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Dees DC. Heparin Induced Thrombocytopenia Testing. Clin Lab Med 2024; 44:541-550. [PMID: 39089757 DOI: 10.1016/j.cll.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
This article provides a comprehensive overview of Heparin-Induced Thrombocytopenia (HIT) with an emphasis on laboratory testing and advantages of automation. HIT is a critical condition arising from heparin exposure, leading to a contradictory combination of thrombocytopenia with an increased thrombosis risk. The article discusses HIT's history, clinical presentation, laboratory diagnosis, and management strategies. It highlights the importance of interdisciplinary collaboration for effective diagnosis and treatment, underscoring advancements in technology and targeted therapies that are shaping future approaches to HIT management.
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Affiliation(s)
- Daniel C Dees
- Clinical Hematology, Brigham and Women's Hospital, Boston, MA, USA.
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2
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Li R, Xu J, Li Y, Yi P, Sun C, Yang Q, Wang Q, Mao Y, Mei Z, Zhou G, Ruan F, Shi S, Zhang M, Gong YK. An endothelium membrane mimetic antithrombotic coating enables safer and longer extracorporeal membrane oxygenation application. Acta Biomater 2024:S1742-7061(24)00438-0. [PMID: 39103136 DOI: 10.1016/j.actbio.2024.07.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/07/2024]
Abstract
Thrombosis and plasma leakage are two of the most frequent dysfunctions of polypropylene (PP) hollow fiber membrane (PPM) used in extracorporeal membrane oxygenation (ECMO) therapy. In this study, a superhydrophilic endothelial membrane mimetic coating (SEMMC) was constructed on polydopamine-polyethyleneimine pre-coated surfaces of the PPM oxygenator and its ECMO circuit to explore safer and more sustainable ECMO strategy. The SEMMC is fabricated by multi-point anchoring of a phosphorylcholine and carboxyl side chained copolymer (PMPCC) and grafting of heparin (Hep) to form PMPCC-Hep interface, which endows the membrane superior hemocompatibility and anticoagulation performances. Furthermore, the modified PPM reduces protein adsorption amount to less than 30 ng/cm2. More significantly, the PMPCC-Hep coated ECMO system extends the anti-leakage and non-clotting oxygenation period to more than 15 h in anticoagulant-free animal extracorporeal circulation, much better than the bare and conventional Hep coated ECMO systems with severe clots and plasma leakage in 4 h and 8 h, respectively. This SEMMC strategy of grafting bioactive heparin onto bioinert zwitterionic copolymer interface has great potential in developing safer and longer anticoagulant-free ECMO systems. STATEMENT OF SIGNIFICANCE: A superhydrophilic endothelial membrane mimetic coating was constructed on surfaces of polypropylene hollow fiber membrane (PPM) oxygenator and its ECMO circuit by multi-point anchoring of a phosphorylcholine and carboxyl side chain copolymer (PMPCC) and grafting of heparin (Hep). The strong antifouling nature of the PMPCC-Hep coating resists the adsorption of plasma bio-molecules, resulting in enhanced hemocompatibility and anti-leakage ability. The grafted heparin on the zwitterionic PMPCC interface exhibits superior anticoagulation property. More significantly, the PMPCC-Hep coating achieves an extracorporeal circulation in a pig model for at least 15 h without any systemic anticoagulant. This endothelial membrane mimetic anticoagulation strategy shows great potential for the development of safer and longer anticoagulant-free ECMO systems.
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Affiliation(s)
- Rong Li
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Provincial Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Yin Li
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China
| | - Panpan Yi
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China
| | - Chenwei Sun
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China
| | - Qiankun Yang
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China
| | - Qianqian Wang
- Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing, China
| | - Yi Mao
- Department of Emergency Medicine, The First People's Hospital of Wenling, Taizhou, China
| | - Zhihan Mei
- Department of Emergency Medicine, Tiantai Country People's Hospital, Taizhou, China
| | - Guangju Zhou
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Provincial Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Feng Ruan
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Provincial Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Suqing Shi
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China.
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Provincial Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China.
| | - Yong-Kuan Gong
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, China; Institute of Materials Science and New Technology, Northwest University, Xian 710127, Shaanxi, China.
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3
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Song D, Jin Y, Zhang Y, Zhou Z. Heparin-induced thrombocytopenia in extracorporeal membrane oxygenation-supported patients: a systematic review and meta-analysis. Thromb J 2024; 22:55. [PMID: 38937784 PMCID: PMC11212165 DOI: 10.1186/s12959-024-00624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in critically ill patients with respiratory or cardiac failure. Heparin is usually used as anticoagulation therapy during ECMO support. However, heparin-induced thrombocytopenia (HIT) in ECMO-supported patients, which results in considerable morbidity and mortality, has not yet been well described. This meta-analysis and systematic review aimed to thoroughly report the incidence of HIT on ECMO, as well as the characteristics and outcomes of HIT patients. METHODS We searched the PubMed, Embase, Cochrane Library, and Scopus databases for studies investigating HIT in adult patients supported by ECMO. All studies conforming to the inclusion criteria were screened from 1975 to August 2023. Nineteen studies from a total of 1,625 abstracts were selected. The primary outcomes were the incidence of HIT and suspected HIT. RESULTS The pooled incidence of HIT in ECMO-supported patients was 4.2% (95% CI: 2.7-5.6; 18 studies). A total of 15.9% (95% CI: 9.0-22.8; 12 studies) of patients on ECMO were suspected of having HIT. Enzyme-linked immunosorbent assay (ELISA) is the most commonly used immunoassay. The median optical density (OD) of the ELISA in HIT-confirmed patients ranged from 1.08 to 2.10. In most studies, the serotonin release assay (SRA) was performed as a HIT-confirming test. According to the subgroup analysis, the pooled incidence of HIT in ECMO patients was 2.7% in studies whose diagnostic mode was functional assays, which is significantly lower than the incidence in studies in which the patients were diagnosed by immunoassay (14.5%). Argatroban was most commonly used as an alternative anticoagulation agent after the withdrawal of heparin. Among confirmed HIT patients, 45.5% (95% CI: 28.8-62.6) experienced thrombotic events, while 50.1% (95% CI: 24.9-75.4) experienced bleeding events. Overall, 46.6% (95% CI: 30.4-63.1) of patients on ECMO with HIT died. CONCLUSION According to our study, the pooled incidence of HIT in ECMO-supported patients is 4.2%, and it contributes to adverse outcomes. Inappropriate diagnostic methods can easily lead to misdiagnosis of HIT. Further research and development of diagnostic algorithms and laboratory assays are warranted.
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Affiliation(s)
- Danyu Song
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Nilius H, Hamzeh-Cognasse H, Hastings J, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Vishnu P, Graf L, Kremer Hovinga JA, Bakchoul T, Cognasse F, Nagler M. Proteomic profiling for biomarker discovery in heparin-induced thrombocytopenia. Blood Adv 2024; 8:2825-2834. [PMID: 38588487 PMCID: PMC11176969 DOI: 10.1182/bloodadvances.2024012782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT New analytical techniques can assess hundreds of proteins simultaneously with high sensitivity, facilitating the observation of their complex interplay and role in disease mechanisms. We hypothesized that proteomic profiling targeting proteins involved in thrombus formation, inflammation, and the immune response would identify potentially new biomarkers for heparin-induced thrombocytopenia (HIT). Four existing panels of the Olink proximity extension assay covering 356 proteins involved in thrombus formation, inflammation, and immune response were applied to randomly selected patients with suspected HIT (confirmed HIT, n = 32; HIT ruled out, n = 38; and positive heparin/platelet factor 4 [H/PF4] antibodies, n = 28). The relative difference in protein concentration was analyzed using a linear regression model adjusted for sex and age. To confirm the test results, soluble P-selectin was determined using enzyme-linked immunosorbent assay (ELISA) in above mentioned patients and an additional second data set (n = 49). HIT was defined as a positive heparin-induced platelet activation assay (washed platelet assay). Among 98 patients of the primary data set, the median 4Ts score was 5 in patients with HIT, 4 in patients with positive H/PF4 antibodies, and 3 in patients without HIT. The median optical density of a polyspecific H/PF4 ELISA were 3.0, 0.9, and 0.3. Soluble P-selectin remained statistically significant after multiple test adjustments. The area under the receiver operating characteristic curve was 0.81 for Olink and 0.8 for ELISA. Future studies shall assess the diagnostic and prognostic value of soluble P-selectin in the management of HIT.
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Hind Hamzeh-Cognasse
- French Blood Establishment Auvergne-Rhone-Alpes, Saint-Etienne, France
- University Jean Monnet, Mines Saint-Etienne, INSERM, U 1059 SAINBIOSE, Saint-Etienne, France
| | - Janna Hastings
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zurich, Zurich, Switzerland
- School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Lucerne, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Prakash Vishnu
- Division of Hematology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA
| | - Lukas Graf
- Cantonal Hospital of St. Gallen, Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital Bern University Hospital, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Fabrice Cognasse
- French Blood Establishment Auvergne-Rhone-Alpes, Saint-Etienne, France
- University Jean Monnet, Mines Saint-Etienne, INSERM, U 1059 SAINBIOSE, Saint-Etienne, France
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
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Choi PYI, Uzun G, Bakchoul T. Results of an international survey of opinions on the definitions and treatments for heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:1772-1778. [PMID: 38301999 DOI: 10.1016/j.jtha.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is rare, affecting fewer than 1 in 1500 hospital admissions. Despite the increasing adoption of new therapies in HIT, such as direct oral anticoagulants and pooled immunoglobulins, there is limited high-quality evidence to guide clinicians. Numerous uncommon presentations of HIT and HIT-like entities have recently been recognized, and a harmonized approach to their classification is required to study them better. We present the results of an international survey of opinions from experts and practitioners in the field of platelet immunology regarding the role of direct oral anticoagulants in HIT, novel definitions of subclassifications of HIT-like platelet factor 4 immune conditions (spontaneous autoimmune HIT, persistent autoimmune HIT, and treatment-refractory HIT), and the role for intravenous immunoglobulins in the treatment paradigm of HIT and these HIT-like conditions. From 102 survey responses, there was broad acceptance of rivaroxaban (74.5%) and apixaban (73.5%) even before platelet recovery, as well as for intravenous immunoglobulin in the management of spontaneous (85.6%), persistent (83.7%), and treatment-refractory HIT (87.4%). With this mandate for harmonizing terminologies and treatment approaches in special situations without robust clinical data owing to their rarity, we plan to conduct a robust survey, establish international consensus, and draft management guidelines for HIT and platelet factor 4 immune diseases in the near future.
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MESH Headings
- Humans
- Heparin/adverse effects
- Heparin/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Thrombocytopenia/chemically induced
- Thrombocytopenia/immunology
- Thrombocytopenia/diagnosis
- Anticoagulants/adverse effects
- Platelet Factor 4/immunology
- Surveys and Questionnaires
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Blood Platelets/immunology
- Blood Platelets/drug effects
- Blood Platelets/metabolism
- Pyridones/adverse effects
- Pyridones/therapeutic use
- Rivaroxaban/adverse effects
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Health Care Surveys
- Terminology as Topic
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Affiliation(s)
- Philip Young-Ill Choi
- Haematology Department, the Canberra Hospital, Garran, Canberra, Australian Capital Territory, Australia; John Curtin School of Medical Research, Australian National University, Acton, Canberra, Australian Capital Territory, Australia
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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Subah G, Zeller S, Damodara N, Fortunato M, Garrett J, Syed S, Uddin A, Pak I, Feldstein E, Mayer S, Gandhi CD, Al-Mufti F. Outcomes of heparin-induced thrombocytopenia type II in aneurysmal subarachnoid hemorrhage patients: A US nationwide analysis. J Neurointerv Surg 2024:jnis-2023-021438. [PMID: 38631904 DOI: 10.1136/jnis-2023-021438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Despite the widespread use of heparin during and following endovascular procedures in the management of aneurysmal subarachnoid hemorrhage (SAH) patients, limited research has explored the incidence and impact of heparin-induced thrombocytopenia (HIT) on SAH. METHODS Descriptive statistics, multivariate regressions, and propensity score-matching were employed to compare clinical characteristics, comorbidities, interventions, complications, and outcomes of HIT in SAH patients identified within the US National Inpatient Sample database from 2010 to 2019. RESULTS Among 76 387 SAH patients from 2010 to 2019, 166 (0.22%) developed HIT. HIT was identified as a significant predictor of prolonged length of stay (OR 6.799, 95% CI 3.985 to 11.6, P<0.01) and poor functional outcomes (OR 2.541, 95% CI 1.628 to 3.966, P<0.01) after adjusting for relevant factors. HIT incidence was higher in patients with elevated SAH severity scores (1.42 vs 1.06, P<0.01), younger patients (58.04 vs 61.39 years, P=0.01), overweight individuals (0.4% vs 0.2%, P<0.01), those on long-term anticoagulants (10.84% vs 5.72%, P<0.01), or with a cerebrospinal fluid drainage device (external ventricular drain, ventriculoperitoneal shunt; P<0.01). HIT patients showed increased rates of endovascular coiling, ventricular drain placement, shunt placement, deep vein thrombosis, urinary tract infection, acute kidney injury, pulmonary embolism, venous sinus thrombosis, pneumonia, and cerebral vasospasm (all P<0.01). CONCLUSION SAH patients with HIT exhibited various comorbidities and increased rates of complications, which may contribute to extended hospital stays. This nationwide study aids clinical suspicion and highlights HIT's impact on SAH patients.
