1
|
Tao Z, Feng Y, Wang J, Zhou Y, Yang J. Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis. Blood Purif 2024; 53:436-464. [PMID: 38310853 DOI: 10.1159/000536312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear. METHOD The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail. RESULTS Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT. CONCLUSIONS There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.
Collapse
Affiliation(s)
- ZhongBin Tao
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - YanDong Feng
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jie Wang
- Department of Pediatrics, The Second People's Hospital of Gansu Province, Lanzhou, China
| | - YongKang Zhou
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - JunQiang Yang
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| |
Collapse
|
2
|
May J, Westbrook B, Cuker A. Heparin-induced thrombocytopenia: An illustrated review. Res Pract Thromb Haemost 2023; 7:100283. [PMID: 37601013 PMCID: PMC10439402 DOI: 10.1016/j.rpth.2023.100283] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug effect from unfractionated or low-molecular-weight heparin that results in thrombocytopenia and potentially catastrophic thrombosis. HIT occurs due to the development of platelet-activating antibodies against multimolecular complexes of platelet factor 4 and heparin. Given the frequency of thrombocytopenia and heparin use among hospitalized patients, calculation of the 4Ts Score is recommended to identify patients at increased likelihood of HIT and direct further evaluation. In patients with an intermediate or high probability 4Ts Score, an immunoassay and functional assay are recommended to confirm or refute the diagnosis of HIT. Heparin avoidance and initiation of nonheparin anticoagulation are the mainstays of acute HIT management. In this illustrated review, we provide visual summaries of the diagnosis and management of HIT, highlighting connections between pathophysiology and clinical care as well as summarizing efforts in quality improvement in the field. We further emphasize common pitfalls and pearls in diagnosis and management to encourage evidence-based care. We include graphical representation of the unique challenges of HIT with cardiopulmonary bypass and also delineate autoimmune HIT and its subtypes.
Collapse
Affiliation(s)
- Jori May
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Westbrook
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Revelly E, Scala E, Rosner L, Rancati V, Gunga Z, Kirsch M, Ltaief Z, Rusca M, Bechtold X, Alberio L, Marcucci C. How to Solve the Conundrum of Heparin-Induced Thrombocytopenia during Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030786. [PMID: 36769435 PMCID: PMC9918281 DOI: 10.3390/jcm12030786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients.
Collapse
Affiliation(s)
- Etienne Revelly
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Correspondence:
| | - Emmanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Valentina Rancati
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Ziyad Gunga
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Matthias Kirsch
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Zied Ltaief
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Marco Rusca
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Xavier Bechtold
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
| |
Collapse
|
4
|
Wittstock M, Walter U, Volmer E, Storch A, Weber MA, Großmann A. Cerebral venous sinus thrombosis after adenovirus-vectored COVID-19 vaccination: review of the neurological-neuroradiological procedure. Neuroradiology 2022; 64:865-874. [PMID: 35184205 PMCID: PMC8929723 DOI: 10.1007/s00234-022-02914-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/03/2022] [Indexed: 01/22/2023]
Abstract
Cerebral venous and sinus thrombosis (CVST) after adenovirus-vectored COVID-19 ChAdOx1 nCov-19 (Oxford–AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson) is a rare complication, occurring mainly in individuals under 60 years of age and more frequently in women. It manifests 4–24 days after vaccination. In most cases, antibodies against platelet factor-4/polyanion complexes play a pathogenic role, leading to thrombosis with thrombocytopenia syndrome (TTS) and sometimes a severe clinical or even fatal course. The leading symptom is headache, which usually increases in intensity over a few days. Seizures, visual disturbances, focal neurological symptoms, and signs of increased intracranial pressure are also possible. These symptoms may be combined with clinical signs of disseminated intravascular coagulation such as petechiae or gastrointestinal bleeding. If TTS-CVST is suspected, checking d-dimers, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are diagnostically and therapeutically guiding. The imaging method of choice for diagnosis or exclusion of CVST is magnetic resonance imaging (MRI) combined with contrast-enhanced venous MR angiography (MRA). On T2*-weighted or susceptibility weighted MR sequences, the thrombus causes susceptibility artefacts (blooming), that allow for the detection even of isolated cortical vein thromboses. The diagnosis of TTS-CVST can usually be made reliably in synopsis with the clinical and laboratory findings. A close collaboration between neurologists and neuroradiologists is mandatory. TTS-CVST requires specific regimens of anticoagulation and immunomodulation therapy if thrombocytopenia and/or pathogenic antibodies to PF4/polyanion complexes are present. In this review article, the diagnostic and therapeutic steps in cases of suspected TTS associated CSVT are presented.
Collapse
Affiliation(s)
- Matthias Wittstock
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany.
