critically ill patients receiving heparin while on CRRT that is not associated with HIT.
Collapse
Affiliation(s)
- Christopher A Droege
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
| | - Neil E Ernst
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
| | | | | | - Eric W Mueller
- 1 University of Cincinnati Medical Center, OH, USA.,2 University of Cincinnati James L. Winkle College of Pharmacy, OH, USA
| |
Collapse
|
7
|
Implementation of a rapid HIT immunoassay at a university hospital - Retrospective analysis of HIT laboratory orders in patients with thrombocytopenia. Thromb Res 2017; 158:65-70. [PMID: 28843825 DOI: 10.1016/j.thromres.2017.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a rare cause of thrombocytopenia and a potentially life-threatening adverse drug reaction. Clinical overdiagnosis of HIT results in costly laboratory tests and anticoagulation. Criteria and algorithms for diagnosis are established, but their translation into clinical practice is still challenging. STUDY DESIGN AND METHODS In a retrospective approach we studied all HIT related laboratory test requests within four years and evaluated data before (1st period, 24month) and after (2nd period, 24month) replacing particle gel immunoassay (PaGIA) and enzyme-linked immunosorbent assay (ELISA) by a chemiluminescent immunoassay (CLIA). HIT was confirmed by heparin-induced platelet activation (HIPA) test. Clinical pretest probability for HIT using an implemented simplified 4Ts score and platelet count were evaluated. Costs for laboratory tests and alternative anticoagulation were calculated. RESULTS In 1850 patients with suspected HIT, 2327 laboratory orders were performed. In 87.2% of these orders an intermediate/high simplified 4Ts score was found. Thrombocytopenia was present in 87.1%. After replacing PaGIA and ELISA by CLIA the number of immunological and functional laboratory tests was reduced by 38.2%. The number of positive HIT immunoassays declined from 22.6% to 6.0%, while the number of positive HIPA tests among positive immunological tests increased by 19%. Altogether, acute HIT was confirmed in 59 patients. A decline in the use of alternative anticoagulants was observed in the 2nd period. CONCLUSION Our study shows that in a university hospital setting HIT is well-known, but diagnosis requires a precise laboratory confirmation. Replacing PaGIA and ELISA by CLIA did not influence laboratory order behavior but results in reduced overall costs for laboratory diagnostics and alternative anticoagulation.
Collapse
|
8
|
Salter BS, Weiner MM, Trinh MA, Heller J, Evans AS, Adams DH, Fischer GW. Heparin-Induced Thrombocytopenia: A Comprehensive Clinical Review. J Am Coll Cardiol 2017; 67:2519-32. [PMID: 27230048 DOI: 10.1016/j.jacc.2016.02.073] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 12/13/2022]
Abstract
Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.
Collapse
Affiliation(s)
- Benjamin S Salter
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York.
| | - Menachem M Weiner
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Muoi A Trinh
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Joshua Heller
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Adam S Evans
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - David H Adams
- Department of Cardiac Surgery, Mount Sinai Medical Center, New York, New York
| | - Gregory W Fischer
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| |
Collapse
|
9
|
Abstract
OBJECTIVE Recent studies reveal a high occurrence of overdiagnosis of heparin-induced thrombocytopenia in surgical patients with critical illness. The optimal criteria for diagnosis of heparin-induced thrombocytopenia remain unclear, contributing to unnecessary treatment. We reviewed patients who were admitted to surgical ICUs and were suspected of heparin-induced thrombocytopenia to identify how often patients were correctly treated. DESIGN In this clinical prospective study, data were collected including age, sex, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, serotonin release assay, and Warkentin 4Ts scores. Heparin-induced thrombocytopenia-positive patients were defined as those with both positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay (optical density, ≥ 0.40) and positive serotonin release assay results. SETTING Urban tertiary medical center. PATIENTS Patients admitted to the surgical and cardiac ICU who were presumed to have heparin-induced thrombocytopenia and underwent antiplatelet factor 4/heparin enzyme-linked immunosorbent assay and serotonin release assay testing between January 1, 2011, and August 1, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 135 patients had 4Ts, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, and serotonin release assay scores. A total of 11 patients (8.1%) had positive serotonin release assay and 80 patients had positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay; 10 patients were identified as heparin-induced thrombocytopenia positive. Positive serotonin release assay was noted in nine of 11 patients (81.8%) with antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density greater than or equal to 2.0, compared with one of 22 patients (4.5%) with optical density values of 0.85-1.99, and one of 102 patients (1.0%) with optical density values of 0-0.84. Out of 135 patients, 29 patients (21.5%) received treatment with argatroban, lepirudin, or fondaparinux: 10 of 10 heparin-induced thrombocytopenia-positive patients (100%) compared with 19 of 125 heparin-induced thrombocytopenia-negative patients (15%). CONCLUSIONS Overtreatment of heparin-induced thrombocytopenia in the surgical ICU continues even with recent increased caution encouraging a higher antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density threshold before initiating treatment. More stringent criteria should be used to determine when to order serologic testing and when the results of such testing should prompt a change in anticoagulant treatment. If antiplatelet factor 4/heparin enzyme-linked immunosorbent assay is used to consider immediate treatment, an optical density greater than or equal to 2.0 may be a more appropriate threshold.