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Affiliation(s)
- Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- School of Medicine, New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
| | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Michael Fortunato
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jenna Garrett
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Shoaib Syed
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anaz Uddin
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Issac Pak
- Department of Nephrology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Stephan Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
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Arachchillage DJ, Rajakaruna I, Makris M, Laffan M. Heparin-induced Thrombocytopenia with Thrombosis in COVID-19 versus Vaccine-induced Immune Thrombocytopenia and Thrombosis in the United Kingdom. Semin Thromb Hemost 2024. [PMID: 38593858 DOI: 10.1055/s-0044-1785484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Indika Rajakaruna
- Department of Computer Science, University of East London, London, United Kingdom
| | - Mike Makris
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
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8
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Wang Y, Jiang Q, Xie D, Li X, Wang H, Zeng C, Lei G, Yang T. In-hospital complications and readmission patterns in 13,937 patients with developmental dysplasia of the hip undergoing total hip arthroplasty: Evidence from the Chinese national database. Surgeon 2024; 22:99-106. [PMID: 37872053 DOI: 10.1016/j.surge.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/15/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE Clarifying the prognosis and readmission patterns of patients with developmental dysplasia of the hip (DDH) following total hip arthroplasty (THA) would provide important references for clinical management for this population. Using the Chinese national inpatient database (i.e., Hospital Quality Monitoring System [HQMS]), we aimed to compare in-hospital complications and readmission patterns following THA in patients with DDH and primary osteoarthritis (OA). METHODS Patients undergoing THA for DDH and OA between 2013 and 2019 were identified using the HQMS. Demographics and clinical characteristics were compared between the two groups. After propensity score matching, in-hospital complications and readmission patterns were compared using a logistic regression model. RESULTS According to the analysis of 13,937 propensity-score matched pairs, there were no significant differences in the incidence of in-hospital death (0.01 % vs 0.04 %, P = 0.142), transfusion (8.09 % vs 7.89 %, P = 0.536), wound infection (0.31 % vs 0.25 %, P = 0.364), deep venous thrombosis (0.45 % vs 0.43 %, P = 0.786), pulmonary embolism (0.03 % vs 0.05 %, P = 0.372) or all-cause readmission (2.87 % vs 3.12 %, P = 0.219) between two groups. However, DDH patients had higher surgical readmission rates than OA patients (1.43 % vs 1.14 %, P = 0.033). When analyzing causes of surgical readmission, DDH patients had increased risk of dislocation (0.37 % vs 0.21 %, P = 0.011) and aseptic loosening (0.17 % vs 0.07 %, P = 0.024) than OA patients. CONCLUSION DDH patients had an increased risk of surgical readmission following THA, mainly driven by dislocation and aseptic loosening, which should be recognized and appropriately prevented.
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Affiliation(s)
- Yuqing Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qiao Jiang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Dongxing Xie
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaoxiao Li
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen, Guangdong, China; Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tuo Yang
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China; Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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9
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Li R, Li Y, Bai Y, Yi P, Sun C, Shi S, Gong YK. Achieving superior anticoagulation of endothelial membrane mimetic coating by heparin grafting at zwitterionic biocompatible interfaces. Int J Biol Macromol 2024; 257:128574. [PMID: 38052281 DOI: 10.1016/j.ijbiomac.2023.128574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/16/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023]
Abstract
Thrombosis and bleeding are common complications of blood-contacting medical device therapies. In this work, an endothelium membrane mimetic coating (PMPCC/Hep) has been created to address these challenges. The coating is fabricated by multi-point anchoring of a phosphorylcholine copolymer (poly-MPC-co-MSA, PMPCC) with carboxylic side chains and end-group grafting of unfractionated heparin (Hep) onto polydopamine precoated blood-contacting material surfaces. The PMPCC coating forms an ultrathin cell outer membrane mimetic layer to resist protein adsorption and platelet adhesion. The tiny defects/pores of the PMPCC layer provide entrances for heparin end-group to be inserted and grafted onto the sub-layer amino groups. The combination of the PMPCC cell membrane mimetic anti-fouling nature with the grafted heparin bioactivity further enhances the anticoagulation performance of the formed endothelium membrane mimetic PMPCC/Hep coating. Compared to conventional Hep coating, the PMPCC/Hep coating further decreases protein adsorption and platelet adhesion by 50 % and 90 %, respectively. More significantly, the PMPCC/Hep coating shows a superior anticoagulation activity, even significantly higher than that of an end-point-attached heparin coating. Furthermore, the blood coagulation function is well preserved in the PMPCC/Hep coating anticoagulation strategy. All the results support that the PMPCC/Hep coating strategy has great potential in developing more efficient and safer blood-contacting medical devices.
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Affiliation(s)
- Rong Li
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China
| | - Yin Li
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China
| | - Yunjie Bai
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China
| | - Panpan Yi
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China
| | - Chenwei Sun
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China
| | - Suqing Shi
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China; Institute of Materials Science and New Technology, Northwest University, Xian 710127, Shaanxi, China
| | - Yong-Kuan Gong
- Key Laboratory of Synthetic and Natural Functional Molecule Chemistry of Ministry of Education, College of Chemistry and Materials Science, Northwest University, Xian 710127, Shaanxi, PR China; Institute of Materials Science and New Technology, Northwest University, Xian 710127, Shaanxi, China.
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10
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Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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11
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Wang Q, Qin Y, Ma J, Zhou K, Xia G, Li Y, Xie L, Afful RG, Lan Q, Huo X, Zou J, Yang H. An early warning indicator of mortality risk in patients with COVID-19: the neutrophil extracellular traps/neutrophilic segmented granulocyte ratio. Front Immunol 2024; 15:1287132. [PMID: 38348024 PMCID: PMC10859410 DOI: 10.3389/fimmu.2024.1287132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Background Neutrophil extracellular traps (NETs) play a key role in thrombus formation in patients with coronavirus disease 2019 (COVID-19). However, the existing detection and observation methods for NETs are limited in their ability to provide quantitative, convenient, and accurate descriptions of in situ NETs. Therefore, establishing a quantitative description of the relationship between NETs and thrombosis remains a challenge. Objective We employed morphological observations of blood cells and statistical analyses to investigate the correlation between the NETs/neutrophilic segmented granulocyte ratio and mortality risk in patients with COVID-19. Methods Peripheral blood samples were collected from 117 hospitalized patients with COVID-19 between November 2022 and February 2023, and various blood cell parameters were measured. Two types of smudge cells were observed in the blood and counted: lymphatic and neutral smudge cells. Statistical data analysis was used to establish COVID-19 mortality risk assessment indicators. Results Morphological observations of neutrophilic smudge cells revealed swelling, eruption, and NETs formation in the neutrophil nuclei. Subsequently, the NETs/neutrophilic segmented granulocyte ratio (NNSR) was calculated. A high concentration of NETs poses a fatal risk for thrombus formation in patients. Statistical analysis indicated that a high NNSR was more suitable for evaluating the risk of death in patients with COVID-19 compared to elevated fibrinogen (FIB) and D-dimer (DD) levels. Conclusion Observing blood cell morphology is an effective method for the detection of NETs, NNSR are important markers for revealing the mortality risk of patients with COVID-19.
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Affiliation(s)
- Qiong Wang
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Yu Qin
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jingyun Ma
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Kehao Zhou
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Guiping Xia
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Ya Li
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Li Xie
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Richmond Godwin Afful
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Qian Lan
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Xingyu Huo
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jian Zou
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Hailin Yang
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
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12
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Jiang Q, Wang Y, Xie D, Wei J, Li X, Zeng C, Lei G, Yang T. Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study. Arch Orthop Trauma Surg 2024; 144:483-491. [PMID: 37737901 DOI: 10.1007/s00402-023-05051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/01/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA. MATERIALS AND METHODS Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups. RESULTS A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001). CONCLUSIONS This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.
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Affiliation(s)
- Qiao Jiang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuqing Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Dongxing Xie
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jie Wei
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
- Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaoxiao Li
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
- Hunan Engineering Research Center for Osteoarthritis, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
- Hunan Engineering Research Center for Osteoarthritis, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tuo Yang
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China.
- Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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13
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Gabarin N, Hack M, Revilla R, Arnold DM, Nazy I. Hematology in the post-COVID era: spotlight on vaccine-induced immune thrombotic thrombocytopenia and a conceptual framework (the 4P's) for anti-PF4 diseases. Expert Rev Hematol 2024; 17:39-45. [PMID: 38149432 DOI: 10.1080/17474086.2023.2298333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a life-threatening prothrombotic disorder first identified following the introduction of adenoviral vector vaccines for COVID-19. The condition is characterized by anti-PF4 antibodies and clinically presents with thrombocytopenia and thrombosis often in unusual anatomical sites. AREAS COVERED In this review, we discuss the clinical presentation, diagnostic testing, and treatment of VITT. We also review VITT-like syndromes that have been described in patients without previous vaccination. We propose a conceptual framework for the mechanism of anti-PF4 diseases that includes sufficiently high levels of PF4, the presence of a Polyanion that can form immune complexes with PF4, a Pro-inflammatory milieu, and an immunological Predisposition - the 4Ps. EXPERT OPINION Significant progress has been made in understanding the characteristics of the VITT antibody and in testing methods that can confirm that diagnosis. Future work should be directed at understanding long-term outcomes, mechanisms of thrombosis, and individual risk factors for this rare but dangerous immune-thrombotic disease.
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Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Michael Hack
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ryan Revilla
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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14
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Yesantharao LV, Etchill EW, Canner J, Alejo D, Choi CW, Lawton JS, Sussman M, Schena S. Heparin-Induced Thrombocytopenia After Cardiac Surgery-A Statewide Review of Health Care Utilization. Ann Thorac Surg 2024; 117:221-228. [PMID: 35988740 DOI: 10.1016/j.athoracsur.2022.07.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/20/2022] [Accepted: 07/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite its severe consequences, clinical and economic impacts of heparin-induced thrombocytopenia (HIT) after cardiac operations have not been well characterized. This study assessed statewide incidence, outcomes, and resource consumption associated with HIT after cardiac operations. METHODS This was a retrospective investigation of cardiac surgery patients using the Maryland Health Services Cost Review Commission's database from 2012 to 2020. Health care costs, utilization, and outcomes for those who experienced postoperative HIT were compared with propensity score-matched controls. RESULTS Of 33 583 cardiac surgery patients, 184 (0.55%) were diagnosed with postoperative HIT. Compared with non-HIT patients, HIT patients were significantly more likely to be in the oldest age group (>80 years; P < .001) and to have greater severity of illness at admission (P < .001). HIT was associated with a longer hospitalization (21 vs 7 days; P < .001), greater mortality (13.6% vs 2.3%; P < .001), and greater hospital charges ($123 160 vs $45 303; P < .001), even after propensity score matching. Readmission rates were not significantly different, however, and readmission hospital charges did not significantly differ between HIT and non-HIT patients. CONCLUSIONS In addition to worse outcomes, HIT was associated with higher costs during index admissions but not during readmissions of cardiac surgery patients. Strategies to minimize HIT could yield better outcomes and reduced costs, particularly relevant for health care systems seeking improved value-based care while reducing unnecessary hospitalizations.
