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Facchetti N, Hinrichs JB, Becker LS, Schneider MA, Brüning R, Rademacher J, Lenz J, Kudrass K, Vogel A, Wacker FK, Dewald CLA. Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more? Cancer Imaging 2023; 23:68. [PMID: 37452405 PMCID: PMC10349410 DOI: 10.1186/s40644-023-00590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP. MATERIALS AND METHODS All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0). RESULTS Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine. CONCLUSION Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.
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Affiliation(s)
- Nadia Facchetti
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Lena S. Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martin A. Schneider
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Roland Brüning
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jan Rademacher
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jochen Lenz
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Kirsten Kudrass
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank K. Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Cornelia L. A. Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Frackiewicz A, Kalaska B, Miklosz J, Mogielnicki A. The methods for removal of direct oral anticoagulants and heparins to improve the monitoring of hemostasis: a narrative literature review. Thromb J 2023; 21:58. [PMID: 37208753 DOI: 10.1186/s12959-023-00501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
The assessment of hemostasis is necessary to make suitable decisions on the management of patients with thrombotic disorders. In some clinical situations, for example, during thrombophilia screening, the presence of anticoagulants in sample makes diagnosis impossible. Various elimination methods may overcome anticoagulant interference. DOAC-Stop, DOAC-Remove and DOAC Filter are available methods to remove direct oral anticoagulants in diagnostic tests, although there are still reports on their incomplete efficacy in several assays. The new antidotes for direct oral anticoagulants - idarucizumab and andexanet alfa - could be potentially useful, but have their drawbacks. The necessity to remove heparins is also arising as heparin contamination from central venous catheter or therapy with heparin disturbs the appropriate hemostasis assessment. Heparinase and polybrene are already present in commercial reagents but a fully-effective neutralizer is still a challenge for researchers, thus promising candidates remain in the research phase.
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Affiliation(s)
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland.
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
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3
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Stone ME, Vespe MW. Heparin Rebound: An In-Depth Review. J Cardiothorac Vasc Anesth 2023; 37:601-612. [PMID: 36641308 DOI: 10.1053/j.jvca.2022.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/17/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022]
Abstract
The common conception of "heparin rebound" invokes heparin returning to circulation in the postoperative period after apparently adequate intraoperative reversal with protamine. This is believed to portend increased postoperative bleeding and provides the rationale for administering additional empiric doses of protamine in response to prolonged coagulation tests and/or bleeding. However, the relevant literature of the last 60+ years provides only a weak level of evidence that "rebounded" heparin itself is a significant etiology of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Notably, many of the most frequently cited heparin rebound investigators ultimately concluded that although exceedingly low levels of heparin activity could be detected by anti-Xa assay in some (but not all) patients postoperatively, there was no correlation with actual bleeding. An understanding of the literature requires a careful reading of the details because the investigators lacked standardized definitions for "heparin rebound" and "adequate reversal" while studying the phenomenon with significantly different experimental methodologies and laboratory tests. This review was undertaken to provide a modern understanding of the "heparin rebound" phenomenon to encourage an evidence-based approach to postoperative bleeding. Literature searches were conducted via PubMed using the following MeSH terms: heparin rebound, heparin reversal, protamine, platelet factor 4, and polybrene. Relevant English language articles were reviewed, with subsequent references obtained from the internal citations. Perspective is provided for both those who use HepCon-guided management and those who do not, as are practical recommendations for the modern era based on the published data and conclusions of the various investigators.
