1
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Rollin J, Charuel N, Gruel Y, Billy S, Guéry E, May M, Pouplard C, Vayne C. Variable serotonin release assay pattern and specificity of PF4-specific antibodies in HIT, and clinical relevance. J Thromb Haemost 2022; 20:2646-2655. [PMID: 35971886 PMCID: PMC9826218 DOI: 10.1111/jth.15848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The diagnosis of heparin-induced thrombocytopenia (HIT) requires functional assays to demonstrate that platelet factor 4 (PF4)-specific antibodies activate platelets, typically when therapeutic heparin (H) concentrations are tested ("classical" pattern). Some HIT samples also activate platelets without heparin ("atypical" pattern), but with unclear clinical significance. OBJECTIVES We aimed to assess whether platelet activation pattern and some characteristics of PF4-specific antibodies were associated with the severity of HIT. PATIENTS/METHODS Serotonin release assay (SRA) pattern of 81 HIT patients were analyzed and compared with their clinical and biological data, including levels of anti-PF4/H immunoglobulin G (IgG) and anti-PF4 IgG in 47 of them. RESULTS Higher anti-PF4/H IgG titers were measured in patients with an "atypical" SRA (optical density 2.52 vs. 1.94 in those with a "classical" pattern, p < .001). Patients of both groups had similar platelet count (PC) nadir and time to recovery, but those with an "atypical" SRA more frequently developed thrombotic events (69% vs. 34%, p = .037). Significant levels of anti-PF4 IgG were detected in both groups (38% and 61%, respectively). Whatever the SRA pattern, a lower PC nadir (35 vs. 53 G/L, p = .006) and a longer PC recovery time (6 vs. 3 days, p = .015) were evidenced in patients with anti-PF4 antibodies, compared with those with anti-PF4/H IgG only. CONCLUSIONS An atypical SRA pattern with elevated anti-PF4/H IgG titers seems associated with an increased risk of thrombosis in HIT. IgG antibodies to native PF4 may contribute to more severe and persistent thrombocytopenia, and their detection could be useful in clinical practice.
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Affiliation(s)
- Jérôme Rollin
- University of ToursToursFrance
- Department of HaemostasisRegional University Hospital Centre ToursToursFrance
| | | | - Yves Gruel
- University of ToursToursFrance
- Department of HaemostasisRegional University Hospital Centre ToursToursFrance
| | | | - Eve‐Anne Guéry
- Department of HaemostasisRegional University Hospital Centre ToursToursFrance
| | - Marc‐Antoine May
- Department of Cardiovascular SurgeryRegional University Hospital Centre ToursToursFrance
- Department of AnesthesiologyRegional University Hospital Centre ToursToursFrance
| | - Claire Pouplard
- University of ToursToursFrance
- Department of HaemostasisRegional University Hospital Centre ToursToursFrance
| | - Caroline Vayne
- University of ToursToursFrance
- Department of HaemostasisRegional University Hospital Centre ToursToursFrance
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2
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Douxfils J, Vayne C, Pouplard C, Lecompte T, Favresse J, Potier F, Gasser E, Mathieux V, Dogné JM, Gruel Y, Rollin J, Mullier F. Fatal exacerbation of ChadOx1-nCoV-19-induced thrombotic thrombocytopenia syndrome after initial successful therapy with intravenous immunoglobulins - a rational for monitoring immunoglobulin G levels. Haematologica 2021; 106:3249-3252. [PMID: 34847660 PMCID: PMC8634183 DOI: 10.3324/haematol.2021.279509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; QUALIblood s.a., Namur.
