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Yang J, Jing J, Chen S, Liu X, Wang J, Pan C, Tang Z. Reversal and resumption of anticoagulants in patients with anticoagulant-associated intracerebral hemorrhage. Eur J Med Res 2024; 29:252. [PMID: 38659079 PMCID: PMC11044346 DOI: 10.1186/s40001-024-01816-5] [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: 09/27/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
The use of anticoagulants has become more frequent due to the progressive aging population and increased thromboembolic events. Consequently, the proportion of anticoagulant-associated intracerebral hemorrhage (AAICH) in stroke patients is gradually increasing. Compared with intracerebral hemorrhage (ICH) patients without coagulopathy, patients with AAICH may have larger hematomas, worse prognoses, and higher mortality. Given the need for anticoagulant reversal and resumption, the management of AAICH differs from that of conventional medical or surgical treatments for ICH, and it is more specific. Understanding the pharmacology of anticoagulants and identifying agents that can reverse their effects in the early stages are crucial for treating life-threatening AAICH. When patients transition beyond the acute phase and their vital signs stabilize, it is important to consider resuming anticoagulants at the right time to prevent the occurrence of further thromboembolism. However, the timing and strategy for reversing and resuming anticoagulants are still in a dilemma. Herein, we summarize the important clinical studies, reviews, and related guidelines published in the past few years that focus on the reversal and resumption of anticoagulants in AAICH patients to help implement decisive diagnosis and treatment strategies in the clinical setting.
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Affiliation(s)
- Jingfei Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jie Jing
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiahui Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Warkentin TE. Autoimmune Heparin-Induced Thrombocytopenia. J Clin Med 2023; 12:6921. [PMID: 37959386 PMCID: PMC10649402 DOI: 10.3390/jcm12216921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; ; Tel.: +1-(905)-527-0271 (ext. 46139)
- Service of Benign Hematology, Hamilton Health Sciences (General Site), Hamilton, ON L8L 2X2, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, ON L8L 2X2, Canada
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3
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Facchetti N, Hinrichs JB, Becker LS, Schneider MA, Brüning R, Rademacher J, Lenz J, Kudrass K, Vogel A, Wacker FK, Dewald CLA. Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more? Cancer Imaging 2023; 23:68. [PMID: 37452405 PMCID: PMC10349410 DOI: 10.1186/s40644-023-00590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP. MATERIALS AND METHODS All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0). RESULTS Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine. CONCLUSION Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.
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Affiliation(s)
- Nadia Facchetti
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Lena S. Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martin A. Schneider
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Roland Brüning
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jan Rademacher
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jochen Lenz
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Kirsten Kudrass
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank K. Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Cornelia L. A. Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [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: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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Jiang Y, Liu Y, Jia X, Xin W, Wang H. The emerging role of adopting protamine for reducing the risk of bleeding complications during the percutaneous coronary intervention: A meta-analysis. J Card Surg 2022; 37:5341-5350. [PMID: 36352811 DOI: 10.1111/jocs.17139] [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: 04/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The safety and the benefits of reducing the risk of bleeding complications via protamine administration during the percutaneous coronary intervention (PCI) remains unclear. This study aimed to systematically assessed the efficacy and safety of using protamine in PCI. METHOD Potential academic studies were identified from PubMed, Cochrane Library, EMBASE, and Web of Science. The time range we retrieved from was that from the inception of electronic databases to March 31, 2022. Gray studies were identified from the references of included literature reports. Stata version 12.0 statistical software (StataCorp LP) was used to analyze the pooled data. RESULTS A total of seven studies were involved in our study. The overall participants of the protamine group were 4983, whereas it was 1953 in the nonprotamine group. This meta-analysis indicated that protamine was preferable for PCI as its lower value of major bleeding (odds ratio [OR] = 0.489, 95% confidence interval [CI]: 0.362-0.661, p < .001) and minor bleeding (OR = 0.281, 95% CI: 0.123-0.643, p = .003). Additionally, the protamine did not tend to be related a higher incidence of mortality (p = .143), myocardial infarction (p = .990), and stent thrombosis (p = .698). CONCLUSIONS Based on available evidence, use of protamine may reduce the risk of bleeding complications without increasing the risk of mortality, myocardial infarction, and stent thrombosis. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.