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Affiliation(s)
- Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
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Ranger A, Gaspar M, Elkhatteb A, Jackson T, Fox S, Aw TC, Vipond L, Cotterill J, Ghori A, Laffan M, Arachchillage DRJ. The heparin-von Willebrand factor interaction and conventional tests of haemostasis - the challenges in predicting bleeding in cardiopulmonary bypass. Br J Haematol 2020; 192:1073-1081. [PMID: 33278841 DOI: 10.1111/bjh.17263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/13/2020] [Indexed: 01/04/2023]
Abstract
Bleeding is a significant complication of cardiopulmonary bypass (CPB), despite routine anticoagulation monitoring. This is likely to be multifactorial. In this prospective, single-centre cohort study of 30 patients undergoing CPB surgery, our aim was to characterise the changes in von Willebrand factor (VWF) function, platelet interaction and the global coagulation changes during and after CPB surgery and to determine whether bleeding can be predicted. Samples were taken at six time points before, during and after CPB surgery. We observed a significant rise in VWF antigen (VWF:Ag) throughout surgery, which continued postoperatively. The absolute VWF collagen-binding assays (VWF:CB) and VWF ristocetin cofactor (VWF:RCo) rose significantly but the VWF:CB/VWF:Ag and VWF:Ag/VWF:RCo fell significantly (P = 0·0015 and P = 0·0143), suggesting loss of large multimers. We detected a non-significant trend to loss of VWF:RCo after heparinisation and a significant recovery after protamine reversal which could reflect a direct heparin effect. There was a significant increase in the R and K times with a fall in alpha angle and maximum amplitude after heparin administration, using heparinase-thromboelastography (TEG). The parameters both significantly improved following protamine (P = 0·007 and P = 0·0054). The activated clotting time (ACT) and heparin anti-Xa level correlated poorly; neither predicted clinically significant bleeding. None of these parameters had a relationship with intraoperative blood loss or requirement for blood product replacement.
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Affiliation(s)
- Amita Ranger
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Mihaela Gaspar
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Amira Elkhatteb
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Tim Jackson
- Department of Perfusion, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Steve Fox
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - T C Aw
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Lisa Vipond
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Judy Cotterill
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Arshad Ghori
- Department of Anaesthesia, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Mike Laffan
- Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Deepa R J Arachchillage
- Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Intravenous thrombolysis for the management of acute ischemic stroke in patients therapeutically anticoagulated with heparin: A review. Clin Neurol Neurosurg 2020; 200:106382. [PMID: 33276218 DOI: 10.1016/j.clineuro.2020.106382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase is effective in acute ischemic stroke (AIS). However, its use rate remains low due to the many exclusion criteria. Recent guidelines recommend excluding patients suffering AIS with an elevated aPTT secondary to heparin exposure from receiving IVT. The purpose of this review is to explore the safety and efficacy of IVT in patients therapeutically anticoagulated with heparin. We also propose a treatment algorithm for IVT in patients with AIS that are therapeutically anticoagulated with heparin. METHODS We performed a systematic review of PubMed and Embase through March 2020 to identify the literature regarding AIS in patients exposed to heparin, followed by IVT treatment, emphasizing safety, efficacy, and clinical outcome using PRISMA guidelines. RESULTS We included thirteen articles in the final analysis, including three retrospective studies, two observational studies, one randomized trial, five case reports, and two case series. CONCLUSION There is limited information about the off-label use of IVT in patients with elevated aPTT. Patients with AIS are excluded from IVT if they have recent exposure to heparin. Our review indicates that this population of patients may benefit from IVT as the cases of active bleeding after IVT are few, and functional outcomes are favorable in the long term suggesting that IVT in therapeutically anticoagulated patients may be safe and efficacious.
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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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Meesters MI, Veerhoek D, de Lange F, de Vries JW, de Jong JR, Romijn JWA, Kelchtermans H, Huskens D, van der Steeg R, Thomas PWA, Burtman DTM, van Barneveld LJM, Vonk ABA, Boer C. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thromb Haemost 2018; 116:251-61. [DOI: 10.1160/th16-02-0117] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.
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Abstract
Heparin and heparan sulfate glycosaminoglycans are long, linear polysaccharides that are made up of alternating dissacharide sequences of sulfated uronic acid and amino sugars. Unlike heparin, which is only found in mast cells, heparan sulfate is ubiquitously expressed on the cell surface and in the extracellular matrix of all animal cells. These negatively-charged glycans play essential roles in important cellular functions such as cell growth, adhesion, angiogenesis, and blood coagulation. These biomolecules are also involved in pathophysiological conditions such as pathogen infection and human disease. This review discusses past and current methods for targeting these complex biomolecules as a novel therapeutic strategy to treating disorders such as cancer, neurodegenerative diseases, and infection.
