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Beheshtizadeh N, Mohammadzadeh M, Mostafavi M, Seraji AA, Esmaeili Ranjbar F, Tabatabaei SZ, Ghafelehbashi R, Afzali M, Lolasi F. Improving hemocompatibility in tissue-engineered products employing heparin-loaded nanoplatforms. Pharmacol Res 2024; 206:107260. [PMID: 38906204 DOI: 10.1016/j.phrs.2024.107260] [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: 04/24/2024] [Revised: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
The enhancement of hemocompatibility through the use of nanoplatforms loaded with heparin represents a highly desirable characteristic in the context of emerging tissue engineering applications. The significance of employing heparin in biological processes is unquestionable, owing to its ability to interact with a diverse range of proteins. It plays a crucial role in numerous biological processes by engaging in interactions with diverse proteins and hydrogels. This review provides a summary of recent endeavors focused on augmenting the hemocompatibility of tissue engineering methods through the utilization of nanoplatforms loaded with heparin. This study also provides a comprehensive review of the various applications of heparin-loaded nanofibers and nanoparticles, as well as the techniques employed for encapsulating heparin within these nanoplatforms. The biological and physical effects resulting from the encapsulation of heparin in nanoplatforms are examined. The potential applications of heparin-based materials in tissue engineering are also discussed, along with future perspectives in this field.
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Affiliation(s)
- Nima Beheshtizadeh
- Department of Tissue Engineering, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Mahsa Mohammadzadeh
- Department of Materials Engineering, Isfahan University of Technology, Isfahan 84156-83111, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mehrnaz Mostafavi
- Faculty of Allied Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Abbas Seraji
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada; Department of Polymer Engineering and Color Technology, Amirkabir University of Technology, Tehran, Iran
| | - Faezeh Esmaeili Ranjbar
- Molecular Medicine Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Seyedeh Zoha Tabatabaei
- Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robabehbeygom Ghafelehbashi
- Dental Materials Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; Department of Materials and Textile Engineering, College of Engineering, Razi University, Kermanshah, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maede Afzali
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Farshad Lolasi
- Department of pharmaceutical biotechnology, Faculty of Pharmacy And Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Warkentin TE, Greinacher A. Laboratory Testing for Heparin-Induced Thrombocytopenia and Vaccine-Induced Immune Thrombotic Thrombocytopenia Antibodies: A Narrative Review. Semin Thromb Hemost 2023; 49:621-633. [PMID: 36455619 PMCID: PMC10421650 DOI: 10.1055/s-0042-1758818] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT) are highly prothrombotic (thrombosis frequency ≥50%). Both are caused by platelet-activating anti-platelet factor 4 (PF4) antibodies, forming PF4/IgG-containing immune complexes that engage platelet FcγIIa receptors, producing strong platelet activation. In HIT, heparin crosslinks several PF4 molecules, whereas in VITT, anti-PF4 antibodies alone crosslink PF4. Sufficient levels of circulating anti-PF4 antibodies are needed to create the pathogenic immune complexes on platelet surfaces; this explains why certain serum (plasma)-based assays are highly sensitive for detecting HIT/VITT antibodies. Accordingly, HIT and VITT are "clinical-pathological" disorders, that is, positive testing for such antibodies-together with a compatible clinical picture-is integral for diagnosis. Heparin (low concentrations) enhances HIT antibody-induced platelet activation, but platelet activation by VITT sera is usually inhibited by heparin. For both HIT and VITT, high sensitivity (>99% and >95%, respectively) characterizes PF4-dependent enzyme immunoassays (EIAs) and PF4-enhanced platelet activation assays; in contrast, certain rapid immunoassays have high sensitivity for HIT (>90-97%) but poor sensitivity (<25%) for VITT. HIT and VITT antibodies are directed at distinct sites on PF4: solid-phase EIAs and platelet activation assays are indifferent to these distinct antigen targets, but rapid immunoassays are not. We discuss a conceptual model where PF4 is viewed as a "globe," with the heparin-binding site the "equator"; in this model, HIT antibodies are primarily directed at antigen site(s) at the north and south "poles" of PF4 (formed when PF4 binds to heparin), whereas VITT antibodies recognize sites on the equator.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institute for Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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Rittener‐Ruff L, Marchetti M, Matthey‐Guirao E, Grandoni F, Gomez FJ, Alberio L. Combinations of rapid immunoassays for a speedy diagnosis of heparin-induced thrombocytopenia. J Thromb Haemost 2022; 20:2407-2418. [PMID: 35808841 PMCID: PMC9796930 DOI: 10.1111/jth.15811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/23/2022] [Accepted: 06/27/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Early recognition and treatment of heparin-induced thrombocytopenia (HIT) are key to prevent severe complications. OBJECTIVE To assess the diagnostic performance of rapid immunoassays (IA) in detecting anti-PF4/heparin-antibodies. METHODS Diagnostic performances of lateral-flow IA (LFIA; STic Expert HIT) and latex IA (LIA; HemosIL HIT-Ab) were analyzed in pilot (n = 74) and derivation cohorts (n = 267). Two novel algorithms based on the combination of HIT clinical probability with sequentially performed LIA and chemiluminescent IA (CLIA; HemosIL AcuStar-HIT-IgG) were compared with published rapid diagnostic algorithms: the "Lausanne algorithm" sequentially combining CLIA and particle-gel IA (PaGIA) and the "Hamilton algorithm" based on simultaneously performed LIA and CLIA. RESULTS LFIA missed 6/30 HIT. The sensitivity and specificity of LIA were 90.9% and 93.5%. The Lausanne algorithm correctly predicted HIT in 19/267 (7.1%), excluded it in 240/267 (89.9%), leaving 8/267 (3%) cases unsolved. The algorithm sequentially combining CLIA and LIA predicted HIT in 19/267 (7.1%) with 1/19 wrong prediction, excluded it in 236/267 (88.4%), leaving 11/267 (4.1%) cases unsolved. The algorithm employing LIA as a first assay predicted HIT in 22/267 (8.2%), excluded it in 235/267 (88%), leaving 9/267 (3.4%) cases unsolved. Finally, the Hamilton algorithm correctly predicted HIT in 10/267 (3.7%), excluded it in 229/267 (85.7%), leaving 28/267 (10.5%) cases unsolved. CONCLUSION LFIA cannot be used to exclude or predict HIT when using frozen plasma. A Bayesian approach sequentially employing two rapid immunoassays for anti-PF4/heparin antibodies is most effective for the accurate diagnosis of HIT. Based on retrospective data, the combination LIA/CLIA is a candidate for a prospective validation.