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Affiliation(s)
- Lekha V Yesantharao
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric W Etchill
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Canner
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diane Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun W Choi
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Sussman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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15
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Mushtaq AH, Rasheed AW, Jamil MG, Maghrabi K, Khoja O, Sajid MR, Tamim H, Hijazi M, Owaidah T. A retrospective analysis of the frequency of heparin-induced thrombocytopenia in the intensive care unit at a tertiary care center in Riyadh, Saudi Arabia. AMERICAN JOURNAL OF BLOOD RESEARCH 2023; 13:198-206. [PMID: 38223315 PMCID: PMC10784120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/21/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an extremely serious and potentially fatal condition that can develop in patients taking heparin-based medications, such as unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). The incidence and risk factors for HIT in critically ill patients, however, are not well defined. METHODS We retrospectively collected data on HIT test results, route of heparin administration, age, sex, heparin type (UFH or LMWH), and date of illness from patients admitted to the intensive care unit (ICU) and regular nursing floor (non-ICU) at our hospital between January 2011 and December 2014. We screened patients for HIT using the 4T score and confirmed the diagnosis through laboratory testing (direct enzyme immunoassay immunoglobulin G [IgG] or a platelet-activating antibody). RESULTS We screened a total of 946 patients, 56 (5.9%) of whom were positive for HIT. Among 776 patients receiving UFH and 180 receiving LMWH, 2.8 and 6.6% developed HIT, respectively (P = 0.051). We then classified our patients into two groups: ICU, and non-ICU. In the non-ICU group (n = 317), 4 (2.7%) patients receiving LMWH and 25 (5.1%) receiving UFH were positive for HIT (P = 0.221). In the ICU group (n = 639), 1 (3.1%) patient receiving LMWH and 26 (9.1%) receiving UFH were positive for HIT (P = 0.249). The ICU group, therefore, had a higher cumulative incidence rate of HIT than the non-ICU group (8.5 vs. 4.5%). CONCLUSION HIT was more common in ICU patients than non-ICU patients and in more patients receiving UFH than LMWH, although the differences were not statistically significant. Early diagnosis and appropriate treatment are essential to prevent adverse outcomes in patients with HIT.
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Affiliation(s)
- Ali H Mushtaq
- Al Faisal UniversityRiyadh, Saudi Arabia
- Department of Internal Medicine, Cleveland Clinic FoundationCleveland, Ohio, The United States of America
| | - Abdulrahman W Rasheed
- Department of Internal Medicine, Cleveland Clinic FoundationCleveland, Ohio, The United States of America
| | - Mouhamad G Jamil
- Department of Hematology, King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
| | - Khalid Maghrabi
- Department of Hematology, King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
| | - Osama Khoja
- Department of Hematology, King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
| | | | - Hani Tamim
- Al Faisal UniversityRiyadh, Saudi Arabia
| | - Mohammad Hijazi
- Department of Hematology, King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
| | - Tarek Owaidah
- Al Faisal UniversityRiyadh, Saudi Arabia
- Department of Hematology, King Faisal Specialist Hospital and Research CenterRiyadh, Saudi Arabia
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16
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Kostyak JC, McKenzie SE, Naik UP. The Function of ASK1 in Sepsis and Stress-Induced Disorders. Int J Mol Sci 2023; 25:213. [PMID: 38203381 PMCID: PMC10778746 DOI: 10.3390/ijms25010213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Apoptosis signal-regulating kinase 1 (ASK1) is a serine-threonine kinase that is ubiquitously expressed in nucleated cells and is responsible for the activation of multiple mitogen-activated protein kinases (MAPK) to regulate cell stress. Activation of ASK1 via cellular stress leads to activation of downstream signaling components, activation of transcription factors, and proinflammatory cytokine production. ASK1 is also expressed in anucleate platelets and is a key player in platelet activation as it is important for signaling. Interestingly, the mechanism of ASK1 activation is cell type-dependent. In this review we will explore how ASK1 regulates a variety of cellular processes from innate immune function to thrombosis and hemostasis. We will discuss how ASK1 influences FcγRIIA-mediated platelet reactivity and how that reactivity drives platelet clearance. Furthermore, we will explore the role of ASK1 in thromboxane (TxA2) generation, which highlights differences in the way ASK1 functions in mouse and human platelets.
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Affiliation(s)
- John C. Kostyak
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; (S.E.M.); (U.P.N.)
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17
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Shi D, Zhao H, Bu C, Fraser K, Wang H, Dordick JS, Linhardt RJ, Zhang F, Shi F, Chi L. New insights into the binding of PF4 to long heparin oligosaccharides in ultralarge complexes using mass spectrometry. J Thromb Haemost 2023; 21:3608-3618. [PMID: 37648114 DOI: 10.1016/j.jtha.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication caused by heparin drugs. The ultralarge complexes formed by platelet factor 4 (PF4) with heparin or low molecular weight heparins (LMWHs) are important participants in inducing the immune response and HIT. OBJECTIVES We aim at characterizing the interaction between PF4 and long-chain heparin oligosaccharides and providing robust analytical methods for the analysis of PF4-heparin complexes. METHODS In this work, the characteristics of PF4-enoxaparin complexes after incubation in different molar ratios and concentrations were analyzed by multiple analytical methods, especially liquid chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry with multiple reaction monitoring were developed to qualitatively and quantitatively monitor heparin oligosaccharides and PF4 in HIT-inducing complexes. RESULTS The results showed that the largest proportion of ultralarge complexes formed by PF4 and enoxaparin was at a specific molar ratio, ie, a PF4/enoxaparin ratio of 2:1, while the ultralarge complexes contained PF4 tetramer and enoxaparin at a molar ratio of approximately 2:1. CONCLUSION A binding model of PF4 and enoxaparin in ultralarge complexes is proposed with one heparin oligosaccharide chain (∼ dp18) bound to 2 PF4 tetramers in different morphologies to form ultralarge complexes, while PF4 tetramer is surrounded by multiple heparin chains in smaller complexes. Our study provides new insights into the structural mechanism of PF4-LMWH interaction, which help to further understand the mechanism of LMWH immunogenicity and develop safer heparin products.
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Affiliation(s)
- Deling Shi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China; Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Huimin Zhao
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Changkai Bu
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Keith Fraser
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Haoran Wang
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Jonathan S Dordick
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemistry and Chemical Biology, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Fuming Zhang
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA.
| | - Feng Shi
- Shandong Institute for Food and Drug Control, Jinan, Shandong Province, China.
| | - Lianli Chi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China.
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18
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Liu L, Zheng H, Chen S, Wang S, Yang M. Heparin-induced thrombocytopenia associated with low-molecular-weight heparin: clinical feature analysis of cases and pharmacovigilance assessment of the FAERS database. Front Pharmacol 2023; 14:1247253. [PMID: 37808193 PMCID: PMC10552922 DOI: 10.3389/fphar.2023.1247253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Background: Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are commonly used anticoagulants for the management of arterial and venous thromboses. However, it is crucial to be aware that LMWH can, in rare cases, lead to a dangerous complication known as heparin-induced thrombocytopenia (HIT). The objective of this study was to evaluate the pharmacovigilance and clinical features of HIT associated with LMWH, as well as identify treatment strategies and risk factors to facilitate prompt management. Methods: We extracted adverse event report data from the FDA Adverse Event Reporting System (FAERS) database for pharmacovigilance assessment. Case reports on LMWH-induced thrombocytopenia dated up to 20 March 2023 were collected for retrospective analysis. Results: Significantly elevated reporting rates of HIT were shown in adverse event (AE) data of LMWHs in the FAERS database, while tinzaparin had a higher proportional reporting ratio (PRR) and reporting odds ratio (ROR) than other LMWHs, indicating a greater likelihood of HIT. Case report analysis indicated that a total of 43 patients showed evidence of LMWH-induced thrombocytopenia with a median onset time of 8 days. Almost half of the events were caused by enoxaparin. LMWHs were mainly prescribed for the treatment of embolism and thromboprophylaxis of joint operation. Patients with a history of diabetes or surgery appeared to be more susceptible to HIT. Clinical symptoms were mostly presented as thrombus, skin lesion, and dyspnea. Almost 90% of the patients experienced a platelet reduction of more than 50% and had a Warkentin 4T score of more than 6, indicating a high likelihood of HIT. In all patients, LMWHs that were determined to be the cause were promptly withdrawn. Following the discontinuation of LMWHs, almost all patients were given alternative anticoagulants and eventually achieved recovery. Conclusion: LMWH-induced thrombocytopenia is rare but serious, with increased risk in patients with diabetes or a surgical history. Prompt recognition and management are crucial for the safe use of LMWHs.
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Affiliation(s)
- Leping Liu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Zheng
- Department of Pediatrics, The Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shanshan Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Shengfeng Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Postdoctoral Research Station of Clinical Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Minghua Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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19
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Gbadamosi S, Feick KL. Update on the Treatment of Heparin-Induced Thrombocytopenia. AACN Adv Crit Care 2023; 34:173-178. [PMID: 37644631 DOI: 10.4037/aacnacc2023462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Sheriff Gbadamosi
- Sheriff Gbadamosi is Clinical Pharmacy Specialist-Critical Care, Temple University Hospital Main Campus, 3401 N Broad Street, Philadelphia, PA 19140
| | - Kristin L Feick
- Kristin L. Feick is Clinical Pharmacy Specialist-Critical Care, University of Pittsburgh Medical Center Central Pennsylvania Region
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20
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Giles JB, Rollin J, Martinez KL, Selleng K, Thiele T, Pouplard C, Sheppard JAI, Heddle NM, Phillips EJ, Roden DM, Gruel Y, Warkentin TE, Greinacher A, Karnes JH. Laboratory and demographic predictors of functional assay positive status in suspected heparin-induced thrombocytopenia: A multicenter retrospective cohort study. Thromb Res 2023; 229:198-208. [PMID: 37541168 PMCID: PMC10528503 DOI: 10.1016/j.thromres.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/16/2023] [Accepted: 07/18/2023] [Indexed: 08/06/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against platelet factor 4 (PF4) bound to heparin anticoagulants. A priori identification of patients at-risk for HIT remains elusive and a number of risk factors have been identified, but these associations and their effect sizes have limited validation in large cohorts of suspected HIT patients. The aim of this study was to investigate existing anti-PF4/heparin antibody thresholds and model the relationship of demographic variables and anti-PF4/heparin antibody levels with functional assay positivity across multiple institutions in the absence of detailed clinical data. In a large collection of suspected HIT patients (n = 8904), we tested for associations between laboratory and demographic variables and functional assay positive status as well as anti-PF4/heparin antibody levels. We also tested for correlation between IgG-specific and polyspecific (IgG/IgA/IgM) anti-PF4/heparin antibody values and their ability to predict functional assay positive status using area under the receiver operating characteristic (AUROC). Logistic regression identified increasing anti-PF4/heparin antibody OD levels (OR = 51.84 [37.27-74.34], p < 2.0 × 10-16) and female sex (OR = 1.47 [1.19-1.82], p = 3.5 × 10-4) as risk factors for positive functional assay in the largest cohort with consistent effect sizes in two other cohorts. In a subset of 1175 patients, polyspecific and IgG-specific anti-PF4/heparin antibody values were heterogeneous (mean coefficient of variation = 31.9 %), but strongly correlated (rho = 0.878; p < 2 × 10-16) with similar prediction of functional assay positivity (polyspecific AUROC = 0.976 and IgG-specific AUROC = 0.980). Thus, we recapitulate previously identified risk factors of functional assay positivity, providing precise effect sizes in a large observational population of suspected HIT patients. Our data reinforce the necessity of functional assay confirmation and suggest that, despite heterogeneity, polyspecific and IgG-specific anti-PF4/heparin antibody assays predict functional assay positive status similarly, even in the absence of 4Ts scores and detailed clinical data.