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany
| | - Erik Volmer
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany
| | - Marc-André Weber
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
| | - Annette Großmann
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
| |
Collapse
|
5
|
Pishko AM. Heparin-induced thrombocytopenia and cardiovascular surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:536-544. [PMID: 34889428 PMCID: PMC8791147 DOI: 10.1182/hematology.2021000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Clinicians generally counsel patients with a history of heparin-induced thrombocytopenia (HIT) to avoid heparin products lifelong. Although there are now many alternative (nonheparin) anticoagulants available, heparin avoidance remains challenging for cardiac surgery. Heparin is often preferred in the cardiac surgery setting based on the vast experience with the agent, ease of monitoring, and reversibility. To "clear" a patient with a history of HIT for cardiac surgery, hematologists must first confirm the diagnosis of HIT, which can be challenging due to the ubiquity of heparin exposure and frequency of thrombocytopenia in patients in the cardiac intensive care unit. Next, the "phase of HIT" (acute HIT, subacute HIT A/B, or remote HIT) should be established based on platelet count, immunoassay for antibodies to platelet factor 4/heparin complexes, and a functional assay (eg, serotonin release assay). As long as the HIT functional assay remains positive (acute HIT or subacute HIT A), cardiac surgery should be delayed if possible. If surgery cannot be delayed, an alternative anticoagulant (preferably bivalirudin) may be used. Alternatively, heparin may be used with either preoperative/intraoperative plasma exchange or together with a potent antiplatelet agent. The optimal strategy among these options is not known, and the choice depends on institutional experience and availability of alternative anticoagulants. In the later phases of HIT (subacute HIT B or remote HIT), brief intraoperative exposure to heparin followed by an alternative anticoagulant as needed in the postoperative setting is recommended.
Collapse
Affiliation(s)
- Allyson M. Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Correspondence Allyson M. Pishko, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3rd Floor Dulles, Philadelphia, PA 19104; e-mail:
| |
Collapse
|
6
|
Lee HW, An JN, Lee HS, Song YR, Kim HJ, Kim SG, Kim JK. Neutrophil extracellular traps and heparin-induced antibodies contribute to vascular access thrombosis in hemodialysis patients. Kidney Res Clin Pract 2021; 40:712-723. [PMID: 34370931 PMCID: PMC8685352 DOI: 10.23876/j.krcp.21.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/03/2021] [Indexed: 11/05/2022] Open
Abstract
Background Anti-heparin/platelet factor 4 (PF4) antibodies may trigger severe thrombotic complications in hemodialysis (HD) patients. Tetrameric PF4 has a high affinity for extracellular DNA, which is a key component of neutrophil extracellular traps (NETs); therefore, the interactions between anti-heparin/PF4 antibodies and NETs can contribute to prothrombotic events. Methods Anti-heparin/PF4 antibody levels were measured by enzyme-linked immunosorbent assay and an optical density > 1.8 was regarded as clinically significant. We additionally measured serum nucleosome levels as representative markers of NETs, and the contributions of anti-heparin/PF4 and increased serum nucleosome levels to the primary functional patency loss of vascular access was assessed. Results The frequency of anti-heparin/PF4 antibodies was significantly higher in incident HD patients compared to prevalent HD patients (23.6% vs. 7.7%). Serum nucleosome levels, as well as the white blood cell counts, neutrophil counts, and high- sensitivity C-reactive protein levels, were significantly higher in anti-heparin/PF4 antibody-positive patients compared to the control. Platelet counts tended to be lower in the patients with anti-heparin/PF4 of >1.8 than in the controls. Relative risk calculations showed that the presence of anti-heparin/PF4 antibodies increased the risk of primary functional patency failure by 4.28-fold, and this risk increased further with higher nucleosome levels. Furthermore, in the anti-heparin/PF4 antibody-positive group, the time to first vascular intervention was much shorter, and the risk of repeated intervention was higher, compared to the controls. Conclusion In incident HD patients, the presence of anti-heparin/PF4 antibodies was associated with increased NET formation; this could be a strong predictor of vascular access complications
Collapse
Affiliation(s)
- Hoi Woul Lee
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jung Nam An
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Seok Lee
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Young Rim Song
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Jik Kim
- Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sung Gyun Kim
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Department of Internal Medicine and Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| |
Collapse
|
7
|
[Cerebral venous sinus thrombosis after COVID-19 vaccination : Neurological and radiological management]. Radiologe 2021; 61:923-932. [PMID: 34327553 PMCID: PMC8320717 DOI: 10.1007/s00117-021-00887-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND Vaccine-induced cerebral venous and sinus thrombosis (VI-CVST) is a rare complication in recipients of the adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccine ChAdOx1 nCov-19 (Vaxzevria®; AstraZeneca). OBJECTIVES Development of a diagnostic and therapeutic standard. MATERIALS AND METHODS Analysis of clinical and basic research findings, expert opinions, and experience with our own cases. RESULTS VI-CVST usually manifests on day 4-24 after vaccination, mostly in individuals aged < 60 years, and women. In the majority there is an immune pathogenesis caused by antibodies against platelet factor 4/polyanion complexes, leading to thrombotic thrombocytopenia which can result in severe, sometimes fatal, course. The cardinal symptom is headache worsening within days which, however, also can be of variable intensity. Other possible symptoms are seizures, visual disturbance, focal neurological deficits and signs of increased intracranial pressure. If VI-CVST is suspected, the determination of plasma D‑dimer level, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are essential for treatment decision-making. Magnetic resonance imaging (MRI) with venous MR-angiography is the neuroimaging modality of choice to confirm or exclude VI-CVST. On T2* susceptibility-weighted MRI, the clot in the sinuses or veins produces marked susceptibility artifacts ("blooming"), which also enables the detection of isolated cortical venous thromboses. MRI/MR-angiography or computed tomography (CT)/CT-angiography usually allow-in combination with clinical and laboratory findings-reliable diagnosis of VI-CVST. CONCLUSIONS The clinical suspicion of VI-CVST calls for urgent laboratory and neuroimaging workup. In the presence of thrombocytopenia and/or pathogenic antibodies, specific medications for anticoagulation and immunomodulation are recommended.