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Affiliation(s)
- Ryan J Weiss
- Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center, University of California, San Diego, La Jolla, CA 92093-0358, USA
| | - Jeffrey D Esko
- Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center, University of California, San Diego, La Jolla, CA 92093-0358, USA
| | - Yitzhak Tor
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA 92093-0358, USA.
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Sekiya A, Oishi S, Fujii N, Koide T. High-Throughput Turbidimetric Screening for Heparin-Neutralizing Agents and Low-Molecular-Weight Heparin Mimetics. Chem Pharm Bull (Tokyo) 2012; 60:371-6. [DOI: 10.1248/cpb.60.371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Atsushi Sekiya
- Department of Chemistry and Biochemistry, School of Advanced Science and Engineering, Waseda University
| | - Shinya Oishi
- Graduate School of Pharmaceutical Sciences, Kyoto University
| | - Nobutaka Fujii
- Graduate School of Pharmaceutical Sciences, Kyoto University
| | - Takaki Koide
- Department of Chemistry and Biochemistry, School of Advanced Science and Engineering, Waseda University
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10
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King JT, Desai UR. Linear polyalkylamines as fingerprinting agents in capillary electrophoresis of low-molecular-weight heparins and glycosaminoglycans. Electrophoresis 2011; 32:3070-7. [PMID: 22002802 PMCID: PMC3516877 DOI: 10.1002/elps.201100175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/18/2011] [Accepted: 04/20/2011] [Indexed: 02/05/2023]
Abstract
Glycosaminoglycan (GAG) analysis represents a challenging frontier despite the advent of many high-resolution technologies because of their unparalleled structural complexity. We previously developed a resolving agent-aided capillary electrophoretic approach for fingerprinting low-molecular-weight heparins (LMWHs) to profile their microscopic differences and assess batch-to-batch variability. In this report, we study the application of this approach for fingerprinting other GAGs and analyze the basis for the fingerprints observed in CE. Although the resolving agents, linear polyalkylamines, could resolve the broad featureless electropherogram of LMWH into a large number of distinct, highly reproducible peaks, longer GAGs such as chondroitin sulfate, dermatan sulfate, and heparin responded in a highly individualistic manner. Full-length heparin interacted with linear polyalkylamines very strongly followed by dermatan sulfate, whereas chondroitin sulfate remained essentially unaffected. Oversulfated chondroitin sulfate could be easily identified from full-length heparin. Scatchard analysis of the binding profile of enoxaparin with three linear polyalkylamines displayed a biphasic binding profile suggesting two distinctly different types of interactions. Some LMWH chains were found to interact with linear polyalkylamines with affinities as high as 10 nM, whereas others displayed nearly 5000-fold weaker affinities. These observations provide fundamental insight into the basis for fingerprinting of LMWHs by linear polyalkylamine-based resolving agents, which could be utilized in the design of advanced resolving agents for compositional profiling, direct sequencing, and chemoinformatics studies.
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Affiliation(s)
- J. Timothy King
- Department of Medicinal Chemistry and Institute for Structural Biology and Drug Discovery, Virginia Commonwealth University, Richmond, VA
| | - Umesh R. Desai
- Department of Medicinal Chemistry and Institute for Structural Biology and Drug Discovery, Virginia Commonwealth University, Richmond, VA
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GODAL HC. The Interaction of Protamine with Human Fibrinogen and the Significance of this Interaction for the Coagulation of Fibrinogen. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 12:433-45. [PMID: 13706168 DOI: 10.3109/00365516009065408] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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GODAL HC. A Comparison of two Heparin-Neutralizing Agents: Protamine and Polybrene. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 12:446-57. [PMID: 13706163 DOI: 10.3109/00365516009065409] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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13
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Abstract
In a search for small molecule antagonists of heparan sulfate, we examined the activity of bis-2-methyl-4-amino-quinolyl-6-carbamide, also known as surfen. Fluorescence-based titrations indicated that surfen bound to glycosaminoglycans, and the extent of binding increased according to charge density in the order heparin > dermatan sulfate > heparan sulfate > chondroitin sulfate. All charged groups in heparin (N-sulfates, O-sulfates, and carboxyl groups) contributed to binding, consistent with the idea that surfen interacted electrostatically. Surfen neutralized the anticoagulant activity of both unfractionated and low molecular weight heparins and inhibited enzymatic sulfation and degradation reactions in vitro. Addition of surfen to cultured cells blocked FGF2-binding and signaling that depended on cell surface heparan sulfate and prevented both FGF2- and VEGF(165)-mediated sprouting of endothelial cells in Matrigel. Surfen also blocked heparan sulfate-mediated cell adhesion to the Hep-II domain of fibronectin and prevented infection by HSV-1 that depended on glycoprotein D interaction with heparan sulfate. These findings demonstrate the feasibility of identifying small molecule antagonists of heparan sulfate and raise the possibility of developing pharmacological agents to treat disorders that involve glycosaminoglycan-protein interactions.