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Affiliation(s)
- Jason B Giles
- Department of Pharmacy Practice and Science, University of Arizona R. Ken Coit College of Pharmacy, Tucson, AZ, USA
| | - Jerome Rollin
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France; University of Tours, EA4245, T2i, Tours, France
| | - Kiana L Martinez
- Department of Pharmacy Practice and Science, University of Arizona R. Ken Coit College of Pharmacy, Tucson, AZ, USA
| | - Kathleen Selleng
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Claire Pouplard
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France; University of Tours, EA4245, T2i, Tours, France
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Nancy M Heddle
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yves Gruel
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France; University of Tours, EA4245, T2i, Tours, France
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona R. Ken Coit College of Pharmacy, Tucson, AZ, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
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21
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Hammerer-Lercher A, Nilius H, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Bakchoul T, Nagler M. Limited concordance of heparin/platelet factor 4 antibody assays for the diagnosis of heparin-induced thrombocytopenia: an analysis of the TORADI-HIT study. J Thromb Haemost 2023; 21:2559-2568. [PMID: 37247669 DOI: 10.1016/j.jtha.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/26/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Anecdotal reports suggest that the correlation between heparin/platelet factor 4 (PF4) antibody assays for the diagnosis of heparin-induced thrombocytopenia (HIT) is limited. OBJECTIVES To investigate the correlation between widely used assays and examine possible factors contributing to variability. METHODS This is a large, prospective cohort study with 10 participating tertiary care hospitals including 1393 patients with suspected HIT in clinical practice. HIT was defined by a positive heparin-induced platelet activation (HIPA) assay (washed platelet reference standard test). Three different immunoassays were used to measure heparin/PF4 antibodies: chemiluminescent immunoassay, enzyme-linked immunosorbent assay, and particle gel immunoassay. Various factors that could influence the assays were examined: sex (male or female), age (<65 years or ≥65 years), unfractionated heparin exposure, presence of thrombosis, cardiovascular surgery, and intensive care unit. Spearman's correlation coefficients were calculated. Z-scores and diagnostic odds ratios were determined in the aforementioned subgroups of patients. RESULTS Among 1393 patients, 119 were classified as HIT-positive (prevalence, 8.5%). The median 4Ts score was 5 (IQR, 4-6) in patients with HIT compared with 3 (IQR, 2-4) in patients without HIT. Correlations (rs) between immunoassays were weak (0.53-0.65). Inconsistencies between immunoassays could not be explained by further analyses of z-scored test results and diagnostic odds ratios in subgroups of patients. CONCLUSION The correlation between widely used heparin/PF4 antibody assays was weak, and key factors could not explain this variability. Standardization of immunoassays is requested to improve comparability.
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Affiliation(s)
- Angelika Hammerer-Lercher
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, USA
| | - Lukas Graf
- Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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22
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Shah NB, Sharedalal P, Shafi I, Tang A, Zhao H, Lakhter V, Kolluri R, Rao AK, Bashir R. Prevalence and outcomes of heparin-induced thrombocytopenia in hospitalized patients with venous thromboembolic disease: Insight from national inpatient sample. J Vasc Surg Venous Lymphat Disord 2023; 11:723-730. [PMID: 36893884 DOI: 10.1016/j.jvsv.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The mainstay of therapy for patients with venous thromboembolic disease (VTE) is anticoagulation. In the inpatient setting, majority of these patients are treated with heparin or low molecular weight heparin. The prevalence and outcomes of heparin-induced thrombocytopenia (HIT) in hospitalized patients with venous thromboembolic disease (VTE) is unknown. METHODS This nationwide study identified patients with VTE from the National Inpatient Sample database between January 2009 and December 2013. Among these patients, we compared in-hospital outcomes of patients with and without HIT using a propensity score-matching algorithm. The primary outcome was in-hospital mortality. Secondary outcomes included rates of blood transfusions, intracranial hemorrhage, gastrointestinal bleed, length of hospital stay, and total hospital charges. RESULTS Among 791,932 hospitalized patients with VTE, 4948 patients (0.6%) were noted to have HIT (mean age, 62.9 ±16.2 years; 50.1% female). Propensity-matched comparison showed higher rates of in-hospital mortality (11.01% vs 8.97%; P < .001) and blood transfusions (27.20% vs 20.23%; P < .001) in patients with HIT compared with those without HIT. No significant differences were noted in intracranial hemorrhage rates (0.71% vs 0.51%; P > .05), gastrointestinal bleed (2.00% vs 2.22%; P > .05), length of hospital stay (median, 6.0 days; interquartile range [IQR], 3.0-11.0 vs median, 6.0 days; IQR, 3.0-10.0 days; P > .05), and total hospital charges (median, $36,325; IQR, $17,798-$80,907 vs median, $34,808; IQR, $17,654-$75,624; P > .05). CONCLUSIONS This nationwide observational study showed that 0.6% of hospitalized patients with VTE in the United States have HIT. The presence of HIT was associated with higher in-hospital mortality and blood transfusion rates compared with those without HIT.
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Affiliation(s)
- Neal B Shah
- Department of Internal Medicine, New York Medical College, Valhalla, NY
| | - Parija Sharedalal
- Department of Cardiovascular Disease, New York Medical College, Valhalla, NY
| | - Irfan Shafi
- Department of Internal Medicine, Wayne State University, Detroit, MI
| | - Alice Tang
- Department of Internal Medicine, Boston Medical Center, Boston, MA
| | - Huaqing Zhao
- Department of Clinical Sciences, Temple University Hospital, Philadelphia, PA
| | - Vladimir Lakhter
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, PA
| | - Raghu Kolluri
- Department of Cardiovascular Medicine, OhioHealth/Riverside Methodist Hospital, Columbus, OH
| | - A Koneti Rao
- Hematology Section and Sol Sherry Thrombosis Research Center, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, PA.
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23
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May J, Westbrook B, Cuker A. Heparin-induced thrombocytopenia: An illustrated review. Res Pract Thromb Haemost 2023; 7:100283. [PMID: 37601013 PMCID: PMC10439402 DOI: 10.1016/j.rpth.2023.100283] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug effect from unfractionated or low-molecular-weight heparin that results in thrombocytopenia and potentially catastrophic thrombosis. HIT occurs due to the development of platelet-activating antibodies against multimolecular complexes of platelet factor 4 and heparin. Given the frequency of thrombocytopenia and heparin use among hospitalized patients, calculation of the 4Ts Score is recommended to identify patients at increased likelihood of HIT and direct further evaluation. In patients with an intermediate or high probability 4Ts Score, an immunoassay and functional assay are recommended to confirm or refute the diagnosis of HIT. Heparin avoidance and initiation of nonheparin anticoagulation are the mainstays of acute HIT management. In this illustrated review, we provide visual summaries of the diagnosis and management of HIT, highlighting connections between pathophysiology and clinical care as well as summarizing efforts in quality improvement in the field. We further emphasize common pitfalls and pearls in diagnosis and management to encourage evidence-based care. We include graphical representation of the unique challenges of HIT with cardiopulmonary bypass and also delineate autoimmune HIT and its subtypes.
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Affiliation(s)
- Jori May
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Westbrook
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Khan SA, Shakoor A. Recent Strategies and Future Recommendations for the Fabrication of Antimicrobial, Antibiofilm, and Antibiofouling Biomaterials. Int J Nanomedicine 2023; 18:3377-3405. [PMID: 37366489 PMCID: PMC10290865 DOI: 10.2147/ijn.s406078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/06/2023] [Indexed: 06/28/2023] Open
Abstract
Biomaterials and biomedical devices induced life-threatening bacterial infections and other biological adverse effects such as thrombosis and fibrosis have posed a significant threat to global healthcare. Bacterial infections and adverse biological effects are often caused by the formation of microbial biofilms and the adherence of various biomacromolecules, such as platelets, proteins, fibroblasts, and immune cells, to the surfaces of biomaterials and biomedical devices. Due to the programmed interconnected networking of bacteria in microbial biofilms, they are challenging to treat and can withstand several doses of antibiotics. Additionally, antibiotics can kill bacteria but do not prevent the adsorption of biomacromolecules from physiological fluids or implanting sites, which generates a conditioning layer that promotes bacteria's reattachment, development, and eventual biofilm formation. In these viewpoints, we highlighted the magnitude of biomaterials and biomedical device-induced infections, the role of biofilm formation, and biomacromolecule adhesion in human pathogenesis. We then discussed the solutions practiced in healthcare systems for curing biomaterials and biomedical device-induced infections and their limitations. Moreover, this review comprehensively elaborated on the recent advances in designing and fabricating biomaterials and biomedical devices with these three properties: antibacterial (bacterial killing), antibiofilm (biofilm inhibition/prevention), and antibiofouling (biofouling inhibition/prevention) against microbial species and against the adhesion of other biomacromolecules. Besides we also recommended potential directions for further investigations.
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Affiliation(s)
- Shakeel Ahmad Khan
- Department of Applied Biology and Chemical Technology, the Hong Kong Polytechnic University, Hung Hom, Kowloon, 999077, Hong Kong
| | - Adnan Shakoor
- Department of Control and Instrumentation Engineering, King Fahd University of Petroleum & Minerals, Dhahran, Saudi Arabia
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25
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Mongirdienė A, Liuizė A, Kašauskas A. Novel Knowledge about Molecular Mechanisms of Heparin-Induced Thrombocytopenia Type II and Treatment Targets. Int J Mol Sci 2023; 24:ijms24098217. [PMID: 37175923 PMCID: PMC10179321 DOI: 10.3390/ijms24098217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Heparin-induced thrombocytopenia type II (HIT II), as stated in the literature, occurs in about 3% of all patients and in 0.1-5% of surgical patients. Thrombosis develops in 20-64% of patients with HIT. The mortality rate in HIT II has not decreased using non-heparin treatment with anticoagulants such as argatroban and lepirudin. An improved understanding of the pathophysiology of HIT may help identify targeted therapies to prevent thrombosis without subjecting patients to the risk of intense anticoagulation. The review will summarize the current knowledge about the pathogenesis of HIT II, potential new therapeutic targets related to it, and new treatments being developed. HIT II pathogenesis involves multi-step immune-mediated pathways dependent on the ratio of PF4/heparin and platelet, monocyte, neutrophil, and endothelium activation. For years, only platelets were known to take part in HIT II development. A few years ago, specific receptors and signal-induced pathways in monocytes, neutrophils and endothelium were revealed. It had been shown that the cells that had become active realised different newly formed compounds (platelet-released TF, TNFα, NAP2, CXCL-7, ENA-78, platelet-derived microparticles; monocytes-TF-MPs; neutrophils-NETs), leading to additional cell activation and consequently thrombin generation, resulting in thrombosis. Knowledge about FcγIIa receptors on platelets, monocytes, neutrophils and FcγIIIa on endothelium, chemokine (CXCR-2), and PSGL-1 receptors on neutrophils could allow for the development of a new non-anticoagulant treatment for HIT II. IgG degradation, Syk kinase and NETosis inhibition are in the field of developing new treatment possibilities too. Accordingly, IdeS and DNases-related pathways should be investigated for better understanding of HIT pathogenesis and the possibilities of being the HIT II treatment targets.