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Affiliation(s)
- Luana Rittener‐Ruff
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Matteo Marchetti
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Elena Matthey‐Guirao
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Francesco Grandoni
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Francisco J. Gomez
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology LaboratoryLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
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Warkentin TE, Greinacher A. Seminars in Hematology Laboratory testing for VITT antibodies. Semin Hematol 2022; 59:80-88. [DOI: 10.1053/j.seminhematol.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/07/2023]
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Favaloro EJ, Pasalic L, Henry B, Lippi G. Laboratory testing for platelet factor 4 antibodies: differential utility for diagnosis/exclusion of heparin induced thrombocytopenia versus suspected vaccine induced thrombotic thrombocytopenia. Pathology 2022; 54:254-261. [PMID: 35125202 DOI: 10.1016/j.pathol.2021.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
Platelet factor 4 (PF4), a protein stored in the alpha-granules of platelets and released upon activation, forms cationic tetramers that bind with various polymeric anions, including heparin. Some individuals develop antibodies against PF4 in complex with heparin (PF4/H), which potentially lead to the onset of heparin induced thrombocytopenia (HIT). In some patients, this may cause activation and aggregation of platelets, promoting pathological thrombosis, in a process called heparin induced thrombocytopenia with thrombosis ('HITT'). Laboratories can assess for the presence of these antibodies using many PF4 antibody tests, including by enzyme linked immunosorbent assay (ELISA), latex immunoassay (LIA), chemiluminescence immunoassay (CLIA) and even rapid nanoparticle based lateral flow immunoassays. All these assays can identify such antibodies with high sensitivity, but methods may have variable specificity. For example, several studies have shown CLIA assays to have higher specificity to HITT than ELISA assays. Very recently, a new 'HITT-like' syndrome has been described in some individuals receiving adenovirus based COVID-19 (coronavirus disease 2019) vaccines. This condition has been given several names, including vaccine induced thrombotic thrombocytopenia (VITT) and thrombosis with thrombocytopenia syndrome (TTS), and also involves a mechanism mediated by antibodies formed against PF4. These antibodies can also be detected by PF4 antibody tests, but detection sensitivity appears to favour ELISA assays, with most other tests (including CLIA and LIA) not generally capable of detecting such antibodies. Additional functional assays assessing for PF4 mediated platelet activation may also be performed. The current review is focussed on laboratory testing for PF4 antibodies, in particular to distinguishing patterns in HITT versus VITT.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia; Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia.
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
| | - Brandon Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, USA; Host-Pathogens Interactions and Population Health Programs, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Karwasra R, Singh S, Raza K, Sharma N, Varma S. A brief overview on current status of nanomedicines for treatment of pancytopenia: Focusing on chemotherapeutic regime. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Marcucci R, Berteotti M, Gori AM, Giusti B, Rogolino AA, Sticchi E, Liotta AA, Ageno W, De Candia E, Gresele P, Marchetti M, Marietta M, Tripodi A. Heparin induced thrombocytopenia: position paper from the Italian Society on Thrombosis and Haemostasis (SISET). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:14-23. [PMID: 33370230 PMCID: PMC7850929 DOI: 10.2450/2020.0248-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare immune mediated adverse drug reaction occurring after exposure to heparin. It is a serious and potentially fatal condition, which may be associated with the development of arterial or venous thrombotic events. Although known for many years, HIT is still often misdiagnosed. Pre- test clinical probability, screening for anti-PF4/heparin antibodies and documentation of their platelet activating capacity are the cornerstones of diagnosis. However, both clinical algorithms and test modalities have limited predictive values and limited diffusion so that the diagnosis and management is challenging in the clinical practice. For this reason, there is an unmet need for novel rational non-anticoagulant therapies based on the pathogenesis of HIT.The present paper reports the position of the Italian Society on Haemostasis and Thrombosis (SISET) in order to increase awareness of HIT among clinicians and other health care professionals and to provide information on the most appropriate management.