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Brown JR, Crawford BE, Esko JD. Glycan antagonists and inhibitors: a fount for drug discovery. Crit Rev Biochem Mol Biol 2008; 42:481-515. [PMID: 18066955 DOI: 10.1080/10409230701751611] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Glycans, the carbohydrate chains of glycoproteins, proteoglycans, and glycolipids, represent a relatively unexploited area for drug development compared with other macromolecules. This review describes the major classes of glycans synthesized by animal cells, their mode of assembly, and available inhibitors for blocking their biosynthesis and function. Many of these agents have proven useful for studying the biological activities of glycans in isolated cells, during embryological development, and in physiology. Some are being used to develop drugs for treating metabolic disorders, cancer, and infection, suggesting that glycans are excellent targets for future drug development.
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Alston SM, Solen KA, Broderick AH, Sukavaneshvar S, Mohammad SF. New method to prepare autologous fibrin glue on demand. Transl Res 2007; 149:187-95. [PMID: 17383592 DOI: 10.1016/j.trsl.2006.08.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Revised: 08/24/2006] [Accepted: 08/27/2006] [Indexed: 10/23/2022]
Abstract
Fibrin-based sealants are commonly employed to arrest bleeding after surgery. Usually, fibrinogen obtained from pooled human plasma is used to prepare sealants, with attendant risk of blood-borne infections. Availability of autologous fibrinogen would eliminate this risk. To prepare autologous fibrin sealant, fibrinogen was precipitated from human plasma using protamine. Under optimal conditions (10-mg/mL protamine and 22 degrees C), 96 +/- 4% of clottable fibrinogen was recovered by a simple and inexpensive technique. Nearly 50% of the plasma factor XIII was also recovered with the fibrinogen. Using bovine thrombin, the fibrinogen was clotted (1) in a specially designed mold to measure tensile strength and (2) in a lap joint between 2 aortic vessel strips to measure adhesion strength. Tensile and adhesion strengths increased with increasing fibrinogen concentration, and they were increased by the addition of calcium chloride. The addition of aprotinin and -aminocaproic acid to the fibrinogen concentrate before clotting had no effect on the mechanical properties of the clots. After adding thrombin to sealant containing 15-mg/mL fibrinogen, maximum tensile strength was achieved in 1-5 min, and maximum adhesion strength was reached in 5-15 min. For the sealant with 30-60-mg/mL fibrinogen and added calcium, the tensile strength was equivalent to that of the commercial fibrin sealant Tisseel. The adhesion strength of sealant with 30-60-mg/mL fibrinogen exceeded the adhesive strength of Tisseel under identical conditions. Autologous fibrin sealant is an attractive alternative to commercial sealants. It can be readily prepared from 5-mL plasma or more and exhibits mechanical properties equivalent to those of the leading commercial sealant.
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Affiliation(s)
- Steven M Alston
- Chemical Engineering Department, Brigham Young University, Provo, UT 84602, USA
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Abstract
Protamines are the major nuclear sperm proteins. The human sperm nucleus contains two types of protamine: protamine 1 (P1) encoded by a single-copy gene and the family of protamine 2 (P2) proteins (P2, P3 and P4), all also encoded by a single gene that is transcribed and translated into a precursor protein. The protamines were discovered more than a century ago, but their function is not yet fully understood. In fact, different hypotheses have been proposed: condensation of the sperm nucleus into a compact hydrodynamic shape, protection of the genetic message delivered by the spermatozoa, involvement in the processes maintaining the integrity and repair of DNA during or after the nucleohistone-nucleoprotamine transition and involvement in the epigenetic imprinting of the spermatozoa. Protamines are also one of the most variable proteins found in nature, with data supporting a positive Darwinian selection. Changes in the expression of P1 and P2 protamines have been found to be associated with infertility in man. Mutations in the protamine genes have also been found in some infertile patients. Transgenic mice defective in the expression of protamines also present several structural defects in the sperm nucleus and have variable degrees of infertility. There is also evidence that altered levels of protamines may result in an increased susceptibility to injury in the spermatozoan DNA causing infertility or poor outcomes in assisted reproduction. The present work reviews the articles published to date on the relationship between protamines and infertility.