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Affiliation(s)
- Yunshan Jiang
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yuzhi Liu
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Xiaoli Jia
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyan Wang
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
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Warkentin TE, Sheppard JI, Whitlock RP. Temporal presentations of heparin-induced thrombocytopenia following cardiac surgery: A single-center, retrospective cohort study. J Thromb Haemost 2022; 20:2601-2616. [PMID: 35869817 PMCID: PMC9805231 DOI: 10.1111/jth.15826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an important adverse drug reaction that can occur postcardiac surgery. Preoperative exposure to unfractionated heparin (UFH) is common, raising the issue of how frequently cardiac surgery-associated HIT occurs after immunizing preoperative exposure to heparin. OBJECTIVE To determine the frequency and clinical picture of HIT occurring within 4 days of cardiac surgery (early presentation) versus later presentations (typical, delayed). METHODS We identified patients with laboratory-confirmed HIT following cardiac surgery over 30 years in a single cardiac surgery center. Three different clinical presentations of HIT were identified: typical (HIT-related platelet count fall beginning between postoperative days [PODs] 5-10), delayed (patients with falls after POD10 or who presented following hospital discharge), and early (established before POD5, including during cardiac surgery [acute intraoperative HIT]). RESULTS Of 129 patients identified with HIT complicating cardiac surgery, 100 had typical and 16 had delayed presentation of HIT; only 13 patients (10.1%) presented with early HIT, all of whom had received exposure to UFH during the 10 days before cardiac surgery. No patient was identified in whom remote preoperative UFH exposure was implicated in explaining early HIT. Notably, five patients appeared to have had acute intraoperative HIT, without immediate adverse consequences. CONCLUSIONS Approximately 90% of patients with HIT after cardiac surgery appear to develop this complication due to immunization triggered by cardiac surgery; however, in approximately 10% of patients, early presentation during the first four PODs (or intraoperatively) can be explained by recent immunizing exposure to heparin.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Transfusion MedicineHamilton Regional Laboratory Medicine ProgramHamiltonOntarioCanada
- Service of Benign HematologyHamilton Health SciencesHamiltonOntarioCanada
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Richard P. Whitlock
- Department of Surgery, Division of Cardiac SurgeryMcMaster UniversityHamiltonOntarioCanada
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Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:1949-1962. [PMID: 35550692 DOI: 10.1016/j.jacc.2022.02.052] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.
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Pan Y, Zhao Z, Yang T, Jiao Q, Wei W, Ji J, Xin W. A Meta-Analysis of Using Protamine for Reducing the Risk of Hemorrhage During Carotid Recanalization: Direct Comparisons of Post-operative Complications. Front Pharmacol 2022; 13:796329. [PMID: 35281915 PMCID: PMC8914204 DOI: 10.3389/fphar.2022.796329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Protamine can decrease the risk of hemorrhage during carotid recanalization. However, it may cause severe side effects. There is no consensus on the safety and efficacy of protamine during surgery. Thus, we conduct a comprehensive review and meta-analysis to compare the differences between the protamine and the no-protamine group.Method: We systematically obtained literature from Medline, Google Scholar, Cochrane Library, and PubMed electronic databases. All four databases were scanned from 1937 when protamine was first adopted as a heparin antagonist until February 2021. The reference lists of identified studies were manually checked to determine other eligible studies that qualify. The articles were included in this meta-analysis as long as they met the criteria of PICOS; conference or commentary articles, letters, case report or series, and animal observation were excluded from this study. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool are used to assess the risk of bias of each included observational study and RCT, respectively. Stata version 12.0 statistical software (StataCorp LP, College Station, Texas) was adopted as statistical software. When I2 < 50%, we consider that the data have no obvious heterogeneity, and we conduct a meta-analysis using the fixed-effect model. Otherwise, the random-effect model was performed.Result: A total of 11 studies, consisting of 94,618 participants, are included in this study. Our analysis found that the rate of wound hematoma had a significant difference among protamine and no-protamine patients (OR = 0.268, 95% CI = 0.093 to 0.774, p = 0.015). Furthermore, the incidence of hematoma requiring re-operation (0.7%) was significantly lower than that of patients without protamine (1.8%). However, there was no significant difference in the incidence of stroke, wound hematoma with hypertension, transient ischemic attacks (TIA), myocardial infarction (MI), and death.Conclusion: Among included participants undergoing recanalization, the use of protamine is effective in reducing hematoma without increasing the risk of having other complications. Besides, more evidence-based performance is needed to supplement this opinion due to inherent limitations.