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Affiliation(s)
- Rossella Marcucci
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Martina Berteotti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Anna M. Gori
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Betti Giusti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Angela A. Rogolino
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Elena Sticchi
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Agatina Alessandrello Liotta
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Erica De Candia
- Department of Translational Medicine and Surgery, Catholic University of Rome, Rome, Italy
- Department of Image Diagnostics, Radiotherapy and Haematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marina Marchetti
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Marietta
- Department of Oncology and Haematology, University Hospital, Modena, Italy
| | - Armando Tripodi
- IRCCS “Ca’ Granda Maggiore” Hospital Foundation, “Angelo Bianchi Bonomi” Haemophilia and Thrombosis Center and “Fondazione Luigi Villa”, Milan, Italy
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Jousselme E, Guéry EA, Nougier C, Sobas F, Rollin J, Gruel Y, Vayne C, Pouplard C. Prospective evaluation of two specific IgG immunoassays (HemosIL ® AcuStar HIT-IgG and HAT45G ® ) for the diagnosis of heparin-induced thrombocytopenia: A Bayesian approach. Int J Lab Hematol 2020; 43:468-476. [PMID: 33244896 DOI: 10.1111/ijlh.13404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The accurate diagnosis of heparin-induced thrombocytopenia (HIT) is essential to ensure adequate treatment and prevent complications. First step diagnosis test are immunoassays including enzyme-linked immunosorbent assays (ELISAs) and rapid immunoassays. METHODS Using a Bayesian approach, we prospectively evaluated the performance of the IgG PF4/polyvinylsulfonate ELISA and a chemiluminescent immunoassay (CLIA), which are specific for IgG and use the same antigenic target to detect HIT antibodies. RESULTS One hundred and eighty-four 184 consecutive patients with an intermediate (n = 159) or high (n = 25) clinical pretest probability of HIT based on the 4Ts score or platelet pattern were included. Both immunoassays (IAs) were performed on all 184 samples, and definite HIT was confirmed with a positive serotonin release assay in 29 patients (12.7%). The sensitivity (Ss) and negative predictive value (NPV) of ELISA were excellent (100%) allowing HIT to be excluded with good confidence when the test was negative. In addition, the Ss and NPV of the CLIA equalled 93.1% and 98.6%, respectively, as it was negative in two definite HIT. When the CLIA was negative, the post-test probability of HIT was 0.7% in case of intermediate risk. Although there was excellent agreement between CLIA and ELISA results, the quantitative values provided by the two IAs were not correlated. CONCLUSION AcuStar HIT® detects more than 90% of HIT, as do all rapid IAs, and appears to be a good tool for excluding HIT when the pretest probability is intermediate. A chemiluminescent signal higher than 10 IU/mL is highly predictive of definite HIT with a PPV of 100%.
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Affiliation(s)
- Emilie Jousselme
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Eve-Anne Guéry
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France
| | - Christophe Nougier
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Frédéric Sobas
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Jérôme Rollin
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Caroline Vayne
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Claire Pouplard
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
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Favaloro EJ, Mohammed S, Donikian D, Kondo M, Duncan E, Yacoub O, Zebeljan D, Ng S, Malan E, Yuen A, Beggs J, Moosavi S, Coleman R, Klose N, Chapman K, Cavanaugh L, Pasalic L, Motum P, Tan CW, Brighton T. A multicentre assessment of contemporary laboratory assays for heparin induced thrombocytopenia. Pathology 2020; 53:247-256. [PMID: 33032809 DOI: 10.1016/j.pathol.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/25/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare but potentially fatal complication of heparin therapy. In some patients, HIT causes platelet activation and thrombosis (sometimes abbreviated HITT), which leads to adverse clinical sequalae ('pathological HIT'). The likelihood of HIT is initially assessed clinically, typically using a scoring system, of which the 4T score is that most utilised. Subsequent laboratory testing to confirm or exclude HIT facilitates exclusion or diagnosis and management. The current investigation comprises a multicentre (n=9) assessment of contemporary laboratory testing for HIT, as performed over the past 1-3 years in each site and comprising testing of over 1200 samples. The primary laboratory test used by study participants (n=8) comprised a chemiluminescence procedure (HIT-IgG(PF4-H)) performed on an AcuStar instrument. Additional immunological testing performed by study sites included lateral flow (STiC, Stago), enzyme linked immunosorbent assay (ELISA), Asserachrom (HPIA IgG), PaGIA (BioRad), plus functional assays, primarily serotonin release assay (SRA) or platelet aggregation methods. The chemiluminescence procedure yielded a highly sensitive screening method for identifying functional HIT, given high area under the curve (AUC, generally ≥0.9) in a receiver operator characteristic (ROC) analysis against SRA as gold standard. ELISA testing resulted in lower ROC AUC scores (<0.8) and higher levels of false positives. Although there is clear association with the likelihood of HIT, the 4T score had less utility than literature suggests, and was comparable to a previous study reported by some of the authors.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia
| | - Dea Donikian
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | - Mayuko Kondo
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | | | | | - Diane Zebeljan
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Sara Ng
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Agnes Yuen
- Monash Health, Melbourne, Vic, Australia
| | | | | | - Robyn Coleman
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Nathan Klose
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Kent Chapman
- NSW Health Pathology, NSW, Australia; John Hunter Hospital, Newcastle, NSW, Australia
| | - Lauren Cavanaugh
- NSW Health Pathology, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Penelope Motum
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Chee Wee Tan
- South Australia Pathology, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Brighton
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
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Zelepukin IV, Yaremenko AV, Yuryev MV, Mirkasymov AB, Sokolov IL, Deyev SM, Nikitin PI, Nikitin MP. Fast processes of nanoparticle blood clearance: Comprehensive study. J Control Release 2020; 326:181-191. [PMID: 32681949 DOI: 10.1016/j.jconrel.2020.07.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/29/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022]