Collapse
|
8
|
Management of heparin-induced thrombocytopenia: systematic reviews and meta-analyses. Blood Adv 2021; 4:5184-5193. [PMID: 33095876 DOI: 10.1182/bloodadvances.2020002963] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic adverse drug reaction occurring in <0.1% to 7% of patients receiving heparin products depending on the patient population and type of heparin. Management of HIT is highly dependent on a sequence of tests for which clinicians may or may not have the results when care decisions need to be made. We conducted systematic reviews of the effects of management strategies in persons with acute HIT, subacute HIT A or B, and remote HIT. We searched Medline, EMBASE, and the Cochrane Database through July 2019 for previously published systematic reviews and primary studies. Two investigators independently screened and extracted data and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. We found primarily noncomparative studies and case series assessing effects of treatments, which led to low to very low certainty evidence. There may be little to no difference in the effects between nonheparin parenteral anticoagulants and direct oral anticoagulants in acute HIT. The benefits of therapeutic-intensity may be greater than prophylactic-intensity anticoagulation. Using inferior vena cava filters or platelet transfusion may result in greater harm than not using these approaches. Evidence for management in special situations, such as for patients undergoing cardiovascular interventions or renal replacement therapy, was also low to very low certainty. Additional research to evaluate nonheparin anticoagulants is urgently needed, and the development of novel treatments that reduce thrombosis without increasing hemorrhage should be a priority.
Collapse
|
9
|
Hvas AM, Favaloro EJ, Hellfritzsch M. Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment. Expert Rev Hematol 2021; 14:335-346. [PMID: 33736552 DOI: 10.1080/17474086.2021.1905512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Immune-mediated heparin-induced thrombocytopenia (HIT) is an infrequent complication following heparin exposure but with potentially fatal outcome due to thrombotic complications. Prompt suspension of heparin is necessary if HIT is suspected, followed by initiation of non-heparin anticoagulant therapy.Areas covered: In this review, the pathophysiology and challenges in diagnosing HIT are elucidated. Current and emerging treatment options are discussed with special focus on parenteral thrombin inhibitors (argatroban, bivalirudin), parenteral factor Xa inhibitors (danaparoid, fondaparinux) and direct oral anticoagulants (DOACs [rivaroxaban, apixaban, dabigatran]) including dosing strategies for DOACs. The database PubMed was employed without time boundaries.Expert opinion: Only argatroban holds regulatory approval for HIT treatment in both U.S. and Europe. This treatment is, however, challenged by the need for close monitoring and high costs. Fondaparinux has been increasingly used for off-label treatment and during recent years, evidence for the use of DOACs has emerged. Preliminary results from observational studies hold promise for future use of DOACs in the acute and subacute phase of HIT. However, so far, the use of DOACs in acute HIT should be reserved for clinically stable patients without severe thrombotic complications. Importantly, both fondaparinux and DOAC use is contraindicated in severe renal insufficiency.
Collapse
Affiliation(s)
- Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University. Address: Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Australia
| | - Maja Hellfritzsch
- Department of Cardiology, Herning Regional Hospital, Herning, Denmark
| |
Collapse
|
10
|
Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 270] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
11
|
Vayne C, Guéry EA, Charuel N, Besombes J, Lambert WC, Rollin J, Gruel Y, Pouplard C. Evaluation of functional assays for the diagnosis of heparin induced thrombocytopenia using 5B9, a monoclonal IgG that mimics human antibodies. J Thromb Haemost 2020; 18:968-975. [PMID: 31997532 DOI: 10.1111/jth.14749] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Serotonin release assay (SRA) is considered as the "gold standard" for detecting pathogenic heparin-induced thrombocytopenia (HIT) antibodies. However, this method is time consuming, expensive, and uses radioelements. Heparin-induced multiple electrode aggregometry (HIMEA), light transmission aggregometry (LTA) with platelet rich plasma (PRP) or washed platelets (WP), adenosine triphosphate (ATP) release, and flow cytometry (FC) are available alternatives. OBJECTIVES To evaluate the performance of these assays, comparatively with SRA, for detecting HIT antibodies, using 5B9, a monoclonal IgG fully mimicking human HIT antibodies. PATIENTS/METHODS Heparin-dependent platelet activation induced by 5B9 (50/20/10 µg/mL) was evaluated by all assays performed on the same day using platelets from 20 healthy donors. The three methods exhibiting the highest sensitivity to 5B9 were then assessed by testing samples from patients with either likely (n = 10), or indeterminate/unlikely HIT (n = 10). RESULTS All methods exhibited good sensitivity for detecting 5B9 50 µg/mL, but only SRA and HIMEA were positive with 100% of donors using 5B9 20 µg/mL, followed by FC (83%). SRA detected 5B9 10 μg/mL with 90% of donors, while HIMEA and FC were positive in 45% and 44% of cases, respectively. Whereas SRA was positive with 9/10 samples from likely HIT, HIMEA and FC were positive with 6 and 7 of them, respectively. Neither SRA nor HIMEA was positive with indeterminate/unlikely HIT samples, while FC was positive or doubtful in three cases. CONCLUSIONS Serotonin release assay likely remains the most sensitive and specific assay for detecting platelet activating HIT antibodies, but HIMEA or FC are potential alternatives, despite being less performant.