| | - Caroline Vayne
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours
| | - Claire Pouplard
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours
| | - Thomas Lecompte
- Département de Médecine, Hôpitaux Universitaires de Genève, service d'angiologie et d'hémostase et Faculté de Médecine, Geneva Platelet Group (GpG), Université de Genève, Geneva
| | - Julien Favresse
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; Clinique Saint-Luc Bouge, Department of Laboratory Medicine, Bouge
| | - Florence Potier
- Service de gériatrie, CHU UCL Namur site Sainte-Elisabeth, Namur
| | - Emy Gasser
- Université Catholique de Louvain, service de gériatrie, CHU UCL Namur site Sainte-Elisabeth, Namur
| | - Valérie Mathieux
- CHU UCL Namur
- site Sainte-Elizabeth, Université catholique de Louvain, Department of Hematology, Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Yvoir
| | - Jean-Michel Dogné
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur
| | - Yves Gruel
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours
| | - Jérôme Rollin
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Namur Research Institute for Life Sciences, Yvoir
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3
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Vayne C, Nguyen TH, Rollin J, Charuel N, Poupon A, Pouplard C, Normann N, Gruel Y, Greinacher A. Characterization of New Monoclonal PF4-Specific Antibodies as Useful Tools for Studies on Typical and Autoimmune Heparin-Induced Thrombocytopenia. Thromb Haemost 2020; 121:322-331. [PMID: 33086397 DOI: 10.1055/s-0040-1717078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is typically caused by platelet-activating immunoglobulin G (IgG) antibodies (Abs) against platelet factor 4 (PF4) complexed with heparin (H). Much less frequent "autoimmune" HIT is distinguished from typical HIT by platelet activation without heparin and the presence of both anti-PF4/H and anti-PF4 IgG. We developed three murine monoclonal anti-PF4 Abs with a human Fc-part, 1E12, 1C12, and 2E1, resembling autoimmune HIT Abs. OBJECTIVES To characterize 1E12, 1C12, and 2E1 in comparison to the heparin-dependent monoclonal anti-PF4/H Abs 5B9 and KKO, and polyclonal Abs from patients with typical HIT (group-2) and autoimmune HIT (group-3). METHODS Interactions of Abs with PF4 and PF4/H were studied by enzyme-linked-immunosorbent assay, single-molecule force spectroscopy, isothermal titration calorimetry, and dynamic light scattering. Serotonin release assay and heparin-induced platelet activation assay were used to assess platelet activation. The binding sites of monoclonal Abs on PF4 were predicted in silico (MAbTope method). RESULTS 1C12, 1E12, and 2E1 displayed higher affinity for PF4/H complexes than 5B9 and KKO, comparable to human group-3 Abs. Only 1C12, 1E12, 2E1, and group-3 Abs formed large complexes with native PF4, and activated platelets without heparin. The predicted binding sites of 1C12, 1E12, and 2E1 on PF4 differed from those of KKO and 5B9, but were close to each other. 2E1 exhibited unique bivalent binding, involving its antigen recognition site to PF4 and charge-dependent interactions with heparin. CONCLUSION 1C12, 1E12, and 2E1 are tools for studying the pathophysiology of autoimmune HIT. 2E1 provides evidence for a new binding mechanism of HIT Abs.
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Affiliation(s)
- Caroline Vayne
- EA7501 GICC, University of Tours, Tours, France.,Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France
| | - Thi-Huong Nguyen
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany.,Institute for Bioprocessing and Analytical Measurement Techniques, Heilbad Heiligenstadt, Germany
| | - Jérôme Rollin
- EA7501 GICC, University of Tours, Tours, France.,Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France
| | | | - Anne Poupon
- PRC, INRA, CNRS, University of Tours, Nouzilly, France.,MAbSilico SAS, Nouzilly, France
| | - Claire Pouplard
- EA7501 GICC, University of Tours, Tours, France.,Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France
| | - Nicole Normann
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Yves Gruel
- EA7501 GICC, University of Tours, Tours, France.,Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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4
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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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5
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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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6
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Khandelwal S, Ravi J, Rauova L, Johnson A, Lee GM, Gilner JB, Gunti S, Notkins AL, Kuchibhatla M, Frank M, Poncz M, Cines DB, Arepally GM. Polyreactive IgM initiates complement activation by PF4/heparin complexes through the classical pathway. Blood 2018; 132:2431-2440. [PMID: 30309891 PMCID: PMC6284214 DOI: 10.1182/blood-2018-03-834598] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/06/2018] [Indexed: 11/20/2022] Open