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Affiliation(s)
- Aušra Mongirdienė
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
| | - Agnė Liuizė
- Medicine Academy, Lithuanian University of Health Sciences, Eiveniu Str. 4, LT-50103 Kaunas, Lithuania
| | - Artūras Kašauskas
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
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26
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Zhu W, Zheng Y, Yu M, Wu Y, Wei J, Zhou L, Fu G, Schneider N, Jones C, Irani M, Padmanabhan A, Aster R, Wang D, Wen R. Cloned antibodies from patients with HIT provide new clues to HIT pathogenesis. Blood 2023; 141:1060-1069. [PMID: 36493339 PMCID: PMC10023725 DOI: 10.1182/blood.2022017612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction characterized by antibodies that recognize platelet factor 4/heparin complexes (PF4/H) and activate platelets to create a prothrombotic state. Although a high percentage of heparin-treated patients produce antibodies to PF4/H, only a subset also makes antibodies that are platelet activating (PA). A close correlation between PA antibodies and the likelihood of experiencing HIT has been demonstrated in clinical studies, but how PA (presumptively pathogenic) and nonactivating (NA) (presumptively benign) antibodies differ from each other at the molecular level is unknown. To address this issue, we cloned 7 PA and 47 NA PF4/H-binding antibodies from 6 patients with HIT and characterized their structural and functional properties. Findings showed that PA clones differed significantly from NA clones in possessing 1 of 2 heavy chain complementarity-determining region 3 (HCDR3) motifs, RX1-2R/KX1-2R/H (RKH) and YYYYY (Y5), in an unusually long complementarity-determining region 3 (≥20 residues). Mutagenic studies showed that modification of either motif in PA clones reduced or abolished their PA activity and that appropriate amino acid substitutions in HCDR3 of NA clones can cause them to become PA. Repertoire sequencing showed that the frequency of peripheral blood IgG+ B cells possessing RKH or Y5 was significantly higher in patients with HIT than in patients without HIT given heparin, indicating expansion of B cells possessing RKH or Y5 in HIT. These findings imply that antibodies possessing RKH or Y5 are relevant to HIT pathogenesis and suggest new approaches to diagnosis and treatment of this condition.
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Affiliation(s)
- Wen Zhu
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Mei Yu
- Versiti Blood Research Institute, Milwaukee, WI
| | - Yaling Wu
- Versiti Blood Research Institute, Milwaukee, WI
- Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou, Fujian, China
| | - Jianhui Wei
- Versiti Blood Research Institute, Milwaukee, WI
- Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou, Fujian, China
| | - Lu Zhou
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Guoping Fu
- Versiti Blood Research Institute, Milwaukee, WI
| | | | | | - Mehraboon Irani
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Anand Padmanabhan
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Richard Aster
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
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27
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Doubrovinskaia S, Mooshage CM, Seliger C, Lorenz H, Nagel S, Lehnert P, Purrucker J, Wildemann B, Bendszus M, Wick W, Schönenberger S, Kaulen LD. Neurological autoimmune diseases following vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): A follow-up study. Eur J Neurol 2023; 30:463-473. [PMID: 36259114 PMCID: PMC9874608 DOI: 10.1111/ene.15602] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Population-based studies suggest severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines may trigger neurological autoimmunity including immune-mediated thrombotic thrombocytopenia. Long-term characterization of cases is warranted to facilitate patient care and inform vaccine-hesitant individuals. METHODS In this single-center prospective case study with a median follow-up of 387 days long-term clinical, laboratory and imaging characteristics of patients with neurological autoimmunity diagnosed in temporal association (≤6 weeks) with SARS-CoV-2 vaccinations are reported. RESULTS Follow-up data were available for 20 cases (central nervous system demyelinating diseases n = 8, inflammatory peripheral neuropathies n = 4, vaccine-induced immune thrombotic thrombocytopenia n = 3, myositis n = 2, myasthenia n = 1, limbic encephalitis n = 1, giant cell arteritis n = 1). Following therapy, the overall disability level improved (median modified Rankin Scale at diagnosis 3 vs. 1 at follow-up). The condition of two patients worsened despite immunosuppressants possibly related to their autoimmune diagnoses (limbic encephalitis n = 1, giant cell arteritis n = 1). At 12 months' follow-up, 12 patients achieved complete clinical remissions with partial responses in five and stable disease in one case. Correspondingly, autoimmune antibodies were non-detectable or titers had significantly lowered in all, and repeat imaging revealed radiological responses in most cases. Under vigilant monitoring 15 patients from our cohort underwent additional SARS-CoV-2 vaccinations (BNT162b2 n = 12, mRNA-1273 n = 3). Most patients (n = 11) received different vaccines than prior to diagnosis of neurological autoimmunity. Except for one short-lasting relapse, which responded well to steroids, re-vaccinations were well tolerated. CONCLUSIONS In this study long-term characteristics of neurological autoimmunity encountered after SARS-CoV-2 vaccinations are defined. Outcome was favorable in most cases. Re-vaccinations were well tolerated and should be considered on an individual risk/benefit analysis.
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Affiliation(s)
- Sofia Doubrovinskaia
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Christoph M. Mooshage
- Department of NeuroradiologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Corinna Seliger
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Hanns‐Martin Lorenz
- Division of RheumatologyDepartment of Internal Medicine V, University Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Simon Nagel
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
- Department of NeurologyHospital LudwigshafenLudwigshafenGermany
| | - Pascal Lehnert
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Jan Purrucker
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Brigitte Wildemann
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Martin Bendszus
- Department of NeuroradiologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Wolfgang Wick
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Silvia Schönenberger
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Leon D. Kaulen
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
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28
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Nilius H, Cuker A, Haug S, Nakas C, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Kashev A, Sznitman R, Bakchoul T, Nagler M. A machine-learning model for reducing misdiagnosis in heparin-induced thrombocytopenia: A prospective, multicenter, observational study. EClinicalMedicine 2023; 55:101745. [PMID: 36457646 PMCID: PMC9706528 DOI: 10.1016/j.eclinm.2022.101745] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) at the bedside remains challenging, exposing a significant number of patients at risk of delayed diagnosis or overtreatment. We hypothesized that machine-learning algorithms could be utilized to develop a more accurate and user-friendly diagnostic tool that integrates diverse clinical and laboratory information and accounts for complex interactions. METHODS We conducted a prospective cohort study including 1393 patients with suspected HIT between 2018 and 2021 from 10 study centers. Detailed clinical information and laboratory data were collected, and various immunoassays were conducted. The washed platelet heparin-induced platelet activation assay (HIPA) served as the reference standard. FINDINGS HIPA diagnosed HIT in 119 patients (prevalence 8.5%). The feature selection process in the training dataset (75% of patients) yielded the following predictor variables: (1) immunoassay test result, (2) platelet nadir, (3) unfractionated heparin use, (4) CRP, (5) timing of thrombocytopenia, and (6) other causes of thrombocytopenia. The best performing models were a support vector machine in case of the chemiluminescent immunoassay (CLIA) and the ELISA, as well as a gradient boosting machine in particle-gel immunoassay (PaGIA). In the validation dataset (25% of patients), the AUROC of all models was 0.99 (95% CI: 0.97, 1.00). Compared to the currently recommended diagnostic algorithm (4Ts score, immunoassay), the numbers of false-negative patients were reduced from 12 to 6 (-50.0%; ELISA), 9 to 3 (-66.7%, PaGIA) and 14 to 5 (-64.3%; CLIA). The numbers of false-positive individuals were reduced from 87 to 61 (-29.8%; ELISA), 200 to 63 (-68.5%; PaGIA) and increased from 50 to 63 (+29.0%) for the CLIA. INTERPRETATION Our user-friendly machine-learning algorithm for the diagnosis of HIT (https://toradi-hit.org) was substantially more accurate than the currently recommended diagnostic algorithm. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies shall validate this model in wider settings. FUNDING Swiss National Science Foundation (SNSF), and International Society on Thrombosis and Haemostasis (ISTH).
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sigve Haug
- Mathematical Institute, University of Bern, Bern, Switzerland
- Albert Einstein Center for Fundamental Physics and Laboratory for High Energy Physics, University of Bern, Bern, Switzerland
| | - Christos Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, United States
| | - Lukas Graf
- Cantonal Hospital of St Gallen, Switzerland
| | | | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author. Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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Farmakis IT, Barco S, Mavromanoli AC, Agnelli G, Cohen AT, Giannakoulas G, Mahan CE, Konstantinides SV, Valerio L. Cost-of-Illness Analysis of Long-Term Health Care Resource Use and Disease Burden in Patients With Pulmonary Embolism: Insights From the PREFER in VTE Registry. J Am Heart Assoc 2022; 11:e027514. [PMID: 36250664 DOI: 10.1161/jaha.122.027514] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background As mortality from pulmonary embolism (PE) decreases, the personal and societal costs among survivors are receiving increasing attention. Detailing this burden would support an efficient public health resource allocation. We aimed to provide estimates for the economic and disease burden of PE also accounting for long-term health care use and both direct and indirect costs beyond the acute phase. Methods and Results This is a cost-of-illness analysis with a bottom-up approach based on data from the PREFER in VTE registry (Prevention of Thromboembolic Events-European Registry in Venous Thromboembolism). We calculated direct (clinical events and anticoagulation) and indirect costs (loss of productivity) of an acute PE event and its 12-month follow-up in 2020 Euros. We estimated a disability weight for the 12-month post-PE status and corresponding disability adjusted life years presumably owing to PE. Disease-specific costs in the first year of follow-up after an incident PE case ranged between 9135 Euros and 10 620 Euros. The proportion of indirect costs was 42% to 49% of total costs. Costs were lowest in patients with ongoing cancer, mainly because productivity loss was less evident in this already burdened population. The calculated disability weight for survivors who were cancer free 12 months post-PE was 0.017, and the estimated disability adjusted life years per incident case were 1.17. Conclusions The economic burden imposed by PE to society and affected patients is considerable, and productivity loss is its main driver. The disease burden from PE is remarkable and translates to the loss of roughly 1.2 years of healthy life per incident PE case.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Angiology University Hospital Zurich Zurich Switzerland
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine-Stroke Unit University of Perugia Perugia Italy
| | - Alexander T Cohen
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust King's College London London UK
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital Aristotle University of Thessaloniki Thessaloniki Greece
| | | | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Cardiology Democritus University of Thrace Alexandroupolis Greece
| | - Luca Valerio
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Cardiology University Medical Center of the Johannes Gutenberg University Mainz Germany
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30
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Douglass M, Garren M, Devine R, Mondal A, Handa H. Bio-inspired hemocompatible surface modifications for biomedical applications. PROGRESS IN MATERIALS SCIENCE 2022; 130:100997. [PMID: 36660552 PMCID: PMC9844968 DOI: 10.1016/j.pmatsci.2022.100997] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
When blood first encounters the artificial surface of a medical device, a complex series of biochemical reactions is triggered, potentially resulting in clinical complications such as embolism/occlusion, inflammation, or device failure. Preventing thrombus formation on the surface of blood-contacting devices is crucial for maintaining device functionality and patient safety. As the number of patients reliant on blood-contacting devices continues to grow, minimizing the risk associated with these devices is vital towards lowering healthcare-associated morbidity and mortality. The current standard clinical practice primarily requires the systemic administration of anticoagulants such as heparin, which can result in serious complications such as post-operative bleeding and heparin-induced thrombocytopenia (HIT). Due to these complications, the administration of antithrombotic agents remains one of the leading causes of clinical drug-related deaths. To reduce the side effects spurred by systemic anticoagulation, researchers have been inspired by the hemocompatibility exhibited by natural phenomena, and thus have begun developing medical-grade surfaces which aim to exhibit total hemocompatibility via biomimicry. This review paper aims to address different bio-inspired surface modifications that increase hemocompatibility, discuss the limitations of each method, and explore the future direction for hemocompatible surface research.
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Affiliation(s)
- Megan Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Mark Garren
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Ryan Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Arnab Mondal
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
- Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, University of Georgia, Athens, GA, USA
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31
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Kanack AJ, Padmanabhan A. Vaccine-induced immune thrombotic thrombocytopenia. Best Pract Res Clin Haematol 2022; 35:101381. [PMID: 36494147 PMCID: PMC9467921 DOI: 10.1016/j.beha.2022.101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is primarily a complication of adenoviral vector-based covid-19 vaccination. In VITT, thrombocytopenia and thrombosis mediated by anti-platelet factor 4 (PF4) antibodies can be severe, often characterized by thrombosis at unusual sites such as the cerebral venous sinus and splanchnic circulation. Like in heparin-induced thrombocytopenia (HIT) and spontaneous HIT, VITT antibodies recognize PF4-polyanion complexes and activate PF4-treated platelets but additionally bind to un-complexed PF4, a critical finding that could be leveraged for more specific detection of VITT. Intravenous immunoglobulin and non-heparin-based anticoagulation remain the mainstay of treatment. Second dose/boosters of mRNA covid-19 vaccines appear safe in patients with adenoviral vector-associated VITT. Emerging data is consistent with the possibility that ultra-rare cases of VITT may be seen in the setting of mRNA and virus-like particle (VLP) technology-based vaccinations and until more data is available, it is prudent to consider VITT in the differential diagnosis of all post-vaccine thrombosis and thrombocytopenia reactions.