Collapse
Affiliation(s)
- Caroline Vayne
- Department of Haemostasis, University Hospital of Tours, Tours, France
- EA 7501 GICC, University of Tours, Tours, France
| | - Eve-Anne Guéry
- Department of Haemostasis, University Hospital of Tours, Tours, France
| | | | - Joevin Besombes
- Department of Haemostasis, University Hospital of Tours, Tours, France
| | - Wayne C Lambert
- Department of Haemostasis, University Hospital of Tours, Tours, France
| | - Jérôme Rollin
- Department of Haemostasis, University Hospital of Tours, Tours, France
- EA 7501 GICC, University of Tours, Tours, France
| | - Yves Gruel
- Department of Haemostasis, University Hospital of Tours, Tours, France
- EA 7501 GICC, University of Tours, Tours, France
| | - Claire Pouplard
- Department of Haemostasis, University Hospital of Tours, Tours, France
- EA 7501 GICC, University of Tours, Tours, France
| |
Collapse
|
12
|
Patriarcheas V, Pikoulas A, Kostis M, Charpidou A, Dimakakos E. Heparin-induced Thrombocytopenia: Pathophysiology, Diagnosis and Management. Cureus 2020; 12:e7385. [PMID: 32337112 PMCID: PMC7179984 DOI: 10.7759/cureus.7385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/24/2020] [Indexed: 01/16/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT), even rare, is a life-threatening, immune-mediated complication of heparin exposure. It is considered the most severe non-bleeding adverse reaction of heparin treatment and one of the most important adverse drug reactions. The pathophysiological basis of HIT results from the formation of an immunocomplex consisting of an auto-antibody against platelet factor 4 (PF4) - heparin complex, which binds to the surface of platelets and monocytes, provoking their activation by cross-linking FcgIIA receptors. Platelets and monocyte activation, leads to the generation of catastrophic arterial and venous thrombosis, with a mortality rate of 20%, without early recognition. The definitive diagnosis of HIT i.e., clinical and laboratory evidence, can not be done at the onset of symptoms because laboratory results may not be available for several days. Thus, the initial approach is to predict the likelihood of HIT, because in highly suspected patients immediate heparin cessation and initiation of alternative anticoagulation treatment are crucial for the prevention of the devastating thrombotic sequelae. Herein, we describe the pathophysiology, the clinical manifestations, the diagnostic approach, and the management of patients with HIT.
Collapse
Affiliation(s)
| | | | - Minas Kostis
- Internal Medicine, University Hospital of Patras, Patras, GRC
| | - Andriani Charpidou
- Internal Medicine, Thoracic Diseases General Hospital Sotiria, Athens, GRC
| | | |
Collapse
|
13
|
Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
Collapse
Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
14
|
Suljevic I, Basic S, Surkovic I, Turan M, Musija E. The Effect of Prophylactic Doses of Reviparin on the Postoperative Value of Platelets. Med Arch 2020; 73:404-407. [PMID: 32082009 PMCID: PMC7007632 DOI: 10.5455/medarh.2019.73.404-407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Low molecular weight heparin (LMWH) is used as anticoagulant in diseases characterized by possible thrombosis, as well as for thromboprophylaxis in surgery. The administration of LMWH preoperatively and postoperatively allows satisfactory thromboprophylaxis of patients undergoing surgery. Their application can reduce the number of platelets. Aim To determine what effect Reviparin has on platelet values postoperatively in patients undergoing open cholecystectomy. Methods The study was conducted at the Clinic for Anesthesia and Resuscitation of the Clinical Center of the University of Sarajevo. A retrospective study was performed that included data analysis for 33 patients undergoing open cholecystectomy over a two-year period. There were 22 male and 11 female patients out of a total of 33 patients. Platelet values from laboratory findings of patient's medical history were monitored for 5 days. The values found were recorded in a table containing the patient's first and last name, gender, age and platelet value. All patients had the same endotracheal anesthesia with Propofol, Fentanyl, and Atracurium supplemented with oxygen and nitric oxide at the appropriate dose. All of the patients received same dose of 0.25ml (1432 IU) Reviparin (Clivarin) from Abbott GmbH & Co.KG, preoperatively and postoperatively. Patients undergoing laparoscopic surgery as well as patients receiving other low-molecular-weight heparin or receiving higher doses of Reviparin were excluded from the study. Statistical analysis was performed using the MedCalc v12.7 statistical package for biomedical research. Results An analysis of gender representation in the total sample shows that there was 22 or 66.7% of males while there was 11 or 33.3% of female patients. Analysis of platelet values indicates that there is no statistically significant correlation with gender, but that there is a statistically significant correlation between platelet values between samples, ie. that patients who had higher preoperative values retained more platelet values even during postoperative measurements. Conclusion Platelet values do not change significantly postoperatively with the use of prophylactic doses of Reviparin, after an open cholecystectomy.