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Affiliation(s)
- Rafael Oliva
- Human Genetics Laboratory, Genetics Unit, Department of Ciències Fisiològiques I, Faculty of Medicine, University of Barcelona and Hospital Clínic, IDIBAPS, Casanova 143, 08036 Barcelona, Spain.
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DE VRIES A, SCHWAGER A, KATCHALSKI E. The action of some water-soluble poly-alpha-amino-acids on blood clotting. Biochem J 2004; 49:10-7. [PMID: 14848021 PMCID: PMC1197447 DOI: 10.1042/bj0490010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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WOLFE LS, McILWAIN H. Migration of histones from the nuclei of isolated cerebral tissues kept in cold media. Biochem J 1998; 78:33-40. [PMID: 13786309 PMCID: PMC1205169 DOI: 10.1042/bj0780033] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
A unique and simple colorimetric method for the quantitation of plasma protamine levels has been developed. The method is established on the competitive binding displacement mechanism between protamine and heparin-azure A dye complex, and the metachromatic color change of azure A dye in the presence of heparin. Because the method is based on the clinical specificity of protamine as the heparin antagonist, it is specific for protamine quantitation. Plasma protamine levels determined by this method are within 94% of accuracy when compared with their aqueous counterparts determined by the conventional Lowry protein assay. Since the method measures the protamine excess after heparin neutralization, it potentially could be employed during clinical heparin reversal with protamine to monitor protamine excess. In addition, the method may provide a useful means to identify the mechanism of the so-called "heparin rebound".
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Affiliation(s)
- V C Yang
- College of Pharmacy, University of Michigan, Ann Arbor 48109-1065
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Abstract
A study was performed to investigate if protamine covalently attached to CNBr-activated agarose is a useful tool for the purification of fibrinogen from human plasma samples. One chromatography step yielded a preparation with a clottability greater than 90% from platelet-poor plasma with a yield of 65-80% of fibrinogen applied. The preparation is free of plasminogen, immunoglobulins, fibronectin, albumin, antithrombin III, alpha 2-macroglobulin, and alpha 1-antitrypsin, as determined by immunological and functional methods. 6.5 mg of fibrinogen were adsorbed to 1.0 ml of protamine-agarose. Protamine-agarose chromatography can be applied to plasma samples as small as 200 microliters.
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Porter P, Porter MC, Shanberge JN. Heparin cofactor and plasma antithrombin in relation to the mechanism of inactivation of thrombin by heparin. Clin Chim Acta 1967; 17:189-200. [PMID: 6035543 DOI: 10.1016/0009-8981(67)90118-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Saba HI, Roberts HR, Herion JC. The anticoagulant activity of lysosomal cationic proteins from polymorphonuclear leukocytes. J Clin Invest 1967; 46:580-9. [PMID: 6021205 PMCID: PMC442041 DOI: 10.1172/jci105559] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
A cationic protein fraction from rabbit polymorphonuclear leukocyte lysosomes has been shown to exert a potent anticoagulant effect on human blood in vitro. The anticoagulant activity is detectable in the whole blood clotting time, the recalcification time of platelet-rich plasma, the prothrombin time, the partial thromboplastin time, and the thromboplastin generation test. The lysosomal cationic proteins do not inhibit any of the known specific procoagulants. They appear to inhibit clotting by blocking the formation of intrinsic thromboplastin possibly by interfering with the role of phospholipids in the reaction involving Factors V and X and calcium.