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Affiliation(s)
- Yongli Pan
- Department of Neurology, Weifang Medical University, Weifang, China
| | - Zhiqiang Zhao
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Tao Yang
- Department of Neurosurgery, Heji Hospital Affiliated Changzhi Medical College, Changzhi, China
| | - Qingzheng Jiao
- Second Department of Internal Medicine, Gucheng Country Hospital, Shijiazhuang, China
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Mianyang, China
| | - Jianyong Ji
- Department of Neurosurgery, Liaocheng People’s Hospital, Liaocheng, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Jianyong Ji, ; Wenqiang Xin,
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10
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Warkentin TE, Smythe MA, Ali MA, Aslam N, Sheppard JI, Smith JW, Moore JC, Arnold DM, Nazy I. Serotonin-release assay-positive but platelet factor 4-dependent enzyme-immunoassay negative: HIT or not HIT? Am J Hematol 2021; 96:320-329. [PMID: 33326124 DOI: 10.1002/ajh.26075] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/28/2022]
Abstract
IgG-specific and polyspecific PF4-dependent enzyme-immunoassays (EIAs) have exceptionally high sensitivity (≥99%) for diagnosis of heparin-induced thrombocytopenia (HIT), a drug reaction caused by platelet-activating antibodies detectable by serotonin-release assay (SRA). The IgG-specific EIAs are recommended for screening, as their high sensitivity is accompanied by relatively high specificity vis-à-vis polyspecific EIAs. We investigated the frequency of SRA-positive/EIA-negative (SRA+/EIA-) HIT, prompted by referral to our reference HIT laboratory of serial blood samples from a patient ("index case") with false-negative IgG-specific EIAs. Despite initial clinical suspicion for HIT, repeat negative IgG-specific EIAs prompted heparin resumption, which triggered recurrent thrombocytopenia and near-fatal cardiac arrest, indicating likely post-heparin HIT-associated anaphylactoid reaction. Further investigations revealed a strong-positive SRA, whether performed with heparin alone, PF4 alone, or PF4/heparin, with inhibition by Fc receptor-blocking monoclonal antibody (indicating IgG-mediated platelet activation); however, five different IgG-specific immunoassays yielded primarily negative (or weak-positive) results. To investigate the frequency of SRA+/EIA- HIT, we reviewed the laboratory and clinical features of patients with this serological profile during a 6-year period in which our reference laboratory investigated for HIT using both SRA and IgG-specific EIA. Although ~0.2% of 8546 patients had an SRA+/EIA- profile, further review of 15 such cases indicated clerical/laboratory misclassification or false-positive SRA in all, with no SRA+/EIA- HIT case identified. We conclude that while SRA+/EIA- HIT is possible-as shown by our index case-this clinical picture is exceptionally uncommon. Moreover, the requirement for a positive EIA is a useful quality control maneuver that reduces risk of reporting a false-positive SRA result.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
| | - Maureen A. Smythe
- Department of Pharmaceutical Services Beaumont Hospital Royal Oak Michigan USA
- Department of Pharmacy Practice Wayne State University Detroit Michigan USA
- Oakland University William Beaumont School of Medicine Rochester Michigan USA
| | - Mona A. Ali
- Department of Pharmaceutical Services Beaumont Hospital Royal Oak Michigan USA
| | - Naveed Aslam
- Oakland University William Beaumont School of Medicine Rochester Michigan USA
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - James W. Smith
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - Jane C. Moore
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
| | - Ishac Nazy
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
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Vayne C, Guéry EA, Rollin J, Baglo T, Petermann R, Gruel Y. Pathophysiology and Diagnosis of Drug-Induced Immune Thrombocytopenia. J Clin Med 2020; 9:E2212. [PMID: 32668640 PMCID: PMC7408966 DOI: 10.3390/jcm9072212] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/12/2022] Open
Abstract