Collapse
|
10
|
Bain J, Flannery AH, Flynn J, Dager W. Heparin induced thrombocytopenia with mechanical circulatory support devices: review of the literature and management considerations. J Thromb Thrombolysis 2017; 44:76-87. [DOI: 10.1007/s11239-017-1494-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
11
|
Abstract
Due to familiarity, short half-life, ease of monitoring, and the availability of a reversal agent, heparin remains the anticoagulant of choice for cardiac operations requiring cardiopulmonary bypass (CPB). However, occasionally patients require CPB but should not receive heparin, most often because of acute or subacute heparin-induced thrombocytopenia (HIT). In these cases, if it is not feasible to wait for the disappearance of HIT antibodies, an alternative anticoagulant must be selected. A number of non-heparin anticoagulant options have been explored. However, current recommendations suggest the use of a direct thrombin inhibitor such as bivalirudin. This review describes the use of heparin alternatives for the conduct of CPB with a focus on the direct thrombin inhibitors.
Collapse
|
12
|
How I evaluate and treat thrombocytopenia in the intensive care unit patient. Blood 2016; 128:3032-3042. [PMID: 28034871 DOI: 10.1182/blood-2016-09-693655] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/04/2016] [Indexed: 12/20/2022] Open
Abstract
Multiple causes (pseudothrombocytopenia, hemodilution, increased consumption, decreased production, increased sequestration, and immune-mediated destruction of platelets) alone or in combination make thrombocytopenia very common in intensive care unit (ICU) patients. Persisting thrombocytopenia in critically ill patients is associated with, but not causative of, increased mortality. Identification of the underlying cause is key for management decisions in individual patients. While platelet transfusion might be indicated in patients with impaired platelet production or increased platelet destruction, it could be deleterious in patients with increased intravascular platelet activation. Sepsis and trauma are the most common causes of thrombocytopenia in the ICU. In these patients, treatment of the underlying disease will also increase platelet counts. Heparin-induced thrombocytopenia requires alternative anticoagulation at a therapeutic dose and immune thrombocytopenia immunomodulatory treatment. Thrombocytopenia with symptomatic bleeding at or above World Health Organization grade 2 or planned invasive procedures are established indications for platelet transfusions, while the evidence for a benefit of prophylactic platelet transfusions is weak and controversial. If the platelet count does not increase after transfusion of 2 fresh ABO blood group-identical platelet concentrates (therapeutic units), ongoing platelet consumption and high-titer anti-HLA class I antibodies should be considered. The latter requires transfusion of HLA-compatible platelet concentrates.
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Thrombocytopenia and heparin exposure are common in critically ill patients, yet immune heparin-induced thrombocytopenia (HIT), a prothrombotic adverse effect of heparin, rarely accounts for thrombocytopenia in this patient population. The review discusses the clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia. RECENT FINDINGS The frequency of HIT in heparin-exposed critically ill patients is approximately 0.3-0.5% versus at least a 30-50% background frequency of non-HIT thrombocytopenia. Most patients who form anti-PF4/heparin antibodies do not develop HIT, contributing to HIT overdiagnosis. Disseminated intravascular coagulation (DIC), particularly in the setting of cardiogenic or septic shock associated with 'shock liver', can cause ischemic limb gangrene with pulses, mimicking a clinical picture of HIT. However, whereas non-HIT-related DIC with microthrombosis can be treated with heparin, HIT usually requires nonheparin anticoagulation. HIT-associated DIC can result in an elevated INR, which could reflect factor VII depletion because of extrinsic (tissue factor) pathway-mediated activation of coagulation. SUMMARY Greater understanding of the various clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia could help improve outcomes in patients who develop thrombocytopenia and coagulopathies in the ICU.