Collapse
Affiliation(s)
- Ismet Suljevic
- Clinic for Anesthesia and Resuscitation, Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Suad Basic
- Public Health institution, Institute for Addiction Diseases of Zenica-Doboj Canton, Zenica, Bosnia and Herzegovina
| | - Ismana Surkovic
- Clinic for Nuclear Medicine and Endocrinology, Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Maida Turan
- Acibadem Health Group, Representative Office in Sarajevo, Bosnia and Herzegovina
| | - Ehlimana Musija
- Clinic for Heart and Blood vessel Diseases and Rheumatism, Clinical Center Sarajevo, Bosnia and Herzegovina
| |
Collapse
|
15
|
Barlow A, Barlow B, Reinaker T, Harris J. Potential Role of Direct Oral Anticoagulants in the Management of Heparin-induced Thrombocytopenia. Pharmacotherapy 2019; 39:837-853. [PMID: 31233222 DOI: 10.1002/phar.2298] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare, potentially life-threatening condition secondary to unfractionated heparin or low molecular weight heparin exposure. This immune-mediated drug reaction manifests as thrombocytopenia with a paradoxical hypercoagulable state that can result in life-threatening thrombosis. It is imperative to ensure cessation of heparin-based products as soon as HIT is identified. Traditional treatment options include argatroban, bivalirudin, fondaparinux, and danaparoid with a transition to warfarin upon platelet recovery. These anticoagulants are notwithstanding limitations including parenteral administration and routine laboratory monitoring leading to prolonged hospitalizations, emphasizing the need for new therapies. Direct oral anticoagulants (DOACs) have been increasingly investigated for the management of HIT and may overcome the aforementioned challenges of current therapies. The objective of this narrative review is to summarize the current HIT guidelines, discuss limitations to contemporary treatment options, provide insight into the emerging evidence for the DOACs rivaroxaban, apixaban, and dabigatran, and conclude with a clinical summary for their use in this setting. The PubMed, Google Scholar, and MEDLINE databases were searched for peer-reviewed literature from January 1, 2012, to June 31, 2018. Twenty-seven articles met inclusion criteria for review: 1 prospective trial, 5 retrospective cohort studies, and 21 case reports totaling 104 patients treated with a DOAC for HIT. The DOACs prevented new and recurrent thrombosis in 98% (n=102) of cases, and bleeding complications occurred in 3% (n=3). While current literature remains limited, it is suggestive of a potential role of DOACs for HIT, which has led to their integration into the 2018 American Society Hematology Guidelines with a conditional recommendation.
Collapse
Affiliation(s)
- Ashley Barlow
- Thomas Jefferson College of Pharmacy, Philadelphia, Pennsylvania
| | - Brooke Barlow
- Thomas Jefferson College of Pharmacy, Philadelphia, Pennsylvania
| | - Travis Reinaker
- Department of Pharmacy, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Justin Harris
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Joseph J, Rabbolini D, Enjeti AK, Favaloro E, Kopp M, McRae S, Pasalic L, Tan CW, Ward CM, Chong BH. Diagnosis and management of heparin‐induced thrombocytopenia: a consensus statement from the Thrombosis and Haemostasis Society of Australia and New ZealandHITWriting Group. Med J Aust 2019; 210:509-516. [DOI: 10.5694/mja2.50213] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Joanne Joseph
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical SchoolUniversity of New South Wales Sydney NSW
| | - David Rabbolini
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | | - Emmanuel Favaloro
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | | | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | - Christopher M Ward
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | |
Collapse
|
17
|
Ivascu NS, Fitzgerald M, Ghadimi K, Patel P, Evans AS, Goeddel LA, Shaefi S, Klick J, Johnson A, Raiten J, Horak J, Gutsche J. Heparin-Induced Thrombocytopenia: A Review for Cardiac Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2019; 33:511-520. [DOI: 10.1053/j.jvca.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 01/02/2023]
|
18
|
Nagrebetsky A, Al-Samkari H, Davis N, Kuter D, Wiener-Kronish J. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 2019; 122:19-31. [DOI: 10.1016/j.bja.2018.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/19/2023] Open
|
19
|
Cuker A, Arepally GM, Chong BH, Cines DB, Greinacher A, Gruel Y, Linkins LA, Rodner SB, Selleng S, Warkentin TE, Wex A, Mustafa RA, Morgan RL, Santesso N. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2:3360-3392. [PMID: 30482768 PMCID: PMC6258919 DOI: 10.1182/bloodadvances.2018024489] [Citation(s) in RCA: 359] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis. CONCLUSIONS Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.