Drug-induced immune thrombocytopenia (DITP) is a life-threatening clinical syndrome that is under-recognized and difficult to diagnose. Many drugs can cause immune-mediated thrombocytopenia, but the most commonly implicated are abciximab, carbamazepine, ceftriaxone, eptifibatide, heparin, ibuprofen, mirtazapine, oxaliplatin, penicillin, quinine, quinidine, rifampicin, suramin, tirofiban, trimethoprim-sulfamethoxazole, and vancomycin. Several different mechanisms have been identified in typical DITP, which is most commonly characterized by severe thrombocytopenia due to clearance and/or destruction of platelets sensitized by a drug-dependent antibody. Patients with typical DITP usually bleed when symptomatic, and biological confirmation of the diagnosis is often difficult because detection of drug-dependent antibodies (DDabs) in the patient's serum or plasma is frequently not possible. This is in contrast to heparin-induced thrombocytopenia (HIT), which is a particular DITP caused in most cases by heparin-dependent antibodies specific for platelet factor 4, which can strongly activate platelets in vitro and in vivo, explaining why affected patients usually have thrombotic complications but do not bleed. In addition, laboratory tests are readily available to diagnose HIT, unlike the methods used to detect DDabs associated with other DITP that are mostly reserved for laboratories specialized in platelet immunology.
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Affiliation(s)
- Caroline Vayne
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Eve-Anne Guéry
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Jérôme Rollin
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Tatiana Baglo
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
- Laboratoire d’Hématologie, CNHU de Cotonou, Cotonou 01 BP 386, Benin
| | - Rachel Petermann
- Département d’Immunologie plaquettaire, Institut National de la Transfusion Sanguine (INTS), 75015 Paris, France;
- Equipe ETRES (Ethics, Research, Translations), Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université de Paris, 75006 Paris, France
| | - Yves Gruel
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
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Miklosz J, Kalaska B, Kaminski K, Rusak M, Szczubialka K, Nowakowska M, Pawlak D, Mogielnicki A. The Inhibitory Effect of Protamine on Platelets is Attenuated by Heparin without Inducing Thrombocytopenia in Rodents. Mar Drugs 2019; 17:E539. [PMID: 31533230 PMCID: PMC6780366 DOI: 10.3390/md17090539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 01/09/2023] Open
Abstract
Protamine sulfate (PS) is a polycationic protein drug obtained from the sperm of fish, and is used to reverse the anticoagulant effect of unfractionated heparin (UFH). However, the interactions between PS, UFH, and platelets are still not clear. We measured the platelet numbers and collagen-induced aggregation, P-selectin, platelet factor 4, β-thromboglobulin, prostacyclin metabolite, D-dimers, activated partial thromboplastin time, prothrombin time, anti-factor Xa, fibrinogen, thrombus weight and megakaryocytopoiesis in blood collected from mice and rats in different time points.. All of the groups were treated intravenously with vehicle, UFH, PS, or UFH with PS. We found a short-term antiplatelet activity of PS in mice and rats, and long-term platelet-independent antithrombotic activity in rats with electrically-induced thrombosis. The antiplatelet and antithrombotic potential of PS may contribute to bleeding risk in PS-overdosed patients. The inhibitory effect of PS on the platelets was attenuated by UFH without inducing thrombocytopenia. Treatment with UFH and PS did not affect the formation, number, or activation of platelets, or the thrombosis development in rodents.
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Affiliation(s)
- Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Kamil Kaminski
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Malgorzata Rusak
- Department of Haematological Diagnostics, Medical University of Bialystok, 15-269 Bialystok, Poland
| | - Krzysztof Szczubialka
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Maria Nowakowska
- Department of Physical Chemistry, Faculty of Chemistry, Jagiellonian University, 30-387 Krakow, Poland
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, 15-222 Bialystok, Poland.