Abstract
The mechanisms by which exposure to heparin initiates antibody responses in many, if not most, recipients are poorly understood. We recently demonstrated that antigenic platelet factor 4 (PF4)/heparin complexes activate complement in plasma and bind to B cells. Here, we describe how this process is initiated. We observed wide stable variation in complement activation when PF4/heparin was added to plasma of healthy donors, indicating a responder "phenotype" (high, intermediate, or low). Proteomic analysis of plasma from these healthy donors showed a strong correlation between complement activation and plasma immunoglobulin M (IgM) levels (r = 0.898; P < .005), but not other Ig isotypes. Complement activation response to PF4/heparin in plasma displaying the low donor phenotype was enhanced by adding pooled IgM from healthy donors, but not monoclonal IgM. Depletion of IgM from plasma abrogated C3c generation by PF4/heparin. The complement-activating features of IgM are likely mediated by nonimmune, or natural, IgM, as cord blood and a monoclonal polyreactive IgM generate C3c in the presence of PF4/heparin. IgM facilitates complement and antigen deposition on B cells in vitro and in patients receiving heparin. Anti-C1q antibody prevents IgM-mediated complement activation by PF4/heparin complexes, indicating classical pathway involvement. These studies demonstrate that variability in plasma IgM levels correlates with functional complement responses to PF4/heparin. Polyreactive IgM binds PF4/heparin, triggers activation of the classical complement pathway, and promotes antigen and complement deposition on B cells. These studies provide new insights into the evolution of the heparin-induced thrombocytopenia immune response and may provide a biomarker of risk.
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Affiliation(s)
| | - Joann Ravi
- Division of Hematology, Duke University Medical Center, Durham, NC
| | - Lubica Rauova
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Grace M Lee
- Division of Hematology, Duke University Medical Center, Durham, NC
| | | | - Sreenivasulu Gunti
- Experimental Medicine Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Abner L Notkins
- Experimental Medicine Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | | | - Michael Frank
- Department of Pediatrics, Duke University Medical Center, Durham, NC; and
| | | | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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7
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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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8
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Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth 2018; 120:914-927. [DOI: 10.1016/j.bja.2018.01.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 01/10/2023] Open
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9
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Jouni R, Zöllner H, Khadour A, Wesche J, Grotevendt A, Brandt S, Delcea M, Krauel K, Schwertz H, Sachs UJ, Greinacher A, Bakchoul T. Partially desulfated heparin modulates the interaction between anti-protamine/heparin antibodies and platelets. Thromb Haemost 2017; 115:324-32. [DOI: 10.1160/th15-07-0539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/24/2015] [Indexed: 11/05/2022]
Abstract
SummaryProtamine (PRT) is the standard drug to neutralise heparin. PRT/heparin complexes induce an immune response similar to that observed in heparin-induced thrombocytopenia (HIT). Partially desulfated heparin (ODSH) was shown to interfere with anti-platelet factor 4/heparin antibodies (Abs), which are responsible for HIT. In this study, we analyse the impact of ODSH on the interaction between anti-PRT/heparin Abs and platelets. The ability of ODSH to prevent anti-PRT/heparin Ab-induced platelet destruction in vivo was investigated using the NOD/ SCID mouse model. ODSH improved platelet survival in the presence of PRT, heparin and anti-PRT/heparin Abs (median platelet survival after 300 minutes (min) with 20 μg/ml ODSH: 75 %, range 70–81 % vs without ODSH: 49%, range 44–59%, p=0.006). Furthermore, when ODSH was applied 60 min after Ab injection platelet survival was improved (median platelet survival after 300 min with ODSH: 83 %, range 77–93 % vs without ODSH: 59 %, range 29–61 %, p=0.02). In in vitro experiments ODSH inhibited platelet activation at concentrations > 16 μg/mL (p< 0.001), as well as PRT/heparin complex binding to platelets (mean fluorescence intensity [MFI] without ODSH: 85 ± 14 vs with ODSH: 15 ± 0.6, p=0.013). ODSH also displaced pre-bound complexes from the platelet surface (MFI without ODSH: 324 ± 43 vs with 32 μg/ml ODSH: 53 ± 9, p< 0.001). While interfering with platelet activation by anti-PRT/heparin Abs, up to a concentration of 16 μg/ml, ODSH had only minimal impact on neutralisation of heparin by PRT. In conclusion, our study shows that ODSH is able to inhibit platelet activation and destruction suggesting a potential clinical use to reduce anti-PRT/heparin Ab-mediated adverse effects.