Collapse
Affiliation(s)
- Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Beng H Chong
- Department of Haematology, University of New South Wales, Sydney, NSW, Australia
| | - Douglas B Cines
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Yves Gruel
- Department of Haematology-Haemostasis, Trousseau Hospital, Tours, France
| | - Lori A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Sixten Selleng
- Department of Anaesthesiology, University of Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
| |
Collapse
|
20
|
Fathi M. Heparin-induced thrombocytopenia (HIT): Identification and treatment pathways. Glob Cardiol Sci Pract 2018; 2018:15. [PMID: 30083545 PMCID: PMC6062760 DOI: 10.21542/gcsp.2018.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major health problem, especially in cardiac surgery theaters, cardiac catheterization labs, and intensive care units. Some patients with HIT develop serious thrombotic complications like limb ischemia and gangrene, while others may not develop such complications and have only mild thrombocytopenia. Current laboratory diagnostic tools incur significant time delays before confirming HIT, therefore upon clinical suspicion, treatment of HIT should start immediately while awaiting laboratory results. This is a review of the types, phases, pathophysiology, clinical presentation and diagnosis of HIT, and its current management strategies.
Collapse
|
21
|
Gernhofer YK, Ross M, Khoche S, Pretorius V. The use of cangrelor with heparin for left ventricular assist device implantation in a patient with acute heparin-induced thrombocytopenia. J Cardiothorac Surg 2018; 13:30. [PMID: 29665860 PMCID: PMC5904976 DOI: 10.1186/s13019-018-0721-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/11/2018] [Indexed: 12/22/2022] Open
Abstract
Background Optimal anticoagulation strategy for cardiopulmonary bypass (CPB) in end-stage heart failure patients with heparin-induced thrombocytopenia (HIT) requiring left ventricular assist device (LVAD) implantation remains uncertain. Presently, there are no large-scale randomized studies comparing outcomes of alternative anticoagulation strategies for CPB in this patient population. A novel antiplatelet agent – cangrelor, which is a potent P2Y12 inhibitor with robust antiplatelet efficacy, rapid reversibility, and measurable drug effect, has become available since 2015. Intraoperative anticoagulation for CPB using cangrelor with heparin has not been reported before. Case presentation We report the case of a 47-year-old male with ischemic cardiomyopathy and acute HIT, who underwent an urgent LVAD implantation using cangrelor with heparin for anticoagulation on CPB. This novel strategy resulted in satisfactory anticoagulation for CPB without perioperative thromboembolic events or major bleeding requiring reoperation. Conclusions Cangrelor with heparin was an effective anticoagulation strategy for CPB in this critically ill patient with acute HIT requiring an urgent LVAD implantation. Further studies are warranted to evaluate its efficacy and replicability in other patients with acute or subacute HIT who require urgent cardiac surgery.
Collapse
Affiliation(s)
- Yan K Gernhofer
- Department of Surgery, Division of Cardiothoracic Surgery, University of California San Diego, Sulpizio Cardiovascular Center, 9434 Medical Center Drive, La Jolla, CA, 92093, USA.