Abstract
Blood circulation is the key parameter that determines the in vivo efficiency of nanoagents. Despite clinical success of the stealth liposomal agents with their inert and shielded surfaces, a great number of non-stealth nanomaterials is being developed due to their potential of enhanced functionality. By harnessing surface phenomena, such agents can offer advanced control over drug release through intricately designed nanopores, catalysis-propelled motion, computer-like analysis of several disease markers for precise target identification, etc. However, investigation of pharmacokinetic behavior of these agents becomes a great challenge due to ultra-short circulation (usually around several minutes) and impossibility to use the invasive blood-sampling techniques. Accordingly, the data on circulation of such agents has been scarce and irregular. Here, we demonstrate high-throughput capabilities of the developed magnetic particle quantification technique for nanoparticle circulation measurements and present a comprehensive investigation of factors that affect blood circulation of the non-stealth nanoparticles. Namely, we studied the following 9 factors: particle size, zeta-potential, coating, injection dose, repetitive administration, induction of anesthesia, mice strain, absence/presence of tumors, tumor size. Our fundamental findings demonstrate potential ways to extend the half-life of the agents in blood thereby giving them a better chance of achieving their goal in the organism. The study will be valuable for design of the next generation nanomaterials with advanced biomedical functionality.
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Affiliation(s)
- Ivan V Zelepukin
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, Moscow, Russia; National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), Moscow, Russia.
| | - Alexey V Yaremenko
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, Moscow, Russia
| | - Mikhail V Yuryev
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia
| | - Aziz B Mirkasymov
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, Moscow, Russia
| | - Ilya L Sokolov
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia; Sirius University of Science and Technology, Sochi, Russia
| | - Sergey M Deyev
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, Moscow, Russia; National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), Moscow, Russia
| | - Petr I Nikitin
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Moscow, Russia; National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), Moscow, Russia
| | - Maxim P Nikitin
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, Moscow, Russia; Sirius University of Science and Technology, Sochi, Russia.
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Singh N, Singh Lubana S, Tsai HM. Myocardial Infarction with Limb Arterial and Venous Thrombosis in a Patient with Enoxaparin-Induced Thrombocytopenia. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922498. [PMID: 32469847 PMCID: PMC7286187 DOI: 10.12659/ajcr.922498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Female, 67-year-old Final Diagnosis: Enoxaparin induced thrombocytopenia with life threatening thrombosis Symptoms: Chest discomfort Medication:— Clinical Procedure: — Specialty: Hematology
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Affiliation(s)
- Navdeep Singh
- Department of Medicine, Division of Hospice and Palliative Care, North Shore University Hospital, Manhasset, NY, USA
| | - Sandeep Singh Lubana
- Department of Medicine, Division of Hematology and Oncology, State University New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Han-Mou Tsai
- Department of Medicine, Division of Hematology and Oncology, State University New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
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Small BL, Gomes MP, McCurry KR, Han X, Ataya A, Akindipe O, Lane CR, Budev M. A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients. Prog Transplant 2019; 30:4-12. [PMID: 31838929 DOI: 10.1177/1526924819892918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. DESIGN A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. RESULTS Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. CONCLUSION Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.
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Affiliation(s)
- Bronwyn Larissa Small
- Pulmonary, Critical Care and Allergy Department, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marcelo P Gomes
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaozhen Han
- Biostatistics Core, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Allergy, University of Florida, Gainesville, FL, USA
| | - Olufemi Akindipe
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - C Randall Lane
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Budev
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Dulicek P, Ivanova E, Kostal M, Fiedlerova Z, Sadilek P, Hirmerova J. Heparin-induced thrombocytopenia treated with fondaparinux: single center experience. INT ANGIOL 2019; 39:76-81. [PMID: 31782283 DOI: 10.23736/s0392-9590.19.04247-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is the most frequent drug-induced, immune-mediated thrombocytopenia. It is associated with significant morbidity and mortality. Anticoagulation with heparin must be stopped immediately and replaced by some suggested alternative - lepirudin, danaparoid or argatroban. Fondaparinux has been also successfully used in HIT. METHODS We present a cohort of 10 patients diagnosed with HIT and treated in a university hospital in a period of four years. Diagnosis was based on Keeling´s scoring system, screening immunologic test for HIT (STic EXPERT® HIT) and sandwich ELISA (detection of IgG/heparin-PF4 antibodies). While other alternative anticoagulants are not readily available in our hospital, we used fondaparinux in all cases. RESULTS From 2014 to 2018, eight males and two females (mean age 67 years, range 46-86 years) were diagnosed with HIT in our hospital. This complication developed in 9 cases after low-molecular-weight heparin and in one after heparin flushes in hemodialysis. A drop-in platelet count developed in all patients, thrombotic complications in 7 and skin necrosis in 2 cases. Fondaparinux was used in all patients, including two cases with severe renal impairment, the dose was chosen individually. We observed complete platelet recovery in all cases. One patient died because of advanced malignancy, others did not have any complication. In 6 cases we switched to oral anticoagulation after platelet recovery. CONCLUSIONS In our group of 10 HIT patients fondaparinux was shown to be both safe and effective, even in those with severe renal impairment. Additional studies are warranted to confirm this observation.