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10
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Pishko AM, Cuker A. Heparin-Induced Thrombocytopenia in Cardiac Surgery Patients. Semin Thromb Hemost 2017; 43:691-698. [PMID: 28597462 DOI: 10.1055/s-0037-1602664] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Sommers CD, Ye H, Liu J, Linhardt RJ, Keire DA. Heparin and homogeneous model heparin oligosaccharides form distinct complexes with protamine: Light scattering and zeta potential analysis. J Pharm Biomed Anal 2017; 140:113-121. [DOI: 10.1016/j.jpba.2017.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 12/17/2022]
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12
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Serologic characterization of anti-protamine/heparin and anti-PF4/heparin antibodies. Blood Adv 2017; 1:644-651. [PMID: 29296706 DOI: 10.1182/bloodadvances.2017004408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/22/2017] [Indexed: 11/20/2022] Open
Abstract
Anti-protamine (PRT)/heparin antibodies are a newly described class of heparin-dependent antibodies occurring in patients exposed to PRT and heparin during cardiac surgery. To understand the biologic significance of anti-PRT/heparin antibodies, we developed a murine monoclonal antibody (ADA) specific for PRT/heparin complexes and compared it to patient-derived anti-PRT/heparin antibodies, as well as comparing polyclonal and monoclonal antibodies with anti-platelet factor 4 (PF4)/heparin. Using monoclonal antibodies and polyclonal patient-derived antibodies, we show distinctive binding patterns of anti-PRT/heparin antibodies as compared with PF4/heparin antibodies. Whereas heparin-induced thrombocytopenia (HIT) antibody binding to PF4/heparin is inhibited by relatively low doses of heparin (0-1 U/mL), anti-PRT/heparin antibodies, including ADA, retain binding to PRT/heparin over a broad range of heparin concentrations (0-50 U/mL). Unlike PF4/heparin antibodies, which recognize PF4 complexed to purified or cell-associated glycosaminoglycans (GAGs), anti-PRT/heparin antibodies show variable binding to cell-associated GAGs. Further, binding of anti-PRT/heparin antibodies to PRT/dextran complexes correlates closely with the ability of antibodies to bind to cell-surface PRT. These findings suggest that antibody binding to PRT/dextran may identify a subset of clinically relevant anti-PRT/heparin antibodies that can bind to cell-surface GAGs. Together, these findings show important serologic differences between HIT and anti-PRT/heparin antibodies, which may account for the variability in disease expression of the two classes of heparin-dependent antibodies.
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13
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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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14
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Zöllner H, Jouni R, Panzer S, Khadour A, Janzen L, Wesche J, Ten Berg M, Schellong S, Heinken A, Greinacher A, Bakchoul T. Platelet activation in the presence of neutral protamine Hagedorn insulin: a new feature of antibodies against protamine/heparin complexes. J Thromb Haemost 2017; 15:176-184. [PMID: 27759896 DOI: 10.1111/jth.13547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/18/2016] [Indexed: 01/22/2023]
Abstract
Essentials Protamine (PRT) is used to stabilize insulin in neutral protamine Hagedorn (NPH) insulin. The interaction between NPH-insulin, anti-PRT/heparin antibodies and platelets was investigated. Anti-PRT/heparin antibodies activate platelets in presence of NPH-insulin dependent on heparin. Cross-reactivity seems to have no major effect on the clinical outcome of medical patients. SUMMARY Background Protamine (PRT) is used to stabilize insulin in neutral protamine Hagedorn (NPH) insulin, a commonly used therapeutic agent for diabetes mellitus. Immunization against PRT/heparin complexes is common in diabetic patients. Objectives To investigate the impact of NPH-insulin on the interaction between anti-PRT/heparin antibodies and platelets. Methods The interaction between NPH-insulin and anti-PRT/heparin antibodies was tested using in-house enzyme immunoassays. The ability of anti-PRT/heparin antibodies to activate platelets in the presence of NPH-insulin (and heparin) was investigated using flow cytometry. Results Twenty-one out of 80 sera containing anti-PRT/heparin IgG showed binding to NPH-insulin. Anti-PRT/heparin IgG from immunized patients bound to platelets in the presence of NPH-insulin, but not in the presence of native insulin. Anti-PRT/heparin antibodies induced