| | - Michael Ross
- Department of Anesthesiology, University of California San Diego, Sulpizio Cardiovascular Center, La Jolla, CA, USA
| | - Swapnil Khoche
- Department of Anesthesiology, University of California San Diego, Sulpizio Cardiovascular Center, La Jolla, CA, USA
| | - Victor Pretorius
- Department of Surgery, Division of Cardiothoracic Surgery, University of California San Diego, Sulpizio Cardiovascular Center, 9434 Medical Center Drive, La Jolla, CA, 92093, USA
| |
Collapse
|
22
|
Greinacher A, Warkentin TE, Bakchoul T. Heparin-induced thrombocytopenia in 2017 and beyond. Thromb Haemost 2017; 116:781-782. [DOI: 10.1160/th16-09-0742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 09/30/2016] [Indexed: 11/05/2022]
|
23
|
Greinacher A, Selleng K, Warkentin TE. Autoimmune heparin-induced thrombocytopenia. J Thromb Haemost 2017; 15:2099-2114. [PMID: 28846826 DOI: 10.1111/jth.13813] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/18/2023]
Abstract
Autoimmune heparin-induced thrombocytopenia (aHIT) indicates the presence in patients of anti-platelet factor 4 (PF4)-polyanion antibodies that are able to activate platelets strongly even in the absence of heparin (heparin-independent platelet activation). Nevertheless, as seen with serum obtained from patients with otherwise typical heparin-induced thrombocytopenia (HIT), serum-induced platelet activation is inhibited at high heparin concentrations (10-100 IU mL-1 heparin). Furthermore, upon serial dilution, aHIT serum will usually show heparin-dependent platelet activation. Clinical syndromes associated with aHIT include: delayed-onset HIT, persisting HIT, spontaneous HIT syndrome, fondaparinux-associated HIT, heparin 'flush'-induced HIT, and severe HIT (platelet count of < 20 × 109 L-1 ) with associated disseminated intravascular coagulation (DIC). Recent studies have implicated anti-PF4 antibodies that are able to bridge two PF4 tetramers even in the absence of heparin, probably facilitated by non-heparin platelet-associated polyanions (chondroitin sulfate and polyphosphates); nascent PF4-aHIT-IgG complexes recruit additional heparin-dependent HIT antibodies, leading to the formation of large multimolecular immune complexes and marked platelet activation. aHIT can persist for several weeks, and serial fibrin, D-dimer, and fibrinogen levels, rather than the platelet count, may be helpful for monitoring treatment response. Although standard anticoagulant therapy for HIT ought to be effective, published experience indicates frequent failure of activated partial thromboplastin time (APTT)-adjusted anticoagulants (argatroban, bivalirudin), probably because of underdosing in the setting of HIT-associated DIC, known as 'APTT confounding'. Thus, non-APTT-adjusted therapies with drugs such as danaparoid and fondaparinux, or even direct oral anticoagulants, such as rivaroxaban or apixaban, are suggested therapies, especially for long-term management of persisting HIT. In addition, emerging data indicate that high-dose intravenous immunoglobulin can interrupt HIT antibody-induced platelet activation, leading to rapid platelet count recovery.
Collapse
MESH Headings
- Administration, Oral
- Animals
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/immunology
- Autoantibodies/blood
- Autoimmunity/drug effects
- Blood Coagulation/drug effects
- Blood Platelets/drug effects
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Heparin/adverse effects
- Heparin/immunology
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Immunologic Factors/administration & dosage
- Partial Thromboplastin Time
- Platelet Activation/drug effects
- Platelet Factor 4/immunology
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
Collapse
Affiliation(s)
- A Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - K Selleng
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, Department of Medicine, and McMaster Centre for Transfusion Research, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
24
|
Jones CG, Pechauer SM, Curtis BR, Bougie DW, Irani MS, Dhakal B, Pierce B, Aster RH, Padmanabhan A. A Platelet Factor 4-Dependent Platelet Activation Assay Facilitates Early Detection of Pathogenic Heparin-Induced Thrombocytopenia Antibodies. Chest 2017; 152:e77-e80. [PMID: 28991552 DOI: 10.1016/j.chest.2017.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/18/2017] [Accepted: 06/01/2017] [Indexed: 11/15/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin therapy. HIT diagnosis is established by recognizing thrombocytopenia and/or thrombosis in an affected patient and from the results of serological tests such as the platelet factor 4 (PF4)/heparin immunoassay (PF4 ELISA) and serotonin release assay (SRA). Recent studies suggest that HIT antibodies activate platelets by recognizing PF4 in a complex with platelet glycosaminoglycans (and/or polyphosphates) and that an assay based on this principle, the PF4-dependent P-selectin expression assay (PEA), may be even more accurate than the SRA for HIT diagnosis. Here, we demonstrate that the PEA detected pathogenic antibodies before the SRA became positive in two patients with HIT studied serially, in one case even before seropositivity in the PF4 ELISA. In one of the patients treated with plasma exchange, persistent dissociation between the PEA and SRA test results was observed. These results support a role for the PEA in early HIT diagnosis.
Collapse
Affiliation(s)
- Curtis G Jones
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI
| | - Daniel W Bougie
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Mehraboon S Irani
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Brenda Pierce
- Division of Medical Oncology, Aurora Advanced Healthcare, Milwaukee, WI
| | - Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Anand Padmanabhan
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI.
| |
Collapse
|
25
|
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
| |
Collapse
|
26
|
Padmanabhan A, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Irani MS, Bryant BJ, Alperin JB, Deloughery TG, Mulvey KP, Dhakal B, Wen R, Wang D, Aster RH. IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia. Chest 2017; 152:478-485. [PMID: 28427966 DOI: 10.1016/j.chest.2017.03.050] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) complicated by severe thrombocytopenia and thrombosis can pose significant treatment challenges. Use of alternative anticoagulants in this setting may increase bleeding risks, especially in patients who have a protracted disease course. Additional therapies are lacking in this severely affected patient population. METHODS We describe three patients with HIT who had severe thromboembolism and prolonged thrombocytopenia refractory to standard treatment but who achieved an immediate and sustained response to IVIg therapy. The mechanism of action of IVIg was evaluated in these patients and in five additional patients with severe HIT. The impact of a common polymorphism (H/R 131) in the platelet IgG receptor FcγRIIa on IVIg-mediated inhibition of platelet activation was also examined. RESULTS At levels attained in vivo, IVIg inhibits HIT antibody-mediated platelet activation. The constant domain of IgG (Fc) but not the antigen-binding portion (Fab) is required for this effect. Consistent with this finding, IVIg had no effect on HIT antibody binding in a solid-phase HIT immunoassay (platelet factor 4 enzyme-linked immunoassay). The H/R131 polymorphism in FcγRIIa influences the susceptibility of platelets to IVIg treatment, with the HH131 genotype being most susceptible to IVIg-mediated inhibition of antibody-induced activation. However, at high doses of IVIg, activation of platelets of all FcγRIIa genotypes was significantly inhibited. All three patients did well on long-term anticoagulation therapy with direct oral anticoagulants. CONCLUSIONS These studies suggest that IVIg treatment should be considered in patients with HIT who have severe disease that is refractory to standard therapies.