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Affiliation(s)
- Adam J Kanack
- Division of Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine & Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
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32
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A Rare Case of Extensive Cerebral Venous Sinus Thrombosis Complicated by Heparin-Induced Thrombocytopenia. Case Rep Hematol 2022; 2022:7845786. [PMID: 35707792 PMCID: PMC9192252 DOI: 10.1155/2022/7845786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/20/2022] [Indexed: 01/08/2023] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare but potentially life-threatening cause of stroke. Several risk factors have been identified including hypercoagulable state, malignancy, use of oral contraceptives, pregnancy, head injury, infection, and prothrombotic states such as heparin-induced thrombocytopenia (HIT). HIT is a prothrombotic state leading to thrombosis in several distinct locations including CVST requiring prompt discontinuation of heparin and initiation of nonheparin anticoagulation to prevent catastrophic consequences. Very rarely, HIT can complicate the ongoing CVST leading to worsening thrombosis and clinical deterioration. We here report an exceedingly rare case of CVST complicated by HIT in a 22-year-old female patient who showed remarkable clinical improvement after discontinuation of heparin and initiation of argatroban.
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33
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Liu P, Yang L, Shi A, Qian Y, Liu X, Dong D, Zhang X, Lv Y, Xiang J. Regional anticoagulation magnetic artificial blood vessels constructed by heparin-PLCL core-shell nanofibers for rapid deployment of veno-venous bypass. Biomater Sci 2022; 10:3559-3568. [PMID: 35621240 DOI: 10.1039/d2bm00205a] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Veno-venous bypass (VVB) is necessary for maintaining hemodynamic and internal environment stabilities in complex liver surgeries. However, the current VVB strategies require systematic anticoagulation and are time-consuming, leading to unexpected complications. This study aims to overcome these limitations by using a novel magnetic artificial blood vessel constructed with heparin-PLCL core-shell nanofibers. Coaxial electrospinning was used to fabricate core-shell nanofibers with heparin encapsulated into the core layer. The microstructure, physical and chemical properties, hemocompatibility, and heparin release behavior were characterized. The regional anticoagulation magnetic artificial vessel was constructed with these nanofibers and used to perform VVB in a rat liver transplantation model for in vivo evaluation. The core-shell nanofibers appeared smooth and uniform without apparent defects. Fluorescence and TEM images indicated that heparin was successfully encapsulated into the core layer. In addition, the in vitro heparin release test presented a two-phase release profile, burst release at day 1 and sustained release from days 2 to 14, which resulted in better hemocompatibility. The VVB could be rapidly deployed in 3.65 ± 0.83 min by the magnetic artificial vessel without systemic anticoagulation. Moreover, the novel device could reduce portal pressure and abdominal organ congestion, protect intestinal function, and increase the survival rate of liver transplantation with a long anhepatic phase from 0 to 65%. In summary, VVB can be rapidly deployed using regional anticoagulation magnetic artificial blood vessels without systemic anticoagulation, which is promising for improving patient outcomes after complex liver surgery.
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Affiliation(s)
- Peng Liu
- Center for Regenerative and Reconstructive Medicine, Med-X Institute, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Lifei Yang
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Aihua Shi
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Yerong Qian
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xin Liu
- Department of Radiotherapy, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi 710061, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xufeng Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Yi Lv
- Center for Regenerative and Reconstructive Medicine, Med-X Institute, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Junxi Xiang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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Kanack AJ, Singh B, George G, Gundabolu K, Koepsell SA, Abou‐Ismail MY, Moser KA, Smock KJ, Green D, Major A, Chan CW, Wool GD, Reding M, Ashrani AA, Bayas A, Grill DE, Padmanabhan A. Persistence of Ad26.COV2.S-associated vaccine-induced immune thrombotic thrombocytopenia (VITT) and specific detection of VITT antibodies. Am J Hematol 2022; 97:519-526. [PMID: 35132672 PMCID: PMC8986571 DOI: 10.1002/ajh.26488] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/22/2022]
Abstract
Rare cases of COVID‐19 vaccinated individuals develop anti‐platelet factor 4 (PF4) antibodies that cause thrombocytopenia and thrombotic complications, a syndrome referred to as vaccine‐induced immune thrombotic thrombocytopenia (VITT). Currently, information on the characteristics and persistence of anti‐PF4 antibodies that cause VITT after Ad26.COV2.S vaccination is limited, and available diagnostic assays fail to differentiate Ad26.COV2.S and ChAdOx1 nCoV‐19‐associated VITT from similar clinical disorders, namely heparin‐induced thrombocytopenia (HIT) and spontaneous HIT. Here we demonstrate that while Ad26.COV2.S‐associated VITT patients are uniformly strongly positive in PF4‐polyanion enzyme‐linked immunosorbent assays (ELISAs); they are frequently negative in the serotonin release assay (SRA). The PF4‐dependent p‐selectin expression assay (PEA) that uses platelets treated with PF4 rather than heparin consistently diagnosed Ad26.COV2.S‐associated VITT. Most Ad26.COV2.S‐associated VITT antibodies persisted for >5 months in PF4‐polyanion ELISAs, while the PEA became negative earlier. Two patients had otherwise unexplained mild persistent thrombocytopenia (140‐150 x 103/µL) 6 months after acute presentation. From an epidemiological perspective, differentiating VITT from spontaneous HIT, another entity that develops in the absence of proximate heparin exposure, and HIT is important, but currently available PF4‐polyanion ELISAs and functional assay are non‐specific and detect all three conditions. Here, we report that a novel un‐complexed PF4 ELISA specifically differentiates VITT, secondary to both Ad26.COV2.S and ChAdOx1 nCoV‐19, from both spontaneous HIT, HIT and commonly‐encountered HIT‐suspected patients who are PF4/polyanion ELISA‐positive but negative in functional assays. In summary, Ad26.COV2.S‐associated VITT antibodies are persistent, and the un‐complexed PF4 ELISA appears to be both sensitive and specific for VITT diagnosis.
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Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Bandana Singh
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Gemlyn George
- Department of Medicine University of Colorado Aurora Colorado USA
| | - Krishna Gundabolu
- Department of Internal Medicine University of Nebraska Medical Center Omaha Nebraska USA
| | - Scott A. Koepsell
- Department of Pathology and Microbiology University of Nebraska Medical Center Omaha Nebraska USA
| | | | - Karen A. Moser
- Department of Pathology University of Utah Health Sciences Center and ARUP Institute for Clinical and Experimental Pathology Salt Lake City Utah USA
| | - Kristi J. Smock
- Department of Pathology University of Utah Health Sciences Center and ARUP Institute for Clinical and Experimental Pathology Salt Lake City Utah USA
| | - David Green
- Department of Medicine NYU Langone Health New York New York USA
| | - Ajay Major
- Department of Medicine University of Chicago Chicago Illinois USA
| | - Clarence W. Chan
- Department of Pathology University of Chicago Chicago Illinois USA
| | - Geoffrey D. Wool
- Department of Pathology University of Chicago Chicago Illinois USA
| | - Mark Reding
- Department of Medicine University of Minnesota Medical Center Minneapolis Minnesota USA
| | | | - Antonios Bayas
- Department of Neurology and Clinical Neurophysiology University Hospital of Augsburg Augsburg Germany
| | - Diane E. Grill
- Department of Health Sciences Research Mayo Clinic Rochester Minnesota USA
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
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35
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Abstract
Heparin-induced thrombocytopenia is a severe prothrombotic disease. Timely diagnosis and treatment are essential. Application of diagnostic algorithms based on validated clinical scoring tools and rapid, specific laboratory assays may improve outcomes.
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36
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Mccandlish JA, Feizullayeva C, Spyropoulos A, Cronin PP, Naidich J, Brenner B, Mcginn T, Sanelli PC, Cohen SL. Comparison of guidelines for evaluation of suspected PE in pregnancy: a cost-effectiveness analysis. Chest 2021; 161:1628-1641. [PMID: 34914975 DOI: 10.1016/j.chest.2021.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. RESEARCH QUESTION Which societal-level diagnostic guideline for evaluation of suspected PE in pregnancy is an optimal policy in terms of its cost-effectiveness? STUDY DESIGN AND METHODS We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guideline for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a U.S. health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and U.S. dollars respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000 per QALY. One-way, multi-way, and probabilistic sensitivity analyses were performed. RESULTS We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society-Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guideline proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs per 100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guideline optimal in 86% of probabilistic sensitivity analysis scenarios. INTERPRETATION The ATS-STR guideline for diagnosis of suspected PE in pregnancy is cost-effective and generates better expected health outcomes than guidelines proposed by other medical societies.
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Affiliation(s)
- John Austin Mccandlish
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Georgia Institute of Technology, Atlanta, Georgia
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Alex Spyropoulos
- The Institute for Health System Science, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Paul P Cronin
- Emory University Hospital Department Of Radiology and Imaging Science, Atlanta, Georgia
| | - Jason Naidich
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York
| | - Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Thomas Mcginn
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
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Chen Y, Wang J, Shi ZJ, Zhang Y, Yang Q, Xu Y. Incidence, Outcomes and Risk Factors of Heparin-Induced Thrombocytopenia After Total Joint Arthroplasty: A National Inpatient Sample Database Study. Clin Appl Thromb Hemost 2021; 27:10760296211042938. [PMID: 34558329 PMCID: PMC8495517 DOI: 10.1177/10760296211042938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Backgrounds: Heparin-induced thrombocytopenia (HIT) is a severe immune-mediated complication of heparin exposure, leading to negative consequences after total hip (THA) and knee arthroplasty (TKA). Materials and Methods: A retrospective study was conducted using the National Inpatient Sample (NIS) database from 2005 to 2014. The incidence and outcomes of HIT after THA or TKA were documented. Logistic regression analysis was performed to identify the postoperative HIT risk factors. Results: A total of 59 3045 patients who underwent THA and 1228 707 patients who underwent TKA were identified. The cumulative incidences were 0.02% and 0.01%, respectively. The HIT group presented significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index scores, longer hospital stays (LOS), and higher medical costs. HIT led to a significantly higher mortality rate after THA (2.17% vs 0.16%, P = .0091). In THA, the HIT risk factors were racial minority, AIDS, pulmonary circulation disorders (PCD), psychoses, and hypertension. In TKA, the HIT risk factors were racial minority, PCD, and weight loss. Conclusion: The incidence of HIT after THA and TKA is relatively low; however, HIT significantly increases inpatient mortality, LOS, and medical cost.
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Affiliation(s)
- Yuhang Chen
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China.,* These authors have contributed equally to this manuscript
| | - Jian Wang
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China.,* These authors have contributed equally to this manuscript
| | - Zhan-Jun Shi
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Yang Zhang
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Qinfeng Yang
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Yichuan Xu
- Department of Orthopaedic Surgery, Division of Orthopaedics, Nanfang Hospital, 198153Southern Medical University, Guangzhou, Guangdong 510515, China
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Singh B, Kanack A, Bayas A, George G, Abou-Ismail MY, Kohlhagen M, Christ M, Naumann M, Moser K, Smock K, Grazioli A, Murray D, Padmanabhan A. Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 34611669 PMCID: PMC8491860 DOI: 10.1101/2021.09.23.21263047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies. Methods Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination. Results All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation. Conclusion Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.