Collapse
|
14
|
Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis? J Thromb Haemost 2016; 14:231-5. [PMID: 26662371 DOI: 10.1111/jth.13219] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 11/29/2022]
Abstract
For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.
Collapse
Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
15
|
Lu BY, Kudlowitz D, Gardner LB. Clinical and laboratory characteristics associated with a high optical density anti-platelet factor 4 ELISA test. J Blood Med 2015; 6:277-83. [PMID: 26640392 PMCID: PMC4657791 DOI: 10.2147/jbm.s90179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Diagnosing heparin-induced thrombocytopenia, a potentially catastrophic immune-mediated disorder, continues to pose significant challenges for clinicians, as both clinical and laboratory tools lack specificity. There is mounting evidence supporting a positive correlation between definitive heparin-induced thrombocytopenia and optical density (OD) positivity from the widely available anti-platelet factor 4 enzyme-linked immunosorbent assays (PF4 ELISAs). However, the clinical features distinguishing these patients remain poorly understood. PATIENTS AND METHODS To better characterize this group, we conducted a case-controlled, retrospective chart review of patients from two large, urban academic institutions who underwent a PF4 ELISA at a central laboratory. Associations between OD and 18 clinical characteristics were calculated using the Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS In total, 184 negative patients (OD <0.7), and 121 positive patients (OD >0.7), including 74 low-positive patients (0.7< OD <1.4) and 47 high-positive patients (OD >1.4) were identified. Several clinical variables were significantly different in the negative group compared with the positive group, including hospital day (P<0.001), previous admission within the past 3 months (P<0.001), and the presence of a new thrombus (P=0.003). However, many of these variables were not different between the negative and low-positive group, and were only distinct between the negative and high-positive group. When the low-positive and high-positive groups were compared, only the 4T score was significantly different (P=0.003). CONCLUSION These data indicate that those with OD >1.4 form a distinct clinical group and support the clinical utility of the 4T score.
Collapse
Affiliation(s)
- Benjamin Y Lu
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - David Kudlowitz
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - Lawrence B Gardner
- Department of Medicine, NYU School of Medicine, New York, NY, USA ; Department of Biochemistry and Molecular Pharmacology, NYU School of Medicine, New York, NY, USA ; The Perlmutter Cancer Center, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
| |
Collapse
|
16
|
Heparin-Induced Thrombocytopenia in a Patient with Essential Thrombocythemia: A Case Based Update. Case Rep Hematol 2015; 2015:985253. [PMID: 26579318 PMCID: PMC4633557 DOI: 10.1155/2015/985253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 11/20/2022] Open
Abstract
Vascular thrombosis is a common clinical feature of both essential thrombocythemia (ET) and heparin-induced thrombocytopenia (HIT). The development of HIT in a patient with ET is rare and underrecognized. We report the case of a 77-year-old woman with preexisting ET, who was admitted with acute coronary syndrome, and IV heparin was started. She was exposed to unfractionated heparin (UFH) 5 days prior to this admission. Decrease in platelet count was noted, and HIT panel was sent. Heparin was discontinued. Patient developed atrial fibrillation, and Dabigatran was started. On day three, patient also developed multiple tiny cerebral infarctions and acute right popliteal DVT. On day ten of admission, HIT panel was positive, and Dabigatran was changed to Lepirudin. Two days later, Lepirudin was also discontinued because patient developed pseudoaneurysm on the right common femoral artery at the site of cardiac catheterization access. A progressive increase in the platelet count was noted after discontinuing heparin. Physicians should be aware of the coexistence of HIT and ET, accompanied challenges of the prompt diagnosis, and initiation of appropriate treatment.