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Douglas AS, McNicol GP, Bain WH, Mackey WA. The haemostatic defect following extracorporeal circulation. Br J Surg 1966; 53:455-67. [PMID: 4952897 DOI: 10.1002/bjs.1800530518] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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GORE I, TANAKA K, ENJOJI M, WHITE HJ, LARKEY BJ. Pulmonary arterial lesions produced by protamine. ACTA ACUST UNITED AC 1963; 86:209-14. [PMID: 13949252 DOI: 10.1002/path.1700860125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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KENDALL AG, LOWENSTEIN L. Alterations in blood coagulation and hemostasis during extracorporeal circulation. II. CANADIAN MEDICAL ASSOCIATION JOURNAL 1962; 87:859-64. [PMID: 14031889 PMCID: PMC1849695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
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GROSS R, HOLEMANS R. Fragen der Blutgerinnung bei extrakorporalem Kreislauf mit der Herz-Lungen-Maschine. ACTA ACUST UNITED AC 1961; 39:165-73. [PMID: 13709045 DOI: 10.1007/bf01482946] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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DARBY JP, SORENSEN RJ, O'BRIEN TF, TESCHAN PE. Efficient heparin assay for monitoring regional heparinization and hemodialysis. N Engl J Med 1960; 262:654-7. [PMID: 13814070 DOI: 10.1056/nejm196003312621304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Blumberg JB, Winterscheid LC, Dillard DH, Vetto RR, Merendino KA. The clinical use of polybrene as an antiheparin agent in open heart surgery. J Thorac Cardiovasc Surg 1960. [DOI: 10.1016/s0022-5223(20)31839-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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SELA M, KATCHALSKI E. Biological Properties of Poly-α- Amino Acids. ADVANCES IN PROTEIN CHEMISTRY 1959; 14:391-478. [PMID: 14444673 DOI: 10.1016/s0065-3233(08)60614-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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GORDON LA, PERKINS HA, RICHARDS V. Studies in regional heparinization. I. The use of simultaneous neutralization with protamine; preliminary studies. N Engl J Med 1956; 255:1025-9. [PMID: 13378604 DOI: 10.1056/nejm195611292552202] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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FITZGERALD MA, WAUGH DF. Characterization of a heparin cofactor obtained from bovine plasma fraction I. Arch Biochem Biophys 1955; 58:431-52. [PMID: 13269137 DOI: 10.1016/0003-9861(55)90143-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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SEEGERS WH. Coagulation of the blood. ADVANCES IN ENZYMOLOGY AND RELATED SUBJECTS OF BIOCHEMISTRY 1955; 16:23-103. [PMID: 14376211 DOI: 10.1002/9780470122617.ch2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
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BROWN WD. Effects of heparin and protamine on alimentary lipaemia in rats. ACTA PHYSIOLOGICA SCANDINAVICA 1954; 30:324-34. [PMID: 13171113 DOI: 10.1111/j.1748-1716.1954.tb01102.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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MORALES PA, GORDON SG, PINCK BD, HOTCHKISS RS. The role of the artificial kidney in the treatment of uremia. Surg Clin North Am 1954:423-40. [PMID: 13156935 DOI: 10.1016/s0039-6109(16)34190-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The inactivation of thrombin by serum follows a first order kinetics with thrombin concentrations of the order of 20 to 40 units per ml. of serum. With higher thrombin concentrations of 300 to 600 units per ml. of serum, the rate slows down and not the logarithm of the clotting time, but the clotting time itself increases proportionally with the incubation time. The antithrombic factor is stable at +4 degrees C. for a period of 2 weeks, or for 3 months at -15 degrees C. Heating over 58 degrees C. destroys it rapidly. The heat inactivation has an energy of activation of 121,000 cal. With low thrombin concentrations the rate of thrombin inactivation increases linearly with increasing serum concentration. The pH optimum of the inactivation is at 8.5. Increasing the temperature increases the rate. The energy of activation of the thrombin destruction by serum is 14,000 cal. Heparin increases the rate considerably with low thrombin concentrations, but does not affect the rate with high thrombin concentrations. The effect of heparin can be abolished with protamine or toluidine blue. Some other reagents were also tested with respect to their effect upon the rate of inactivation of thrombin by serum.
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