P-selectin expression in the presence of NPH-insulin in a heparin-dependent way (median mean fluorescence intensity in the presence of NPH-insulin: 55, 95% confidence interval [CI] 18.7-100.5 vs. NPH-insulin and heparin: 204, 95% CI 106.5-372.8). The clinical relevance of platelet-activating anti-PRT/heparin antibodies was assessed by investigating a multicenter study cohort of 332 acutely ill medical patients who received heparin. None of the 21 patients with anti-PRT/heparin IgG developed thrombocytopenia or thromboembolic complications. Conclusions Anti-PRT/heparin antibodies activate platelets in the presence of NPH-insulin in a heparin-dependent way. However, results from our preliminary study indicate no major impact of these antibodies on the clinical outcome in medical patients receiving heparin, particularly on thromboembolic complications.
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Affiliation(s)
- H Zöllner
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
| | - R Jouni
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
- Center for Clinical Transfusion Medicine, Universitätsklinikum Tübingen, Tübingen, Germany
| | - S Panzer
- Department for Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - A Khadour
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
| | - L Janzen
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
| | - J Wesche
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
| | - M Ten Berg
- Department of Clinical Chemistry and Hematology, University of Utrecht, Utrecht, the Netherlands
| | - S Schellong
- Medical Clinic II, Municipal Hospital of Dresden, Dresden, Germany
| | | | - A Greinacher
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
| | - T Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald
- Center for Clinical Transfusion Medicine, Universitätsklinikum Tübingen, Tübingen, Germany
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15
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Warkentin TE. Acute intraoperative HIT during heart surgery: Why so rare? Thromb Res 2016; 146:110-112. [DOI: 10.1016/j.thromres.2016.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 11/26/2022]
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16
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Bakchoul T, Jouni R, Warkentin TE. Protamine (heparin)-induced thrombocytopenia: a review of the serological and clinical features associated with anti-protamine/heparin antibodies. J Thromb Haemost 2016; 14:1685-95. [PMID: 27378603 DOI: 10.1111/jth.13405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Indexed: 01/04/2023]
Abstract
Protamine is widely used in medicine as a rapidly-acting antidote to heparin, particularly for reversing heparin anticoagulation after cardiac surgery. Protamine is also used as a stabilizing additive to certain preparations of insulin. Recent reports demonstrate that protamine and heparin form multimolecular complexes that result in high rates of immunization in post-cardiac surgery patients, particularly of immunoglobulin G (IgG) class antibodies; a subset of these anti-protamine/heparin IgG antibodies activates platelets through their FcγIIA (IgG) receptors. Although the clinical consequences of anti-protamine/heparin antibodies that are newly generated after cardiac surgery are unknown, there is evidence that platelet-activating anti-protamine/heparin antibodies already present at the time of cardiac surgery might occasionally explain more severe thrombocytopenia with delayed platelet count recovery, as well as thromboembolic complications, in the post-cardiac surgery setting. Triggers for such antibodies remain poorly-defined, but could include preoperative administration of heparin to diabetic patients receiving protamine-insulin as well as recent previous cardiac surgery. Anti-protamine/heparin antibodies have several features in common with anti-platelet factor 4 (PF4) PF4/heparin antibodies implicated in heparin-induced thrombocytopenia (HIT), including immunization by heparin-containing multimolecular complexes, predominant IgG class, pathological platelet-activating properties, relatively rapid IgG formation without IgM precedence, and antibody transience. Despite these similarities, the risk of anti-protamine/heparin antibody-mediated complications seems to affect the early post-cardiac surgery period, whereas HIT usually occurs at least 5 days following cardiac surgery. Clinicians need to become aware of this recently recognized immunohematological disorder, and research is needed to identify triggers of immunization, improve detection of pathological antibodies and identify patients at risk of this complication.