Collapse
|
17
|
Coleman DM, Obi A, Henke PK. Update in venous thromboembolism pathophysiology, diagnosis, and treatment for surgical patients. Curr Probl Surg 2015; 52:233-59. [PMID: 26071037 DOI: 10.1067/j.cpsurg.2015.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/20/2015] [Indexed: 11/22/2022]
|
18
|
Park JH, Kim JE, Kim HK, Han KS. Presence of Antiheparin/Platelet Factor 4 Immunoglobulin G Is Associated With Poor Prognosis in Patients With Suspected Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2015; 21:66-71. [DOI: 10.1177/1076029613489596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The underlying inflammatory or infectious condition in disseminated intravascular coagulation (DIC) may stimulate the formation of antiheparin/platelet factor 4 (PF4) antibody, and the resulting antibody may affect the clinical course of DIC. We investigated the prognosis of antiheparin/PF4 antibodies in patients with suspected DIC. We measured heparin/PF4 immunoglobulin G (IgG) and total antibody levels using an automated chemiluminescence system in 118 patients with DIC. Of the 118 patients, 13 (11.0%) patients were positive for total antiheparin/PF4, and 6 (5.1%) patients were positive for antiheparin/PF4 IgG. These 13 patients were negative for platelet-activating antibody and had low-heparin-induced thrombocytopenia probability scores. Patients with antiheparin/PF4 IgG were older and had lower antithrombin levels than patients without antiheparin/PF4 IgG. Patients with antiheparin/PF4 IgG had a higher risk of mortality than those without antiheparin/PF4 IgG. The presence of antiheparin/PF4 IgG in old age or low antithrombin level patients with DIC with old age or low antithrombin level suggests a poor prognosis.
Collapse
Affiliation(s)
- Jae Hyeon Park
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Eun Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyou Sup Han
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Plasmapheresis May Be an Option in Urgent Management of Heparin-Induced Thrombocytopenia in the Setting of Acute Intracerebral Hemorrhage. Neurocrit Care 2014; 22:140-5. [DOI: 10.1007/s12028-014-0052-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
|
21
|
Eichler I. Heparininduzierte Thrombozytopenie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1060-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
22
|
An instrument-based immunoassay with an appropriate normal range: minimizing HIT overdiagnosis. Thromb Res 2014; 133:961-2. [PMID: 24508450 DOI: 10.1016/j.thromres.2014.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/21/2014] [Accepted: 01/23/2014] [Indexed: 11/23/2022]
|
23
|
Martin R, Esper A, Martin GS. Hematologic Complications. NON-PULMONARY COMPLICATIONS OF CRITICAL CARE 2014. [PMCID: PMC7121187 DOI: 10.1007/978-1-4939-0873-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Critically ill patients are at high risk of developing various hematologic complications that may be present on admission or occur during their stay in the Intensive Care Unit (ICU). Often times the etiology of specific hematologic abnormalities is unclear and the diagnosis may be challenging due to the complexity of critically ill patients. This chapter will focus on diagnosis and management of the most commonly encountered hematologic problems in the critically ill such as anemia, neutropenia, thrombocytopenia, coagulopathy and thrombotic complications, with specific focus on diagnosis and management of these conditions.
Collapse
|
24
|
Winkler AM, Tormey CA. Pathology consultation on monitoring direct thrombin inhibitors and overcoming their effects in bleeding patients. Am J Clin Pathol 2013; 140:610-22. [PMID: 24124139 DOI: 10.1309/ajcp9vjs6kuknchw] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Direct thrombin inhibitors (DTIs), a relatively new class of anticoagulants, present several challenges regarding monitoring of their anticoagulant effects and overcoming bleeding associated with their use. The aim of this article is to (1) briefly present the pharmacologic properties of currently available DTIs, (2) discuss approaches to laboratory assessment of these drugs, and (3) review management of bleeding associated with their use. METHODS Published literature on DTIs, including clinical trials, case reports, and experimental animal models, was reviewed. The primary authors also reviewed their first-hand experiences with DTI anticoagulation. RESULTS Based on the literature review and the practical experiences of the authors, suggestions for the monitoring of DTIs and algorithmic approaches for the management of DTI-associated bleeding were developed. CONCLUSIONS Routine coagulation assays (eg, the prothrombin time) show a relatively poor correlation with the degree of anticoagulation and DTI drug concentrations. Newer assays, such as the ecarin clotting time and dilute thrombin time, may be more useful in assessing DTI anticoagulation, but these assays are not yet widely available. Low-grade DTI-associated bleeds are best managed with cessation of the drug and supportive care, while higher-grade and/or life-threatening bleeds may best be reversed by active drug removal (eg, via the administration of activated charcoal or hemodialysis). At present there is little evidence to suggest that transfusion products such as factor concentrates or thawed plasma are of any particular benefit in DTI reversal; however, these products may play a supportive role in the management of bleeding.