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Affiliation(s)
- Petr Dulicek
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Eva Ivanova
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Milan Kostal
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Zuzana Fiedlerova
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Sadilek
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jana Hirmerova
- Second Department of Internal Medicine, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic - .,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Maličev E. The use of flow cytometry in the diagnosis of heparin-induced thrombocytopenia (HIT). Transfus Med Rev 2019; 34:34-41. [PMID: 31575433 DOI: 10.1016/j.tmrv.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/21/2019] [Accepted: 08/07/2019] [Indexed: 11/25/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) affects some of the patients exposed to heparin. It is mediated by antibodies that recognize neoepitopes on platelet factor 4 (PF4)/heparin complexes. A HIT diagnosis requires both clinical and laboratory evaluation and remains a challenge. Since many patients develop antibodies in response to heparin, but only a few of them generate anti-PF4/heparin antibodies capable of activating platelets which consequently cause clinical complications, the performance of serologic assays is not enough to diagnose HIT. Functional assays can identify pathogenic antibodies capable of platelet activation, but they are more demanding and their limited availability contributes to the problem of diagnosing HIT. Restricted laboratories usually collect sera of multiple patients to perform functional assays only once or twice a week; hence, a HIT diagnosis can take several days. The use of flow cytometry appears to be a promising alternative in the confirmation of pathogenic anti-PF4/heparin antibodies. Flow cytometric assays detect either activation markers on a healthy donor's platelet surfaces or platelet derived microparticles formed after platelet incubation with a patient's serum. Flow cytometers are readily available in many clinical laboratories, so this technology introduces the possibility of an earlier HIT diagnosis. The objective of this review was to collect findings on flow cytometric HIT confirmations to the present date, and to review the currently available flow cytometric assays used in the diagnosis of HIT.
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Affiliation(s)
- Elvira Maličev
- Blood Transfusion Center of Slovenia, Ljubljana, Slovenia.
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Evaluation of STic Expert ® HIT Kit and Its Comparison with ID-PaGIA™ Test in Suspected Heparin-Induced Thrombocytopenia. Indian J Hematol Blood Transfus 2019; 35:155-160. [PMID: 30828164 DOI: 10.1007/s12288-018-0996-z] [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: 09/15/2017] [Accepted: 07/24/2018] [Indexed: 10/28/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction caused by heparin. HIT occurs due to IgG antibodies directed against heparin-bound platelet factor 4 (PF4). The aim of this study was to evaluate the STic® Expert HIT for detection of anti-PF4/heparin antibodies in comparison with ID-PaGIA™ kit. The results were further confirmed by Heparin-induced platelet aggregation test (HIPA). A total of 17 patients with a suspected diagnosis of HIT were enrolled. The 4 T scoring of each case was performed. Testing for HIT was carried out by ID-PaGIA™, STic® Expert HIT, and HIPA. Testing by STic® Expert HIT test demonstrated positivity in three cases while testing by ID-PaGIA™ test kit revealed four positive cases. Two of these cases were confirmed as HIT by HIPA. The study suggests that STic® Expert HIT an equally effective test, in combination with the 4T scoring system for detecting/excluding the diagnosis of HIT. A large number of cases are needed for validation.
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Amiral J, Seghatchian J. An update on evidence based diagnostic and confirmatory testing strategies for heparin induced thrombocytopenia using combined immunological and functional assays. Transfus Apher Sci 2018; 57:804-811. [PMID: 30401517 DOI: 10.1016/j.transci.2018.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This manuscript aims to provide a concise review on current diagnostic/ confirmatory strategies of Heparin Induced Thrombocytopenia (HIT) with the combined use of immunological / functional assays in addition to the clinical probability. Laboratory diagnosis of HIT is of primordial importance as the related complications could become rapidly severe and life-threatening and can provoke limb amputation in some cases. The first action in the presence of HIT suspicion is to withdraw heparin and to initiate an alternative anticoagulant. Whilst vitamin K antagonists are not appropriate, anticoagulant options include Fondaparinux, Sodium Danaparoid, DOACs, Argatroban, and Bivalirudin. However, if HIT is excluded, patients can benefit again from the high therapeutic and antithrombotic efficacy of this drug, which remains superior to all the substitutive anticoagulant treatments. HIT is suspected in the presence of a platelet count drop > 50% on 2 successive counts, or a platelet count < 100 G/L, and of a significant clinical probability (4 Ts score). Testing patients' plasma is required for establishing the diagnosis. Laboratory investigation involves first the immunological measurement of heparin dependent IgG antibodies (mainly targeted to Heparin-Platelet Factor 4 complexes). When positive, a functional assay for platelet activation, performed at a low and high heparin concentration, allows confirming this disease. In any case, if the immuno-assay is negative, HIT can be excluded with a high probability, and heparin can be continued (if clinical examination favors this decision). Conversely, the higher the IgG antibody concentration is (and affinity), the higher is the probability of developing HIT. The functional assay has now become for confirming the platelet activation capacity of antibodies, and therefore confirming the presence of HIT. Up to now, the gold reference method for testing antibody-dependent platelet activation is the C14-Serotonin Release Assay, available only in very few laboratories working with radio-isotopes. A simple, sensitive, and accurate flow cytometry assay becomes now available to all clinical sites, and it can be easily used for testing the capacity of heparin dependent-antibodies to activate platelets, at low heparin concentration. This technique can be performed in any laboratory equipped with a flow cytometer and can make the HIT confirmation diagnosis rapidly available, which introduces a great improvement for management of patients with HIT. We believe that an evidence-based update on this topic is timely and well warranted.