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Kaur J, Arsene C, Yadav SK, Ogundipe O, Malik A, Sule AA, Krishnamoorthy G. Risk Factors in Hospitalized Patients for Heparin-Induced Thrombocytopenia by Real World Database: A New Role for Primary Hypercoagulable States. J Hematol 2021; 10:171-177. [PMID: 34527113 PMCID: PMC8425805 DOI: 10.14740/jh876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background The aims of the study were to identify predictors of heparin-induced thrombocytopenia (HIT) in hospitalized adults, and to find additional factors associated with higher odds of HIT in primary hypercoagulable states. Methods A retrospective matched case-control study using discharge data from National Inpatient Sample database (2012 - 2014) was conducted. In primary outcome analysis, hospitalized patients with and without HIT were included as cases and controls, both matched for age and gender. In secondary outcome analysis, hospitalized patients with primary hypercoagulable states with and without HIT were included as cases and controls, both matched for age and gender. The statistical analyses were performed using Statistical Package for Social Sciences version 25. Results There are several predictors of HIT in hospitalized patients, such as obesity, malignancy, diabetes, renal failure, major surgery, congestive heart failure, and autoimmune diseases. In patients with primary hypercoagulable states, the presence of renal failure (odds ratio (OR) 2.955, 95% confidence interval (CI) 1.994 - 4.380), major surgery (OR 1.735, 95% CI 1.275 - 2.361), congestive heart failure (OR 4.497, 95% CI 2.466 - 8.202), or autoimmune diseases (OR 1.712, 95% CI 1.120 - 2.618) further increases the odds of HIT. Conclusions In hospitalized patients with primary hypercoagulable states, especially in association with renal failure, major surgery, congestive heart failure, or autoimmune diseases, unfractionated heparin should be used with caution.
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Affiliation(s)
- Jasmeet Kaur
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Camelia Arsene
- Department of Medical Education, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Sumeet Kumar Yadav
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Olusola Ogundipe
- Department of Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ambreen Malik
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Anupam Ashutosh Sule
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
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Camoin-Jau L, Mariotti A, Suchon P, Morange PE. [Heparin-induced thrombocytopenia: Update]. Rev Med Interne 2021; 43:18-25. [PMID: 34535328 DOI: 10.1016/j.revmed.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/27/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy. It is due to the synthesis of antibodies most often directed against platelet factor 4 (FP4) modified by heparin (H). HIT is manifested by a platelet count fall, associated with a high risk of venous or arterial thrombosis. The diagnosis of HIT is based on the assessment of clinical probability (4Ts score or change in platelet count after cardiac surgery) and the demonstration of heparin-modified anti-FP4 antibodies (FP4/H). If the immunological tests are positive, functional tests should be performed. In case of suspicion of HIT, it is necessary to urgently stop heparin therapy, to perform a doppler ultrasound of the lower limbs, and to prescribe an alternative anticoagulation agent at a curative dose. Currently, danaparoid sodium and argatroban are authorized. The diagnosis and management of HIT remain complex and requires multidisciplinary collaboration.
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Affiliation(s)
- L Camoin-Jau
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; Aix-Marseille univsersité, IRD, AP-HM, MEPHI, IHU Méditerranée infection, Marseille, France.
| | - A Mariotti
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France
| | - P Suchon
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
| | - P-E Morange
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Onwuemene OA. Bleeding is associated with intravenous immunoglobulin and therapeutic plasma exchange use in heparin‐induced thrombocytopenia: A propensity matched analysis. EJHAEM 2021; 2:466-470. [PMID: 35844687 PMCID: PMC9175867 DOI: 10.1002/jha2.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023]
Abstract
Intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE) are used in select cases with heparin‐induced thrombocytopenia (HIT). In a cross‐sectional analysis, a propensity matched sample was generated by IVIG or TPE treatment status to assess the primary outcome of mortality. In 500 HIT cases, IVIG or TPE was not associated with increased mortality (OR = 1.46; 95% CI: 0.81–2.63, p = 0.2052) but was associated with a higher likelihood of major bleeding (OR = 1.75; 95% CI: 1.03–2.96, p = 0.0376). The use of IVIG or TPE in HIT cases with bleeding contraindications to standard therapies should be further investigated.
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Affiliation(s)
- Alexandre Soares Ferreira Júnior
- School of Medicine Barretos School of Health Sciences Dr. Paulo Prata Barretos São Paulo Brazil
- Department of Medicine Faculdade de Medicina de São José do Rio Preto (FAMERP) São José do Rio Preto São Paulo Brazil
| | | | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics Duke University School of Medicine Durham North Carolina USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology Department of Medicine Duke University School of Medicine Durham North Carolina USA
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Tardy-Poncet B, de Maistre E, Pouplard C, Presles E, Alhenc-Gelas M, Lasne D, Horellou MH, Mouton C, Serre-Sapin A, Bauters A, Nguyen P, Mullier F, Perrin J, Le Gal G, Morange PE, Grunebaum L, Lillo-Le Louet A, Elalamy I, Gruel Y, Greinacher A, Lecompte T, Tardy B. Heparin-induced thrombocytopenia: Construction of a pretest diagnostic score derived from the analysis of a prospective multinational database, with internal validation. J Thromb Haemost 2021; 19:1959-1972. [PMID: 33872452 DOI: 10.1111/jth.15344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diagnosis of heparin-induced thrombocytopenia (HIT) requires pretest probability assessment and dedicated laboratory assays. OBJECTIVE To develop a pretest score for HIT. DESIGN Observational; analysis of prospectively collected data of hospitalized patients suspected with HIT (ClinicalTrials.gov NCT00748839). SETTING Thirty-one tertiary hospitals in France, Switzerland, and Belgium. PATIENTS Patients tested for HIT antibodies (2280 evaluable), randomly allocated to derivation and validation cohorts. MEASUREMENTS Independent adjudicators diagnosed HIT based on the prospectively collected data and serotonin release assay results. RESULTS Heparin-induced thrombocytopenia was diagnosed in 234 (14.7%) and 99 (14.5%) patients in the two cohorts. Eight features were associated with HIT (in brackets, points assigned for score calculation of the score): unfractionated heparin (1); therapeutic-dose heparin (1); cardiopulmonary bypass (cardiac surgery) (2); major trauma (3); 5- to 21-day interval from anticoagulation initiation to suspicion of HIT (4); ≥40% decrease in platelet count over ≤6 days (3); thrombotic event, arterial (3) or venous (3). The C-statistic was 0.79 (95% CI, 0.76-0.82). In the validation cohort, the area under the receiver operating characteristic curve was 0.77 (95% CI, 0.74-0.80). Three groups of scores were defined; HIT prevalence reached almost 30% in the high-probability group. LIMITATION The performance of the score may depend on settings and practices. CONCLUSION The objective, easy-to-collect, clinical features of HIT we evidenced were incorporated into a pretest score, which may guide clinical decisions regarding diagnostic testing and anticoagulation.
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Affiliation(s)
- Brigitte Tardy-Poncet
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Claire Pouplard
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Emilie Presles
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Dominique Lasne
- Hemostasis Unit, Hôpital Necker, AP-HP, Paris, France
- Université Paris Sud Paris Saclay, Inserm U1176, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | - François Mullier
- Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | | | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, ON, Canada
| | - Pierre-Emmanuel Morange
- C2VN, Aix Marseille University, INSERM, INRA; Laboratory of Hematology, La Timone Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Lélia Grunebaum
- Laboratory of Hematology, CHU Strasbourg, Strasbourg, France
| | - Agnès Lillo-Le Louet
- Pharmacovigilance Center, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Ismail Elalamy
- Hematology and Thrombosis Center, Tenon University Hospital, INSERM UMRS 938, Sorbonne University, Paris, France
| | - Yves Gruel
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Andreas Greinacher
- Institut fuer Immunologie und Transfusionsmedizin, Universitaetsmedizin Greifswald, Greifswald, Germany
| | - Thomas Lecompte
- Department of Medicine, Geneva University Hospitals, and Geneva Platelet Group (GpG), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Tardy
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
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Northam KA, Johnson JA, Behrens A, Chen SL, Kasthuri RS, Rollins-Raval M. Minimizing cost associated with management of heparin-induced thrombocytopenia: A cost analysis of various laboratory testing models. Int J Lab Hematol 2021; 43:1599-1605. [PMID: 34275201 DOI: 10.1111/ijlh.13658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Management of patients with suspected heparin-induced thrombocytopenia (HIT) can lead to significant costs. Reported cost-saving initiatives have focused on minimizing inappropriate testing in low-risk patients and optimizing alternative anticoagulant selection. We sought to further investigate how utilizing various HIT laboratory testing models would impact total cost of testing and alternative anticoagulant use. METHODS Utilizing a retrospective cohort of adult patients tested for HIT over three years within our institution, we evaluated how utilization of four distinct laboratory models impacted total number of HIT test combinations completed, time to HIT testing finalization, percentage of patients discharged from the hospital prior to HIT testing finalization, total alternative anticoagulant days, and total anticipated major bleed events. Additionally, we calculated cost of laboratory testing and alternative anticoagulant associated with each model. RESULTS A total of 482 patients were included in our cohort. A laboratory testing model that utilized an in-house platelet factor 4 (PF4)-heparin enzyme-linked immunosorbent assay (ELISA) completed three days weekly, and reflex serotonin release assay (SRA) with a five-day turnaround resulted in the shortest mean time to HIT testing finalization, lowest percentage of patients discharged prior to HIT testing finalization, and lowest total alternative anticoagulant days. CONCLUSIONS Institutions should evaluate current HIT laboratory testing practices and assess for opportunities for optimization. Testing models utilizing a PF4-heparin antibody ELISA with a reflex SRA for positive results may improve testing metrics and lead to lower utilization of alternative anticoagulants.
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Affiliation(s)
- Kalynn A Northam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Jasmine A Johnson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Allison Behrens
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Raj S Kasthuri
- Division of Hematology, University of North Carolina, Chapel Hill, NC, USA
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Devine R, Douglass M, Ashcraft M, Tayag N, Handa H. Development of Novel Amphotericin B-Immobilized Nitric Oxide-Releasing Platform for the Prevention of Broad-Spectrum Infections and Thrombosis. ACS APPLIED MATERIALS & INTERFACES 2021; 13:19613-19624. [PMID: 33904311 PMCID: PMC9683085 DOI: 10.1021/acsami.1c01330] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Indwelling medical devices currently used to diagnose, monitor, and treat patients invariably suffer from two common clinical complications: broad-spectrum infections and device-induced thrombosis. Currently, infections are managed through antibiotic or antifungal treatment, but the emergence of antibiotic resistance, the formation of recalcitrant biofilms, and difficulty identifying culprit pathogens have made treatment increasingly challenging. Additionally, systemic anticoagulation has been used to manage device-induced thrombosis, but subsequent life-threatening bleeding events associated with all available therapies necessitates alternative solutions. In this study, a broad-spectrum antimicrobial, antithrombotic surface combining the incorporation of the nitric oxide (NO) donor S-nitroso-N-acetylpenicillamine (SNAP) with the immobilization of the antifungal Amphotericin B (AmB) on polydimethylsiloxane (PDMS) was developed in a two-step process. This novel strategy combines the key advantages of NO, a bactericidal agent and platelet inhibitor, with AmB, a potent antifungal agent. We demonstrated that SNAP-AmB surfaces significantly reduced the viability of adhered Staphylococcus aureus (99.0 ± 0.2%), Escherichia coli (89.7 ± 1.0%), and Candida albicans (93.5 ± 4.2%) compared to controls after 24 h of in vitro exposure. Moreover, SNAP-AmB surfaces reduced the number of platelets adhered by 74.6 ± 3.9% compared to controls after 2 h of in vitro porcine plasma exposure. Finally, a cytotoxicity assay validated that the materials did not present any cytotoxic side effects toward human fibroblast cells. This novel approach is the first to combine antifungal surface functionalization with NO-releasing technology, providing a promising step toward reducing the rate of broad-spectrum infection and thrombosis associated with indwelling medical devices.