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14
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Treatment of bleeding complications in patients on anticoagulant therapy. Blood 2018; 133:425-435. [PMID: 30559261 DOI: 10.1182/blood-2018-06-820746] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Anticoagulant therapy is often refrained from out of fear of hemorrhagic complications. The most frequent type of major bleeding is gastrointestinal, but intracranial hemorrhage has the worst prognosis. Management of these complications in patients on anticoagulants should follow the same routines as for nonanticoagulated patients, as described here with the previously mentioned bleeds as examples. In addition, for life-threatening or massive hemorrhages, reversal of the anticoagulant effect is also crucial. Adequate reversal requires information on which anticoagulant the patient has taken and when the last dose was ingested. Laboratory data can be of some help, but not for all anticoagulants in the emergency setting. This is reviewed here for the different types of anticoagulants: vitamin K antagonists, heparins, fondaparinux, thrombin inhibitors and factor Xa inhibitors. Specific antidotes for the latter are becoming available, but supportive care and nonspecific support for hemostasis with antifibrinolytic agents or prothrombin complex concentrates, which are widely available, should be kept in mind.
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15
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Natural, not immune; classical, not alternative. Blood 2018; 132:2421-2422. [PMID: 30523121 DOI: 10.1182/blood-2018-10-880799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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16
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Bakchoul T, Marini I. Drug-associated thrombocytopenia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:576-583. [PMID: 30504360 PMCID: PMC6246020 DOI: 10.1182/asheducation-2018.1.576] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Many drugs have been implicated in drug-induced immune thrombocytopenia (DITP). Patients with DITP develop a drop in platelet count 5 to 10 days after drug administration with an increased risk of hemorrhage. The diagnosis of DITP is often challenging, because most hospitalized patients are taking multiple medications and have comorbidities that can also cause thrombocytopenia. Specialized laboratory diagnostic tests have been developed and are helpful to confirm the diagnosis. Treatment of DITP involves discontinuation of the offending drug. The platelet count usually starts to recover after 4 or 5 half-lives of the responsible drug or drug metabolite. High doses of intravenous immunoglobulin can be given to patients with severe thrombocytopenia and bleeding. Although in most cases, DITP is associated with bleeding, life-threatening thromboembolic complications are common in patients with heparin-induced thrombocytopenia (HIT). Binding of antiplatelet factor 4/heparin antibodies to Fc receptors on platelets and monocytes causes intravascular cellular activation, leading to an intensely prothrombotic state in HIT. The clinical symptoms include a decrease in platelet counts by >50% and/or new thromboembolic complications. Two approaches can help to confirm or rule out HIT: assessment of the clinical presentation using scoring systems and in vitro demonstration of antiplatelet factor 4/heparin antibodies. The cornerstone of HIT management is immediate discontinuation of heparin when the disease is suspected and anticoagulation using nonheparin anticoagulant. In this review, we will provide an update on the pathophysiology, diagnosis, and management of both DITP and HIT.
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Affiliation(s)
- Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tubingen, University of Tubingen, Tubingen, Germany
| | - Irene Marini
- Transfusion Medicine, Medical Faculty of Tubingen, University of Tubingen, Tubingen, Germany
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East JM, Cserti-Gazdewich CM, Granton JT. Heparin-Induced Thrombocytopenia in the Critically Ill Patient. Chest 2017; 154:678-690. [PMID: 29253554 DOI: 10.1016/j.chest.2017.11.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 11/22/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is associated with clinically significant morbidity and mortality. Patients who are critically ill are commonly thrombocytopenic and exposed to heparin. Although HIT should be considered, it is not usually the cause of thrombocytopenia in the medical-surgical ICU population. A systematic approach to the patient who is critically ill who has thrombocytopenia according to clinical features, complemented by appropriate laboratory confirmation, should lead to a reduction in inappropriate laboratory testing and reduce the use of more expensive and less reliable anticoagulants. If the patient is deemed as being at intermediate or high risk for HIT or if HIT is confirmed by means of the serotonin-release assay, heparin should be stopped, heparin-bonded catheters should be removed, and a direct antithrombin or fondaparinux should be initiated to reduce the risk of thrombosis. Warfarin is absolutely contraindicated in the acute phase of HIT; if administered, its effects must be reversed by using vitamin K.