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Affiliation(s)
- T Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany. ,
| | - R Jouni
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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17
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Joglekar M, Khandelwal S, Cines DB, Poncz M, Rauova L, Arepally GM. Heparin enhances uptake of platelet factor 4/heparin complexes by monocytes and macrophages. J Thromb Haemost 2015; 13:1416-27. [PMID: 25960020 PMCID: PMC4516590 DOI: 10.1111/jth.13003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/23/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an iatrogenic complication of heparin therapy caused by antibodies to a self-antigen, platelet factor (4) and heparin. The reasons why antibodies form to PF4/heparin, but not to PF4 bound to other cellular glycosaminoglycans are poorly understood. OBJECTIVE To investigate differences in cellular responses to cell-bound PF4 and PF4/heparin complexes, we studied the internalization of each by peripheral blood-derived monocytes, dendritic cells and neutrophils. METHODS AND RESULTS Using unlabeled and fluorescently-labeled antigen and/or labeled monoclonal antibody to PF4/heparin complexes (KKO), we show that PF4/heparin complexes are taken up by monocytes in a heparin-dependent manner and are internalized by human monocytes and dendritic cells, but not by neutrophils. Complexes of PF4/low-molecular-weight heparin and complexes composed of heparin and murine PF4, protamine or lysozyme are internalized similarly, suggesting a common endocytic pathway. Uptake of complexes is mediated by macropinocytosis, as shown by inhibition using cytochalasin D and amiloride. Internalized complexes are transported intact to late endosomes, as indicated by co-staining of vesicles with KKO and lysosomal associated membrane protein-2 (LAMP-2). Lastly, we show that cellular uptake is accompanied by expression of MHCII and CD83 co-stimulatory molecules. CONCLUSIONS Taken together, these studies establish a distinct role for heparin in enhancing antigen uptake and activation of the initial steps in the cellular immune response to PF4-containing complexes.
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Affiliation(s)
- M Joglekar
- Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | - S Khandelwal
- Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | - D B Cines
- Department of Pathology and Laboratory Medicine, Perelman-University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - M Poncz
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L Rauova
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - G M Arepally
- Division of Hematology, Duke University Medical Center, Durham, NC, USA
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18
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Grieshaber P, Bakchoul T, Wilhelm J, Wagner A, Wollbrück M, Böning A, Sachs U. Platelet-activating protamine-heparin-antibodies lead to higher protamine demand in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2015; 150:967-73.e1. [PMID: 26298870 DOI: 10.1016/j.jtcvs.2015.07.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 05/14/2015] [Accepted: 07/16/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Platelet-activating antibodies against protamine-heparin-complexes were described in patients undergoing cardiac surgery, but their clinical consequences remain unclear. This prospective single-center observational study aimed to describe the prevalence and clinical consequences of protamine-heparin-complex antibodies in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS A total of 200 patients undergoing cardiac surgery with cardiopulmonary bypass were included. Blood samples were collected preoperatively and 1 hour, 24 hours, and 7 days after weaning from cardiopulmonary bypass. All sera were tested for the presence of protamine-heparin-complex antibodies using a modified heparin-induced platelet-activation assay. Specific Fcγ receptor IIa-dependent platelet activation was confirmed by repeated testing in the presence of the Fcγ receptor IIa-blocking antibody IV.3. RESULTS Samples from 185 patients were obtained, of whom 24 patients (13%) were positive for protamine-heparin-complex antibodies preoperatively. In all positive samples, functional reactivity was reversible in the presence of IV.3. Although patients with a preoperative presence of protamine-heparin-complex antibodies were significantly older compared with patients negative for protamine-heparin-complex antibodies (73 ± 9.8 years vs 68 ± 10 years, P = .037), no other potential risk factors were identified at 1 day before operation. Patients with protamine-heparin-complex antibodies required significantly more protamine to neutralize heparin (47.66 mg vs 41.67 mg, P = .027). Protamine-heparin-complex antibodies have no significant influence on perioperative platelet numbers, bleeding complications, transfusion requirement, thromboembolic events, major cardiovascular and cerebrovascular events, inflammation parameters, or kidney function. CONCLUSIONS Protamine-heparin-complex antibodies occur frequently in patients undergoing cardiac surgery on cardiopulmonary bypass, resulting in specific platelet activation in vitro. Protamine-heparin-complex antibodies are associated with increased protamine requirement after cardiopulmonary bypass and possibly slower recovery of platelet numbers.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany.