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Affiliation(s)
- Jean Amiral
- SH-Consulting, Scientific Director and Consultant in Hemostasis, Andrésy France.
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement, Audit/ Inspection and DDR Strategies, London, UK.
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Witten A, Bolbrinker J, Barysenka A, Huber M, Rühle F, Nowak-Göttl U, Garbe E, Kreutz R, Stoll M. Targeted resequencing of a locus for heparin-induced thrombocytopenia on chromosome 5 identified in a genome-wide association study. J Mol Med (Berl) 2018; 96:765-775. [PMID: 29934777 DOI: 10.1007/s00109-018-1661-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 06/05/2018] [Accepted: 06/12/2018] [Indexed: 12/18/2022]
Abstract
Immune-mediated heparin-induced thrombocytopenia (HIT) is the clinically most important adverse drug reaction (ADR) in response to heparin therapy characterized by a prothrombotic state despite a decrease in platelet count. We conducted a genome-wide association study in 96 suspected HIT cases and 96 controls to explore the genetic predisposition for HIT within a case-control pharmacovigilance study followed by replication in additional 86 cases and 86 controls from the same study. One single nucleotide polymorphism (SNP, rs1433265, P = 6.5 × 10-5, odds ratio (OR) 2.79) from 16 identified SNPs was successfully replicated (P = 1.5 × 10-4, OR 2.77; combined data set P = 2.7 × 10-8, OR 2.77) and remained the most strongly associated SNP after imputing locus genotypes. Fine mapping revealed a significantly associated risk-conferring haplotype (P = 4.9 × 10-6, OR 2.41). In order to find rare variants contributing to the association signals, we applied a targeted resequencing approach in a subgroup of 73 HIT patients and 23 controls for the regions with the 16 most strongly HIT-associated SNPs. C-alpha testing was applied to test for the impact of rare variants and we detected two candidate genes, the discoidin domain receptor tyrosine kinase 1 (DDR1, P = 3.6 × 10-2) and the multiple C2 and transmembrane domain containing 2 (MCTP2, P = 4.5 × 10-2). For the genes interactor of little elongation complex ELL subunit 1 (ICE1) and a disintegrin-like and metalloproteinase with thrombospondin type 1 motif, 16 (ADAMTS16) nearby rs1433265, we identified several missense variants. Although replication in an independent population is warranted, these findings provide a basis for future studies aiming to identify and characterize genetic susceptibility factors for HIT. KEY MESSAGES: We identified and validated a HIT-associated locus on chromosome 5. Targeted NGS analysis for rare variants identifies DDR1 and MCTP2 as novel candidates. In addition, missense variants for ADAMTS16 and ICE1 were identified in the locus.
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Affiliation(s)
- Anika Witten
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Juliane Bolbrinker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Andrei Barysenka
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Matthias Huber
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Frank Rühle
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, University Hospital of Kiel and Lübeck, Kiel, Germany
| | - Edeltraut Garbe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.,Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Monika Stoll
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany. .,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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18
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HIT or miss? A comprehensive contemporary investigation of laboratory tests for heparin induced thrombocytopenia. Pathology 2018; 50:426-436. [DOI: 10.1016/j.pathol.2017.11.089] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 11/17/2022]
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Nagler M, Bakchoul T. Clinical and laboratory tests for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 2017; 116:823-834. [DOI: 10.1160/th16-03-0240] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 08/16/2016] [Indexed: 12/27/2022]
Abstract
SummaryA rapid diagnostic work-up is required in patients with suspected heparin-induced thrombocytopenia (HIT). However, diagnosis of HIT is challenging due to a number of practical issues and methodological limitations. Many laboratory tests and a few clinical scoring systems are available but the individual characteristics and the diagnostic accuracy of these are hard to appraise. The 4Ts score is a well evaluated clinical assessment tool with the potential to rule out HIT in many patients. Still, it requires experience and is subject to a relevant inter-observer variability. Immunoassays such as enzyme-linked immunosorbent assays or recently developed rapid assays are able to exclude HIT in a number of patients. But, accuracy of immunoassays differs depending on type of assay, threshold, antibody specificity and even manufacturer. Due to a comparatively low positive predictive value, HIT cannot be confirmed by immunoassays alone. In addition, only some of them are immediately accessible, particularly in small laboratories. While functional assays such as the serotonin release assay (SRA) and the heparin-induced platelet activation assay (HIPA) are considered as gold standard for diagnosis of HIT, they require a highly specialised laboratory. In addition, some of them are not adequately evaluated. In clinical practice, we recommend an integrated diagnostic approach combining not only clinical assessment (the 4Ts score) but immunoassays and functional assays as well. We propose a clear diagnostic algorithm supporting clinical decision-making. Furthermore, we provide an overview of all current laboratory techniques for HIT and discuss diagnostic pathways and strategies to reduce diagnostic errors, and future perspectives.