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Affiliation(s)
- James M East
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - John T Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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18
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Wadowski PP, Felli A, Schiferer A, Panzer S, Opfermann P, Dworschak M, Holaubek C, Aliabadi-Zuckermann A, Steinlechner B. Argatroban in Thrombocytopenic Patients Sensitized to Circulating Protamine-Heparin Complexes. J Cardiothorac Vasc Anesth 2017; 31:1779-1783. [PMID: 28764988 DOI: 10.1053/j.jvca.2017.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Patricia Pia Wadowski
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Alessia Felli
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Arno Schiferer
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Opfermann
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Caroline Holaubek
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | | | - Barbara Steinlechner
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria.
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19
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Yu Y, Chen Y, Mikael P, Zhang F, Stalcup AM, German R, Gould F, Ohlemacher J, Zhang H, Linhardt RJ. Surprising absence of heparin in the intestinal mucosa of baby pigs. Glycobiology 2017; 27:57-63. [PMID: 27744271 PMCID: PMC5193109 DOI: 10.1093/glycob/cww104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/05/2016] [Accepted: 10/09/2016] [Indexed: 12/21/2022] Open
Abstract
Heparin, a member of a family of molecules called glycosaminoglycans, is biosynthesized in mucosal mast cells. This important anticoagulant polysaccharide is primarily produced by extraction of the mast cell-rich intestinal mucosa of hogs. There is concern about our continued ability to supply sufficient heparin to support the worldwide growth of advanced medical procedures from the static population of adult hogs used as food animals. While the intestinal mucosa of adult pigs is rich in anticoagulant heparin (containing a few hundred milligrams per animal), little is known about how the content of heparin changes with animal age. Using sophisticated mass spectral analysis we discovered that heparin was largely absent from the intestinal mucosa of piglets. Moreover, while the related, nonanticoagulant heparan sulfate glycosaminoglycan was present in significant amounts we found little chondroitin sulfate E also associated with mast cells. Histological evaluation of piglet intestinal mucosa showed a very low mast cell content. Respiratory mast cells have been reported in baby pigs suggesting that there was something unique about the piglets used in the current study. These piglets were raised in the relatively clean environment of a university animal facility and treated with antibiotics over their lifetime resulting in a depleted microbiome that greatly reduced the number of mast cells and heparin content of the intestinal mucosal in these animals. Thus, from the current study it remains unclear whether the lack of intestinal mast cell-derived heparin results from the young age of these animals or their exposure to their depleted microbiome.
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Affiliation(s)
- Yanlei Yu
- School of Food Science and Biological Engineering, Zhejiang Gongshang University, No. 18 Xuezheng Street, Xiasha High Education Zone, Hangzhou, Zhejiang 310018, China
- Departments of Chemistry, Biology, Chemical Engineering, and Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, 110 Eighth Street, Troy, NY 12180, USA
| | - Yin Chen
- Departments of Chemistry, Biology, Chemical Engineering, and Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, 110 Eighth Street, Troy, NY 12180, USA
| | - Paiyz Mikael
- Departments of Chemistry, Biology, Chemical Engineering, and Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, 110 Eighth Street, Troy, NY 12180, USA
| | - Fuming Zhang
- Departments of Chemistry, Biology, Chemical Engineering, and Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, 110 Eighth Street, Troy, NY 12180, USA
| | - Apryll M Stalcup
- Irish Separation Science Cluster, National Centre for Sensor Research, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Rebecca German
- Department of Anatomy and Neurobiology, Northeastern Ohio Medical University, D-106, 4209 St. Rt. 44, PO Box 95 Rootstown, OH 44272, USA
| | - Francois Gould
- Department of Anatomy and Neurobiology, Northeastern Ohio Medical University, D-106, 4209 St. Rt. 44, PO Box 95 Rootstown, OH 44272, USA
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, Northeastern Ohio Medical University, D-106, 4209 St. Rt. 44, PO Box 95 Rootstown, OH 44272, USA
| | - Hong Zhang
- School of Food Science and Biological Engineering, Zhejiang Gongshang University, No. 18 Xuezheng Street, Xiasha High Education Zone, Hangzhou, Zhejiang 310018, China
| | - Robert J Linhardt
- Departments of Chemistry, Biology, Chemical Engineering, and Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, 110 Eighth Street, Troy, NY 12180, USA
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20
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B cells, PF4/heparin complexes, and complement. Blood 2016; 128:1781-1782. [PMID: 28832327 DOI: 10.1182/blood-2016-08-729517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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