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
| | - Jochen Wilhelm
- Department of Internal Medicine, German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Alexander Wagner
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Matthias Wollbrück
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Giessen, Giessen, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Ulrich Sachs
- Institute for Clinical Immunology und Transfusion Medicine, Justus Liebig University Giessen, Giessen, Germany
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Abstract
PURPOSE OF REVIEW To review the recent developments in understanding the pathophysiology of heparin-induced thrombocytopenia (HIT) and in applying this knowledge to the treatment of patients with suspected and proven HIT. RECENT FINDINGS HIT pathophysiology is dynamic and complex. HIT pathophysiology is initiated by four essential components--heparin (Hep), platelet factor 4 (PF4), IgG antibodies against the Hep-PF4 complex, and platelet FcγRIIa. HIT is propagated by activated platelets, monocytes, endothelial cells, and coagulation proteins. Insights into the unique HIT antibody response continue to emerge, but without consensus as to the relative roles of B cells, T cells, and antigen-presenting cells. Platelet activation via FcγRIIa, the sine qua non of HIT, has become much better appreciated. Therapy remains challenging for several reasons. Suspected HIT is more frequent than proven HIT, because of the widespread use of Hep and the inadequacies of current diagnostic tests and scoring systems. In proven HIT, approved treatments reduce but do not eliminate thrombosis, and have substantial bleeding risk. Rational novel therapeutic strategies, directed at the initiating steps in HIT pathophysiology and with potential combinations staged over time, are in various phases of development. SUMMARY Progress continues in understanding the breadth of molecular and cellular players in HIT. Translation to improved diagnosis and treatment is needed.
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20
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Lee GM, Welsby IJ, Phillips-Bute B, Ortel TL, Arepally GM. High incidence of antibodies to protamine and protamine/heparin complexes in patients undergoing cardiopulmonary bypass. Blood 2013; 121:2828-35. [PMID: 23422751 PMCID: PMC3624931 DOI: 10.1182/blood-2012-11-469130] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/09/2013] [Indexed: 12/26/2022] Open
Abstract
Protamine is routinely used to reverse heparin anticoagulation during cardiopulmonary bypass (CPB). Heparin interacts with protamine to form ultralarge complexes that are immunogenic in mice. We hypothesized that patients exposed to protamine and heparin during CPB will develop antibodies (Abs) to protamine/heparin (PRT/H) complexes that are capable of platelet activation. Specimens from a recently completed prospective clinical trial (HIT [for heparin-induced thrombocytopenia] 5801 study; n = 500) of CPB patients were examined for PRT/H Abs at baseline, at time of hospital discharge (between days 3 through 7), and 30 days after CPB. PRT/H antibody features were characterized and correlated with adverse cardiovascular outcomes. We found a high incidence of PRT/H antibody formation (29%) in patients undergoing cardiac surgery. PRT/H Abs were of high titer (mean titer 1:14,744), showed heparin-dependent binding, and activated platelets in the presence of protamine. PRT/H Abs showed no cross-reactivity to platelet factor 4/heparin complexes, but were cross-reactive with protamine-containing insulin preparations. In the absence of circulating antigen at day 30, there were no complications of thrombocytopenia, thrombotic events, or long-term cardiovascular events. These studies show that Abs to PRT/H occur commonly after cardiac bypass surgery, share a number of serologic features with HIT Abs, including platelet activation, and may pose health risks to patients requiring drug reexposure.
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Affiliation(s)
- Grace M Lee
- Division of Hematology, Duke University Medical Center, Durham, NC 27710, USA
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