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Warkentin T. Scoring systems for heparin-induced thrombocytopenia (HIT): Whither now? Thromb Haemost 2017; 113:437-8. [DOI: 10.1160/th14-11-0974] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/24/2014] [Indexed: 11/05/2022]
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Vayne C, Guery EA, Kizlik-Masson C, Rollin J, Bauters A, Gruel Y, Pouplard C. Beneficial effect of exogenous platelet factor 4 for detecting pathogenic heparin-induced thrombocytopenia antibodies. Br J Haematol 2017; 179:811-819. [DOI: 10.1111/bjh.14955] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/09/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Caroline Vayne
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Eve-Anne Guery
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | | | - Jérôme Rollin
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Anne Bauters
- Institute of Haematology-Transfusion; University Hospital of Lille; Lille France
| | - Yves Gruel
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Claire Pouplard
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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Raschke RA, Gallo T, Curry SC, Whiting T, Padilla-Jones A, Warkentin TE, Puri A. Clinical effectiveness of a Bayesian algorithm for the diagnosis and management of heparin-induced thrombocytopenia. J Thromb Haemost 2017; 15:1640-1645. [PMID: 28622439 DOI: 10.1111/jth.13758] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 11/28/2022]
Abstract
Essentials We previously published a diagnostic algorithm for heparin-induced thrombocytopenia (HIT). In this study, we validated the algorithm in an independent large healthcare system. The accuracy was 98%, sensitivity 82% and specificity 99%. The algorithm has potential to improve accuracy and efficiency in the diagnosis of HIT. SUMMARY Background Heparin-induced thrombocytopenia (HIT) is a life-threatening drug reaction caused by antiplatelet factor 4/heparin (anti-PF4/H) antibodies. Commercial tests to detect these antibodies have suboptimal operating characteristics. We previously developed a diagnostic algorithm for HIT that incorporated 'four Ts' (4Ts) scoring and a stratified interpretation of an anti-PF4/H enzyme-linked immunosorbent assay (ELISA) and yielded a discriminant accuracy of 0.97 (95% confidence interval [CI], 0.93-1.00). Objectives The purpose of this study was to validate the algorithm in an independent patient population and quantitate effects that algorithm adherence could have on clinical care. Methods A retrospective cohort comprised patients who had undergone anti-PF4/H ELISA and serotonin release assay (SRA) testing in our healthcare system from 2010 to 2014. We determined the algorithm recommendation for each patient, compared recommendations with the clinical care received, and enumerated consequences of discrepancies. Operating characteristics were calculated for algorithm recommendations using SRA as the reference standard. Results Analysis was performed on 181 patients, 10 of whom were ruled in for HIT. The algorithm accurately stratified 98% of patients (95% CI, 95-99%), ruling out HIT in 158, ruling in HIT in 10 and recommending an SRA in 13 patients. Algorithm adherence would have obviated 165 SRAs and prevented 30 courses of unnecessary antithrombotic therapy for HIT. Diagnostic sensitivity was 0.82 (95% CI, 0.48-0.98), specificity 0.99 (95% CI, 0.97-1.00), PPV 0.90 (95% CI, 0.56-0.99) and NPV 0.99 (95% CI, 0.96-1.00). Conclusions An algorithm incorporating 4Ts scoring and a stratified interpretation of the anti-PF4/H ELISA has good operating characteristics and the potential to improve management of suspected HIT patients.
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Affiliation(s)
- R A Raschke
- Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
- Department of Critical Care Medicine, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - T Gallo
- Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - S C Curry
- Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
- Department of Medical Toxicology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - T Whiting
- Department of Critical Care Medicine, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - A Padilla-Jones
- Banner Research Institute, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Puri
- Internal Medicine Residency, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate cellular FcγRIIA on platelets and monocytes to propagate a hypercoagulable state culminating in life-threatening thrombosis. It is now recognized that anti-PF4/heparin antibodies develop commonly after heparin exposure, but only a subset of sensitized patients progress to life-threatening complications of thrombocytopenia and thrombosis. Recent scientific developments have clarified mechanisms underlying PF4/heparin immunogenicity, disease susceptibility, and clinical manifestations of disease. Insights from clinical and laboratory findings have also been recently harnessed for disease prevention. This review will summarize our current understanding of HIT by reviewing pathogenesis, essential clinical and laboratory features, and management.
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Onwuemene O, Arepally GM. Heparin-induced thrombocytopenia: research and clinical updates. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:262-268. [PMID: 27913490 PMCID: PMC6142447 DOI: 10.1182/asheducation-2016.1.262] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) remains an important diagnosis to consider in hospitalized patients developing thrombocytopenia. HIT is an immune-mediated prothrombotic disorder caused by antibodies to platelet factor 4 (PF4) and heparin. Recent basic scientific studies have advanced our understanding of disease pathogenesis through studies of the PF4/heparin structure, immune mechanisms, and cellular basis of thrombosis. Clinical advances have also occurred in areas of HIT prevention, description of disease variants, and diagnostic strategies. Emerging anticoagulants with the potential to change HIT treatment are evolving, although with limited data. This review will provide a current perspective on HIT pathogenesis, disease features, diagnostic strategies, and role of emerging therapies for the management of HIT.