Collapse
Affiliation(s)
- Anne M. Winkler
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Christopher A. Tormey
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
25
|
Warkentin TE. Anticoagulant failure in coagulopathic patients: PTT confounding and other pitfalls. Expert Opin Drug Saf 2013; 13:25-43. [DOI: 10.1517/14740338.2013.823946] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, 237 Barton St. E, Hamilton, Ontario L8L 2X2, Canada
| |
Collapse
|
26
|
Abstract
Abstract
Thrombocytopenia is a common hematologic finding with variable clinical expression. A low platelet count may be the initial manifestation of infections such as HIV and hepatitis C virus or it may reflect the activity of life-threatening disorders such as the thrombotic microangiopathies. A correct identification of the causes of thrombocytopenia is crucial for the appropriate management of these patients. In this review, we present a systematic evaluation of adults with thrombocytopenia. The approach is clearly different between outpatients, who are frequently asymptomatic and in whom we can sometimes indulge in sophisticated and relatively lengthy investigations, and the dramatic presentation of acute thrombocytopenia in the emergency department or in the intensive care unit, which requires immediate intervention and for which only a few diagnostic tests are available. A brief discussion of the most common etiologies seen in both settings is provided.
Collapse
|
27
|
Abstract
Thrombocytopenia is common in critically ill patients and increases morbidity and mortality. A diagnosis of heparin-induced thrombocytopenia (HIT) is frequently considered in any ICU patient who develops thrombocytopenia in the context of ongoing heparin exposure. As the usual tests to diagnose HIT are often neither specific nor sensitive enough to be confirmatory, the intensivist must largely rely on clinical judgment in treatment decisions. Patients in the ICU may also develop thrombocytopenia resulting from non-HIT immune mechanisms, nonimmune platelet consumption, and from decreased platelet production due to preexisting disorders or as a result of their critical illness and/or drug therapy.
Collapse
Affiliation(s)
- Robert I Parker
- Department of Pediatrics, Stony Brook University School of Medicine, Pediatric Hematology/Oncology, Stony Brook Long Island Children's Hospital, Stony Brook, NY 11794-8111, USA.
| |
Collapse
|
28
|
|
29
|
Abstract
Thrombocytopenia, usually defined as a platelet count of less than 150,000/μL, is a common reason for a hematology consult in both the inpatient and outpatient setting. In most patients, the cause of the thrombocytopenia can be identified and treated. This article reviews the clinical approach to the patient with thrombocytopenia, the mechanisms that underlie it, and the laboratory tests available to investigate it. A practical approach to the investigation and management of thrombocytopenia in the clinical settings commonly encountered by the hematology consultant is then described.
Collapse
Affiliation(s)
- Ellice Y Wong
- Yale University School of Medicine and Cancer Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | | |
Collapse
|
30
|
Warkentin TE. HITlights: a career perspective on heparin-induced thrombocytopenia. Am J Hematol 2012; 87 Suppl 1:S92-9. [PMID: 22367928 DOI: 10.1002/ajh.23127] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/13/2012] [Accepted: 01/15/2012] [Indexed: 12/11/2022]
Abstract
Two decades of research into heparin-induced thrombocytopenia (HIT) permit a personal historical perspective on this fascinating syndrome. Previously, the frequency of HIT was unknown, although complicating thrombosis was believed to be rare and primarily arterial. The opportunity to apply a remarkable test for "HIT antibodies"--the (14) C-serotonin-release assay (SRA)--to serial plasma samples obtained during a clinical trial of heparin thromboprophylaxis, provided insights into the peculiar nature of HIT, such as, its prothrombotic nature--including its strong association with venous thrombosis (RR = 11.6 [95%CI, 6.4-20.8; P < 0.0001); its more frequent occurrence with unfractionated versus low-molecular-weight heparin; the "iceberg" model, which states that among the many patients who form anti-PF4/heparin antibodies during heparin therapy, only a minority whose antibodies evince strong platelet-activating properties develop HIT; and the characteristic HIT timeline, whereby serum/plasma antibodies are readily detectable at or prior to the HIT-associated platelet count fall. Applying the SRA also to patients encountered in clinical practice led to recognition of warfarin-induced venous limb gangrene (for which HIT is a major risk factor via its extreme hypercoagulability) and delayed-onset HIT (whereby thrombocytopenia begins or worsens following heparin discontinuation, due to the ability of HIT antibodies strongly to activate platelets even in the absence of heparin--so-called heparin-"independent" platelet activation). Recent concepts include the increasing recognition of HIT "overdiagnosis" (due to the low diagnostic specificity of the widely-applied PF4-dependent immunoassays), and the observation that HIT-associated consumptive coagulopathy is a risk factor for treatment failure with PTT-adjusted direct thrombin inhibitor therapy ("PTT confounding" secondary to HIT-associated coagulopathy).
Collapse
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|