Collapse
Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI.
| | - Curtis G Jones
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI
| | - Daniel W Bougie
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Mehraboon S Irani
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Barbara J Bryant
- Department of Pathology, University of Texas Medical Branch, Galveston, TX
| | - Jack B Alperin
- Department of Pathology, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - Kevin P Mulvey
- Department of Medicine, Kootenai Health, Coeur d'Alene, ID
| | - Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
27
|
Wang X, Jiang C, Qin Y, Peng Y, Wen G, Liang A, Jiang Z. SERS spectral study of HAuCl 4-cysteine nanocatalytic reaction and its application for detection of heparin sodium with label-free VB4r molecular probe. Sci Rep 2017; 7:45979. [PMID: 28378828 PMCID: PMC5380991 DOI: 10.1038/srep45979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/07/2017] [Indexed: 12/23/2022] Open
Abstract
In the presence of nanocatalyst, L-cysteine reduce HAuCl4 rapidly to form gold nanoparticles (AuNP), and a quick nanocatalytic preparation procedure was established for Au/AuNP sol with highly active surface enhanced Raman scattering (SERS) effect and good stability. The nanoreaction was also studied by absorption, resonance Rayleigh scattering (RRS), transmission electron microscopy (TEM) and energy spectra. In the selected conditions, the analyte heparin sodium (HS) could react with victoria blue 4 R (VB4r) to form associated complexes which have very weak SERS effect to make the SERS signals decrease. The SERS signals at 1617 cm−1 reduced linearly with HS concentration increasing. Upon addition of FeCl3, it hydrolyzed to form stable Fe(OH)3 sol platform that carried SERS active Au/AuNPs to enhance the sensitivity. Accordingly, we established a SERS quantitative analysis method in the sol substrate of Fe(OH)3-Au/AuNPs, with a linear range of 0.5–75 ng/mL HS and a detection limit of 0.2 ng/mL. HS in real samples was determined, with a relative standard deviation of 2.65–7.63% and a recovery of 99.3–101%.
Collapse
Affiliation(s)
- Xiaoliang Wang
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Caina Jiang
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Yanna Qin
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Yutao Peng
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Guiqing Wen
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Aihui Liang
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| | - Zhiliang Jiang
- Key Laboratory of Ecology of Rare and Endangered Species and Environmental Protection of Ministry Education, Guangxi Key Laboratory of Environmental Pollution Control Theory and Technology, Guangxi Normal University, Guilin 541004, China
| |
Collapse
|
28
|
Cruz ML, Farooq S, Testai FD. Neurological and Neurosurgical Emergencies in Patients with Hematological Disorders. Curr Neurol Neurosci Rep 2017; 17:24. [PMID: 28283960 DOI: 10.1007/s11910-017-0728-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Hematologic diseases are blood disorders which can affect different organs, including the central and peripheral nervous systems. Some of them are associated with increased risk of permanent disability and death. This review highlights a selected group of primary and acquired hematologic disorders that can present as neurologic or neurosurgical emergencies. RECENT FINDINGS There is an increasing recognition of the broad neurologic presentations of hematologic disorders. Diagnostic criteria continue to be revised as we learn more about these diseases. Treatment options are varied depending on the hematologic syndrome. Clinical judgment is important on a case by case basis given the complexity of these patients. Early recognition of neurologic manifestations of hematologic disorders is important as emergent treatment may be warranted. Clinical signs, appropriate laboratory testing and progression of disease must be taken into consideration to make a timely and definitive diagnosis which will aid in guiding treatment.
Collapse
Affiliation(s)
- Martha L Cruz
- Department of Neurology and Rehabilitation, University of Illinois at Chicago Medical Center, 912 S Wood Street, Suite 164C, Neuropsychiatric Institute (NPI Building, M/C 796), Chicago, IL, 60612-7330, USA
| | - Shama Farooq
- Department of Neurology and Rehabilitation, University of Illinois at Chicago Medical Center, 912 S Wood Street, Suite 164C, Neuropsychiatric Institute (NPI Building, M/C 796), Chicago, IL, 60612-7330, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago Medical Center, 912 S Wood Street, Suite 164C, Neuropsychiatric Institute (NPI Building, M/C 796), Chicago, IL, 60612-7330, USA.
| |
Collapse
|