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Affiliation(s)
- Oluwatoyosi Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Gowthami M Arepally
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC
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Demand on-demand testing for the diagnosis of heparin-induced thrombocytopenia. Thromb Res 2016; 140:163-164. [DOI: 10.1016/j.thromres.2016.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 12/31/2022]
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Assessing the clinical and cost impact of on-demand immunoassay testing for the diagnosis of heparin induced thrombocytopenia. Thromb Res 2016; 140:155-162. [DOI: 10.1016/j.thromres.2016.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/11/2016] [Accepted: 01/31/2016] [Indexed: 11/18/2022]
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Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia. A systematic review and meta-analysis. Thromb Haemost 2016; 115:1044-55. [PMID: 26763074 DOI: 10.1160/th15-06-0523] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/03/2015] [Indexed: 01/15/2023]
Abstract
The platelet factor 4/heparin ELISA has limited specificity for heparin-induced thrombocytopenia (HIT) and frequently does not provide same-day results. Rapid immunoassays (RIs) have been developed which provide results in 30 minutes or less. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of RIs for HIT. We searched the literature for studies in which samples from patients with suspected HIT were tested using a RI and a functional assay against which the performance of the RI could be measured. We performed sensitivity analyses of studies that directly compared different RIs with each other and with ELISAs. Estimates of sensitivity and specificity for each RI were calculated. Twenty-three articles, collectively involving six different RIs, met eligibility criteria. All RIs exhibited high sensitivity (0.96 to 1.00); there was wider variability in specificity (0.68 to 0.94). Specificity of the IgG-specific chemiluminescent assay (IgG-CA) was greater than the polyspecific chemiluminescent assay [0.94 (95 %CI 0.89-0.99) vs 0.82 (0.77-0.87)]. The particle gel immunoassay demonstrated greater specificity than the polyspecific ELISA [0.96 (0.95-0.97) vs 0.91 (0.89-0.92)]. The IgG-CA and lateral flow immunoassay [0.94 (0.91-0.97)] exhibited greater specificity than the IgG-specific ELISA [0.86 (0.82-0.90)]. Given their high sensitivity and rapid turnaround time, RIs are a reliable means of excluding HIT at the point-of-care in patients with low or intermediate clinical probability. Additionally, some RIs have greater specificity than HIT ELISAs. In summary, IgG-specific RIs appear to have improved diagnostic accuracy compared with ELISAs in patients with suspected HIT and may reduce misdiagnosis and overtreatment.
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Affiliation(s)
| | | | | | - Adam Cuker
- Adam Cuker, MD, MS, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA, Tel.: +1 215 615 6555, Fax: +1 215 615 6599, E-mail:
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Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 2015; 127:546-57. [PMID: 26518436 DOI: 10.1182/blood-2015-07-661215] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/27/2015] [Indexed: 01/20/2023] Open
Abstract
Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.
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Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood 2015; 126:597-603. [DOI: 10.1182/blood-2014-12-618165] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/14/2015] [Indexed: 11/20/2022] Open
Abstract
Key Points
A negative PaGIA test in a patient with low/intermediate 4Ts score excludes HIT with a high level of confidence. A low 4Ts score was insufficient to exclude HIT in some cases because the posttest probability of HIT with a positive PaGIA was moderate.
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De Cooman L, Devreese KMJ. A rapid test (STic Expert®) for the diagnosis of heparin-induced thrombocytopenia. Br J Haematol 2015; 172:464-5. [DOI: 10.1111/bjh.13488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Liesbeth De Cooman
- Coagulation Laboratory; Department of Clinical Chemistry, Microbiology and Immunology; University Hospital Ghent; Ghent Belgium
| | - Katrien M. J. Devreese
- Coagulation Laboratory; Department of Clinical Chemistry, Microbiology and Immunology; University Hospital Ghent; Ghent Belgium
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Pouplard C, Gruel Y. A rapid test (STic Expert®) for the diagnosis of heparin-induced thrombocytopenia - response to De Cooman and Devreese. Br J Haematol 2015; 172:466-7. [DOI: 10.1111/bjh.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Claire Pouplard
- UMR CNRS 7292 and Université François Rabelais; Tours France
- Laboratoire d'Hématologie-Hémostase; CHU Tours; Tours France
| | - Yves Gruel
- UMR CNRS 7292 and Université François Rabelais; Tours France
- Laboratoire d'Hématologie-Hémostase; CHU Tours; Tours France
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Sakr Y. What's new about heparin-induced thrombocytopenia type II. Intensive Care Med 2015; 41:1824-7. [PMID: 25904184 DOI: 10.1007/s00134-015-3811-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 103, 07743, Jena, Germany.
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Gardiner EE, Andrews RK, Cuker A. DiagnoSTic assays for heparin-induced thrombocytopenia. Br J Haematol 2014; 166:631-3. [PMID: 24824208 DOI: 10.1111/bjh.12940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Elizabeth E Gardiner
- Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
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