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Affiliation(s)
- Ryan Devine
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
| | - Megan Douglass
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
| | - Morgan Ashcraft
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
- Pharmaceutical and Biomedical Sciences Department, College of Pharmacy, University of Georgia, Athens, Georgia 30602, United States
| | - Nicole Tayag
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, Georgia 30602, United States
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Colarossi G, Maffulli N, Trivellas A, Schnöring H, Hatam N, Tingart M, Migliorini F. Superior outcomes with Argatroban for heparin-induced thrombocytopenia: a Bayesian network meta-analysis. Int J Clin Pharm 2021; 43:825-838. [PMID: 33774764 PMCID: PMC8352815 DOI: 10.1007/s11096-021-01260-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/15/2021] [Indexed: 12/20/2022]
Abstract
Background Argatroban, lepirudin, desirudin, bivalirudin, and danaparoid are commonly used to manage heparin-induced thrombocytopenia related complications. However, the most suitable drug for this condition still remains controversial. Aim of the review This Bayesian network meta-analysis study compared the most common anticoagulant drugs used in the management of heparin-induced thrombocytopenia. Method All clinical trials comparing two or more anticoagulant therapies for suspected or confirmed heparin-induced thrombocytopenia were considered for inclusion. Studies concerning the use of heparins or oral anticoagulants were not considered. Data concerning hospitalisation length, thromboembolic, major, and minor haemorrhagic events, and mortality rate were collected. The network analyses were made through the STATA routine for Bayesian hierarchical random-effects model analysis with standardised mean difference (SMD) and log odd ratio (LOR) effect measures. Results Data from a total of 4338 patients were analysed. The overall mean age was 62.31 ± 6.6 years old. Hospitalization length was considerably shorter in favour of the argatroban group (SMD: − 1.70). Argatroban evidenced the lowest rate of major (LOR: − 1.51) and minor (LOR: − 0.57) haemorrhagic events. Argatroban demonstrated the lowest rate of thromboembolic events (LOR: 0.62), and mortality rate (LOR: − 1.16). Conclusion Argatroban performed better overall for selected patients with HIT. Argatroban demonstrated the shortest hospitalization, and lowest rate of haemorrhages, thromboembolisms, and mortality compared to bivalirudin, lepirudin, desirudin, and danaparoid.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
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Samuelson Bannow B, Warad DM, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Sharma R, Grill DE, Redman MW, Khalighi PR, Leger RR, Pruthi RK, Chen D, Sabath DE, Aster RH, Garcia DA, Padmanabhan A. A prospective, blinded study of a PF4-dependent assay for HIT diagnosis. Blood 2021; 137:1082-1089. [PMID: 32898858 PMCID: PMC7907721 DOI: 10.1182/blood.2020008195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/23/2020] [Indexed: 12/22/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, prothrombotic, antibody-mediated disorder. To maximize the likelihood of recovery, early and accurate diagnosis is critical. Widely available HIT assays, such as the platelet factor 4 (PF4) heparin enzyme-linked immunosorbent assay (ELISA) lack specificity, and the gold-standard carbon 14-labeled serotonin release assay (SRA) is of limited value for early patient management because it is available only through reference laboratories. Recent studies have demonstrated that pathogenic HIT antibodies selectively activate PF4-treated platelets and that a technically simpler assay, the PF4-dependent P-selectin expression assay (PEA), may provide an option for rapid and conclusive results. Based upon predefined criteria that combined 4Ts scores and HIT ELISA results, 409 consecutive adults suspected of having HIT were classified as disease positive, negative, or indeterminate. Patients deemed HIT indeterminate were considered disease negative in the primary analysis and disease positive in a sensitivity analysis. The ability of PEA and SRA to identify patients judged to have HIT was compared using receiver operating characteristic curve statistics. Using these predefined criteria, the diagnostic accuracy of PEA was high (area under the curve [AUC], 0.94; 95% confidence interval [CI], 0.87-1.0) and similar to that of SRA (AUC, 0.91; 95% CI, 0.82-1.0). In sensitivity analysis, the AUCs of PEA and SRA were also similar at 0.88 (95% CI, 0.78-0.98) and 0.86 (95% CI, 0.77-0.96), respectively. The PEA, a technically simple nonradioactive assay that uses ∼20-fold fewer platelets compared with the SRA, had high accuracy for diagnosing HIT. Widespread use of the PEA may facilitate timely and more effective management of patients with suspected HIT.
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Affiliation(s)
| | - Deepti M Warad
- Department of Pediatric and Adolescent Medicine and
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | | | - Ruchika Sharma
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | - Diane E Grill
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Parisa R Khalighi
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO
| | - Rachel R Leger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Rajiv K Pruthi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Medicine, Mayo Clinic, Rochester, MN; and
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Daniel E Sabath
- Department of Laboratory Medicine and
- Department of Medicine, University of Washington, Seattle, WA
| | | | - David A Garcia
- Department of Medicine, University of Washington, Seattle, WA
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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A population-based analysis on the use of therapeutic plasma exchange and intravenous immunoglobulin in heparin-induced thrombocytopenia. Thromb Res 2021; 201:6-14. [PMID: 33621860 DOI: 10.1016/j.thromres.2021.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/30/2020] [Accepted: 02/08/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION In heparin-induced thrombocytopenia (HIT), selected patients are treated with therapies directed at the immune response, intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE). To determine IVIG and TPE characteristics and outcomes in HIT, we analyzed the National Inpatient Sample (NIS) database. METHODS In a population-based analysis of the NIS, we identified hospital discharges of adult patients with a HIT diagnosis. A two-level statistical analysis was performed comparing cases as follows 1) IVIG or TPE vs. none; and 2) IVIG vs. TPE. For each analysis, the primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, infections, hospital length of stay, and total charges. RESULTS Among 22,152 discharges with a HIT diagnosis, 77 (0.34%) and 52 (0.23%) received TPE and IVIG, respectively. In the first level analysis of TPE or IVIG vs. no treatment, TPE or IVIG treatment was associated with a higher likelihood of in-hospital mortality (OR = 1.85; 95%CI: 1.13-3.03, p = 0.0104), major bleeding (OR = 1.91; 95%CI: 1.25-2.93, p = 0.0030), gastrointestinal bleeding (OR = 1.89; 95%CI: 1.08-3.30, p = 0.0259), and infection (OR = 1.65; 95% CI:1.13-2.41, p = 0.0095). In the second-level analysis comparing IVIG vs. TPE, there were no significant differences in patient characteristics or outcomes in both unadjusted and adjusted analyses. CONCLUSIONS In this population-based analysis of HIT, we found similar outcomes of IVIG and TPE-treated cases. Given the small sample size, future studies are needed to confirm this observation.
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Squiccimarro E, Jiritano F, Serraino GF, ten Cate H, Paparella D, Lorusso R. Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support. J Clin Med 2021; 10:jcm10040615. [PMID: 33561947 PMCID: PMC7914426 DOI: 10.3390/jcm10040615] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
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Affiliation(s)
- Enrico Squiccimarro
- Department of Cardiac Surgery, Mater Dei Hospital, 70125 Bari, Italy;
- Department of Emergency and Organ Transplant (DETO), University of Bari, 70125 Bari, Italy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
- Correspondence:
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Hugo ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, D-55131 Mainz, Germany;
- Thrombosis Center Maastricht, Maastricht University Medical Center (MUMC), 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
| | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70125 Bari, Italy;
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
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Pan X, Shi Z, Shi ZJ, Yang Z, Lin ZM, Wu XP, Wang J. Patients Undergoing Primary Total Joint Arthroplasty with Primary Hypercoagulable States. Orthop Surg 2021; 13:442-450. [PMID: 33470047 PMCID: PMC7957433 DOI: 10.1111/os.12901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 11/27/2022] Open
Abstract
Objective To analyze perioperative complications, resource consumption, and inpatient mortality of patients who receive total joint arthroplasty (TJA) with a concomitant diagnosis of a primary hypercoagulable state (PHS). The following questions were posed in the present paper. First, do patients undergoing TJA with PHS have increased risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and periprosthetic joint infection (PJI)? Second, what other in‐hospital complications are more likely among PHS patients undergoing TJA? Third, do TJA patients with PHS usually consume greater in‐hospital resources? Fourth, do PHS patients suffer higher mortality rates compared to non‐PHS patients? Finally, have PHS patients received proper anticoagulant management in past arthroplasties? Methods The National Inpatient Sample (NIS) database for the years between 2003 and 2014 was searched to identify patients undergoing primary TJA. Patients with PHS were identified with the ICD‐9‐CM code 289.81. The χ2‐test, the Pearson test, and adjusted multivariate regression analysis were performed to evaluate the difference and odds ratios between the positive and negative diagnosis groups. Results From 2003 to 2014, a total of 2,044,356 patients were identified in the NIS as undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) in the United States. A total of 4664 patients (0.2%) were identified as having PHS. Compared with the non‐PHS group, TJA patients with PHS had a higher risk of DVT (THA: odds ratio [OR] = 8.343, 95% CI: 5.362–12.982, P < 0.001; TKA: OR = 4.712, 95% CI: 3.560–6.238, P < 0.001) but did not have increased risk of PE (THA: OR = 1.306, 95% CI: 0.48–3.555, P = 0.602; TKA: OR = 1.143, 95% CI: 0.687–1.903), and only PHS patients in the THA group had higher risks of inpatient mortality (OR = 3.184, 95% CI: 1.348–7.522, P = 0.008) and periprosthetic joint infection (OR = 3.343, 95% CI: 1.084–10.879, P = 0.036). In addition, PHS patients had extended length of stay, higher total costs, and increased risks of certain other complications, such as peripheral vascular disease, hemorrhage, and thrombophlebitis. Conclusion In the present study, PHS patients had higher risks of DVT, greater in‐hospital resource consumption, and certain other perioperative complications. However, PHS was not associated with increased risk of PE in TJA patients in the United States between 2003 and 2014. While potential hazards of PHS have already been recognized, the present study revealed additional concerns and demonstrated that further improvements in the perioperative management of patients with hereditary hypercoagulable disorders are essential.
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Affiliation(s)
- Xin Pan
- Department of Orthopaedics, Southern Medical University, Guangzhou, China.,First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Zhe Shi
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhan-Jun Shi
- Department of Orthopaedics, Southern Medical University, Guangzhou, China
| | - Zhang Yang
- Department of Orthopaedics, Southern Medical University, Guangzhou, China
| | - Ze-Ming Lin
- Department of Orthopaedics, Southern Medical University, Guangzhou, China
| | - Xuan-Ping Wu
- Department of Orthopaedics, Southern Medical University, Guangzhou, China
| | - Jian Wang
- Department of Orthopaedics, Southern Medical University, Guangzhou, China
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Akinyemiju T, Onwuemene OA. Use of therapeutic plasma exchange in heparin-induced thrombocytopenia: A population-based study. J Clin Apher 2021; 36:398-407. [PMID: 33453132 DOI: 10.1002/jca.21876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is characterized by anti-heparin/platelet factor 4 immune complexes, which are removed by therapeutic plasma exchange (TPE). Our main objective was to study TPE outcomes in HIT using a large administrative claims database. STUDY DESIGN AND METHODS We used the National Inpatient Sample (NIS) to identify hospital discharges of adult patients (≥18) with a primary or secondary diagnosis of HIT. Cases were classified into two groups based on TPE use. The primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, hospital length of stay (LOS), and charges. Multivariable regression analysis, controlling for age and medical comorbidities, was used to examine the association of TPE with study outcomes. RESULTS A HIT diagnosis was made in 22 165 discharges, of which 90 (0.4%) received TPE. Corresponding national estimates are 106 435 and 439, respectively. TPE was not associated with decreased in-hospital mortality (OR = 1.72; 95%CI: 0.93-3.17, P = .085). However, TPE was associated with a higher likelihood of major bleeding (OR = 2.35; 95%CI: 1.40-3.68, P = .0009), primarily driven by gastrointestinal bleeding (OR = 2.21; 95%CI: 1.17-4.17, P = .015). TPE was also associated with higher hospital LOS (20.5 vs 10 day, P < .0001) and charges (USD 211181 vs USD 81654, P < .0001). CONCLUSION TPE's association with increased bleeding and a prolonged hospital course indicates that it is being used in HIT cases with a severe clinical phenotype. Future studies are needed to better characterize the HIT phenotype that will most benefit from TPE.
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Affiliation(s)
| | - Stephen H Boyle
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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